Immunisations and Vaccinations, Childhood Infectious Diseases

Introduction

From the 1 April 2013, commissioning responsibilities for immunisation programmes transferred from NHS Haringey to NHS England. Local public health teams have responsibility to ensure that these programmes are delivered to a high standard and that coverage is adequate amongst their local population.

Immunisation is clearly acknowledged by the World Health Organisation (WHO) as one of the most effective public health interventions in the world for saving lives and promoting good health. Vaccination is recognised as one of the most cost effective activities undertaken by health professionals. The WHO estimates that measles vaccination resulted in a 78% drop in measles deaths between 2000 and 2008 worldwide.

Vaccination works on an individual by stimulating the immune system to have memory of a specific disease so they are protected from future exposure to the same germ. It also works by reducing the incidence of the disease in the population so that everyone, including those who are not immunised, is less likely to come into contact with the disease. This effect is called ‘herd immunity’ and relies on an adequate uptake within the population of the specific vaccine. The level of uptake required varies depending on how infectious a particular disease is and how prevalent it is in the community.

In general an uptake of around 95% is required for most vaccines to protect the population from the disease. For many infectious diseases achieving this level will ultimately eliminate it from the population.

The aim of an individual vaccination programme is to offer mass immunisation to eliminate or eradicate the particular disease from the population, or to vaccinate those at particular risk of significant problems due to age, other health problems or other factors that would impact on a person’s ability to fight infection.

Most vaccination programmes are targeted at children and this will generally provide long term protection to the individual into adulthood. This chapter of the JSNA addresses childhood immunisation and vaccination and infectious diseases. Information on adulthood vaccinations are included in the JSNA chapter on respiratory illness and the JSNA chapters on alcohol, drugs and infectious diseases).

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Key issues and gaps

Immunisation coverage in Haringey has improved significantly in recent years and we are almost approaching levels of coverage needed to obtain herd immunity. However, there are pockets of low coverage within the borough. This tends to be more in the east of the borough but there are pockets of good coverage alongside much lower coverage in the same geographical areas. The low uptake is more pronounced in smaller practices without regular nursing or administrative support and is therefore probably more related to the type of service available in the practice rather than the population demographics in the area.

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Who is at risk and why

There are a range of different immunisations for different groups in the population dependent on their age and needs. These can be broadly grouped into vaccinations for children and those for older people. For the routine influenza and pneumococcal vaccination recommended for adults, see the JSNA chapter on respiratory illness.

In addition, when an outbreak occurs or there is a pandemic influenza virus, as in 2009, particular immunisation strategies will need to be adopted to protect those at risk by vaccination, where this is available.

A babies immune system is ‘naive’ to a number of infections and therefore some diseases such as pertussis (whooping cough) or bacterial meningitis can be far more dangerous than in adults. It is therefore important to make sure all children are vaccinated in a timely manner in accordance to the Department of Health guidelines.

Certain vaccinations are given to specific population groups that are at increased risk. For example, babies born to mothers who are positive to hepatitis B infection or who are chronic carriers are at significant risk of contracting hepatitis B and of then becoming chronic carriers of the infection. They would then have a significant subsequent risk of developing hepatic cancer or cirrhosis of the liver. A course of hepatitis B vaccines, commencing at birth, significantly reduces the risk.

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The level of need in the population

In 2012 there were 4,209 births in Haringey. This is down on the number of births in 2011 (4,227) and 2010 (4,456), however the local birth rate remains above the London and England average. All babies born in Haringey and children moving into the borough should have access to all childhood immunisations as recommended by the Department of Health.

There are a number of immunisations that a child should have from birth up to the age of 5, the schedule for which can be found on the NHS Choices website (external link).

Recent years have seen large improvements in the immunisation coverage of children under 5. Figure 1 describes the uptake of 6 key immunisations between 2008/09 and 2012/13 in Haringey. The uptake in each of these has increased, most notably in the uptake of MMR which is given at ages 2 and 5. The immunisation coverage is now almost reaching levels where the population can benefit from herd immunity.

Figure 1: Annual data comparison for 6 key immunisation targets – 2008/09 to 2012/13.

Source: Health and Social Care Information Centre

The improvement in immunisation in Haringey is best demonstrated by the increase in MMR uptake. Amongst the 2 year age cohort the proportion of children immunised has risen to 92.0% in 2012/13 from only 56.3%% in 2008/09. The increase has been such that the rate is now similar to the England average and above the rate in London. In previous years Haringey’s coverage for MMR immunisation was considerably lower than both (Figure 2).

Figure 2: Uptake of MMR in Haringey compared to London and England – 2008/09 to 2012/13

Source: Health and Social Care Information Centre

Routine childhood immunisation programme – Teenage vaccinations

There are 2 vaccines that are routinely given to teenage children. The teenage booster for diphtheria tetanus and polio is generally given to children in school year 10 and the Human Papilloma Virus (HPV) vaccine is generally given to girls around 12-13 years in year 8. Figure 3 shows that the uptake of both vaccinations has fluctuated over recent years. Between 2011/12 and 2012/13 the coverage for HPV increased and is close to its highest level, but over the same period the uptake of DTaP decreased to 66.3%.

Figure 3: Uptake of DTaP and HPV vaccine in Haringey – 2008/09 to 2012/13

Source: Health and Social Care Information Centre

Targeted vaccinations: BCG vaccination

BCG vaccination is offered routinely at birth if TB incidence is higher than 40 per 100,000 population. In Haringey, due to a high incidence of TB, BCG vaccination is offered to all babies.

Targeted vaccinations: Hepatitis B vaccination

Hepatitis B vaccination is given to babies at risk of contracting infection due to maternal infection. The information from antenatal screening, which tests for the prevalence of hepatitis B as well as other infections in pregnant mothers, indicates that the prevalence of chronic hepatitis is high in Haringey compared to London and national rates. In 2012/13, 75 babies in Haringey were offered the vaccination of which there was a 98.7% uptake. This is up from 2011/12 when the uptake was 94.8%.

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Current services in relation to need

Immunisation services to meet the policy requirements from the Department of Health and in ‘The Green Book’ - Immunisation against infectious diseases (external link) are currently provided through a range of providers locally.

Primary Care - Routine childhood Immunisations are primarily provided by practice nurses in GP surgeries. All 52 practices in the borough currently provide immunisation services.

Maternity Services - provide BCG vaccination.

Children’s Services - the children’s services team through the ‘Whittington Health’ community contract provide mostly hepatitis B and BCG vaccination.

School nursing team - provide HPV for Year 8 girls, school booster vaccine for, tetanus, diphtheria and polio, to children in year 10. Meningitis C

Public Health advice - advice and support on delivery of immunisation is available from the local North East North Central London Public Health England Health Protection Team on 0207 8117100.

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Service users and carers opinion

Concerns about the safety or the need for particular vaccines raised in the press naturally make parents anxious about the process and they want to have good evidenced based advice in order to make a decision about their child’s vaccination. The evidence shows that on the whole parents value the advice they get from health professionals particularly where this takes into account their concerns and anxieties and when they feel able to ask questions (see footnote 1).

Parents and carers concerns often stem from what they perceive to be confusing or inconsistent information or where staff appear not to have enough time to answer questions (see footnote 2). There is also evidence that information available on the internet is not always accurate which highlights the importance for staff to be up to date but also be able to advise parents on a good range of additional resources which have accurate and reputable information (see footnote 3 and footnote 4).

In addition, parents often find access to service a real barrier, particularly where families are large and parents are working. If clinics only are provided on certain days or at particular times this can make it very difficult for some parents (see footnote 5 and footnote 6).

Local sessions for parents at Children’s centres and other forums have supported these views.

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Expert opinion and evidence base

Immunisation policy is set out in the Department of Health Immunisation against infectious disease - 'The Green Book' (external link) which includes evidence of vaccine safety and efficacy.

The Department of Health Immunisation website (external link) contains comprehensive, up-to-date and accurate source of information on vaccines, disease and immunisation for the UK.

Public Health England (PHE) (external link) provides advice and information, to the general public, health professionals and to national and local government.

NICE (National Institute for Health and Care Excellence) developed guidance entitled Reducing differences in the uptake of immunisations (including targeted vaccines) - in people younger than 19 years.(external link)

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Projected service use in 3-5 years and 5-10 years

Locally the birth rate is increasing and there is also evidence that the local population is particularly transient which makes it challenging to ensure that services are capturing all children eligible for vaccination. The ethnic diversity and high number of people moving into the UK also has an impact and this is unlikely to change significantly in the next 3 – 5 years. See demographic section.

The immunisation schedule is changing, according to need based on the rates of infectious disease as monitored by PHE (external link). The JCVI will consider these and services will need to be able to adapt to accommodate changes.

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Unmet needs and service gaps

A recent health equity audit of local immunisation services highlighted specific population groups that are not accessing the services, in particular Somali and Jewish populations in the east of the borough. There is a need for individual GP practices to develop services according to the individual needs of their patients and ensure they are able to capture all children eligible for immunisation.

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Recommendations for consideration by commissioniners

Immunisation is complex and various factors need to be addressed in order to have an effective service. The emphasis locally should be on improving the offer in general practice by strengthening the following:

  • Patient reminder and recall systems at each GP practice,
  • Extended hours and/or vaccinating in other settings and/or offering vaccinations opportunistically,
  • Well informed health care professionals who provide accurate and consistent advice,
  • High quality patient education and information resources in a variety of formats such as leaflets, internet forums, and discussion groups,
  • Support with expert advice and information for specific clinical queries,
  • Effective performance management of the commissioned service provided, to ensure it meets the requirements of the area.
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Key Contact

Tamara Djuretic - Assistant Director of Public Health:

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Footnotes

  1. Samad L, Butler N, Peckham C and Bedford H, (2006). Incomplete immunisation uptake in infancy: Maternal reasons. Vaccine. (24) 6823-6829.
  2. Smailbegovic M,Laing G and Bedford H (2003). Why do parents decide against immunisation? The effect of health beliefs and health professionals. Child: Care, Health and Development. Vol 29(4) pp303-311.
  3. Freed G, Clark S, Butchart A, Singer D and Davis M, (2011) Sources of perceived credibility and vaccine safety information for parents. Peadiatrics.127 pp108-112.
  4. Bean S, (2011). Emerging and continuing trends in vaccine opposition website content. Vaccine. (29) pp 1874-1880.
  5. Department of Health (2005) Vaccination services: reducing inequalities in uptake (external link)
  6. NICE PH guidance 21 (2009), Reducing differences in the uptake of immunisations (including targeted vaccines) among children and young people aged under 19 years (external link)
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