General
- The leadership, coordination and organisation of vaccination programmes are key to ensuring a high uptake.
Children
- The national NHS Immunisation Information website http://www.immunisation.nhs.uk/ details up-to-date information on childhood vaccines, disease and immunisation in the UK. The national schedule sets out a vaccination programme to protect children from ten vaccine preventable diseases including diphtheria, tetanus, polio, pertussis (whooping cough), haemophilus influenza B, meningitis C, pneumococcal disease, measles, mumps and rubella. In addition to this, there is a vaccination schedule to protect children at risk of tuberculosis (BCG vaccine) and hepatitis B. It also protects girls from cervical cancer through administration of the human papilloma virus (HPV) vaccine.
- Not achieving national targets of the childhood immunisation programme with poorer rates of uptake in the most deprived practices. NHS Nottingham City has the lowest performance in the East Midlands. However, there has been a sustained improvement in performance over the last four years. Working with and supporting primary care in their leadership, coordination and organisation of vaccination programmes has been key to increasing uptake.
- The Department of Health introduced a human papilloma virus (HPV) vaccine for the prevention of cervical cancer for girls aged 12 – 13 years (School Year 8) commencing September 2008. In December 2008 the DH announced an acceleration of the national programme to enable the girls already identified for the previously announced catch-up. From September 2008 to August 2012 the Department of Health procured Cervarix® as the national vaccine. As from September 2012, following a re-procurement exercise, the centrally procured vaccine is Gardasil®. The programme in Nottingham City is commissioned from Nottingham CityCare school nursing service.
- Low reported coverage of school leaving vaccinations of diphtheria, tetanus and polio age 13 – 18 years old. There is a mixed model of delivery of this vaccine by primary care and school nurses. Recording and reporting of this vaccine is variable and complex. The information is collected through KC50 returns and not through the HPA COVER data returns.
- Most childhood vaccination, excluding HPV vaccine and BCG vaccines, are delivered through primary care. Practice leadership and organisation of vaccination programmes is key to ensuring a high uptake.
- In July 2012, the Department of Health announced that the seasonal flu vaccination programme would be extended to all children from 2014 at the earliest. This is in addition to children in at risk groups. It will be implemented following further work to ensure sufficient supplies of the vaccine and model of delivery.
Adults
- The national NHS Immunisation Information website http://www.immunisation.nhs.uk/ details up-to-date information on vaccines, disease and immunisation for adults in the UK.
- There is an increased emphasis in increasing the uptake of the uptake of the annual seasonal flu vaccination programme for people aged 65 years and over and people aged under-65 years in the 'at risk' categories; The target for people aged over 65 years is 75%. There is a three year trajectory increase in the target for people aged under 65 years in at risk groups, including pregnant women. These targets are 60% in 2011-12, 70% in 2012-13 and 75% in 2013-14.
- Continuing momentum in the administration of the pneumococcal vaccine for people aged 65 years and over.
- In February 2010 the Department of Health announced that the Joint Committee on Vaccination and Immunisation (JCVI) had provided advice on shingles vaccine for people aged 70-79 years that a universal herpes zoster vaccination programme should be introduced provided that a licensed vaccine is available at a cost effective price. JCVI will issue a full statement in due course.
Seasonal flu
In August 2009, the Department of Health announced, in response to the swine flu pandemic, a swine flu (H1N1) vaccination programme for the following groups - individuals aged six months and up to 65 years in the current seasonal flu vaccine clinical at-risk groups, all pregnant women, household contacts of immunocompromised individuals, people aged 65 and over in the current seasonal flu vaccine clinical at-risk groups. This was followed in December 2009 by a Phase 2 programme for all children aged from 6 months to under 5 years. In addition to these groups, frontline health and social care workers were offered the vaccine as they are at increased risk of infection and of transmitting that infection to susceptible patients.
Since 2010-11, the seasonal flu vaccine offers protection against H1N1 along with other A and B strains as recommended by the World Health Organisation.
As part of the annual seasonal flu vaccination programme there is a flu vaccination for frontline health and social care workers. This seeks a year on year increase in uptake. Local targets are set in line with the increased trajectory for people aged under 65 years in clinical at risk groups
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 older people.
See section above regarding priority groups.
The NHS Information Centre holds the national annual uptake of immunisations in England, by region and Primary Care Trusts. This is updated each autumn. See
http://www.ic.nhs.uk/statistics-and-data-collections/health-and-lifestyles/immunisation
Web link to NHS Childhood Immunisation Schedule for 2012 on NHS Choices http://www.nhs.uk/Planners/vaccinations/Pages/Vaccinesforkidshub.aspx
Children
Routine childhood immunisation programme
The national COVER (Cover of Vaccination Evaluated Rapidly) data run by the Health Protection Agency (HPA) programme monitors immunisation coverage data in the UK for ten vaccine preventable diseases for children who reach their first, second, or fifth birthday during each evaluation quarter as well as for the full year. This information is fed back to the Primary Care Trust. Uptake is analysed and strategies and actions devised and implemented to improve coverage and detect changes in vaccine coverage.
Using MMR as a tracer condition, NHS Nottingham City’s performance is below the performance of other Primary Care Trusts in the East Midlands. Even if the performance is compared to comparable cities based on being co-terminous with Local Authority and being ‘nearest neighbours’ based on similar indicators, the performance is still poor. There is also a link with inequalities which shows lower uptake in the most deprived GP quintiles.
Figure 1: NHS Nottingham City - measles, mumps and rubella (MMR) uptake
Year |
% uptake of primary MMR by age 2 years |
% uptake of second MMR by age 5 years |
2006-07 |
78.0 |
64.0 |
2007-08 |
80.0 |
66.0 |
2008-09 |
76.6 |
76.2 |
2009-10 |
82.2 |
80.3 |
2010-11 |
84.0 |
81.3 |
2011-12 |
88.8 |
82.5 |
Figure 2: NHS Nottingham City DTaP/IPV/Hib (Diphtheria, tetanus, polio, pertussis and haemophilus influenza B), known as the ‘5 in 1’ vaccine by age 1 year uptake
Year |
% uptake of DTaP/IPV/Hib
by age 1 year |
2006-07 |
81.0 |
2007-08 |
79.0 |
2008-09 |
87.0 |
2009-10 |
90.5 |
2010-11 |
91.1 |
2011-12 |
92.4 |
Figure 3: NHS Nottingham City DTaP/IPV/Hib (Diphtheria, tetanus, polio, pertussis and haemophilus influenza B) uptake by age 5 years - known as the pre-school booster
Year |
% uptake of DTaP/IPV/Hib
by age 5 years |
2006-07 |
68.0 |
2007-08 |
70.0 |
2008-09 |
79.0 |
2009-10 |
82.0 |
2010-11 |
82.7 |
2011-12 |
83.6 |
See NHS Immunisation Statistics for latest data on all immunisations
Immunisation | The NHS Information Centre
HPV
Human Papilloma Virus (HPV) vaccine programme for girls aged 12 – 13 years commenced in September 2008. HPV is a sexually transmitted virus that causes 99 per cent of invasive cervical cancers. The vaccine protects against the two viruses responsible for about 70 percent of cases. To ensure maximum benefit and protection from this vaccine, it is necessary to administer it before the onset of sexual activity. The vaccine is administered in 3 doses over six months.
Figure 4: NHS Nottingham City HPV vaccine uptake
September – August |
% uptake of
HPV vaccine Year 8 |
2008-09 |
77.8 |
2009-10 |
80.4 |
2010-11 |
87.1 |
2011-12 |
TBC |
Adults
Annual flu vaccination programme
Influenza uptake in patients aged 65 years and over
|
2011-12 |
2010-11 |
2009-10 |
2008-09 |
Nottingham City |
73.7% |
71.9% |
72.3% |
73.2% |
Influenza uptake in patients aged under 65 years in clinical at risk groups
|
2011-12 |
2010-11 |
2009-10 |
2008-09 |
Nottingham City |
51.5% |
49.8% |
52.8% |
48.0% |
Pneumococcal vaccination programme
There is a marked seasonal pattern with the greatest number of reports of pneumococcal infection occurring in December and January each year. All those aged 65 and over are recommended to be vaccinated. The Centre for Infections annually collects pneumococcal vaccine uptake data on the aged 65 years and over population on behalf of the Department of Health each year to estimate the impact and effectiveness of the vaccine programme.
The annual survey of pneumococcal immunisation data for the over 65 year olds 2012 data collection for anyone who had received the pneumococcal vaccine at anytime up until 31 March 2012.
Annual survey of pneumococcal immunisation data for the over 65 year olds
|
2011-12 |
2010-11 |
2009-10 |
2008-09 |
Nottingham City |
71.4 |
72.1 |
71.7 |
71.4 |
Issues of Inequality
Health inequality performance reports show a correlation between low uptake and higher levels of deprivation based on GP practices configured into deprivation quintiles. Evidence of the way in which inequalities in immunisation affect health is highlighted in studies that show poorer children or households with low up-take rates are at increased risk of developing vaccine-preventable diseases. Ref. Department of Health (2005) Vaccination services: reducing inequalities in uptake. Available at http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4105349
Children
The delivery of the childhood vaccination programme is lead primarily through Practice Nurses in GP surgeries. In addition to this, the PCT employs a Specialist Nurse for Immunisations who supports clinicians in delivering immunisation programmes in the PCT. This is done by offering verbal/telephone advice on complex cases, visiting and vaccinating hard to reach families in their own homes, offering supervision to clinicians who have undertaken the immunisation training and required supervised practice, providing a service to families in homeless accommodation and travelling families. In addition to this, there is an increasing cohort of health visitors in the PCT who are also trained to give immunisations and who will opportunistically immunise hard to reach families. In March 2012, following a pilot in 2010, Nottingham CityCare and NHS Nottingham CityCare launched a joint protocol where members of the skill-mixed health visiting team offer home immunisation of unimmunised/incompletely immunised children that have not accessed GP provision despite repeated offers.
The HPV vaccination programme for girls aged 12-13 years is delivered through the Nottingham CityCare School Nursing Service. A Local Enhanced Service (LES) is in place for the accelerated catch up programme for girls aged up to 18 years.
Advice and support is also available from the local Health Protection Agency.
A two day training programme on immunisations and vaccinations follows the Health Protection Agency guidelines for all new staff. There is also a one day update for staff already in post.
See ‘Level of need in the population’ section above
Adults
See ‘Level of need in the population’ section above
Children and Young people
The birth rate is increasing in the City, particularly in BME groups who may have lower uptake of vaccination (DH 2005). For more information on the socio demographic changes projected for Nottingham city please see this chapter of the JSNA.
There is also a new significant population of young families who have migrated to the UK to work from the EU accession countries, who are less likely than the general population to access services including immunisations and vaccinations. A full Health Needs Assessment of this population has been carried out by NHS Nottingham City (Bunting et al 2009) and summarised in another JSNA chapter.
Immunisation activity will increase when the seasonal flu vaccination programme is introduced for all children.
The sustained improvement in the uptake of childhood immunisations will decrease the risk of outbreaks of vaccine preventable diseases and the morbidity associated with each disease and increase the chances of reaching the herd immunity target of 95% uptake.
Adults
For further information about the projected health needs of older people please see the JSNA chapter. The Proportion of people resident in the City aged 65+ will broadly stay the same, however the proportion of the population aged 85+ will increase which may present a challenge in terms of vaccinating this group of particularly vulnerable older people aged 85+, a proportion of whom are likely to be housebound. The number of older people with dementia and the number of people with mental health problems is also increasing and these groups may have lower uptake.
Also of these demographic changes may present challenges in terms of improving uptake of immunisation uptake.
Children
The DH published ‘Vaccination Services – reducing inequality in uptake’ in March 2005. This outlined the particular groups at risk including children in care, young people who missed previous immunisations, children with physical or learning difficulties, children of lone parents, children not registered with a GP, children in larger families, hospitalised children, and minority ethnic groups. It also outlined strategies that can be used to increase uptake, including making specific provisions to improve access for target groups.
NICE (National Institute for Health and Clinical Excellence) developed guidance entitled ‘Reducing differences in the uptake of immunisations’ on differences in the uptake of immunisations (including targeted vaccines) in people younger than 19 years. It was published in September 2009.
http://guidance.nice.org.uk/PH21
Adults
Flu vaccinations are 70-80% effective in healthy adults in years when there is a good match between the vaccine and the strains of flu in circulation.
NHS Immunisation website
A comprehensive, up-to-date and accurate source of information on vaccines, disease and immunisation for the UK.
http://www.immunisation.nhs.uk
Health Protection Agency (HPA)
The Health Protection Agency is an independent UK organisation that was set up by the government in 2003 to protect the public from threats to their health from infectious diseases and environmental hazards. It does this by providing advice and information to the general public, to health professionals such as doctors and nurses, and to national and local government and includes specific information about immunisations and vaccinations
http://www.hpa.org.uk/infections/topics_az/vaccination/vacc_menu.htm
Joint Committee for Vaccinations and Immunisations
The Joint Committee on Vaccination and Immunisation (JCVI) is an independent expert advisory committee first set up in 1963 to advise the Secretaries of State for Health, Scotland, Wales and Northern Ireland on matters relating to communicable diseases, preventable and potentially preventable through immunisation. JCVI gives advice to Ministers based on the best evidence reflecting current good practice and/or expert opinion. The process involves a robust, transparent, and systematic appraisal of all the available evidence from a wide range of sources. The committee is appointed by the Appointments Commission and is independent of the Department of Health. http://www.dh.gov.uk/ab/jcvi/index.htm
Department of Health Immunisation against infectious disease - 'The Green Book'
This includes evidence vaccine efficacy
http://www.dh.gov.uk/en/Publichealth/Healthprotection/Immunisation/Greenbook/dh_4097254
The PCT has actively participated in two city centre Department of Health immunisation roadshows. August 2009 focus on MMR uptake and October 2009 focus on HPV vaccine uptake. Anecdotally, feedback from the public was generally positive. Formal feedback is awaited from the Department of Health.
Individual Equality Impact Assessments are required for each immunisation and vaccination programme.
School leaving boosters
Variable administration and reporting of vaccines given by GP practices. Most vaccines given and reported by the school nursing service. Work underway to scope delivery of the programme and recommend systematic approach.
References
Department of Health (2012) NHS Childhood Immunisation Schedule for 2012. Available at http://www.immunisation.nhs.uk/Immunisation
Department of Health (2012) Immunisation against infectious disease - 'The Green Book'. Available at http://www.dh.gov.uk/en/Publichealth/Healthprotection/Immunisation/Greenbook/dh_4097254 [Accessed 15 March 2012]
Department of Health (2005) Vaccination services: reducing inequalities in uptake. Available at http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4105349 [Accessed 15 March 2012]
NHS Information Centre NHS Immunisation Statistics – annual statistics updated each autumn. Available at: http://www.ic.nhs.uk/statistics-and-data-collections/health-and-lifestyles/immunisation [Accessed 15 March 2012]
National Institute for Clinical Excellence (NICE) (2009) Public Health Guidance ‘Reducing differences in the uptake of immunisations’ Available at:
http://publications.nice.org.uk/reducing-differences-in-the-uptake-of-immunisations-ph21 [Accessed 15 March 2012]