Immunisations and vaccinations Immunisation is an effective public health intervention for promoting good health and protecting individuals and populations against serious disease and infection through passive or active immunity. The terms immunisation and vaccination tend to be used synonymously. Immunisation in childhood can prevent illnesses that have serious long-term consequences. No vaccine is 100 effective as individuals have different immune responses which last varying amounts of time. However it is not necessary for every person to be immune. If a person is not immunised they will be at risk from catching the disease and will rely on other people being immunised to avoid becoming infected. If people choose not to be immunised, then the number of people at risk of catching a disease will increase and outbreaks of the disease will occur. Herd immunity is the degree to which a population is resistant to an infection as high general levels of immunity protect the non-immune. To achieve herd immunity a high percentage of children need to be immunised. Low uptake of the national childhood immunisation schedule puts the individual child at risk, particularly where there is herd immunity of less than the recommended 95 for public protection. This is the WHO cover target for all childhood immunisations by 24 months of age. A single dose of MMR protects around 90 of children who are given it, but a second dose is required to ensure sufficient protection to prevent outbreaks of disease. The schedule for childhood vaccination is:(web link to NHS Childhood Immunisation Schedule for 2008 http://www.immunisation.nhs.uk/immunisation) When to immunise Diseases protected against Two months old Diphtheria, tetanus, pertussis (whooping cough), polio and Haemophilus influenzae type b (Hib), Pneumococcal infection Three months old Diphtheria, tetanus, pertussis, polio and Four months old Diphtheria, tetanus, pertussis, polio and Pneumococcal infection Around 12 months Around 13 months Measles, mumps and rubella Pneumococcal infection Three years and four months or soon Diphtheria, tetanus, pertussis and polio after Measles, mumps and rubella Girls aged 12 to 13 years Cervical cancer caused by human papillomavirus types 16 and 18 (HPV) 13 to 18 years old Diptheria, tetanus, polio The routine childhood immunisation programme is part of the Healthy Child Programme (previously known as the Child Health Promotion Programme).
Key issues and gaps: Using MMR as a trace vaccine some parts of Norfolk are not achieving national targets with poorer rates of uptake of MMR expected in the most deprived areas. There has been some controversy recently following conflicting research evidence about the MMR vaccine, which has resulted in a decrease in the number of children being vaccinated. In August 2008 the Department of Health announced a catch up programme for measles, mumps and rubella (MMR) which should improve the uptake but there is still much work to do to improve the confidence of families towards the MMR vaccine. Who s at risk and why There are a range of immunisations for groups of children in the Norfolk population set out in the immunisation schedule above. The level of need in the population. Routine childhood immunisation programme. The national COVER Programme monitors immunisation coverage data for children in the UK who reach their first, second, or fifth birthday during each evaluation quarter. This information is fed back to the two Primary Care Trusts in Norfolk, in order to plan for improved coverage and to detect changes in vaccine coverage promptly. Headlines: After falling to 80 in 2003-04, uptake of the MMR vaccine for children in England reaching their second birthday, increased steadily to 85 in 2006-07 and has remained at 85 in 2007-08. This has remained at this level through to 2008-09 (NHS immunisation statistics 2007-08 and 2008-09Health and Social Care Information Centre). For children reaching their second birthday uptake of vaccines against diphtheria, tetanus, polio, pertussis, Haemophilus influenzae type b and meningitis C was between 93 and 94 and has been unchanged for the last five years remaining stable through into 2009. In the first year of reporting (as experimental data) uptake of the Pneumococcal conjugate vaccine (PCV) was 84 for children immunised by their first birthday. This has increased to 91 in 2008-09. Percentage immunisation rates by second birthday 2007-08(in brackets) and 2008-09 (England, East of England and PCTs (NHS Norfolk and NHS Great Yarmouth and Waveney) Area Number of children aged 2 (thousands) (=100) Diptheria Tetanus Polio Pertussis Hib (DTaP/IPV/Hib) MMR MenC England (587.3) 631.3 (94)94 (85) 85 (93) 92 East of (67.0) 69.1 (95)95 (84) 84 (96) 95 England NHS Norfolk (7.5) 7.6 (96)96 (85) 85 (95) 95 NHS Great Yarmouth and Waveney (2.2) 2.4 (94)94 (81) 81 (98) 96
The table above show that in 2007-08 primary immunisation rates by a child s second birthday in NHS Norfolk, were broadly in line with England and East of England averages. The rate of MMR vaccination is lower in Great Yarmouth and Waveney than the national and regional average. The situation has remained unchanged in 2008-09. 2007-08 figures for England show that 74 of children have received their first and second dose of MMR vaccine by age 5 years. This compares with 75 in the East of England, 73 in NHS Norfolk and 72 in NHS Great Yarmouth and Waveney. Both areas are lower than the World Health Organisation recommended level of vaccination of 95. By 2008-09 there has been a full four percentage point increase to 78 in England compared to a six percentage point increase in NHS Norfolk to 79, a six percentage point increase to 78 in NHS Great Yarmouth and Waveney and a three percentage point increase to 78 in the East of England. Further analysis of data is needed to show any variation of MMR uptake by GP quintiles. It is expected that this would show a correlation between low uptake and higher levels of deprivation based on GP practices configured into deprivation quintiles. This needs to be tested. An immunisation forum is planned in NHS Norfolk focused on improving the uptake of childhood immunisations. DTaP/IPV/Hib (Diphtheria tetanus polio pertussis haemophilus influenzae B) and meningitis C by second birthday 2007-09 East of England 95 NHS Norfolk 96 Great Yarmouth and Waveney 94 Pneumococcal vaccination Changes to the routine Childhood Immunisation Programme to include the Pneumococcal conjugate vaccine (PCV) for all children from two months of age effective from 4 th September 2006. Pneumococcal conjugate vaccine (PCV) data has been collected for the first time and therefore has been labelled as experimental. East of England 83 by first birthday NHS Norfolk 88 NHS Great Yarmouth and Waveney 81 Source:NHS Immunisation Statistics 2007-08 There has been around a significant increase for 2008-09 from the previous year in all areas. England 91 East of England 93 NHS Norfolk 93 NHS Great Yarmouth and Waveney 92 Non routine vaccination programme BCG Given at birth to babies who are more likely to come into contact with TB than the general population 2007-08
Number of children receiving BCG vaccinations and reinforcing doses given to school leavers by provider = 39,953 East of England, 3068 NHS Norfolk and 1130 NHS Great Yarmouth and Waveney. There has been a ten percent increase in vaccinations in 2008-09 on the previous year in England. 2008-09 East of England 40.4 NHS Norfolk 3056 NHS Great Yarmouth and Waveney 1582 HPV The Department of Health announced the introduction of a national human papilloma virus (HPV) vaccination programme commencing September 2008 for HPV immunisation to be offered routinely to all girls aged 12-13 (school year 8) to protect them against their future risk of cervical cancer. The programme was also extended to girls aged 17-18 years (born between 1.9.90 and 31.8.91). In December 2008 the DH announced the acceleration of the national catch-up programme for girls aged 15 to 18 (born between 1.9.91 and 31.8.95) so that this cohort could be offered protection earlier against cervical cancer. The vaccine protects against the viruses responsible for about 70 of cases. To ensure maximum benefit and protection from this vaccine, it is necessary to administer it before girls become sexually active. The vaccine is administered in 3 doses over 6 months. In 2008/09 the NHS Norfolk outturn against a 90 target was 81.8 for uptake of all 3 doses by year 8 girls. HPV Vaccination Programme: Provisional data, submitted for first, second and third dose vaccine uptake, for the month ending 31 August 2009. Area Cohort 1 (routine 12-13 year olds school year 8 Cohort 2(catch up 17-18 year olds) Total no. in cohort Dose 1 Doses 1&2 All 3 doses Total no. in cohort Dose 1 Doses 1&2 All 3 doses England 305786 87.5 85.1 78.4 322689 62.8 54.1 31.1 East of 34756 88.2 85.7 83.0 35721 66.2 61.7 46.9 England NHS 4154 88.5 87.2 81.8 4245 69.1 64.7 53.9 Norfolk NHS Great Yarmouth and Waveney 1196 90.5 89.7 88.0 1002 82.9 80.7 64.1 Expert opinion and evidence base The DoH published Vaccination Services reducing inequalities in uptake in March 2005. This outlined the particular groups at risk including children in care, young people who missed previous immunisations, children with physical or learning difficulties, children of lone parents, children not
registered with a GP, children in larger families, hospitalised children, and BME groups. It also outlined strategies that can be used to increase uptake, including making specific provisions to improve access for target groups. NICE (National Institute for Health and Clinical Excellence) has developed guidance entitled Reducing differences in the uptake of immunisations ph21 2009 www.nice.org.uk NHS immunisation website www.immunisation.nhs.uk Health Protection Agency www.hpa.org.uk Childhood Immunisation Guidance notes for professionals