The English immunization programme Mary Ramsay Head of Immunisation Public Health England National Health Service Constitution (2009) You have the right to receive the vaccinations that the Joint Committee on Vaccination and Immunisation recommends that you should receive under an NHSprovided national immunisation programme. You should participate in important public health programmes such as vaccination. 1
Joint Committee on Vaccination and Immunisation (JCVI) Independent expert advisory committee Makes recommendations to the Secretary of State for Health All JCVI recommendations relating to national vaccination programmes must be shown to be cost-effective must originate from an initial request to consider the issue by the Secretary of State for Health But JCVI can make advice in other areas and based on other criteria E.g. minor changes to schedules E.g. selective programmes for those at risk Public Health England support to national policy Support to JCVI, including secretariat to committee National surveillance of infection, outbreak investigation National vaccination coverage monitoring Modelling and economic evaluation (alone or in collaboration) Epidemiological research Including responsive clinical trials programme 2
Item Guidance Rules of the game Perspective on costs NHS & Personal Social Services Perspective If a on vaccine outcomes programme All health effects costs on individuals more than Measure of health effects QALYs Comparator Uncertainty Fully expressed. Often probabilistic sensitivity analysis Discounting Time horizon As set out in NICE technology appraisal guidelines Implications of CEA in the UK 20,000-30,000 per QALY gained, it would Current best practice not be considered cost effective NHS resources would be better invested in alternative interventions JCVI cannot recommend that the vaccine is Sufficient to reflect important cost and introduced benefit differences Annual rate of 3.5% for costs & benefits (sensitivity analysis of differential discounting) http://www.nice.org.uk/media/b52/a7/tamethodsguideupdatedjune2008.pdf Economic analysis of vaccination programmes More complex than for other interventions Benefits are often accrued over a very long time period (major impact of discounting future benefits) Each infection prevented has potential to reduce transmission to others indirect effects May need to incorporate impact of type replacement (eg. PCV) Mathematical models are generally used to aid decision making Normally conducted by or in close collaboration with PHE Validated against PHE infectious disease surveillance data 3
JCVI decision options Cost effective at the list price Vaccine is not cost-effective at any price Price of delivery exceeds cost-effective price Cost effective if available at a low enough price Allows PHE to procure vaccine at price that delivers the greatest positive health benefit Eg. MenB Summary of development of immunisation policy in UK National commitment enshrined in NHS constitution Requirement to show the vaccine is cost-effective Has led to optimised and efficient vaccination and rapid strategies e.g. To allow fewer doses in infant schedule (2+1 PCV) based on clinical trials funded by Department of Health To target transmitters (e.g. vaccinating teenagers for MenW) based on modelling conducted with PHE Risk mitigated by high quality surveillance of disease and coverage 4
MenW meningococcal disease by epidemiological year Vaccine Update 9 Strategy to control MenW Wide age range affected Incidence highest in infants, toddlers and adolescents Still high number of cases in older adults (over 65s) Strategy used in Chile of vaccinating children under five, only impacted on vaccinated age group Failed to control overall disease rates Only feasible strategy is to target carriers with conjugate ACWY vaccine Plan to immunise adolescents age 14 years (replace MenC booster) vaccinating older cohorts (14-18 years) in small catch up to accelerate control Commenced in August 2015, completed 10 Introducing a new vaccine 5
Annual cases averted 4/07/2016 Modelling the impact of MenW adolescent vaccination strategies 450 400 350 300 250 200 150 100 50 0 Direct protection, no catch-up Direct & indirect protection, no catch-up Direct protection, with catch-up Direct & indirect protection, with catch-up 0 10 20 30 40 50 Years after vaccination Cumulative MenW cases by epidemiological year (July-June) 12 Introducing a new vaccine 6
Devolution of health services from April 2013 Local NHS GP led clinical commissioning groups commissioning most local health care Local authorities to commission public health E.g. school health, sexual health, drugs and alcohol However, some clinical services to be commissioned nationally by NHS England Specialised and highly specialised drugs Including immunisation and screening programmes Section 7a agreement (between DH and NHS England) Ring fenced national budget Public Health England provides technical support Public Health s national role in supporting implementation National vaccine procurement, supply and distribution (except flu and PPV) National service specifications, programme planning and management Clinical expertise and leadership Rapid communications with healthcare professionals and providers Media engagement and good quality public communications Based on regular attitudinal tracking Support for training and education 7
PHE project planning Introducing a new vaccine 15 94% of parents are confident in the immunisation programme, and 47% are very confident. Confidence does vary by demographic profile however. Confidence in Immunisation Programme Very confident Confident 47% 48% 94% confident Not very confident Not at all confident Unsure 3% 1% 2% % very confident in the immunisation programme decreases amongst - 35yrs+ (43%) - C2DEs (43% cf. 53% ABC1) - BMEs (36% cf. 49% white) - No qualifications (46% cf. 52% a degree or above) Base: All Parents (1683) Q58b. In general, how much confidence do you have in the Immunisation Programme? 8
Post 2013 NHS England provision of immunisation Most routine vaccines administered as part of national GP contract, with GP as preferred provider essential or additional services undertaken by all GPs Some adult vaccines (eg. Flu) are enhanced services which GPs can choose to sign up for Most GPs do and are reimbursed as item of service payments Negotiated at national level with BMA General Practitioners commitee PHE s support to NHS England in local immunisation delivery Local NHS England teams decide how to commission other immunisations Competitive tenders from local providers (independent trusts, pharmacists, GPs, midwives) E.g. HPV currently mainly in schools PHE Screening and Immunisation Teams are embedded in local NHS England support local commissioning and provision through leadership, coordination, performance management National coordination by PHE immunisation team 9
Measurement of vaccine coverage in the UK Historically vaccination coverage was derived from local child health registers Child health information system Population- based register of under 18s resident, attending school or registered with a GP in an area Computerised since late 1980s and used for child health screening, development and immunisation Each system locally managed, although relatively small number of software suppliers More recently based on general practice IT system Registered population eligible for vaccination (95% GP registration) Only four major suppliers all working to common standards 19 DH visit 29 th May 2015 Evolution of coverage measurement Cover of Vaccination Evaluated Rapidly (COVER) uses aggregate standardised reports from CHIS Quarterly vaccine coverage reports at age one, two and five years of age Collected since 1987 Main source of long term data for UK as reported to WHO 2013 : national data used for Public Health Outcomes Framework (PHOF) Recent move to use automated upload from GP systems (>95% of all practices) 20 DH visit 29 th May 2015 10
MMR coverage at two and five years of age, England 1997/8-2013/14 100 95 90 85 80 MMR1 at 2y MMR1 at 5y 75 70 ImmForm GP based vaccine coverage collections Surveys can be weekly/monthly/quarterly/annual within a few days Eligible population can be age based (adults) PPV, Shingles, Influenza Eligible population can be risk-based (using Read codes) Pre-natal pertussis, influenza, PPV Collated, aggregated and fed-back using ImmForm platform Also used for GP vaccine ordering and stock management Local NHS can access local GP level data for performance management 22 DH visit 29 th May 2015 11
VACCINE UPTAKE (%) 31/08/2014 07/09/2014 14/09/2014 21/09/2014 28/09/2014 05/10/2014 12/10/2014 19/10/2014 26/10/2014 02/11/2014 09/11/2014 16/11/2014 23/11/2014 30/11/2014 07/12/2014 14/12/2014 21/12/2014 28/12/2014 04/01/2015 11/01/2015 18/01/2015 25/01/2015 4/07/2016 Rapid monitoring of performance weekly influenza uptake PROVISIONAL SEASONAL FLU VACCINE UPTAKE DATA - WEEKLY SNAPSHOT SEASON 2014/15 (comparison with 2013/14 and 2012/13 baseline figures for similar stages in the flu season) 80 70 60 50 40 30 20 10 0 65 and Over (2014/15) 65 and Over (2013/14) 65 and Over (2012/13) Under 65 - At Risk [excluding pregnant women without other risk factors] (2014/15) Under 65 - At Risk [excluding pregnant women without other risk factors] (2013/14) Under 65 - At Risk [excluding pregnant women without other risk factors] (2012/13) Pregnant women [healthy and at-risk] (2014/15) Pregnant women [healthy and at-risk] (2013/14) Pregnant women (2012/13) 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 1 2 3 4 Week No. / Weeking Ending Date Summary National commitment to immunisation in the UK is current high Enshrined in NHS constitution and section 7a agreement Public and professional acceptance high, reflected in high coverage Immunisation retains national profile, despite devolution in other health services Good evidence base to show benefits Innovative and efficient approach to policy development National coordination and advocacy from a single organisation (PHE) 12