Select a 'from' date Select a 'to' date

Topic last reviewed: Apr-19

JSNA Topic: Immunisation (All Ages)

Background

Infectious diseases are caused by microorganisms such as bacteria and viruses which can be spread directly (e.g. through coughing and sneezing) or indirectly (e.g. by insects or by touching contaminated objects) from one person to another. Immunisation is the process in which a person becomes immune or resistant to an infectious disease, usually by administering a vaccine. It is one of the most cost- effective public health interventions, protecting children and vulnerable adults from serious illness and death. Coordinated international programmes have eradicated some infectious diseases such as smallpox, and reduced death and disability from many others (e.g. polio). Immunisation programmes have clearly defined target groups; they can be delivered effectively through outreach activities; and vaccination does not require any major lifestyle change.

Herd immunity occurs when a large proportion of the population are vaccinated, making it difficult for the infection to spread as there are only a few people who can be infected. This is important as it then provides a measure of protection for vulnerable groups such as new-borns. The European region of the WHO currently recommends that nationally, at least 95% of children are immunised against diseases preventable by immunisation and targeted for elimination or controls detailed in the WHO/Europe Tailoring Immunisation Programmes.

To achieve assurance and herd immunity, the immunisation uptake needs to achieve 95% of the target population for each programme to be effective in protecting vulnerable individuals and prevent an epidemic. Therefore, monitoring uptake of immunisation remains important for Lincolnshire; where in several areas uptake levels remain below the 95% threshold of herd immunity, especially for children who have received one dose of MMR vaccine on or after their 1st birthday and anytime up to their 2nd birthday and for children who have received two doses of MMR vaccine on or after their 1st birthday and any time up to their 5th birthday.

Further research is needed to fully understand the reasons behind this: access, social norms, mistaken belief systems, deprivation or culture.

Greater economic migrant movement to and within Lincolnshire could impact upon the herd immunity and should continue to be monitored.

Context

National strategies, Policies & Guidance

 

The Joint Committee on Vaccination and Immunisation (JCVI) advises the Secretary of State for Health in England, and Welsh ministers on matters relating to the provision of vaccination and immunisation programmes. Advice is scientific and evidence based and used by Government to inform, develop and construct policy.

The current national immunisation schedule sets out the national immunisation programme.

Improving the uptake of childhood immunisations in disadvantaged groups will contribute to narrowing the gap in inequalities and supports the highest priority recommendation of the Marmot Review – giving every child the best start in life.

Nationally commissioned immunisation programme specifications are available from: NHS Service Specifications for Immunisation Programmes

NICE has produced supporting guidance and shared learning documents. Of particular relevance is Immunisations: reducing differences in uptake in under 19s [PH21].

What is the picture in Lincolnshire

What the data is telling us?

 

Childhood Immunisation Programme

 

At 12 months

In 2017/18, the uptake of routine vaccinations against diphtheria, pertussis (whooping cough), tetanus, Haemophilus influenzae type b (an important cause of childhood meningitis and pneumonia) and polio (IPV is inactivated polio vaccine) (DTaP/IPV/Hib) at 12 months in Lincolnshire was 93.5% (n=7,104), similar to the national (93.1%) and regional (94.9%) rates. The overall rate for Lincolnshire is below the 95% threshold required for herd immunity.

The PCV (Pneumococcal Conjugate Vaccine) uptake at 12 months, in Lincolnshire was 94% (n=7,143), similar to the national level (93.9%), but below the regional levels (95%) in 2017/18, meeting the 95% threshold of herd immunity.

Since 1 July 2016 the vaccination schedule for MenC has changed as the success of the MenC vaccination programme has impacted on incidence. This means that there are almost no cases of MenC disease in infants, therefore it has been removed from the vaccination schedule, but all children will continued to be offered the combination Hib/MenC vaccine when they reach age one.

91.4% of children in Lincolnshire have been vaccinated against rotavirus by their first birthday, compared to 90.1% nationally and 92.2% regionally.

At 24 Months

In 2017/18, the uptake for the PCV booster at 24 months in Lincolnshire was 90.4% (n=7,410), which is similar to regional (93.2%) and national rates (91.0%); below the threshold of 95% for herd immunity.

Hib/MenC (Haemophilus Influenza/Meningitis C Infections) booster uptake at 24 months was 91.3% (n=7,478) in Lincolnshire in 2017/18, this is similar to national (91.2%) and regional levels (93.2%), but below the 95% threshold for herd immunity.

The single dose MMR (Measles, Mumps and Rubella) vaccination uptake was 91.2% (n=7,475) in Lincolnshire in 2017/18 which matched exactly the national level but is below the regional (93.1%) level and below the 95% threshold of herd immunity.

The routine vaccination (DTaP/IPV/Hib) uptake at 24 months met the national target of 95% exactly (n=7,786) in 2017/18 and was similar to England rate (95.1%). The East Midland region is above target (96.5%).

The population vaccination coverage - Flu (2-3 years old) is 55.5%, which is above the national level (43.5%) and is also above the East Midland region's level (51.5%) though values are below the 65% target.

At 5 Years

In Lincolnshire in 2017/18, 94.8% of children received a DTaP/IPV/Hib vaccination at 5 years old, compared to 96.8% regionally and 95.6% nationally. The DTaP-IPV booster was received by 85.9% of 5 year old children in Lincolnshire which is similar to the national level (85.6%) and slightly lower than the regional level (88.4%).

The coverage for MMR first doses at 5 years old in Lincolnshire is 93.9% compared to 94.9% nationally and 96.4% regionally. Coverage of MMR (both doses) is 85.2% in Lincolnshire (n=7,472) for 2017/18 and is lower than the national rate of 87.2% and the regional rate (89%) as well as being below the 95% threshold of herd immunity.

The Hib/MenC (Haemophilus Influenza/Meningitis C Infections) booster uptake at 5 years old was 90.2% (n=7,907) in Lincolnshire in 2017/18, which is similar to the national level of 92.4% and regional level of 93.2%.

HPV vaccination (females aged 12 & 13 years)

HPV (Human Papilloma Virus) coverage for the routine programme was changed from a three-dose to a two-dose schedule in September 2014. Data is recorded for two cohorts as the school Years 8 and 9 were offered the vaccination. The national level for Year 8 (86.9%) is recorded for at least one dose. Nationally for Year 9 the figure is 89.1% for one dose and 83.8% for the two dose vaccination. Correspondingly for Lincolnshire, Year 8 was above the national value at 89.7% (n=3,618) for those receiving at least one dose. Year 9 was recorded as 87.1% (n=3,475) for those vaccinated with both the first and the second dose in 2017/18. Although higher than national averages the target of 90% immunisation coverage is not met.

Adult Immunisation Programme

 

PPV vaccination (adults aged 65 years & over)

In 2017/18 the uptake of PPV (Pneumococcal Polysaccharide Vaccine) in Lincolnshire was 70.8% (n=121,442), higher than the national average of 69.5% and similar to the East Midlands region (71%).

Flu vaccination (adults aged 65 years & over)

In 2017/18 the uptake of flu vaccination in Lincolnshire (aged 65+) was 72.3% (n=128,613), which is similar to national and regional rates of 72.6% and 73.6%, despite not meeting the ambition to achieve a 75% uptake the Lincolnshire uptake is comparable to other authorities in the East Midlands. Flu vaccinating programmes for older people are influential in reducing excess winter deaths but the effectiveness of a particular strain of vaccine will contribute towards reducing the annual incidences.

Shingles Vaccination 70 year olds (routine)

Lincolnshire shingles vaccination coverage for 70 year olds at 41.9% (n=4,750) is similar to regional (44.0%) and national levels (44.4%) but is below the 60% threshold of vaccination coverage. No areas in England met the 60% vaccination target in 2017/18.

The 2017/18 Public Health England's Herpes Zoster (Shingles) immunisation programme vaccine coverage data reported the percent of GP participation; vaccine coverage by age (70yrs) routine (78yrs) catch up by CCG:

Lincolnshire East (96.3% GP participation, 33.7% routine and 35.9% catch up) Lincolnshire West (93.5% GP participation, 44.3% routine and 50.1% catch up) South Lincolnshire (92.3% GP participation, 52.6% routine and 53.9% catch up) South West Lincolnshire (89.5% GP participation, 45.3% routine and 43.4% catch up) Nationally, averages are (95.4% GP participation, 44.4% routine and 46.2% catch up) showing that 3 of the 4 Lincolnshire CCGs are near or above national average patient participation with Lincolnshire East being the exception.

There are a wide variety of reasons for variation in uptake - deprivation, access, lack of knowledge and misconceptions. The actual reasons in Lincolnshire are still unclear, but there is evidence that low uptake is often as a result of one or more of these factors.

Trends

 

Childhood Immunisation Programme

 

At 12 months

The routine uptake for vaccinations (DTaP/IPV/Hib) at 12 months in Lincolnshire has met the 95% benchmark in 6 out of the last 8 reporting years with 2015/16 and 2017/18 marginally below target. Patient participation in Lincolnshire is above the national averages for all time periods and the participation percentage for England has shown a year on year decline since 2012/13.

The PCV (Pneumococcal Conjugate Vaccine) uptake at 12 months for Lincolnshire is above the national average for all 8 years reported, with the national average showing a year on year decline since 2013/14. Lincolnshire has met the 95% herd immunity target in 4 out of the last 8 years.

A trend for MenC vaccination is not available due to data quality issues.

At 24 months

Uptakes for the PCV (Pneumococcal Conjugate Vaccine) booster and Hib/MenC (Haemophilus Influenza/Meningitis C Infections) booster at 24 months in Lincolnshire have been below the 95% threshold of herd immunity since 2010/11 with the highest uptake reached in 2013/14. A sharp drop-off in uptake occurred in 2014/15. Percentages for the last 3 reporting years closely match national coverage.

With the exception of 2014/15, vaccination uptake for MMR for one dose at 24 months in Lincolnshire has been above the national average. However, all reported years fail to meet the 95% threshold for herd immunity.

The routine vaccination (DTaP/IPV/Hib) uptake at 24 months has met the 95% threshold of herd immunity since 2010/11. However, since 2015/16 the vaccination coverage has been falling and will fail to meet in the 2018/19 target if the recent decline continues.

At 5 years old

Locally and nationally, Hib/MenC (Haemophilus Influenza/Meningitis C Infections) booster uptake at 5 years of age has been below the 95% threshold of herd immunity since 2011/12. In 2014/15 Lincolnshire's coverage dipped to around 2% below the national average and 3% below the East Midlands region and remained so in 2017/18.

Since 2010/11, coverage of MMR (both doses) has been below the herd immunity benchmark of 95%. The Lincolnshire trend has followed, but lagged behind the national vaccination coverage - both of which have been less than 90%.

Since 2015/16 HPV (Human Papilloma Virus) coverage (females aged 12 & 13) has been recorded for two doses. The period 2016/17 showed the lowest coverage and subsequently increased by almost 10% in 2017/18; a further 3% increase will be required to meet the 90% herd immunity target.

Adult Immunisation Programme

PPV (Pneumococcal Polysaccharide Vaccine) in Lincolnshire has shown consistent vaccination coverage at around 70%. This represents almost a 1% improvement over the national average since 2011/12 but does not meet the 75% vaccination target.

Since 2010/11 uptake of flu vaccination in Lincolnshire (aged 65+) has been below the 75% vaccination threshold and the rate has fluctuated approximately in line with the national coverage since 2014/15.

The shingles vaccination coverage for 70 year olds trends in a strongly negative fashion. The 60% target was met in 2014/15 but, in line with the national trend, has fallen year on year with Lincolnshire's 2017/18 coverage value significantly below target at 41.9%.

Key Inequalities

 

Nationally, we know that immunisation uptake is lower in asylum seekers and migrant workers, homeless families (those housed in temporary accommodation), looked after children/children in care (although that is not the case in Lincolnshire where uptake in this group is high), children with physical or learning difficulties, children of teenage or lone parents, children not registered with a GP, younger children from large families and children who are hospitalised. Data specific to Lincolnshire is not currently available.

Generally, uptake is lower in more deprived areas and the gap between immunisation uptake rates in the most and least deprived increases between primary immunisation and boosters. As mentioned previously some work is planned to examine uptake and how it varies by deprivation. This data is currently unavailable.

Influenza is often implicated in winter deaths as it can cause complications such as bronchitis and pneumonia, especially in vulnerable groups such as the elderly. However, relatively few death certificates actually mention influenza. The winter of 2009/10 was the coldest since 1995/96 (Source: The Met Office, 2010), but levels of influenza were relatively low for most of the winter season (Source: Health Protection Agency, 2010).

Current Activity & Services

 

NHS England (NHSE) is responsible for the commissioning of national immunisation programmes, directly supported by Public Health England (PHE) which has the specialist knowledge needed to ensure that this complex area is commissioned and managed safely. The Director of Public Health (DPH) provides independent scrutiny and challenge of the plans of NHSE, PHE and providers; this assurance function is a statutory function of the DPH.

The complete routine immunisation schedule includes the childhood immunisation programmes, immunisations for those at particular risk, older people and the seasonal flu programme.

In Lincolnshire, the majority of immunisations are provided through GP practices. A school-aged immunisation service (delivered through Lincolnshire Community Health Services) is commissioned to deliver the childhood seasonal flu programme, teenage booster and HPV. This offer includes electively home educated children. United Lincolnshire Healthcare Trust (ULHT) delivers neonatal hepatitis B and BCG vaccine.

The Lincolnshire Immunisation Programme Board includes stakeholders involved in delivering, commissioning and assuring immunisation programmes, and provides a mechanism to explore and address issues around the delivery and outputs of, and outcomes for, Lincolnshire programmes. The Lincolnshire Health Protection Board provides additional oversight.

Working in partnership with the local NHSE office and with the Local Medical Council (LMC), Clinical Commissioning Groups (CCGs) and practices, the Local Authority Public Health team are developing strategies to improve the quality of immunisation uptake data and uptake, and to reduce inequalities. An improvement plan around childhood immunisations is now in place in Lincolnshire. A pilot improvement programme focussing on the Boston area in Lincolnshire is planned for 2019/20 including CCGs, NHSE, Lincolnshire Community Health Service (LCHS), and the 0-19 Service. There is also a programme being developed alongside schools to deliver education around the availability and importance of immunisation. The team are also actively engaged in promoting the uptake of the flu vaccine amongst its own staff, frontline health and social care staff and contracted providers.

Unmet Needs & Gaps

 

Hard to reach/ at risk groups:

  • Caravan dwellers and transient communities can be registered with a GP elsewhere so may be missing from local GP data. This is particularly important for flu immunisation.
  • Migrants – gap in the understanding of their needs and how to address them.
  • Antenatal and Hep B immunisation programmes work well but there is a knowledge gap around the numbers of children living in high risk homes. Similarly, with BCG it is unknown how many children are born into high risk families.
  • There is a need to work more with community groups and migrant worker support groups to access hard to reach populations.
  • Transient populations such as caravan dwellers on the East Coast and economic migrants may move around before call/recall.
  • Historical family support such as health visitors help with hard to reach groups and make a big difference. As the health visitor contact has changed there is a perception that there has been a drop in uptake rates in these groups, including a drop in recall successes. The project focusing on the Boston area will look at alternative delivery options utilising the neighbourhood support teams, maternity pathways and the 0-19 Service.

Data Issues

  • We need better quality data in general; data quality issues obscure the real uptake picture. Various immunisation templates are in use across primary care, however there are issues with coding. More communication is needed around coding changes (which affect continuity of care and recall); more training is needed for immunisation staff around inputting/recording data.
  • Examine barriers to information sharing (e.g. data sharing agreements).
  • Children with late immunisations are excluded from the uptake data; the timing of calling letters needs to accommodate time for recall.

General Health Promotion Issues/Challenges

  • Preschool children – children attending nurseries, Surestart Centres etc. could be a key environment for immunisation activities/promotion
  • Improvement in the uptake of childhood immunisations
  • Uptake in the flu vaccine for frontline domiciliary and residential/nursing care staff is low due to access issues.

Local Views & Insights

 

'

Key partner organisations and services include NHSE, PHE, CCGs, GPs, schools, LCHS, and the 0-19 Service, LCHS Child Health Information System, LCC Children’s Services, child care providers, universities, carer organisations, residential/social/nursing care providers, healthcare trusts.

No local public engagement has been undertaken with patients to gather their views.

Risks of not doing something

If vaccination levels fall lower than the national vaccine coverage target there will be a risk of vaccine preventable disease occurring. This will result in vaccine preventable death (VPD).

If herd immunity is achieved i.e. most of the population is vaccinated (around 95% for most vaccines), this raises protection for everyone to almost 100%. However, research suggests that where vaccination is refused each unvaccinated individual remains susceptible to the infection and is likely to have more severe symptoms. The exact rate to achieve herd immunity depends on the disease; in the case of measles, 19 out of 20 people need to be vaccinated to protect the community population. When measles vaccination levels drop below this level, outbreaks and epidemics become more common.

If herd immunity is not achieved, more people will contract a vaccine preventable disease leading to increase in direct and indirect costs. Direct costs include costs of outbreak control, outpatient and inpatient visits and hospitalization. Indirect costs include productivity losses from number of days of work missed for provision of care to sick children or for resulting disability.

Many immunisation services, such as the UK Vaccination Programme, are based around the idea of universal coverage. However, this is never achieved in practice. Coverage may be lower in certain ethnic, socio- economic, religious, or geographical groups, or may vary due to the beliefs of the parents of the children concerned. Increasing coverage in these harder-to-reach populations almost certainly comes at an increased cost (though there is little quantitative information on this). Hence, an alternative strategy could be to ensure high coverage in the remainder of the population, reducing disease in the hard-to-reach groups, via indirect protection (herd immunity). (Source: NICE - The impact of increasing vaccine coverage on the distribution of disease: measles in the UK)

The Vaccine Knowledge Project aims to be a source of independent, evidence based information about vaccines and infectious diseases from a health risk perspective; they also aim to dispel myths that are barriers to uptake.

What is coming on the horizon?

The BMA vaccinations and immunisation guidance provides up to date information on vaccine programmes including specifications, targeted programmes and projected dates for changes to the vaccination programmes.

What should we be doing next?

Work will commence on improving uptake around all vaccination and immunisations. This will include:

  • Looking at ways to address inequalities of access e.g. with traveller communities/transient populations.
  • Improving links with communities to maximise opportunities to promote uptake of national programmes e.g. providing more information to Surestart, nurseries etc.
  • Working with practices on their call and recall systems, including timing of invites, to try and improve uptake/coverage.
  • Assist the LCHS team in helping schools deliver direct education on the availability and importance of childhood immunisations.
  • Continue to develop and deliver an improvement plan for uptake in childhood immunisations, including a focused pilot in the Boston area of Lincolnshire.

 

If you need to contact us about this topic, please email JSNA@lincolnshire.gov.uk

Area Profiles