OVERVIEW OF THE NATIONAL CHILDHOOD IMMUNISATION PROGRAMME IN SINGAPORE

Transcription

1 OVERVIEW OF THE NATIONAL CHILDHOOD IMMUNISATION PROGRAMME IN SINGAPORE Dr Tiong Wei Wei, MD, MPH Senior Assistant Director Policy and Control Branch, Communicable Diseases Division Ministry of Health 9 April 2018

2 Contents National Childhood Immunisation Programme National Delivery Framework and Programme Implementation Financing Schemes Immunisation Coverage Evaluation of Programme Effectiveness Recent Policy Developments Future Policy Directions 2

3 NATIONAL CHILDHOOD IMMUNISATION PROGRAMME

4 National Childhood Immunisation Programme in Singapore Singapore has a comprehensive National Childhood Immunisation Programme (NCIP) in place We are largely free from vaccine-preventable diseases like poliomyelitis, diphtheria, tetanus and pertussis (whooping cough) because of our successful immunisation programme 4

5 National Childhood Immunisation Programme Diseases Covered under NCIP ( ) Smallpox (1862) removed since its eradication Diphtheria (1938) Tuberculosis, TB (1957) Poliomyelitis (1958) Pertussis and tetanus (1959) Measles and rubella (1976) Hepatitis B (1985) Mumps (1990) Pneumococcal disease (2009) Human Papillomavirus (2010) Haemophilus influenzae type b (2013) 5

6 National Childhood Immunisation Schedule Vaccination against Birth 1 Month 3 months 4 months 5 months 6 months 12 months 15 months 18 months years^ Tuberculosis BCG Hepatitis B HepB (D1) HepB (D2) HepB (D3) # Diphtheria, Tetanus, Pertussis Poliovirus Haemophilus influenzae type b Measles, Mumps, Rubella Pneumococcal Disease Human Papillomavirus DTaP (D1) IPV (D1) Hib (D1) PCV (D1) DTaP (D2) IPV (D2) Hib (D2) DTaP (D3) IPV (D3) Hib (D3) PCV (D2) MMR (D1) PCV (B1) MMR (D2) ## Recommended for females 9 to 26 years; three doses are required at intervals of 0, 2, 6 months DTaP (B1) IPV (B1) Hib (B1) Tdap (B2) OPV (B2) Explanatory notes: BCG Bacillus Calmette-Guérin vaccine D1/D2/D3 1 st dose, 2 nd dose, 3 rd dose HepB Hepatitis B vaccine B1/B2 1 st booster, 2 nd booster DTaP Paediatric diphtheria and tetanus toxoid and acellular pertussis vaccine ^ Primary 5 Tdap Tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine # 3 rd dose of HepB can be given at the same time as the 3 rd dose of DTaP, IPV, and Hib for the convenience of parents. IPV Inactivated polio vaccine ## 2 nd dose of MMR can be given between months OPV MMR Hib PCV Oral polio vaccine Measles, mumps, and rubella vaccine Haemophilus influenzae type b vaccine Pneumococcal conjugate vaccine 6

7 Mandatory Vaccinations in Singapore Two vaccinations mandatory under the Infectious Diseases Act (IDA) Diphtheria Measles 7

8 NATIONAL DELIVERY FRAMEWORK AND PROGRAMME IMPLEMENTATION

9 National Delivery Framework Governance and Organisation Structure Expert Committee on Immunisation Ministry of Health Health Promotion Board Health Sciences Authority Healthcare Institutions National Immunisation Registry School Health Service Healthcare Institutions i.e. KKH Polyclinics Outpatient clinics GP clinics 9

10 National Delivery Framework Governance and Organisation Structure Expert Committee on Immunisation Ministry of Health Health Promotion Board Health Sciences Authority Healthcare Institutions National Immunisation Registry School Health Service Healthcare Institutions i.e. KKH Polyclinics Outpatient clinics GP clinics 10

11 How are NCIS vaccines decided? Expert Committee on Immunisation (ECI) provides MOH with professional advice and expert opinion on vaccination policies A committee comprising specialists and institutional representatives including paediatricians, microbiologists, infectious diseases physicians, public health specialists, representatives from polyclinics (SingHealth & National Healthcare Group), HPB, HSA and private GP sector. 11

12 Expert Committee on Immunisation ECI s recommendations for vaccination are based on the following considerations: - Local disease burden; - Availability of safe and effective vaccine; - Cost-effectiveness; and - Evidence-based practice Evaluations are based on: - Local and overseas scientific evidence; and - Recommendations from professional bodies i.e. World Health Organization (WHO), US Advisory Committee on Immunization (ACIP) and the UK Joint Committee on Vaccination and Immunisation (JCVI) 12

13 National Delivery Framework Governance and Organisation Structure Expert Committee on Immunisation Ministry of Health Health Promotion Board Health Sciences Authority Healthcare Institutions National Immunisation Registry School Health Service* Healthcare Institutions i.e. KKH Polyclinics Outpatient clinics GP clinics * All children (Singapore Citizens and Non-Singapore Citizens) should complete the recommended NCIS vaccinations before entry into Primary One. All parents should produce the vaccination certificates (BCG, diphtheria, pertussis, tetanus, poliomyelitis, measles, mumps, rubella and Hepatitis B) of their children at the time of registration. 13

14 National Delivery Framework Governance and Organisation Structure Expert Committee on Immunisation Ministry of Health Health Promotion Board Health Sciences Authority Healthcare Institutions National Immunisation Registry School Health Service Healthcare Institutions i.e. KKH Polyclinics GP clinics Outpatient clinics 14

15 National Delivery Framework Governance and Organisation Structure Expert Committee on Immunisation Ministry of Health Health Promotion Board Health Sciences Authority Healthcare Institutions National Immunisation Registry School Health Service Healthcare Institutions i.e. KKH Polyclinics Outpatient clinics GP clinics 15

16 FINANCING SCHEMES

17 Financing Principles Medisave use is allowed for all vaccines that are assessed to be clinically-and-cost-effective and recommended under the NCIS. Subsidies are provided for vaccines that prevent against infectious diseases with high community outbreak potential (e.g. measles, diphtheria and polio) at polyclinics Subsidies are provided to: a) achieve high take-up rates; b) enable collective population-level protection (herd immunity); and c) reduce risk of community outbreaks. 17

18 Subsidy Financing Schemes - Subsidies At Polyclinics (government clinics): Full subsidies/free vaccination provided to Singapore Citizens 50% subsidy provided to permanent residents (PR) These include vaccines under NCIS such as DTaP, MMR etc. At Schools (School Health Service, HPB): Free of charge, irrespective of nationality Covers schools under the Ministry of Education (MOE) 18

19 Financing Schemes - Medisave Medisave400 (National Medical Savings Scheme) Annual limit of $400 per parent; increase to $500 from Jun 2018 onwards Medisave use extended to all vaccinations in the NCIS To encourage higher uptake of childhood vaccinations and better protect the children Parents with insufficient Medisave balance can seek special assistance at polyclinics on a means-tested basis 19

20 Financing Schemes Baby Bonus Baby Bonus Parents can also pay for the vaccination using their child s Baby Bonus cash gift (up to $8000 for 1 st /2 nd child); savings (up to $6000 for 1 st /2 nd child) in his/her Child Development Account (CDA) at Baby Bonus-approved healthcare institutions Baby Bonus and CDA can also be used for siblings vaccinations 20

21 IMMUNISATION COVERAGE

22 Immunisation against TB BCG vaccination coverage Table 1: BCG immunisation of infants in Singapore, Year Public Hospitals (%) Polyclinics (%) Private Clinics & Hospitals (%) Total Coverage for children at 2 years of age* ,399 (43.8) 205 (0.5) 20,796 (55.6) 37, ,120 (42.1) 176 (0.5) 21,963 (57.4) 38, ,967 (41.7) 123 (0.3) 22,228 (58.0) 38, ,878 (42.6) 85 (0.3) 18,623 (57.2) 33, ,123 (41.8) 67 (0.2) 18,172 (57.9) 31, ,145 (41.2) 110 (0.4) 17,225 (58.4) 29, ,756 (40.5) 70 (0.2) 23,076 (59.3) 38, ,908 (39.6) 44 (0.1) 19,683 (60.3) 32, ,460 (40.6) 54 (0.2) 18,191 (59.2) 30, ,309 (41.3) 109 (0.4) 18,778 (58.3) 32, * Coverage referred to immunisation given to all Singaporean and Singapore-PR children. Source: Communicable Diseases Surveillance 2016; National Immunisation Registry, Health Promotion Board 22

23 Immunisation against diphtheria, pertussis and tetanus Table 2: Diphtheria, pertussis and tetanus immunisation (Infants and pre-school children), Coverage for children at 2 years of age* Year Completed primary course 1 st booster dose given No. Coverage (%) No. Coverage (%) , , , , , , , , , , , , , , , , , , , , * Coverage referred to immunisation given to all Singaporean and Singapore-PR children. Source: Communicable Diseases Surveillance 2016; National Immunisation Registry, Health Promotion Board 23

24 Immunisation against diphtheria, pertussis and tetanus Table 3: Diphtheria, tetanus and pertussis 2 nd booster given to primary five students (10-11 years of age), (Tdap) Year Total no. of primary 5 students 2 nd booster dose given* No. Coverage (%) ,126 47, ,498 43, ,555 43, ,071 45, ,579 40, ,901 39, ,065 36, ,865 36, ,044 36, * Coverage by SHS did not include booster immunisations done by private practitioners. Source: Communicable Diseases Surveillance 2016; National Immunisation Registry, Health Promotion Board 24

25 Immunisation against Haemophilus influenzae type b Table 4: Haemophilus influenzae type b immunisation, Coverage for children at 2 years of age* Year Completed primary course Booster dose given No. Coverage (%) No. Coverage (%) , , , , , , , , , , , , , , , , * Coverage referred to immunisation given to all Singaporean and Singapore PR children. Source: Communicable Diseases Surveillance 2016; National Immunisation Registry, Health Promotion Board 25

26 Year Immunisation against poliomyelitis Table 5: Poliomyelitis immunisation of infants, pre-school and school children, Coverage for children at 2 years of age* School Children Completed primary 1 st booster dose course given 2 nd booster dose given No. Coverage % No. Coverage % Schoo l entran ts * Coverage referred to immunisation given to all Singaporean and Singapore PR children. Coverage by SHS did not include booster immunisations done by private practitioners. The OPV booster dose for school entrants was discontinued at the end of Source: Communicable Diseases Surveillance 2016; National Immunisation Registry, Health Promotion Board No. Coverage % , , ,122 44, , , ,548 40, , , ,142 39, , , ,465 37, , , ,886 36, , , ,682 36, , , ,385 37, , , , , , ,

27 Immunisation against poliomyelitis Table 6: Poliomyelitis booster dose given to primary five students (10-11 years of age), Year Total no. of primary 5 students * Coverage by SHS did not include booster immunisations done by private practitioners. Booster given* Source: Communicable Diseases Surveillance 2016; National Immunisation Registry, Health Promotion Board No Coverage (%) ,126 47, ,498 43, ,555 44, ,071 47, ,579 42, ,901 41, ,065 38, ,865 38, ,004 38,

28 Immunisation against measles, mumps and rubella Table 7: Measles, mumps and rubella immunisation, Coverage for children at 2 years of age* Primary school children Year Dose 1 Dose 2 Dose 2 No. Coverage No. Coverage No. Cover (%) (%) age (%) , , , , , , , , , , , , , , , , , , , , * Coverage referred to immunization given to all Singaporean and Singapore PR children. Coverage among all students in respective cohorts [11-12 years of age (primary six) up to 2007, 6-7 years of age (primary one) from 2008 to 2011 (reported up to 2012)]. Dose 2 was administered in primary school, at years of age (primary six) up to 2007 and 6-7 years of age (primary one) from 2008 to 2011 (reported up to 2012). From December 2011, dose 2 was administered at months of age (reported from 2013). Source: Communicable Diseases Surveillance 2016; National Immunisation Registry, Health Promotion Board 28

29 Immunisation against hepatitis B Table 8: Hepatitis B immunisation, Full course of Hepatitis B vaccination completed by age 2 years Year Coverage No. (%)* , , , , , , , , , , * Coverage referred to immunization given to all Singaporean and Singapore PR children.. Source: Communicable Diseases Surveillance 2016; National Immunisation Registry, Health Promotion Board 29

30 Immunisation against pneumococcal disease Table 9: Pneumococcal immunisation, Year No. completed two doses by age 1 year No. completed booster (3 rd ) dose by age 2 years No. Coverage %* No. Coverage %* , , , , , , , , , , , , , , , , * Coverage referred to immunisation given to all Singaporean and Singapore PR children.. Source: Communicable Diseases Surveillance 2016; National Immunisation Registry, Health Promotion Board 30

31 EVALUATION OF PROGRAMME EFFECTIVENESS

32 Effectiveness of the National Childhood Immunisation Programme Figure 1: Incidence of reported poliomyelitis cases and immunisation coverage in Singapore ( ) 32

33 Effectiveness of the National Childhood Immunisation Programme (2) Figure 2: Incidence of reported diphtheria cases and immunisation coverage in Singapore ( ) In 2016, no indigenous case of diphtheria, poliomyelitis and neonatal tetanus was reported. 33

34 Effectiveness of the National Childhood Immunisation Programme (3) Figure 3: Impact of catch-up MMR vaccination programme and introduction of 2 nd dose of MMR vaccine on the incidence of reported measles cases in Singapore ( ) 34

35 Effectiveness of the National Childhood Immunisation Programme (4) Rubella incidence decreased from 48 cases in 2013 to 12 cases in There were no reported cases of indigenous congenital rubella and no termination of pregnancy due to rubella infection carried out in The resurgence of mumps which began in 1998, continued until the year The resurgence was due to poor protection conferred by the Rubini strain of the MMR vaccine which was subsequently deregistered in The incidence of mumps has since decreased from 6384 cases in 1999 to 540 cases in

36 Effectiveness of the National Childhood Immunisation Programme (5) Figure 4: Incidence of reported acute hepatitis B cases and immunisation coverage in Singapore ( ) 36

37 National Sero-prevalence Survey 2012 To determine the prevalence of antibody against vaccine preventable diseases and other diseases of public health importance in the adult Singapore resident population aged years using residual sera from the National Health Survey Overall sero-prevalence was 85.0% for rubella in those aged years. 11.1% of women years of age remained susceptible to rubella infection. About 43.9% of Singapore residents aged years possessed immunity against hepatitis B virus (anti-hbs 10 miu/ml). The overall prevalence of HBsAg in the population was low at 3.6%. 37

38 RECENT POLICY DEVELOPMENTS

39 Recent Policy Developments Establishment of the National Adult Immunisation Schedule (Nov 2017) Recommendations for persons aged 18 years and above: Influenza Pneumococcal Human Papillomavirus (HPV) Tetanus, diphtheria and pertussis (Tdap) in pregnant women Measles, mumps and rubella (MMR) Hepatitis B Varicella Implementation of vaccination requirements as pre-requisite for foreign born children applying for long term immigration passes (Dec 2018/Jan 2019) Recommendations for foreign born children aged 0-12 years: Measles Diphtheria 39

40 FUTURE POLICY DIRECTIONS

41 Future Policy Directions Introduce a national school-based HPV vaccination programme Analyse the local cost-effectiveness of these vaccines: Varicella in children Tdap in adults Improve current vaccination strategies Develop and implement new strategies to improve vaccine uptake Enhance public health promotion and education efforts with HPB Strengthen collaboration with various stakeholders including HPB, HSA, MOE and both public and private healthcare providers 41

42 References 1. Ibuka, Y. Paltiel, D. and Galvani, A. P. Impact of Program scale and indirect effects on the cost-effectiveness of vaccination programs. Med Decis Making. 2012;32(3): Ozawa, S. et. al. Cost-effectiveness and economic benefits of vaccines in low-and middle-income countries: a systematic review. Vaccine Dec 17; 31 (1): Deogaonkar, R. et. al. Systematic review of studies evaluating the broader economic impact of vaccination in low middle-income countries. BMC Public Health. 2012;12: Liew, F et. al. Evaluation on the effectiveness of the National Childhood Immunisation Programme in Singapore, Annals Academy of Medicine. 2010; 39: National Immunisation Registry, Health Promotion Board 6. Onorato, I.M. et. al. Mucosal immunity induced by enhanced-potency inactivated and oral polio vaccines. J Infect Dis. 1991; 163: Stratton, K. R., Howe, C.J. and Johnston, R.B. Adverse events associated with childhood vaccines other than pertussis and rubella. Summary of a report from the Institute of Medicine. JAMA. 1994; 25;271: Kita, Y. et. al. Replacement of oral polio vaccine with inactivated polio vaccine and inclusion of Haemophilus influenzae type b vaccine in the National Childhood Immunisation Schedule. Epidemiological News Bulletin Vol. 39 (2):

43 Thank You