Childhood Immunisation

If you only read 4 things

1.   “After clean water, vaccination is the most effective public health intervention in the world for saving lives and promoting good health”1
2.    England is a world leader in childhood vaccinations, with one of the most comprehensive immunisation programmes2.
3.    Childhood immunisation data indicates Suffolk achieves the lower threshold of 90% coverage for all key childhood immunisations3, however more needs to be done to meet the World Health Organisation target of 95% coverage.
4.    Although published trend data indicates coverage of key childhood immunisations is declining both nationally and locally3, latest internal data for 2018-19 indicates an increasing trend in vaccination coverage for MMR and DTaP/IPV.

Key information

“After clean water, vaccination is the most effective public health intervention in the world for saving lives and promoting good health”1

Humans are exposed to limitless numbers of diseases and infectious agents throughout life. Immunisation currently prevents 2-3 million deaths every year globally, and is one of the most successful and cost-effective public health interventions4.

Immunisation is essential for the protection of individual and community health. Vaccines enable an individual’s immune system to learn how to fight a disease, and to create antibodies that protect people from diseases when they are exposed to them5. Vaccinations work by imitating an infection or disease which then stimulates an immune response leading to the development of antibodies. These antibodies can then recognise the disease or infection if a person encounters it. The antibodies will fight and destroy the disease or infection therefore protecting an individual from the disease or infection6. The antibodies decrease over time and hence repeat vaccinations called boosters are needed.

Vaccines help to prevent the spread of disease by attempting to achieve ‘herd immunity’. Herd immunity is where a large percentage of a population is vaccinated which creates an environment where diseases are not easily transmitted as there are far fewer people susceptible to infect. This is also important as it helps protect those within a population who may not be able to have the vaccine. High levels of vaccine coverage lead to greater herd immunity and greater protection for all7. This is also known as the collective immunity of a community.

England is a world leader in childhood vaccinations, with one of the most comprehensive immunisation programmes2.  Individuals can be vaccinated against diseases and viruses throughout life and for a variety for reasons (for example foreign travel).  However, immunisation during childhood is vital, as it helps provide a child with the best start in life.  It can take up to two years for the immune system to be fully developed8, so protecting a child early on is crucial for healthy development.

Childhood immunisation

There are a number of childhood vaccinations that are given by the NHS, for more detail see Appendix 1.

Table 1: Vaccines given to children under 1 year old

Age

Vaccine

8 weeks

6-in-1 vaccine
Pneumococcal (PCV) vaccine
Rotavirus vaccine
MenB

12 weeks

6-in-1 vaccine (2nd dose)
Rotavirus vaccine (2nd dose)

16 weeks

6-in-1 vaccine (3rd dose)
Pneumococcal (PCV) vaccine (2nd dose)
MenB (2nd dose)

Source: 9

Table 2: Vaccines given to children aged 1-15

Age

Vaccine

1 year

Hib/MenC (1st dose)
MMR (1st dose)
Pneumococcal (PCV) vaccine (3rd dose)
MenB (3rd dose)

2 to 10 years

Flu vaccine (every year)

3 years and 4 months

MMR (2nd dose)
4-in-1 pre-school booster

12 to 13 years


HPV vaccine

14 years

3-in-1 teenage booster
MenACWY

Source: 9

The European region of the World Health Organization (WHO) currently recommends that on a national basis at least 95% of children are immunised against diseases preventable by immunisation and targeted for elimination or control (specifically, diphtheria, tetanus, pertussis, polio, Hib, measles, mumps and rubella).90% coverage is considered a lower threshold, and although it is used in the Fingertips data (presented below) 95% coverage is the core target worked towards.

Population vaccination coverage is the best indicator of the level of protection a population will have against vaccine preventable communicable diseases. Coverage is closely correlated with levels of disease. Monitoring coverage identifies possible drops in immunity before levels of disease rise10.

The numbers

Public Health England (PHE) data indicates that, although coverage remains high, children’s vaccine uptake has been slowly decreasing since 2012-13. This means some children have missed out and may remain vulnerable to serious or even fatal infections that are vaccine-preventable2.

The following section identifies Suffolk trends for childhood vaccinations.  Summary data is provided in Figure 1, and shows that for all key vaccinations, Suffolk achieves the lower threshold target of 90% coverage, however there is room for improvement in childhood immunisation coverage to ensure consistent immunisation coverage of 95% and above. This data refers to 2017-18 and we regularly monitor the most up to date data working with our colleagues in Public Health England.

Figure 1: Summary vaccination data for Suffolk and Areas in the East of England

Table showing Suffolk vaccination coverage is in line with or better than England

Source: 3

Dtap/IPV/Hib

The combined DTaP/IPV/Hib is the first in a course of vaccines to protect against: diphtheria, pertussis (whooping cough), tetanus,haemophilus influenzae type b (an important cause of childhood meningitis and pneumonia), polio (IPV is inactivated polio vaccine).

Babies can catch these serious diseases from birth, it's important to protect them as soon as possible. The DTaP/IPV/Hib vaccine is usually given to babies at 8, 12 and 16 weeks of age.

Figure 2: Population vaccination coverage - Dtap / IPV / Hib (1 year old) 2017/18

graph and table showing the population vaccination coverage for Dtap/IPV/Hib for Suffolk is higher than England, however latest data is below 95% (no better than the England average)

Source: 3

This figure above represents children for whom the local authority is responsible who received 3 doses of DTaP/IPV/Hib vaccine at any time by their first birthday. This graph shows that the population vaccination coverage for Dtap/IPV/Hib for Suffolk is higher than England, however latest data indicates that coverage is lower than 95% which has not been seen previously. Trend data shows a significant decrease in coverage compared to 2012/13, mirroring national trends.  

Figure 3: Population vaccination coverage - Dtap / IPV / Hib (2 years old) 2017/18

Graph and table over time showing Suffolk is above the national average for Dtap/IPV/Hib vaccines for children age 2

Source: 3

This information refers to all children for whom the local authority is responsible who received 3 doses of DTaP/IPV/Hib vaccine at any time by their second birthday. The graph above shows that Suffolk is above the national average for Dtap/IPV/Hib vaccines for children age 2, and consistently achieves >95% vaccination coverage.  However, this is an area that will need to be closely monitored, as compared to the peak coverage in 2013-15, coverage has significantly fallen.

Clinical Commissioning Group (CCG) data indicates that every CCG within Suffolk is at least meeting or exceeding the minimum target of 90% coverage3.

2018-19 data update

The latest available internal data (not yet published on Fingertips), indicates that the proportion of children receiving the DTaP/IPV booster at 5 years is increasing (see table 1 below).  Although there is room for further improvement to reach 95% coverage, this is promising trend data.

Table 1: COVER data for Suffolk , 2018-19

2018-19 Suffolk data

Q1

Q4

% CHANGE

DTaP/IPV Booster at 5 yrs

86.0%

89.5%

+3.5%

Source: 11

Meningitis C (MenC) vaccination

The meningococcal C conjugate (MenC) vaccine protected against infection by meningococcal group C bacteria, which can cause meningitis and septicaemia. In July 2016 the MenC vaccine at 3 months was halted and replace by a new immunisation schedule. In the new immunisation schedule, babies get their first dose of MenC vaccine at 12-13 months of age through the combination Hib/MenC vaccine, and then receive a booster dose at 13-14 years of age as part of the MenACWY vaccine12

Haemophilus Influenza Type B (Hib) / Meningococcal group C (MenC) booster

The Hib / MenC booster increases the protection a child gets from the first course of Hib vaccine when they are 8, 12 and 16 weeks old (the 6 in 1 vaccination), and the MenC vaccine when they area year old . This boosted immunity lasts into adulthood.

Figure 4: Population vaccination coverage – Hib/MenC booster (2 years old)

Graph and table showing Suffolk has a higher vaccination coverage rate for Hib/MenC compared to England (at 2 years old), but the difference is not significantSource: 3

This data contains insight on all children for whom the local authority is responsible who received a booster dose of Hib/MenC vaccine at any time by their second birthday. The data above indicates that Suffolk has a higher vaccination coverage rate for Hib/MenC compared to England (at 2 years old). However, there has been a significant decrease in coverage from 2016/17 to 2017/18 only reaching an average value of 92.9% in 2017/18, which dropped from 94.5% in 2016/17.

Figure 5: Population vaccination coverage – Hib/MenC booster (5 years old)

Graph and table showing Suffolk's population vaccination coverage of Hib/MenC booster (5 years old) is in line with the England average

Source: 3

This data refers to all children for whom the local authority is responsible who received a booster dose of Hib/MenC vaccine at any time by their fifth birthday. The data shows that Suffolk are achieving levels of coverage that are comparable to the overall England values, with coverage of 93.6% in 2017/18.  Although trend data indicates coverage in Suffolk has increased, there is room to improve this further.

Pneumococcal conjugate vaccine (PCV)

The PCV vaccine protects against pneumococcal infections that can cause pneumonia, septicaemia or meningitis. The PCV vaccine is given to all children under two years old as part of the childhood vaccination programme. Infants usually receive 3 injections given at: 8 weeks, 16 weeks and 1 year old (booster).

Figure 6: Population vaccination coverage – PCV

Graph and table showing Suffolk's population vaccine coverage for PCV over time has stayed above the England average

Source: 3

This data represents all children for whom the local authority is responsible who completed a course of PCV vaccine at any time by their first birthday. This highlights that Suffolk’s population vaccine coverage for the PCV vaccine is higher than the national average, and has exceeded 95% coverage consistently for the last 6 years.

PCV Booster

Figure 7: Population vaccination coverage - PCV booster

Graph and table showing the percentage of children in Suffolk receiving the PCV booster is not significantly better (higher) than England as a whole.Source: 3

The data is representative for all children for whom the local authority is responsible who received one dose of MMR on or after their first birthday. The trends suggest that Suffolk have significantly increased the vaccine coverage from below the benchmark in 2010/11 with an average coverage of 89.4% to 93.3% in 2017/18 and has consistently remained above England coverage from 2011/12. However, there is still room to improve coverage for the PCV booster, as this has never met or exceeded 95%.

Additionally, although coverage in 2017/18 was above the benchmark target (90%), in comparison with data from 2016/17, coverage has significantly decreased.

Measles, mumps and rubella (MMR)

MMR is the combined vaccine that protects against measles, mumps and rubella. Measles, mumps and rubella are highly infectious, common conditions that can have serious complications, including meningitis, swelling of the brain (encephalitis) and deafness. They can also lead to complications in pregnancy that affect the unborn baby and can lead to miscarriage.

The first MMR vaccine is given to children as part of the routine vaccination schedule, usually within a month of their first birthday. They'll then have a booster dose before starting school, which is usually between three and five years of age.

Figure 8: Population vaccination coverage: MMR (2 years old)

Graph and table showing the percentage MMR vaccination coverage in Suffolk is not significantly better than England as a whole.Source: 3

This data is representative for all children for whom the local authority is responsible who received one dose of MMR on or after their first birthday and at any time up to their second birthday. Suffolk has significantly increased the vaccine coverage from below the benchmark in 2010/11 with an average coverage of 88.9% to 92.9% in 2017/18. Although coverage in 2017/18 is above the benchmark target, in comparison with data from 2016/17 has significantly decreased, coverage remains below 95% indicating room for further improvement.

Data is available at CCG level for this vaccination. There is variation at CCG level, with coverage of only 91.8% in Great Yarmouth and Waveney, compared to 93.9% in Ipswich and East Suffolk and 92.9% in West Suffolk.

MMR 2 doses (5 Years old)

Figure 9: Population vaccination coverage: MMR two doses (5 years old)

Chart and table showing Suffolk's population vaccination coverage of MMR 2 doses is not significantly better than England as a whole.

Source: 3

This data is representative for all children for whom the local authority is responsible who received two doses of MMR on or after their first birthday and at any time up to their fifth birthday. Data for two doses of MMR vaccine at 5 years old shows a slower increase in coverage rate, with coverage not exceeding 90% until 2013/14.  Coverage has fallen to 90.0% from a peak of 92.6% in 2014/15.  This is an area that needs further monitoring.

MMR 1 dose (5 years old)

The full course of MMR vaccination requires 2 doses. However, children up to the age of 18 who missed, or only partially completed, their earlier MMR vaccination can have a "catch-up" MMR vaccination on the NHS13.  

Figure 10: Population vaccination coverage: MMR one dose (5 years old)

Chart and table showing coverage of the MMR 1 dose vaccine is increasing and is significantly higher than for England as a whole.Source: 3

This data is representative for all children for whom the local authority is responsible who received one dose of MMR on or after their first birthday and at any time up to their fifth birthday. Latest data indicates a higher coverage rate compared to England (96.2% vs 94.9%), but historically this has been variable.  Trend data for Suffolk shows increasing coverage since 2010/11.

2018-19 data update

The latest available internal data (not yet published on Fingertips), indicates that Suffolk is bucking the trend of decreasing MMR vaccination coverage, increasing for both 1 dose at 24 months (2 years) and having both doses by 5 years old (see table2 below).  Although there is room for further improvement to reach 95% coverage, this is promising data.

Table 2: COVER data for Suffolk , 2018-19

2018-19 Suffolk data

Q1

Q4

% CHANGE

MMR 1 at 24 months

91.9%

94.5%

+2.6%

MMR 2nd Dose at 5 yrs

87.6%

90.3%

+3.7%

Source: 11

Flu

The children's flu vaccine is a yearly nasal spray given to young children to help protect them against flu, its important as complications of flu can be serious and include bronchitis and pneumonia14.

In the autumn/winter of 2019/20, the vaccine will be available free on the NHS for eligible children, including14:

  • Children aged 2 and 3 on 31 August 2019 – that is, children born between 1 September 2015 and 31 August 2017, Children who are 4 years old are also eligible for flu vaccination provided they were 3 on 31 August 2019. 
  • All primary school children.
  • Children aged 6 months to 17 with long-term health conditions.
  • Children who are home educated will also be offered the vaccine, provided they are in an eligible age group.

Figure 11: Population vaccination coverage: Flu (2-3 years old) current method

Graph and table showing Suffolk's vaccination coverage for flu in 2-3 year old children over time is not significantly better than England as a wholeSource: 3

Vaccination coverage for flu in 2-3 year old children in Suffolk is higher than England value.  Trend data indicates a significant increase in coverage in 2017/18 compared to 2014/15. There is room to improve coverage further.

What are we doing?

  • Akin to nationally, children in Suffolk are offered vaccinations against a variety of diseases as part of the Healthy Child Programme15. A record is kept in the Parent Held Child Health Record (Red Book), which is a book containing information on a child’s health.
  • A Suffolk project was launched in December 2018 to increase the uptake of the MMR as well as the pre-school booster. The group was established with Public Health Suffolk, NHS England and Improvement, Public Health England, Suffolk Clinical Commissioning Groups and Child Health Information Service to identify and remove potential barriers for parents and children in accessing immunisation services. They have also improved the quality of vaccination data and encouraged parents to consider the preschool booster/MMR just prior to school entry.
  • Suffolk provides information around the immunisation programmes to parents and carers in Suffolk. Previous evidence indicates that highlighting vaccination programmes encourages improvements in uptake levels.
  • The School Age Immunisation Service in Suffolk is run by Cambridgeshire Community Services NHS Trust’s Children and Young People’s Health Services teams16. The team works in a variation of educational settings together with independent schools, Pupil Referral Units and community clinics. Vaccinations and immunisations currently offered by the service include:
    • HPV immunisations for females only: 1 dose in year 8 and 1 dose in year. 
    • From 1st September 2019, the HPV will also include boys aged 11-13 as part of the vaccination schedule.
    • Meningitis C vaccination programme for all year 10 children.
    • Annual seasonal Flu vaccination programme to a specific year group as directed by Public Health England.
    • Immunisation nurses would also assist in any community outbreak where vaccinations can be used17.

What more could be done?

  • Childhood immunisations are not mandatory in England, however they are an effective way to keep a child as protected as possible. 
  • Although coverage is generally high for all of the routine childhood immunisations, trend data indicates that this coverage may be falling.
  • Certain vaccinations still have a stigma attached to them.  For example, the MMR controversy that erroneously linked MMR vaccinations and autism13.   This may still have an effect on coverage rates, and further promotion of why vaccination is beneficial may be required.
  • We need to combat the misinformation from anti vaccination campaigners that can put children’s’ life at risk.

Recommendations

  • Encourage and promote childhood vaccinations locally, in order to prevent declines in coverage.
  • Help to signpost parents and caregivers to resources that give further information about vaccinations given on the NHS and their benefits. For example: https://www.nhs.uk/conditions/vaccinations/nhs-vaccinations-and-when-to-have-them/
  • Services that offer immunisation procedures should provide a wide range of information, including leaflets, posters, videos, information packs, factsheets, and websites to support all aspects of the immunisation programme.
  • Encourage all parents and carers to take their ‘red book’s to immunisation, so that they can keep an up to date record of their child’s immunisation history.

Useful Links

Appendix 1: Vaccine Timeline

  • 6-in-one Vaccine: Protects against diphtheria, tetanus, whooping cough, polio, Hib (Haemophilus influenzae type b) and hepatitis B. Given at: 8, 12 and 16 weeks of age to all babies born on or after 1 August 2017.
  • Pneumococcal or pneumo jab (PCV): Protects against some types of pneumococcal infection Given at: 8 weeks, 16 weeks and 1 year of age
  • Rotavirus vaccine: Protects against rotavirus infection, a common cause of childhood diarrhoea and sickness. Given at: 8 and 12 weeks of age
  • Men B vaccine: Protects against meningitis (caused by meningococcal type B bacteria). Given at: 8 weeks, 16 weeks and 1 year of age
  • Hib/Men C vaccine: Protects against Haemophilus influenzae type b (Hib) and meningitis caused by meningococcal group C bacteria. Given at: 1 year of age
  • MMR vaccine: Protects against measles, mumps and rubella. Given at: 1 year and at 3 years and 4 months of age
  • Children's flu vaccine: Protects against flu. Given at: annually as a nasal spray in Sept/Oct for all children aged 2 to 9 years on 31 August 2018
  • 4-in-1 pre-school booster: Protects against diphtheria, tetanus, whooping cough and polio. Given at: 3 years and 4 months of age
  • HPV vaccine: Protects against: cancers caused by HPV viruses including cervical cancer. Given at: 12-13 years as 2 injections at least 6 months apart
  • 3-in-1 teenage booster: Protects against tetanus, diphtheria and polio. Given at: 14 years
  • MenACWY vaccine: Protects against meningitis (caused by meningococcal types A, C, W and Y bacteria). Given at: 14 years and new university students aged 19-25 18.

There are other vaccines available that are optional; these are offered on the NHS in addition to the routine programme to "at-risk" groups of babies and children:

  • Chickenpox vaccination Protects against chickenpox. Siblings of children who have suppressed immune systems and are susceptible to chickenpox, for example because they're having cancer treatment or have had an organ transplant would be required to receive this vaccination. Given from 1 year of age upwards. Children receive 2 doses of chickenpox vaccine given 4 to 8 weeks apart.
  • BCG (tuberculosis) vaccination: Protects against tuberculosis (TB). Babies and children who have a high chance of encountering tuberculosis need this vaccine. Given from birth to 16 years of age.
  • Flu vaccination: Protects against flu. Those in need are children aged 6 months to 2 years and those aged 9 to 17 who have certain medical conditions or a weakened immune system, which may put them at risk of complications from flu. (All children aged 2 to 8 years are given the flu vaccine as part of the routine immunisation schedule.) Given: for children between the ages of 6 months and 2 years as a single jab every year in September/November. For children aged 9 to 17 years of age who are in an at risk group, as a nasal spray every year in September/November.
  • Hepatitis B vaccination: Protects against hepatitis B. Children at high risk of exposure to hepatitis B, and babies born to infected mothers require this vaccine. Given: as 6 doses over 12 months – a baby born to a mother infected with hepatitis B will be given a dose at birth, followed by further doses at 4, 8, 12 and 16 weeks of age, and a final dose at 1 year old 18.

References

1.            Yarwood J. Why vaccinate? Public Health Matters, Public Health England. https://publichealthmatters.blog.gov.uk/2014/05/01/why-vaccinate/. Published 2014. Accessed August 16, 2018.

2.            Kassianos G, Ramsay M. Increasing vaccine uptake: Strategies for addressing barriers in primary care. Public health matters. https://publichealthmatters.blog.gov.uk/2019/05/16/increasing-vaccine-uptake-strategies-for-addressing-barriers-in-primary-care/. Published 2019. Accessed August 13, 2019.

3.            Public Health England. Fingertips -Child and Maternal Health - Vaccines and Immunisations (August 2019). https://fingertips.phe.org.uk/profile/child-health-profiles/data#page/1/gid/1938133237/pat/6/par/E12000006/ati/102/are/E10000029. Published 2019. Accessed August 13, 2019.

4.            World Health Organization. Immunization Coverage. World Health Organization (WHO). https://www.who.int/news-room/facts-in-pictures/detail/immunization. Published 2019. Accessed August 13, 2019.

.            NHS. Why vaccination is safe and important. https://www.nhs.uk/conditions/vaccinations/why-vaccination-is-safe-and-important/. Published 2019. Accessed August 16, 2019.

6.            National Health Service (NHS). How Vaccines Work.

7.            Anderson RM, May RM. Vaccination and herd immunity to infectious diseases. Nature. doi:10.1038/318323a0

8.            Public Health England. Childhood Vaccination What you need to know. https://publichealthengland.exposure.co/childhood-vaccination. Published 2018. Accessed August 13, 2019.

9.            NHS. NHS vaccinations and when to have them. https://www.nhs.uk/conditions/vaccinations/nhs-vaccinations-and-when-to-have-them/. Published 2019. Accessed August 13, 2019.

10.          fingertips. Childhood Immunity. Public Health England.

11.          Public Health Suffolk. COVER Immunisations Data 2018/19 (Internal data).

12.          Loving S. Changes to the MenC vaccination schedule. http://vk.ovg.ox.ac.uk/menc-changes. Published 2016. Accessed August 14, 2019.

13.          NHS. MMR vaccine overview. https://www.nhs.uk/conditions/vaccinations/mmr-vaccine/. Published 2018. Accessed August 14, 2019.

14.          NHS. Children’s flu vaccine overview. https://www.nhs.uk/conditions/vaccinations/child-flu-vaccine/. Published 2019. Accessed August 16, 2019.

15.          Ipswich and East Suffolk CCG. Immunisations. http://www.ipswichandeastsuffolkccg.nhs.uk/Yourhealth/Childhealth05/Generalwelfare/Immunisations.aspx. Published 2019. Accessed August 16, 2019.

16.          Suffolk County Council. School Age Immunisation Service. https://www.suffolk.gov.uk/children-families-and-learning/childrens-health/school-age-immunisation-service/. Published 2019. Accessed August 16, 2019.

17.          Suffolk County Council. School Age Immunisation Service.

18.          National Health Service (NHS). Childhood vaccines timeline.

 

 

 

 

 

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