NHS GRAMPIAN IMMUNISATION PROGRAMMES

NHS GRAMPIAN IMMUNISATION PROGRAMMES ANNUAL REPORT 2009/10 NHS GRAMPIAN IMMUNISATION STEERING GROUP October 2010

Table of Content 1. Purpose of this report...4 2. Childhood Immunisation...4 3. Description of the UK immunisation programme...4 4. Organisation of the delivery of vaccination services...5 5. Training...6 7. Vaccine uptake results- Overview of 2009/2010...7 8. Vaccination errors/incidents...20 9. Achievements...21 10. Conclusions...21 11. Key actions for 2010-2011...22 Appendix 1: Childhood Immunisation Programme as at March 2010...23 Appendix 2: Uptake of Immunisation by Deprivation...24 Appendix 3: Membership of the Grampian Immunisation Steering Group...27 2

List of Tables and Figures Table 1: Uptake of Diphtheria, Tetanus, Pertussis, Polio and Hib by 12 months of age in Grampian 1 April 2009 to 31 March 2010...8 Table 2: Uptake of Diphtheria, Tetanus, Pertussis, Polio and Hib by 24 months of age in Grampian by CHP area, 1 April 2009 to 31 March 2010...9 Table 3: Uptake of Diphtheria, Tetanus, Pertussis, Polio and Hib by 5 years of age in Grampian by CHP area, 1 April 2009 to 31 March 2010...10 Figure 1: Uptake of MMR 1 and 2 by 5 years of age in Grampian by CHP area, 1 April 2009 to 31 March 2010...11 Figure 2: Diphtheria uptake as at 31.12.09 by SIMD and age, Scotland 12 Figure 3: Uptake of HPV Immunisation for Girls in S2 in Grampian by CHP Year 1 (2008/2009)...13 Table 4: Uptake of HPV Immunisation in Girls eligible for the catch-up vaccination in Grampian (year 1)...14 Figure 4: Uptake of HPV Immunisation in Girls eligible for the catch-up vaccination in year 1 (2008/09) in Grampian by CHP area...15 Figure 5: Uptake of HPV Immunisation for Girls in S2 in Grampian by CHP Year 2 (2009/2010)...16 Table 5: Total number of children born to Hep B +ve Mothers who have reached 12 and 24 months during the evaluation period 1 April 2009 to 31 March 2010...16 Table 6: Uptake of pandemic flu vaccination by population group in Grampian. September 2009 to 4 April 2010.18 3

1. Purpose of this report The aim of this report is to provide a brief overview of the delivery of local NHS immunisation services, sufficient to provide assurance to the NHS Grampian clinical governance function that appropriate clinical standards are being maintained in delivery of the programme. It should be noted that, currently, there are no published national quality standards to guide programme delivery. The report specifically relates to delivery of the NHS UK population immunisation programme. It does not address vaccination administered for the purposes of travel abroad or for occupational purposes. 2. Childhood Immunisation Immunisations are the most effective and economical way of reducing the burden of morbidity and mortality associated with serious infectious disease in children. Apart from its protective effect in an individual child, immunisation produces an indirect effect known as herd immunity. Herd immunity occurs when a high proportion of the population have been vaccinated. This reduces the opportunity for specific infections to circulate in the community, thereby protecting those children who remain unvaccinated. To ensure herd immunity 95% of the eligible population usually need to be immunised against each disease. Accordingly, the World Health Organisation (WHO) recommends that at least: 95% of children should receive three primary doses of diphtheria, tetanus, polio and pertussis in the first year of life. 95% should receive a first dose of a measles, mumps and rubella (MMR) containing vaccine by 2 years of age. 90% should receive a booster dose of tetanus, diphtheria and polio between 13 to 18 years of age and 90% of young girls aged 12-13 years should receive a complete course of the human papilloma virus (HPV) vaccine. 3. Description of the UK immunisation programme The programme is extensive and complex comprising: Vaccination against 10 diseases (Diphtheria, Tetanus, Polio, Whooping Cough, Haemophilus influenzae type B, Meningococcal C (MenC) infection, Pneumococcal infection, Measles, Mumps, Rubella to all children. Hepatitis B and BCG (TB) vaccination are offered to selected children based on risk assessment 4

Human Papilloma Virus vaccination is offered to all teenage girls up to 18 years of age Pneumococcal and seasonal flu vaccination is offered to individuals aged less than 65 years who are at increased clinical risk and to all adults aged 65 years or more. Protection against each disease requires one or more doses of vaccine (given at specific intervals) to establish initial immunity, with some diseases requiring further booster doses of vaccine to maintain immunity throughout life. Appendix 1 shows the detail of the routine childhood vaccination programme. 4. Organisation of the delivery of vaccination services The childhood vaccination programme has been in place for many years, quietly being delivered, in the main, as part of routine primary care services. Senior managers and clinical staff not involved in immunisation programmes may overlook the effort required of vaccinators (and the clinical impact of what they do). Over recent years, the national programme has substantially increased in complexity. At the same time, patient, parent and media awareness and concern about vaccines has also increased. These factors have combined to make delivery of the programme increasingly challenging, demanding staff to demonstrate a greater level of knowledge and understanding, coupled with accurate communication of information, in the undertaking of a heavier vaccinationrelated workload. In fact, the scale of the current vaccination effort is vast, being one of the largest and most complex coordinated interventions delivered by the NHS. It is also, arguably, the most evidence-based and cost-effective NHS service, all vaccines being required to undergo intense scientific and economic scrutiny prior to inclusion in the programme. There continues to be no doubt that routine vaccination prevents many cases of severe illness and saves substantial numbers of lives each year. In Grampian, something in the region of 27,000 children and young adults are offered 51,000 appointments for routine immunisations each year. These must be delivered in an accessible, coordinated and cost effective way, taking account of individual vaccine schedule requirements, i.e. one, two, three or four dose schedules with distinct time intervals between doses. Vaccinations which are not part of the routine UK immunisation schedule are offered on a risk assessment basis to individuals at risk of infection, e.g. Hepatitis B and BCG. Almost one thousand individuals under the age of 21 years received either hepatitis B and/or BCG vaccines during the last financial year. 5

Around 140,000 individuals over the age of 65 years and individuals under 65 years in clinical at risk groups are invited for Flu immunisation by their GP practices each year. In the winter of 2009-2010, the uptake of seasonal flu vaccination in Grampian amongst the over 65 yrs age group was 75.4%. This was achieved in parallel with the pandemic H1N1 ( swine ) flu vaccination effort. Eligible staff employed in the health and social care sector are offered flu vaccination through the NHS Grampian Occupational Health Service with over 5.5 thousand staff receiving vaccination last winter. Delivery of the vaccination service requires considerable multidisciplinary and multiagency effort. The majority of vaccinations are administered in a general practice setting by practice nurses and NHSG health visitors. However, this represents the proverbial visible tip of the iceberg. These vaccinators receive essential, coordinated, expert support from a wide range of other staff including administrative staff, community pharmacists, vaccine holding centre staff, transport services, corporate communications, Health Protection Team, Medicines Information Unit, Childrens Hospital and related services, and the Infection Unit. In addition, the vaccination effort is taken forward in schools by the school nursing service working in partnership with the Community Child Health Records Department, Education Departments and individual school management teams. The Maternity Hospital and community maternity services routinely contribute to the selective BCG and hepatitis B programmes and, in addition, (this year) pandemic flu. Finally, the essential core function of coordination of scheduling of child vaccination appointments is provided by Practitioner Services Department (PSD) through their operation of SIRS (Scottish Immunisation Recall System). Overall coordination of the Grampian vaccination effort is led by the NHSG Immunisation Steering Group, which meets quarterly, and has wide membership drawn from across the system. 5. Training In the past, minimal vaccination education and training was incorporated within the undergraduate and postgraduate curricula for nursing and medical staff. This continues to be the case. As a result, individual knowledge of vaccination is mainly the result of self-education and on the job learning (which may be of variable quality) from peers. This has resulted in a variable level of technical knowledge within the current vaccinator workforce. As the complexity of the vaccination programme has grown, and the knowledge and expectation of parents and patients increased, the need for vaccinators to be able to access quality-assured educational material, aimed at improving their knowledge and competence, has been recognised nationally. A national e-learning resource has been developed and introduced to support this. The aim is that, over time, all vaccinators will complete the e-learning programme and a short spell of observed practice, so raising the standard of professional practice throughout the vaccinator workforce. 6

In Grampian, substantial progress has been made in facilitating vaccinator take-up of the e-learning programme. To date almost 180 staff members involved at all levels of the immunisation programme have undertaken the course. A programme of mentor development has been rolled out in the CHP s and we now have over 40 mentors throughout Grampian. Mentors are allocated to staff undertaking the course, usually in close proximity to their workplace. 6. Key new challenges in 2009-2010 In addition to delivery of the routine childhood and seasonal flu vaccination programmes, vaccinators were also required to implement Year 2 of the introduction of Human Papilloma Vaccine (HPV), Pandemic Flu vaccination to selected population groups, and Completion of the Haemophilus influenzae B (Hib) catch-up programme. Implementation of the pandemic flu vaccination programme placed a huge additional workload on all those involved and good uptakes of the pandemic vaccine were achieved. In addition, uptakes in the routine childhood and seasonal flu programmes were maintained at a satisfactory level, the HPV implementation progressed and Hib catch-up completed. Detail on individual vaccine uptake is given in the next section. The patience of staff in managing the uncertainties which surrounded implementation of pandemic flu vaccination, and their commitment to the successful delivery of the other vaccination programmes, was commendable. A lot of people went the extra mile. 7. Vaccine uptake results- Overview of 2009/2010 The uptake of childhood immunisation is the proportion of children who have received an appropriate vaccine for their age. Generally, uptake rates for all immunisation remain high in Grampian compared with the Scottish average. Summary uptake figures for children reaching ages 12 months, 24 months and five years in financial year ending 31 March 2010 in Grampian are shown in the tables and figures below. 7.1 Uptake rate of primary course by 12 months Uptake rate by age 12 months for the financial year ending 31 st March 2010 pertain to children who were born between 1 April 2008 and 31 March 2009. The number of children in this cohort was 6315. This is shown in table 1 below. Pediacel: the five-in-one vaccine The 5 in 1 vaccine (comprising; Diphtheria, Pertussis, Tetanus, Polio, Hib) was introduced in September 2004. These vaccinations can be recorded separately on the SIRS system and therefore individual rates may differ slightly. This may be due to children having received a single vaccine outwith Scotland or due to local recording practices. 7

During the evaluation period, the uptake rate for completing primary courses of Pediacel by 12 months was high between 97.6% and 97.8% across Grampian as a whole. Similar rates were observed across the 3 individual CHP areas with Aberdeenshire having a slightly higher uptake rate than Aberdeen City and Moray. These rates were also higher than the Scottish average except in Aberdeen City. Meningitis C Vaccine The overall uptake in 2009/2010 of the Men C Vaccine across Grampian was 96.6% by the age of 12 months. This was slightly less than the Scottish average of 97%. Uptake of Men C was higher than both the Grampian and Scottish average in Aberdeenshire CHP (97.9%) and Moray (97.1%). The uptake rate in Aberdeen city was 95.4%. PCV PCV was introduced in September 2006. In 2009/10 uptake of PCV across Grampian (96.9%) was lower than the Scottish average of 97.2%. Similar trends were seen in Aberdeen City CHP (95.9%) and Moray CHCP (96.9%). Aberdeenshire CHP had an uptake rate of 98.1%. This was higher than both the Grampian and Scottish average. Overall, uptake rates for the primary course in children reaching 12 months of age during the evaluation year 1 April 2009 to 31 March 2010 were consistently above the WHO recommended target of 95%. Table 1: Uptake of Diphtheria, Tetanus, Pertussis, Polio and Hib by 12 months of age in Grampian 1 April 2009 to 31 March 2010 Area Diphtheria Tetanus Pertussis Polio Hib MenC PCV Aberdeen City CHP 97.1 97.1 97.1 97.0 96.9 95.4 95.9 Aberdeenshire CHP 98.6 98.6 98.6 98.6 98.5 97.9 98.1 Moray CHCP 97.6 97.6 97.6 97.5 97.6 97.1 96.9 Grampian 97.8 97.8 97.8 97.7 97.6 96.6 96.9 Scotland Source: ISD 97.4 97.4 97.4 97.4 97.3 97 97.2 7.2 Uptake of primary and booster course by 24 months Uptake rate by 24 months for the financial year ending 31 st March 2010 pertain to children who were born between 1 April 2007 and 31 March 2008. The number of children in this cohort in Grampian was 6145. As this is a different cohort of children, care should taken in interpreting the results 8

especially if comparison is being made to uptake rate by 12 months for the same financial year. In Grampian as a whole, the percentage completion of primary immunisation by 24 months ranged between 98.3% and 98.7% for Pediacel compared to 98.2% and 98.4% across Scotland. Similar trends were also observed within the different community health partnership CHP areas in Grampian. Percentage completion of Men C in Grampian as a whole by 24 months was 95.9% compared to 96.4% across Scotland. Within the 3 different CHP areas, Aberdeenshire (96.9%) had a higher uptake rate for Men C compared to Moray (96.7%) and Aberdeen City (94.5%). With regards to PCV vaccination uptake, the Grampian (96.4%) average was similar to the Scottish (96.5) average. Within the 3 CHP areas, Aberdeenshire (97.3%) had the highest and Aberdeen City (95.4%) the lowest uptake rate of the 3 areas. MMR A single dose of the MMR vaccine gives about 90% protection against measles and mumps and 95-99% protection against rubella. A second dose of MMR increases the protection of all three diseases to over 99%. To achieve and sustain herd immunity and prevent outbreaks, two doses of MMR vaccine are needed. The first MMR dose is usually given at any time after the first birthday, ideally at 13 months of age. The second dose is normally given before school entry. Uptake of 1 st dose of MMR by 24 months of age was higher in Grampian (95.2%) compared to the Scottish average of 93.7% during the evaluation period. Similar trends were seen across the 3 CHP areas. Table 2: Uptake of Diphtheria, Tetanus, Pertussis, Polio and Hib by 24 months of age in Grampian by CHP area, 1 April 2009 to 31 March 2010 Primary course Booster course D T P Pol Hib MenC PCV MMR1 Hib/MenC PCVB Aberdeen City CHP 98.6 98.6 98.6 98.6 98.0 94.5 95.4 95.5 93.9 94.3 Aberdeenshire CHP 99.1 99.1 99.1 99.0 98.8 96.9 97.3 95.0 95.5 95.1 Moray CH&SCP 97.9 97.9 97.9 97.9 97.9 96.7 96.7 95.4 95.3 95.7 Grampian 98.7 98.7 98.7 98.7 98.3 95.9 96.4 95.2 94.8 94.8 Scotland 98.4 98.4 98.4 98.4 98.2 96.4 96.5 93.7 94.0 94.2 Source: ISD, 2010 9

7.3 Uptake of Primary and Booster course by 5 years Uptake of primary immunisation by 5 years across Grampian is generally high and above the WHO target of 95%. During the evaluation period, uptake rate of Pediacel excluding Hib was over 98% across Scotland, Grampian and within the CHP areas except in Aberdeen City where it was over 97%. Men C uptake at 5 years was over 97% in Aberdeenshire and Moray. This was similar to the Scottish average and higher than the Aberdeen City uptake of 94.4% (Table 3). Percentage of children who had completed the booster course by 5 years across Grampian and within the 3 CHP areas was higher than the Scottish average of 91.9%. Table 3: Uptake of Diphtheria, Tetanus, Pertussis, Polio and Hib by 5 years of age in Grampian by CHP area, 1 April 2009 to 31 March 2010 Primary course Booster course D T P Pol Hib MenC D T P Pol Aberdeen City 97.6 97.6 97.6 97.6 95.8 94.4 93.5 93.5 93.5 93.5 Aberdeenshire 98.5 98.5 98.3 98.4 97.8 97.4 94.9 94.9 94.9 94.9 Moray 98.1 98.1 98 98.1 97.7 97.4 95.9 95.9 95.9 95.9 Grampian 98.0 98.0 97.9 97.9 96.9 96.1 94.4 94.4 94.4 94.4 Scotland 98.4 98.4 98.4 98.3 97.4 97.4 91.9 91.9 91.9 91.9 Source ISD 2010 Haemophilus Influenzae Type B (HIB) Catch-up Programme (5 November 2007-3 March 2009) A booster dose of Haemophilus influenzae type b (Hib) vaccine was introduced into the routine childhood immunisation programme in September 2006 for all children at 12 months of age (as combined Hib/MenC vaccine). This booster extends protection against Hib through childhood. A catch-up programme, which ran from 5 November 2007 to 3 March 2009, offered a booster dose of Hib vaccine to a defined cohort of young children who had not previously been offered this additional dose. The eligible group included children born on or between 4 April 2003 and 3 September 2005, who were therefore aged between two years and two months old and four years and seven months old at the start of the catch-up programme. These children were too young to have had a booster as part of an earlier Hib catch-up programme in 2003 and too old to have received the new routine Hib/MenC booster 10

vaccine at 12 months of age following its introduction in September 2006. The number of children in Grampian who were eligible for the Hib catch-up programme was 13,606. Of these, 11,750 (86.4%) children received the catch-up dose of Hib vaccine. Uptake of MMR 1 and 2 by 5 years Figure 1 below shows that the uptake of MMR 1 during the evaluation period was over 96% across Grampian and within the 3 CHP areas in Grampian. Nationally, there was a decline in the uptake of MMR 2 by 5 years and this was mirrored across Grampian. However, the uptake of MMR2 in the 3 CHP areas and across Grampian was consistently higher than the Scottish average of 89.7%. Several factors contribute to the decline in uptake of MMR2. These include entry into the immunisation programme of non UK born children with uncertain or incomplete immunisations from their country of origin. Delay in amending records when children emigrate from Grampian also contributes to the lowered uptake recorded at 5 years of age. Figure 1: Uptake of MMR 1 and 2 by 5 years of age in Grampian by CHP area, 1 April 2009 to 31 March 2010 Uptake of MMR1 and MMR2 by 5 years of age in Grampian. 1 April 2009-31 March 2010 100 80 96.0 91.3 96.4 92.0 96.1 93.8 96.1 91.9 96.2 89.7 Percentage uptake 60 40 20 0 Aberdeen City Aberdeenshire Moray Grampian Scotland MMR1 MMR2 Source ISD 2010 7.4 Primary Immunisation Uptake rates by Deprivation Across Scotland, there are noticeable differences in the level of increase in uptake as children age, and this appears to be closely related to deprivation. Children in the more deprived areas appear to be vaccinated 11

at a later age compared with children in the less deprived areas (ISD, 2010). Figure 2:Uptake of Diphtheria by SIMD, Scotland Diphtheria uptake 1 as at 31.12.09 by SIMD and age, Scotland 100 % uptake 90 80 70 60 50 40 30 20 10 SIMD Category SIMD5 (Least deprived) SIMD4 SIMD3 SIMD2 SIMD1 (Most deprived) 0 0 1 2 3 4 5 6 7 8 9 10 11 12 age in months 1. Children born during 2008. Source: SIRS, ISD Scotland. February 2010 extract. Although childhood immunisation uptake rates in Grampian are broadly inline with national averages, uptake rates do vary across the three CHP areas and between individual GP practices in Grampian. Available data on uptake of vaccination by deprivation for Grampian (January to December 2009) are shown in appendix 2. In contrast to what is seen across Scotland as a whole, the uptake of vaccination among children in the most deprived areas of Grampian (SIMD1) compares favourably with that for children living in the least deprived areas (SIMD5). In addition, the uptake in SIMD1 areas in Grampian consistently exceeds the national average for areas with similar levels of deprivation. However, at CHP and individual practice level, variation in uptake may, in part, be related to the degree of deprivation in the local child population. 7.5 Uptake of HPV vaccine The HPV vaccine offers protection against the development of cervical cancer in later life. In November 2007 the Scottish Government confirmed that a routine HPV (Human Papilloma Vaccine) immunisation programme for girls aged 12-13 years would commence in September 2008. Alongside the school based programme, a 3 year phased catch-up programme for older girls aged up to 18 years was also commenced. The HPV vaccine is administered as a 3 dose schedule usually given over a 6 month period. To be fully immunised, girls must receive all 3 doses. 12

HPV year 1 Available data shows that the uptake of HPV in school has been generally high. For year 1 of the programme, 91.7% of all girls in S2 received 3 doses of the vaccine compared to 91.4% across Scotland. Similar high uptake rates were observed within the 3 CHP areas in Grampian (figure 3). This is considerably higher than the 80% uptake rate required to make the programme cost effective. Figure 3: Uptake of HPV Immunisation for Girls in S2 in Grampian by CHP Year 1 (2008/2009) HPV Immunisation Uptake rates for girls in second year of secondary school (S2) Year 1 (2008/2009) as at 15 February 2010 Percentage uptake 100 90 80 70 60 50 40 30 20 10 0 93.0 92.1 89.7 Aberdeen City CHP 95.2 94.4 92.6 Aberdeenshire CHP 95.8 95.1 93.3 94.5 93.7 91.7 94.4 93.6 91.4 Moray CH&SCP Grampian Scotland 1st dose 2nd dose 3rd dose ISD 2010 However, uptake rate for girls in the catch-up category, especially those who are out of school has been less successful. There are significant differences in uptake between girls in secondary school and those who have left school. Table 4 shows the uptake rate in all girls in the catch up cohort, eligible for immunisation during year 1 of the programme. These are girls in S5, S6 during the school year 2008/09 and girls aged 16 to less than 18 years on 1 September 2008 who have left school. 13

Table 4: Uptake of HPV Immunisation in Girls eligible for catch-up vaccination in Grampian (year 1) Uptake of HPV Immunisation in Girls in the catch-up Cohort September 2008 August 2009 (Year 1 of the catch-up). Completed doses of HPV vaccine Percentage of all girls eligible for catch-up vaccination in 2008/09 who have been vaccinated Percentage of girls in S5 who have been vaccinated Percentage of girls in S6 who have been vaccinated Percentage of girls out of school who have been vaccinated Grampian (Scotland) Grampian (Scotland) Grampian (Scotland) Grampian (Scotland) First dose 68.1 (70.9) 94.4 (94.6) 92.6 (93.0) 43.5 (48.5) Second dose 65.2 (67.7) 93.2 (93.5) 92.0 (91.8) 38.6 (43.4) Third dose 55 (59.7) 90.1 (89.9) 88.5 (86.6) 21.9 (31.8) ISD statistics for year 1 of the HPV programme (Sep 2008-Aug 2009) As of 15 February 2010, uptake rate for all three doses in the catch-up cohort was generally low in Grampian (43.5%, 38.6% and 21.9% respectively) compared to Scottish average (48.5%, 43.4% and 31.8% respectively). Uptake for girls in the catch-up group in Grampian who had left school were significantly lower (21.9%) compared to uptake rates in girls in the catch-up cohort in S5 (90.1%) and S6 (88.5%). Similar low uptakes were recorded within the 3 CHP areas (table 4 and figure 4). 14

Figure 4: Uptake of HPV Immunisation in Girls eligible for the catch-up vaccination in year 1 (2008/09) in Grampian by CHP area 100 HPV Vaccine uptake in school leavers catch-up cohort by CHP Year 1 (2008/09) as at 15 Feb 2010 Percentage uptake 80 60 40 20 0 36.3 32.0 18.1 Aberdeen City CHP 47.4 42.0 25.2 Aberdeenshire CHP 50.8 43.5 48.5 45.8 22.2 38.6 21.9 43.4 31.8 Moray CH&SCP Grampian Scotland 1st dose 2nd dose 3rd dose ISD statistics for year 1 of the HPV programme (Sep 2008-Aug 2009) HPV year 2 Based on data recorded on the CHI system as at 30th June 2009 and SIRS system as at 15 February 2010, uptake of routine HPV immunisation in girls currently in S2 for the second year of the programme continues to remain exceptionally high in Grampian; 92.1% for the first dose and 89.2% for the second dose. Similar high uptake rates are observed within the 3 CHP areas in Grampian (figure 5). These uptake rates are likely to increase especially for the second dose as some girls may have started their course of the HPV vaccinations later in the school year. It is also possible that some vaccinations may have been given but have not yet been recorded on CHSP. 15

Figure 5: Uptake of HPV Immunisation for Girls in S2 in Grampian by CHP Year 2 (2009/2010) HPV Vaccine Uptake for Girls in S2 in Grampian by CHP Year 2 (2009/10) as at 15 Februrary 2010 Percentage uptake 100 90 80 70 60 50 40 30 20 10 0 91.7 89.4 Aberdeen City CHP 93.0 89.6 Aberdeenshire CHP 90.7 88.1 92.1 89.2 91.9 85.8 Moray CH&SCP Grampian Scotland 1st dose 2nd dose 7.6 Uptake of hepatitis (neonatal) Babies born to mothers who are chronically infected with Hepatitis B virus or who have had acute hepatitis B during pregnancy require a course of 4 vaccinations to reduce their risk of infection. In Grampian, the first dose of vaccine is given to the baby in hospital within 24 hours of birth. Subsequent doses, at 1, 2 and 12 months of age are given in the community, typically by the baby s GP, Health Visitor or Practice Nurse. Babies born to mothers with infectious hepatitis B also receive hepatitis B immunoglobulin at birth. Table 5: Total number of children born to Hep B +ve Mothers who have reached 12 and 24 months during the evaluation period 1 April 2009 to 31 March 2010 Total number of children born to Hep B +ve Mothers April 2008 to 31 March 2009 9 9 (100%) April 2009 to 31 March 2010) 19 19 (100%) Source: Health Protection Team, NHS Grampian September 2010 Proportion completed 3 rd dose at 12 months 16

A database for hepatitis B positive (Chronic/Acute) individuals, including pregnant women, is maintained by the Health Protection Team at NHS Grampian. This is based on laboratory notification of hepatitis B positivity. Infants born to hepatitis B positive mothers are followed up by a Health Protection Nurse Specialist to ensure these babies are vaccinated as appropriate. Many of these mothers are short term family dependants from overseas. Follow-up of these babies is often difficult and the baby may leave Grampian prior to completion of the vaccination course. 7.7 Uptake of targeted BCG vaccination In 2005, the UK Department of Health and the then Scottish Executive Health Department announced the universal school based BCG vaccination programme was to be replaced by more targeted vaccination for individuals at greatest risk of becoming infected with TB. Those at increased risk of TB are identified as: All infants living in UK areas where the incidence of TB is 40/100,00 or greater Infants whose parents or grandparents were born in a country with a TB prevalence of 40/100,000 or higher Previously unvaccinated new entrants from high TB prevalence countries. Children who would previously have received BCG through the school programme are now recommended to be screened for TB risk factors, tested and vaccinated if appropriate In Grampian, a system is in place to risk assess pregnant women attending antenatal care (midwives), children aged 3 months to 5 years (health visitors) and children aged 5 years to less than 16 years (school nursing teams).this includes new entrant children to Grampian who were born in or have lived for more than 3 months in a country with annual incidence of TB > 40/100,000. Unlike the universal childhood vaccinations, the targeted BCG programme is not fully supported by the Scottish Immunisation Recall Scheme. This means that very limited data are available to assess the effectiveness of programme implementation. Aberdeen City CHP In Aberdeen City CHP, children aged 5 to less than 16 years are sent a letter by the school nursing team explaining the BCG programme and parents are requested to complete and return a BCG risk assessment questionnaire. In the 2009-2010 academic year a total of 157 (76 primary and 81 secondary school) children were identified by the school nursing team as being at risk and eligible for BCG. All the 157 (100%) at risk children identified received BCG vaccination. 17

Aberdeenshire CHP Aberdeenshire CHP health visitors follow up those children under 5 years identified as being at increased risk of TB infection in a combined clinic with the health visitors from Aberdeen city. These clinics run quarterly at Royal Aberdeen Children s Hospital. For older children. letters and questionnaires are issued to P1 and S1 schoolchildren shortly after school entry to assess any risk. These children are then followed up in January between scheduled HPV vaccination programmed visits. Limited information suggests around 180 children of school age were identified as being at increased risk of TB infection and received BCG vaccination in the 2009-10 academic year. Moray CHP A similar process takes place in Moray CHP. In 2009-2010 academic year, 12 school age children were identified as being at increased risk and received BCG vaccination. 7.8 Uptake of pandemic influenza H1N1 vaccine In June 2009, the World Health Organisation declared an influenza pandemic. In response to instruction from the Scottish Government, once a licensed vaccine became available, NHS Grampian commenced a phased vaccination programme in September 2009 against the new strain of rapidly spreading influenza A (H1N1) virus. Priority groups to be offered the immunisation included: Individuals aged between six months and up to 65 years in the current seasonal flu vaccine clinical at-risk groups Pregnant women not included in a clinical at-risk group People aged 65 years and over in the current seasonal flu vaccine clinical at-risk groups Table 6: Uptake of pandemic flu vaccination by population group in Grampian. September 2009 to 4 April 2010. 6 months to 65 years at risk including pregnant women Pregnant women Grampian 42.2% 24.5% 52.1% Scotland 52.1% 40.4% 56.2% Individuals at risk aged 65 years and over Source: HPS Sept, 2010 Apart from pregnant women, uptake of pandemic flu vaccination by other groups in NHSG was comparable with the rest of Scotland. There remains substantial doubt about the accuracy of the HPS-reported uptake of vaccination by pregnant women in Grampian, as this has been based on very limited data. Locally, general practices and the midwifery service made considerable efforts to ensure all pregnant women were included in the pandemic flu programme and offered vaccination. An audit of maternity units (January 2010) confirmed that all women who delivered their babies at ARI 18

and almost all at Dr Grays had been offered H1N1 vaccination during pregnancy. Though uptake at that time in this cohort was low, this was because vaccination had been actively declined. Well done to the midwives and practices. 7.9 Uptake of seasonal flu vaccination The routine annual seasonal flu vaccination programme was taken forward during autumn 2009, in addition to the pandemic flu vaccination programme. Individuals eligible to receive seasonal flu vaccination included: All those aged 65 years and over, All those aged over 6 months in a clinical at-risk group, Those living in long-stay residential care homes or other long-stay care facilities where rapid spread is likely to follow introduction of infection and cause high morbidity and mortality, Unpaid carers. Detailed information on uptake by risk group is not available at the time of writing. However, NHSG uptake amongst those aged 65 years and over was 75.4%, comfortably exceeding the national target of 70%. Approximately 33,400 at risk Grampian individuals under the age of 65 years received flu vaccination. 7.10 Key messages NHS Grampian aims for uptakes in excess of 95% for all routine childhood vaccinations, to be achieved at ages consistent with the scheduled programme. Improvement is needed in the timeliness of delivery of some vaccinations and in the uptake of booster doses. It is important that vaccinations are given as early as possible in order that protection from infection is achieved when infants are at highest risk from the consequences of infection. The reasons uptake rates for primary vaccinations are recorded as being lower at 5 years than at 12 and 24 months are: o immigration it is important for new entrant children to be enabled to benefit from the UK immunisation schedule as early as possible following arrival in the UK. o migration out of the Grampian area data artefact as patient s details are not being updated in a timely way, thereby inflating the denominator used to calculate the uptake rate. Bringing new entrant children up to date with the UK vaccination schedule entails a heavy workload for practices, especially around Hepatitis B and BCG vaccinations. For girls at school, uptake of HPV in year 1 was good and average during year 2. However, the low uptake in the catch-up cohort of girls who are not attending school is of concern. This is largely due to the inherent difficulties attached to motivating individuals in this cohort to attend their general practice for vaccination. In addition, the competing 19

workload placed on general practices to deliver the pandemic influenza vaccination programme did not help. During the final year (year 3) of the catch-up, which starts this autumn, a concentrated effort will need to be made to reach this cohort of young women. Seasonal flu the national uptake target for individuals aged 65+ years was met comfortably. There was significant improvement in uptake of vaccination by those at-risk under 65 years, although further improvement is required in order to meet the national target. 8. Vaccination errors/incidents Information about errors in vaccine administration is derived from two sources: Reporting of individual incidents to the Health Protection Team Systematic reporting of errors via the NHSG Datix system. It is likely that neither source is a complete record of all vaccine administration errors. The Health Protection team is usually only contacted when a vaccinator or general practice is seeking expert advice on management of the clinical consequences of the error. All errors made by NHS Grampian employed staff should be reported through Datix. A total of 30 incidents relating to the childhood and influenza vaccination programmes were recorded on Datix during the 2009-2010 financial year. A limited number of general practices are currently able to participate in the Datix system, so not all errors made by general practice-employed staff are reported through Datix. All practices not participating in Datix are expected to have a process in place for investigating and following up clinical and related errors made by their staff. However, no information is currently systematically collected regarding the number and nature of any clinical errors related to vaccine administration occurring in general practices not participating in the Datix system. Aberdeenshire CHP are working with their GP s to transfer to the use of Datix for error reporting. The Health Protection Team received over 500 immunisation queries during 2009-2010. Most of these queries are in relation to patients with unknown vaccination schedules and interpretation of the UK national immunisation programme, although a proportion of all queries are in relation to human error. The commonest errors made by staff are: Administration of vaccines too early/incorrect intervals Incorrect preparation of the vaccine Wrong vaccine administered Out of date vaccine given Cold chain issues, such as incorrect recording of vaccine fridge temperatures, leaving vaccines outwith the cold chain for too long, incorrect fridge being used to store vaccines, power to the fridge interrupted Administration technique problems Many of the reasons underlying these problems are training issues. For example, staff are aware they have to monitor vaccine fridge temperatures but do not fully understand why; vaccines being administered in 20

accordance with the child s age, before the vaccinator has actually checked the child s clinical records to determine if the dose has already been given or whether there are contra-indications to vaccination. 9. Achievements Completion of the Hib catch-up programme. Implementation of the national HPV immunisation programme: The national HPV immunisation programme has been successfully implemented within NHS Grampian and uptake rates in the first two years are commendable, especially given the extra demands placed on staff by the pandemic H1N1 vaccination programme. Main highlights include: Successful coordination of implementation by the local HPV Steering group, with good involvement from all partners. Commitment of CHP staff to ensure the smooth running of the programme. Support and organisation of the vaccine supply by pharmacy and transport services. Implementation of CHSP(S) within Grampian. Support by 99% of General Practices for the catch-up out of school campaign. Pandemic H1N1 immunisation programme: The delivery of the H1N1 vaccination programme, within a very tight timescale, was logistically challenging. Implementation has been very successful in Grampian. Commitment of staff in both primary and secondary care in supporting delivery of the programme has been outstanding. 10. Conclusions Reflection on local progress in implementation of the national immunisation programme indicates There continues to be a need to promote uptake of the e-learning immunisation programme amongst established vaccinators. A majority of the numerous (non adverse incident-related) requests for advice made to the Health Protection Team demonstrate a lack of basic understanding of the principles of immunisation and knowledge about individual vaccines. A similar lack of understanding is often evident as a factor underlying errors of vaccine administration. Although local vaccine uptake for primary childhood immunisations exceeds the 95% level required to provide herd immunity, it is of concern that achievement of this level is delayed in certain population groups. Such delay leaves young infants vulnerable to serious infection at precisely the time they are most at risk of a poor outcome. Investigation is required to establish more clearly those infants, children and young people who are hardest to reach and to identify what further local action might be helpful in achieving vaccination at 21

the optimum age. The provision of more timely feedback on uptake of primary immunisations to individual practices may be helpful in raising local awareness of vaccinators to this problem. The uptake of HPV vaccination in girls who have left school is disappointing. The final year of the catch-up campaign begins in August 2010 and provides an opportunity to encourage uptake in this cohort. 11. Key actions for 2010-2011 The following have been identified as priorities for action, subject to the availability of resource: 1. Establish a process to provide individual practices (and their associated vaccinators) with feedback on their practice primary immunisation uptake, on a quarterly basis. 2. Explore the need for provision of enhanced support to those practices experiencing the poorest and/or delayed uptakes of primary vaccinations. 3. Undertake an information exercise to more clearly map those groups of infants, children and young people who are hard to reach together with the initiatives already in place aimed at improving vaccination uptake. Use this information to explore what further positive action might be feasible and helpful. 4. Implement a local campaign in the autumn of 2010 to achieve improved uptake of HPV immunisation in eligible girls who are no longer attending school. 5. Further encourage immunising staff to undertake the e learning course and, as the number of mentors increase, allocate to students in their own locality so closer support and supervision can be given. 22

Appendix 1: Childhood Immunisation Programme as at March 2010 Disease/Vaccine When given: Age Notes Diphtheria, Tetanus, Pertussis, Polio and Hib (dtap/ipv/hib) 1st dose: 2 months Primary course Diphtheria, tetanus, pertussis, polio and Hib (dtap/ipv/hib) 2nd dose: 3 months Primary course Diphtheria, tetanus, pertussis, polio and Hib (dtap/ipv/hib) 3rd dose: 4 months Primary course Pneumococcal disease (PCV) Meningitis C (MenC) 1st dose: 2 months 2nd dose: 4 months 1st dose: 3 months 2nd dose:4 months Primary course Primary course Hib / MenC around 12 months Booster Measles/Mumps/Rubella (MMR) around 13 months Primary course Pneumococcal disease (PCV) around 13 months Booster Diphtheria, tetanus, pertussis, and polio (dtap/ipv or DTaP/IPV) 3yrs/4 months to 5yrs Booster: 3 years after completion of primary course MMR second dose 3yrs/4 months to 5yrs Booster Cervical cancer (HPV) Girls aged 12-13 yrs Primary course Diphtheria, Tetanus and Polio (Td/IPV) 13 to 18yrs Booster Tuberculosis (BCG) At birth Non- routine. Given to babies more likely to come in contact with tuberculosis than the general population Non-routine. Given to babies whose mothers are hepatitis B Hepatitis B (Hep B) At birth positive 23

Appendix 2: Uptake of Immunisation by Deprivation 100 Diphtheria 1,3 uptake by 12 months by SIMD category Evaluation period: January to December 2009 Grampian Scotland 90 97.4 98.0 97.9 97.6 97.5 97.7 96.9 97.3 98.1 96.8 % Uptake 80 70 60 50 5 4 3 2 1 Least deprived SIMD Category M o st deprived 100 PCV 2 uptake by 24 months by SIMD category Evaluation period: January to December 2009 Grampian Scotland 90 96.6 97.5 97.4 97.3 97.5 97.3 96.2 97.1 96.9 96.8 % Uptake 80 70 60 50 5 4 3 2 1 Least deprived SIMD Category M o st deprived 24

HibM 2 uptake by 24 months by SIMD category Evaluation period: January to December 2009 Grampian Scotland 100 90 94.7 95.7 95.2 94.7 95.8 94.6 94.2 93.3 94.5 92.2 % Uptake 80 70 60 50 5 4 3 2 1 Least deprived SIMD Category M o st deprived 100 MenC 1 uptake by 12 months by SIMD category Evaluation period: January to December 2009 Grampian Scotland 90 96.1 97.3 97.1 97.1 97.6 97.2 96.0 97.1 97.4 96.6 % Uptake 80 70 60 50 5 4 3 2 1 Least deprived SIMD Category M o st deprived 25

100 MMR 2 uptake by 24 months by SIMD category Evaluation period: January to December 2009 Grampian Scotland 90 95.3 94.7 94.6 94.0 94.7 93.8 95.7 93.7 94.8 92.5 % Uptake 80 70 60 50 5 4 3 2 1 Least deprived SIMD Category M o st deprived PCVB 2 uptake by 24 months by SIMD category Evaluation period: January to December 2009 Grampian Scotland 100 90 94.3 95.0 94.5 94.7 95.1 94.5 95.7 94.1 94.2 93.0 % Uptake 80 70 60 50 5 4 3 2 1 Least deprived SIMD Category M o st deprived Notes 1. Aged 12 months: Born January to December 2008 2. Aged 24 months: Born January to December 2007 3. Diphtheria, Tetanus, Pertussis, Polio and Hib are now given as a 5-in-1 vaccination; therefore only one chart has been produced to illustrate the uptake of these vaccines. 4. for analyses using SIMD 2009: ISD have changed their labelling and now label the categories as 1=most deprived to 5=least deprived Source: SIRS, ISD Scotland Extract Date: February 2010. 26

Appendix 3: Membership of the Grampian Immunisation Steering Group Name: Organisation/Area: Title Elaine Allan Aberdeen City Lead School nurse Lorraine Anderson NHS Grampian Kay Barton ATOS Fiona Browning NHS Grampian Health Protection Nurse Specialist Eunice Chisholm Aberdeenshire Lead nurse Sean Coady Moray CHSCP Lead Nurse Susan Duthie NHS Grampian TB Nurse Specialist George Ellis Primary Care General practitioner-skene Medical Practice Ainsley Farquhar Aberdeen City CHP School Nurse Susan Harrold Caroline Hind NHS Grampian Interim Director of Pharmacy Liz Kemp Laura Kluzniak NHS Grampian Immunisation Programme Manager Pamela Molyneaux NHS Grampian Consultant Virologist Gregory Poon Aberdeen City CHP Lead Nurse, Aberdeen City CHP Linda Shaw Aberdeen City CHP Service Manager, North Cluster Heather Smith NHS Grampian Susan Tough PSD Yvonne Watson Diana Webster (Chairperson) NHS Grampian Consultant in Public Health Medicine/Immunisation Coordinator Alison Work Moray CHSCP School Nurse Coordinator 27