Immunisations and Vaccinations, Childhood Infectious Diseases

• Introduction
• Key issues and gaps
• Who is at risk and why
• The level of need in the population
• Current services in relation to need
• Service users and carers opinion
• Expert opinion and evidence base
• Projected service use in 3-5 years and 5-10 years
• Unmet needs and service gaps
• Recommendations for commissioning
• Recommendations for further needs assessments
• Key contact
• Footnotes
• Print-friendly version of this section (PDF, 312KB)

Introduction

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, are 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 adult hood. This chapter of the JSNA addresses childhood immunisation and vaccination and infectious diseases. There are currently no additional routine immunisations recommended for all adults. However, some vaccinations are recommended for adults in certain ‘at risk’ groups, for example, the influenza and pneumococcal vaccines (see the JSNA chapter on respiratory illness), or the hepatitis B vaccine (see the JSNA chapters on alcohol, drugs and infectious diseases).

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Key issues and gaps

In Haringey, as with many other areas in London, there have been ongoing issues with data collection and service delivery. Time consuming and manual systems for transferring information from where vaccinations are given, primarily in GP surgeries, to the Child Health Information System (CHIS), have led to inaccuracies in the data and an inability to accurately report on coverage across the population.

The main emphasis locally has been to improve the quality of the data and strengthen reporting processes, so more accurate monitoring and scrutiny of the effectiveness of the programme is possible. We now have immunisation coverage data at a practice level.

(See quarterly practice coverage data for 2011/12 (PDF, 240KB))

The reasons for low coverage are multifaceted but known to be affected by population mobility, ethnic diversity and the accessibility of the service, which are all well documented issues in Haringey. It is also recognised that, where the service is well coordinated with effective clinical and administrative support within the general practice or service area, a high coverage can be obtained, despite demographic factors of the population.

The immunisation data at practice level show there are some practices where uptake remains low. This tends to be more in the east of the borough but there are pockets of good coverage and high uptake 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 therefore probably more related to the type of service available in the practice rather than the population demographics in the area.

The incidence of infectious diseases is monitored for children and adults by the local Health Protection Unit as part of the Health Protection Agency (see the chapter on Infectious diseases).

The following shows the number of cases of measles, mumps and meningococcal C infections, notified to the Health Protection Agency across NCL.

Figure 1: Number of reported cases of mumps, measles and meningococcal group C infections, with number confirmed in brackets by PCT and year reported.

0 cases of Men C infection reported in years 2009/10 and 2011/12
* Denotes where the total number is less than 5 for data protection

Figure 2: Rates/100,000 population for measles and mumps by PCT & year reported.

Unable to show rates for men C infection in figure 1 as values are less than one.

Rates of infection are due to various factors such as infectivity of a particular disease, local outbreaks and the level of herd immunity. The rates of infection indicate that vaccination coverage locally is not high enough to prevent incidence of measles and mumps disease.

The Public Health NICE Guidance - 21, 2009 (external link), advocates using a multifaceted approach to improving immunisation uptake by having a robust process for advising and reminding families when children’s immunisations are due and following up on those who do not attend. Having a failsafe system has been shown to be very effective at improving uptake.

Currently this is not available locally but we are developing a pilot ‘failsafe initiative’ over 2012 and we will be able to assess the impact and improvement to immunisation rates this makes.

The guidance also recommends children’s services professionals, such as health visitors and school nurses, to work proactively with schools head teachers and children’s centres to promote and advise on immunisation. Using school entry, and when children join a children’s centre, is an opportunity to check on immunisation history and advise accordingly.

This does not happen across Haringey. The Public Health team, now more closely aligned to the Local Authority and as part of the recommendations from the cross party working group, will be working with the schools and children’s services to develop this.

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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 JSNA chapter 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, See JSNA chapter Infectious diseases.

For the routine childhood vaccine preventable diseases young children who are not immune are at highest risk of the diseases and their complications. Diseases like pertussis (whopping cough) and HiB meningitis are far more dangerous when contracted by babies. It is therefore important to make sure all children are vaccinated as soon as possible and older children have booster doses at the appropriate time to ensure long-term protection and minimise the spread of infection.

Certain vaccinations such BCG, to protect against tuberculosis (TB), are given to babies and children at particular risk. This includes babies who live in an area with a rate of TB infection of more than 40 cases per 100,000 or for children up to 16 years of age if their parents or grandparents come from a country where the incidence is high.

The rate of tuberculosis in Haringey is 56 new cases per 100,000 population. All babies in Haringey are offered the BCG vaccination at birth or as soon as possible after.

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. The rates of hepatitis B infection as seen from antenatal screening at the local hospital, North Middlesex, are higher than other maternity units, showing there is a significant need for a robust service locally.

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The level of need in the population

In 2010 there were 4,456 births in Haringey and the local birth rate is high compared to London and England (see JSNA chapter Demographics). All babies born in Haringey and children moving into the borough, from other areas or counties, should have access to the childhood immunisations as recommended by the Department of Health (DH).

The level of need has been assessed here using the uptake of recommended immunisations divided into;

• Routine vaccinations - for children under 5 and teenagers
• Targeted vaccinations - for children at particular risk (BCG and Hepatitis B Vaccination)

NHS Choices has information and guidance on the current schedule of recommended immunisations (external link) for children.

Routine childhood immunisation programme - for children under 5 and teenagers:

Data on childhood immunisation should be available from the Child Health Information System CHIS unfortunately there has been a miss-match between the data obtained from CHIS and the GP practice systems or other providers.

Vaccinations for children under 5

Over the last couple of years data had been obtained directly from the GP systems to give us a more accurate coverage data.

Figure 3: Annual Data comparison for 6 key immunisation targets.

The 2008/09 data is from the CHIS and 2009/10 direct from a manual extract from the GP IT systems and in 2010/11 an electronic transfer of the GP data.

There are still data quality issues for the 5 year cohort which need to be resolved and although the improvements in other areas are significant, the levels are still below that required for herd immunity.

Comparison to other London boroughs and within North Central London indicates that the measures taken locally are beginning to show improvements.

See NHS Immunisation Statistics for full 2008-09 data (external link)

Teenage Vaccinations

The teenage booster, for diphtheria tetanus and polio, is generally given to children in year 10.

Data on uptake from the CHIS system is not reliable as available, - Immunisation | The NHS Information Centre (external link) This is due to problems in obtaining information from other areas when children attend schools out of borough.

The uptake from those attending schools in Haringey from the school nurse data is;

2009/10 = 62%
2010/11 = 70%

The Human Papillomavirus (HPV) vaccine is given to all girls at around 12 – 13 years of age generally in school year 8.

The uptake in Haringey schools for girls in the year 8 completing the course;

2008/09 = 78%
2009/10 = 60%
2010/11 = 72%

See The HPV annual coverage report (external link).

Targeted vaccinations:

BCG vaccination - given to all babies under one year in Haringey.

The data for BCG uptake on the CHIS system, as for other immunisation data, this is unreliable.

The information presented in figure 4; is based on the birth cohort, the number known to be vaccinated in the community clinic plus the BCG vaccination for babies born at the NMH. (NB all babies born at the NMH are offered the BCG vaccine at birth).

Figure 4: BCG uptake in Haringey 2009/10 and 2010/11

* Actual figures not available, estimate given based on an uptake of 95% of all babies born at NMH

** The reduction in the BCGs given in community clinics during 2010/11 was due to a reduction in staff capacity.

Hepatitis B vaccination- given to babies identified as at risk of infection due to maternal infection.

The information from antenatal screening, which tests for the presence of hepatitis B as well as other infections and is offered to all women, strongly indicates that the prevalence of chronic Hepatitis B is high in Haringey. It is therefore a substantial burden of disease when compared with other boroughs in London and nationally.

Figure 5: ESAHB Data (Enhanced surveillance of antenatal hepatitis B)
Cases reported to North Central London boroughs 2008 - 2011 (Source HPA)

The majority of cases reported are from the NMH

The vaccination uptake data below is based on the cohort of women who deliver at the North Middlesex Hospital for which we have accurate screening data for. From this the uptake of hepatitis B vaccine in these babies has been available since 2010/11 Q3.

2010 – 2011(external link)
Quarter 3 and 4 Combined -23 babies identified and 23 completed all three primary doses.

2011 – 12 to date (external link)
Quarter 1 - 17 babies identified and 16 completed the primary course – 94% coverage
Quarter 2 - 20 babies identified and 19 completed the primary course – 95% coverage

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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 primary care and in general by Practice Nurses in GP surgeries, all 52 practices in the borough currently provide immunisation services.

Maternity Services

Maternity services provide BCG vaccination to all babies born at the North Middlesex Hospital. The service also provide, initial hepatitis B vaccination to all babies identified as at risk and liaise with the children’s services special immunisation clinic to ensure the course is completed.

Children’s Services

The children’s services team provide, through the ‘Whittington Health’ community contract.

A Specialist Immunisation Nurse who runs the Specialist Immunisation Clinic based at the Child Development Centre at St Ann’s Hospital to provide,

• Hepatitis B vaccination to any eligible babies within Haringey identified as requiring the Hepatitis B vaccine as a result of antenatal screening.
• Hepatitis B screening and vaccination if appropriate is also offered to any siblings, of these babies, not previously protected.
• BCG Vaccination to any baby or child eligible for BCG vaccination as per national guidance.
• Specialist advice from Consultant Paediatrician where a parent carer or professional has concerns about a specific child’s eligibility or otherwise for vaccination.

School based vaccination sessions for the teenage vaccinations are delivered through the school nursing team. The service also provides drop-in clinics to cover those children who are not in school or who are unable to receive vaccinations in school for.

• The Human Papillomavirus Vaccine (HPV) for all year 8 girls.
• The school leavers’ booster vaccine for, tetanus, diphtheria and polio, to children in year 10. The MMR vaccine is also offered at the same time to those who have not previously received the recommended 2 doses.
• Specific vaccination programmes as necessary through separate contract arrangements for example where there is a specific outbreak or when a new vaccine is introduced.
• Information and advice to individual families and children on immunisation as appropriate.

The children’s services also provide advice and information to all parents and families they work with on immunisation and the schedule recommended.

Public Health

The Specialist Health Protection nurse, through the public health directorate, provides expert advice to local health professionals on vaccination issues. In addition Immunisation training courses for health professionals and others are provided locally, for example a two day training course which follows the Health Protection Agency guidelines on the fundamentals of immunisations and vaccinations is provided twice yearly for all new staff and updates four times a year. As recommended all new staff should attend a two day basic immunisation course and then updates biennially.

Advice and support is also available from the local Health Protection Agency.

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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 (Samad et al, 2006).

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 (Smailbergovic et al, 2003). 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 (Freed et al 2010 and Bean 2011).

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 (DH 2005 and Nice Guidance PH21 2009).

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

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Expert opinion and evidence base

The policy for immunisation is set nationally In the United Kingdom by the Department of Health (DH) based on evidence from the Health Protection Agency, World Health Organisation, the US Centre for Disease Control and European Centre for Disease and Infection Control. The Joint Committee for Vaccinations and Immunisations (JCVI)- (external link), an independent expert advisory committee, scrutinise this evidence to advise the Secretaries of State for Health, Scotland, Wales and Northern Ireland on communicable diseases, preventable and potentially preventable through immunisation.

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.

Due to the crucial role immunisation has in preventing ill health from vaccine preventable diseases, immunisation is now enshrined as a right under the NHS constitution. This means that the public have a right to receive any vaccination deemed as necessary by the JCVI .

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.

Health Protection Agency (HPA) (external link) provides advice and information, to the general public, health professionals and to national and local government, on all areas of health protection with specific information about immunisations and vaccinations and vaccine preventable infections.

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

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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 population is particularly transient which further adds to the problems for services to ensure they are targeting the right children. 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 will change as new vaccines become available, according to need based on the rates of infectious disease as monitored by the HPA (external link). The JCVI will consider these and services will need to be able to adapt to accommodate changes.

For example, there is a new vaccine for meningococcal B vaccine which may be recommended for use in the UK.

There is an increase nationally in pertussis infection, particularly amongst older teenagers and adults. Other countries such as Australia, USA and some European countries have introduced a booster of pertussis containing vaccine for teenagers, (WHO) Footnotes. A similar change to the schedule may be recommended in the UK.

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Unmet needs and service gaps

Although childhood immunisation rates have improved dramatically, the 95% coverage required for herd immunity is not being met in Haringey leaving the community as a whole at risk of vaccine preventable disease.

The coverage data, as detailed above, is currently being taken directly from the GP computer systems. This is not ideal as potentially not all children are registered with a GP. The data therefore needs to come from the Child Health Computer System (CHIS) so it can be better compared with neighbouring boroughs across London and nationally.

The uptake for immunisation in the west of the borough is generally higher according to the GP information. This is probably due to larger practices with the associated, robust IT systems and staff support, for inputting and data reporting. Similarly, in the east of the borough, practices with a similar demographic profile achieve marked differences in uptake.

This indicates a need for better performance management of the data and reporting aspects of immunisation delivery. There is also a need to ensure patients registered with smaller practices have access to the same level of service.

The NICE guidance highlights various strategies to reduce differences in immunisation uptake. Evidence suggest that some of Haringey’s population characteristic may be associated with lower uptake such as:

• The ethnic profile which shows the population is ethnically diverse, especially in the east, and that it is constantly changing. The data also shows that the ethnic diversity is more pronounced in young people.
• The Indices of Multiple deprivation (IMD), based on the Lower Super Output Area (LSOA), currently rank Haringey as the 4^th most deprived borough in London with particularly high levels of deprivation and unemployment in the east of the borough.

There is a need for individual practices to develop services according to the individual needs of their patients and ensure they are able to immunise all children eligible for immunisation.

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Recommendations for Commissioning

Immunisation is complex and various factors need to be addressed in order to have an effective service. The NICE guidelines highlight evidence to show that there are particular interventions which can increase immunisation uptake rates. Ultimately a variety of different approaches and interventions are required:

• Patient reminder and recall systems.
• A variety of ways to access immunisations making it easier and more convenient. 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.

Immunisation programmes need to be flexible and able to meet future requirements and changes in the recommended schedule as recommended by the JCVI.

The guidance from Commissioning Support for London (CSL), - Childhood Immunisation for London Guidance (PDF, 639KB) has been developed following the extensive work carried out across London to improve immunisation coverage. All future immunisation services need to be commissioned on this basis, with clear requirements over four areas.

• Information Management: To make sure that immunisations are recorded accurately and in a timely fashion and data is transferred from the provider to the child health information system for accurate reporting for COVER.

The aim is to improve the data quality and the processes for data flow between providers and the child health administration team and CHIS.

• The process for transferring data from individual services to the central CHIS needs to be automated to minimise errors.
• Where vaccinations are given in schools or community clinics this needs to be available for GP practices for them to maintain a complete history of vaccination.
• Services need to have accurate lists of those not immunized to enable active follow up
• Active Patient and Clinical Management: To make sure children are called for their immunisations at the right time, for services to have call and recall systems, send out reminder letters and or appointment cards, and make sure there is equitable access to services and that appropriate advice and information is available to patients. Ensuring immunisation is available to all and that parents and families have access to good reliable information and are able to access services.
• Immunisation should be embedded and explicit, as part of every contact and assessment health professionals have with children. To ascertain their immunisation history and advice as appropriate on where to go to complete their immunisation and this should include reminders for targeted vaccination, BCG and Hepatitis B, where appropriate. For example, health visitor contacts, children’s clinics, A& E & Urgent Care Centres.
• Non-health care staff involved with children to promote and encourage immunisation. For example, schools and children centres, to introduce immunisation as part of their entry questionnaire requirements.
  • All providers to follow-up on individual children and use reminder and call and recall systems effectively. Ensure these factors are explicit within any contractual agreement, local enhanced service agreement or service level agreement.
• Encourage the provision of immunisation opportunistically and increase the flexibility of clinic times. To consider the use of alternative premises for vaccinations, for example; children’s centres, domiciliary visits and extending existing community clinics to create general immunisation clinics.
• Performance Management: Effective immunisation programmes must set out clear standards, goals and outcomes in order to effectively performance manage service provision. There needs to be clear governance and accountability arrangements with effective processes for reporting to the commissioners to ensure services are delivering appropriate quality and outcomes.
• To develop robust contracts and service agreements with the providers and use data on immunisation uptake to support and ensure best practice is maintained.
• Data on routine children’s immunisation is also reported separately by the GP practices to the Exeter system quarterly. This is used for payment purposes. There is a need to reconcile this with actual returns and reports on the CHIS.
• Skilled workforce: Staff to have the expertise and knowledge to provide up to date consistent advice and information as well as confidently encourage immunisation for their clients. Provision should be available for ongoing training and development.
• Ensure quality training is available which meets the recommendations laid down by the Health Protection agency (HPA).

Provide access to expert information and advice for the public and professionals.

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Recommendations for further needs assessments

Conduct a Health Equity Audit, assess practice based data in comparison to the overall profile of the practice to explore and analyse differences in coverage based on demographics as well as service provision.

Scope issues around teenage vaccinations – the current performance delivery of the service and assuring transfer of data from borough to borough, particularly where vaccinations are given in school. To make recommendations for future service provision.

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Key Contact

Helen Donovan
Immunisation and Health Protection
Lead Nurse
Public Health Directorate
helen.donovan@haringey.gov.uk

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Footnotes

1. Bean S, (2011). Emerging and continuing trends in vaccine opposition website content. Vaccine. (29) pp 1874-1880.
2. CSL London (2010). Childhood Immunisation for London, Guidance - August 2010. Commissioning support for London (639kb PDF) - (external link)
3. Cover data (2011) Health Protection Agency (external link)
4. Department of Health Immunisation against infectious disease - 'The Green Book' (external link)
5. Department of Health 2009 updated in 2010, The NHS Constitution. The NHS belongs to us all (external link)
6. Department of Health (2005) Vaccination services: reducing inequalities in uptake (external link)
7. 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.
8. NHS Information Centre (2011) NHS Immunisation Statistics (external link)
9. Health protection Agency, TB Surveillance London i November 2011
10. NHS Choices Vaccinations Your NHS guide to vaccinations for you and your family (external link)
11. 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)
12. Samad L, Butler N, Peckham C and Bedford H, (2006). Incomplete immunisation uptake in infancy: Maternal reasons. Vaccine. (24) 6823-6829.
13. 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.
14. World Health Organisation Media Centre (external link)

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