TO: Bracknell Forest Health and Wellbeing Board
5 September 2013
Immunisation schedule for routine immunisation and for those in clinical risk groups
Strategic Director of Public Health, Berkshire
1 PURPOSE OF REPORT
1.1 The purpose of this paper is to brief the Bracknell Forest Health and Wellbeing Board about the routine immunisation schedule and the schedule for immunising those in clinical risk groups.
2 RECOMMENDATION
2.1 This paper is for information only.
3 SUPPORTING INFORMATION
3.1 Immunisation schedule for routine immunisation and for those in clinical risk groups
The purpose of this paper is to brief the Bracknell Forest Health and Wellbeing Board about the routine immunisation schedule and the schedule for immunising those in clinical risk groups.
Immunisations are a highly effective way of maintaining the health of the population by reducing the occurrence of infectious disease.
Immunisations are commissioned by NHS England are team from a range of providers, with a focus on General practice. The role of local Public Health is to monitor the delivery of the vaccination programmes and give assurance to the HWB board on the effectiveness of these programmes on delivery to the local communities.
Table 1 shows the routine immunisation schedule.
Table 1 Routine immunisation schedule
|
Age |
Diseases protected against |
Delivered in Berkshire by |
|
2 month old |
Diphtheria, tetanus, pertussis, polio, Haemophilus influenzae (Hib) |
GP/ Practice nurse
|
|
Pneumococcal disease |
||
|
Rota virus |
||
|
3 month old |
Diphtheria, tetanus, pertussis, polio, Hib |
GP /Practice Nurse |
|
Meningococcal group C (Men C) |
||
|
Rota virus |
||
|
4 month old |
Diphtheria, tetanus, pertussis, polio, Hib |
GP /Practice Nurse |
|
Pneumococcal disease |
||
|
Between 12 and 13 month old |
Hib, Men C |
GP /Practice Nurse |
|
Pneumococcal disease |
||
|
MMR |
||
|
2 and 3 years old |
Influenza (from Sept’13) |
GP /Practice Nurse |
|
3 years 4 months old |
Diphtheria, tetanus, pertussis, polio |
GP / Practice Nurse |
|
Girls aged 12-13 year old |
HPV |
School nurse |
|
Around 14 year old |
Tetanus, diphtheria, polio |
School nurse |
|
Men C (from Sept’13) |
||
|
65 year old |
Pneumococcal disease |
GP /Practice Nurse |
|
65 years and older |
Influenza |
GP /Practice Nurse |
|
70 years old |
Shingles (from Sept’13) |
GP /Practice Nurse |
|
79 year olds (for 2013) |
Shingles (catch-up programme) |
GP / Practice Nurse |
Source: Department of Health
Table 2 Immunisation schedule for those in clinical risk groups
|
Age |
Disease protected against |
Delivered in Berkshire by |
|
At birth, 1 month old, 2 months old and 12 months old |
Hepatitis B |
1st dose - Maternity service Remaining doses – GP/ Practice Nurse |
|
At birth |
TB |
Maternity service or TB service (if not given at birth) |
|
6 months – under 65 years |
Influenza |
GP / Practice Nurse |
|
2 years – under 65 years |
Pneumococcal disease |
GP /Practice Nurse |
|
Pregnant women |
Influenza |
GP / Practice Nurse |
|
From 28 weeks of pregnancy |
Pertussis |
GP /Practice Nurse |
Source: Department of Health
In April 2013 The Department of Health, Public Health England and NHS England jointly launched a campaign aiming to drive up demand for MMR vaccination. This was in response to an increase in the number of measles cases in England over the last two years with an annual total of 1,920 confirmed cases in 2012, the highest annual figure since 1994. This was sustained into 2013. There is a high rate of cases in teenagers, which has not been experienced in previous years. The 10 to 16 year old age group is the one most affected by the adverse publicity relating to MMR vaccine between 1998 and 2003 and therefore there are larger numbers of children of this age unimmunised or partially immunised against measles. This creates the potential for school based outbreaks as seen in Swansea and the north east of England.
Although there has not been an increase in confirmed cases in Thames Valley there is still the potential for outbreaks particularly in those areas where coverage of MMR immunisation has been low in the past.
One dose on MMR vaccine is 90-95% effective at protecting against measles infection. Two doses will protect 99% of those immunised. There is a national target to immunise 95% of children with one dose of vaccine by the age of 2 years and 2 doses of vaccine by the age of 5 years.
This report provides an update on Phase 1 of the MMR catch up campaign, an outline of the approach for Phase 2 and
The first phase of the catch-up campaign consists of the following elements running concurrently:
· An urgent communication to encourage parents or guardians of unvaccinated (highest priority) and partially vaccinated young people 10 to 16 years to be vaccinated at their General Practice.
· A rapid programme of identification and invitation of unvaccinated and partially vaccinated young people by General Practice in liaison with Child Health Information System Services.
· Targeting of vulnerable groups such as Gypsy, Roma, traveller families; there are still disproportionate number of cases within this community.
· Sustained intervention over longer term that will strengthen current routine approaches.
· Ensuring there is continued improvement in the routine immunisation programme for under 5’s.
The proposed outcome is that 95% of young people aged 10 to 16 years to have received at least one dose of MMR by September 2013.
A Thames Valley steering group led by NHS England screening and immunisation team planned and co-ordinated the catch up campaign supported by the Director of Public Health and local authority colleagues.
· Local press releases were produced to coincide with the national release of measles data in early May and June with the Director of Public Health providing the local voice for these. This generated radio and newspaper coverage of the MMR catch up campaign.
· The Director of Public Health facilitated the circulation of letters through schools to students and their parents highlighting the importance of MMR immunisation and signposting them to their GP for immunisation.
· This was done at the start of the campaign with a second communication linking the need for MMR vaccination to travel to areas of Europe with a high incidence of measles being sent out to coincide with the start of the school holiday.
· All local GPs, except one, signed up in May to the Enhanced Service requiring them to identify unimmunised and partially immunised 10 to 16 year olds in their registered populations and invite them for immunisation.
· Working with the practice that opted out NHS England Thames Valley area team have identified and invited children registered with this practice for immunisation
· All GPs are commissioned to provide MMR immunisation to children up to the age of 15 years. The Enhanced Service also included provision for the immunisation of young people and adults aged 16 years and over.
· As a longer term sustainable intervention the NHS England Thames Valley Area Team are looking to commission the school nursing service to offer MMR catch up immunisation in secondary schools at the same time as other immunisations that are offered in school. (Human papilloma virus immunisation to Year 8 girls and the diphtheria, tetanus and polio booster in Year9 or 10)
· The routine immunisation of under 5’s is discussed in a later section.
Data on the numbers of children identified and invited will not be available until after the end of August when a new national data collection system goes live.
Nationally it is estimated that as a result of the campaign the number of 10-16 year olds immunised against measles has increased by 1%. This data is not available at local level.
Since the beginning of July coverage information on children up to the age of 18 years has been collected by Public Health England through the Immform weekly and monthly sentinel surveys. This system extracts information directly from a number of GP clinical systems.
It has been recognised nationally that obtaining accurate information on the coverage of MMR immunisation in 10-16 year olds is very difficult. Data on both General Practice clinical systems and Child Health Information systems becomes less accurate as children get older. As families move around the country or move in from abroad immunisation histories are less likely to be entered onto computer systems once a child is beyond the age of the routine immunisation programme.
Audits of records, including some work carried out locally by the public health team have estimated that 30- 50% of 10-16 year olds whose electronic records identify them as unimmunised have actually had MMR immunisation. A national audit is about to start sampling records 24 upper local authorities across England to estimate the magnitude of under recording. The results of this audit will be available in the autumn.
Table 1 presents the immunisation coverage in 10-16 year olds by CCG from Immform sentinel survey week ending 27th July 2013. For each CCG between 45 and 70% of practices are included in the Survey. This shows the proportion of children unprotected against measles to range from less than 9% in Newbury and District to over 14% in Slough and South Reading. These figures have not been adjusted to reflect the under-recording of immunisation discussed above.
Even allowing for under-recording most areas would still be below the target of 95% children having at least one does of MMR. The coverage in Slough and South Reading is of particular concern and these will be priority areas for action in Phase 2 of the catch up campaign.
|
Table 1: MMR immunisation coverage in 10 to 16 year olds taken from Immform sentinel survey week ending 27th July 2013 |
|||
|
CCG |
Children aged 10-16 years Doses MMR vaccine received |
||
|
zero |
only one dose |
two doses |
|
|
% |
% |
% |
|
|
Bracknell and Ascot CCG |
10.9 |
10.6 |
78.5 |
|
Slough CCG |
14.1 |
17.9 |
68.0 |
|
WAM CCG |
10.8 |
14.8 |
74.4 |
|
Newbury and District CCG |
8.6 |
9.3 |
82.1 |
|
N&W Reading CCG |
9.3 |
9.8 |
80.9 |
|
South Reading CCG |
14.2 |
15.4 |
70.4 |
|
Wokingham CCG |
9.6 |
12.3 |
78.1 |
Coverage data collected in July 2013 suggested that the aspiration of 95% coverage in the target age group is unlikely to be met by September. As a result Phase 2 plans are being developed nationally; although the final version has not yet been published the likely elements are set out below.
The following actions are proposed before the end of August
1. Undertake a further push with general practice to encourage those practices who have not yet taken part in the catch-up to do so.
2. Encourage all practices that have not already done so to ‘clean’ their data ensuring that vaccinations are properly recorded as this is fundamental to the success of the programme.
3. Consider further communication to GPs regarding the need to identify and re-invite any remaining unvaccinated children in the target age-range.
Planned developments for the autumn may include:
1. Additional publicity to raise awareness of the need to get vaccinated.
2. Activate a sustainable service checking status and providing MMR vaccine for those
• Moving from primary to secondary school at start of next year
• Having HPV vaccine in Year 8
• Having the teenage booster of diphtheria, tetanus and polio (dT/IPV)
3. In areas which have not reached the 95% target plan to offer school-based vaccine sessions for catch-up vaccination early in the autumn term of next academic year.
4. Audit of a sample of vaccination records for children with no record of MMR in a range of areas to estimate the likely under-estimation of true vaccination coverage.
5. Specific outreach to vulnerable and underserved groups e.g. traveller communities
Implementation of Phase 2 in Berkshire
There will be a meeting of the Thames Valley steering group including Directors of Public Health to agree the actions that will be taken locally to deliver the Phase 2 recommendations in Thames Valley. Proposal will include plans to
· Improve the quality of local data so a true picture of MMR coverage can be obtained
· Deliver school based immunisations in Berkshire in the 2013-14 academic year; possibly an initial focus in Slough and South Reading with wider roll out over the autumn and spring terms
· Ensuring the gypsy, Roma, traveller community in our area have good immunisation uptake.
· Continue work to increase uptake of MMR in under 5’s
Table 2 shows the coverage of MMR immunisation in 2 year olds and 5 year olds in Berkshire 2012-13 by local authority.
Three from six unitary authorities have achieved or almost achieved the 95% target for the first MMR immunisation and all apart from Slough are at or above 90%. Coverage of two MMR immunisations by 5 years old is much lower in all areas and is not at 95% in any area. Slough is the area of greatest concern as uptake is only 81% in this borough.
Appendix 1 shows the upward trend in MMR coverage in Reading, West Berkshire and Wokingham over the last 5 years. (Similar data is not available for other unitary authorities)
A plan is currently being developed by NHS England Thames Valley working with local stakeholders to improve immunisation coverage in Slough in under 5’s. This includes initial work to ensure that the coverage data is robust and accurately reflects the actual coverage.
A change in the Child Health Information System used and disruption resulting from the protracted consultation prior to the merger of child health teams across Berkshire may have had an impact on data quality affecting Slough, Bracknell and Windsor and Maidenhead.
Work continues in all areas to increase the uptake of the second MMR injections. The NHS England Thames Valley screening and immunisation team regularly identify those children late for immunisation and supply this information to practices to ensure these children are followed up.
|
Table 2 MMR immunisation coverage 2012-13 (Cover data) |
||
|
Unitary Authority |
1st MMR by 2 years (%) |
2nd MMR by 5 years (%) |
|
Reading BC |
94.7 |
91.5 |
|
West Berkshire Council |
96.0 |
92.6 |
|
Wokingham BC |
95.5 |
93.3 |
|
Bracknell Forest Council |
90.0 |
88.0 |
|
Royal Borough of Windsor and Maidenhead |
92.1 |
86.7 |
|
Slough BC |
89.3 |
81.0 |
Trend in MMR immunisation in Reading, West Berkshire and Wokingham
|
Reading |
1st MMR by 2 years |
2nd MMR by 5 years |
|
2008-2009 |
81.01 |
66.69 |
|
2009-2010 |
87.29 |
75.75 |
|
2010-2011 |
89.29 |
81.22 |
|
2011-2012 |
93.17 |
86.09 |
|
2012-2013 |
94.69 |
91.50 |
|
Target |
95.00 |
95.00 |
|
|
|
|
|
|
|
|
|
West Berks |
1st MMR by 2 years |
2nd MMR by 5 years |
|
2008-2009 |
85.3 |
77.5 |
|
2009-2010 |
92.54 |
81.97 |
|
2010-2011 |
91.66 |
89.39 |
|
2011-2012 |
94.51 |
90.35 |
|
2012-2013 |
95.99 |
92.62 |
|
Target |
95.00 |
95.00 |
|
|
|
|
|
|
|
|
|
Wokingham |
1st MMR by 2 years |
2nd MMR by 5 years |
|
2008-2009 |
86.1 |
72.2 |
|
2009-2010 |
92.66 |
77.75 |
|
2010-2011 |
93.27 |
87.20 |
|
2011-2012 |
95.16 |
91.30 |
|
2012-2013 |
95.52 |
93.27 |
|
Target |
95.00 |
95.00 |
Contact for further information
Dr Kakoli Choudhury, Public Health - 01344 355215
kakoli.choudhury@bracknell-forest.gov.uk
Dr Lise Llwellyn, Director of Public Health – 01344 352749
Lise.llwellyn@bracknell-forest.gov.uk