Childhood Immunisation: Achievements and Challenges

Helen BedfordCentre for Paediatric Epidemiology and BiostatisticsUCL Institute of Child Health, London

London 13th June 2011 GAVI alliance – Pledging conference for immunisation

"vaccines are magic“ Bill Gates, Co- Chair, Bill & Melinda Gates Foundation

"...If ……. we reach or exceed GAVI’s target of $3.7 billion over the next five years…we will protect at least a quarter of a billion children against killer diseases and save 4 million lives " David Cameron

Edward Jenner 1749-1823

Childhood immunisation

• Highly effective intervention • ‘The two public health interventions that have had

the greatest impact on the world’s health are clean water and vaccines’ WHO

• Data from the USA show the 2-dose measles, mumps and rubella vaccination programme saves $3.5 billion for direct costs and $7.6 billion for societal costs

Immunisation is the safest way to protect your baby from very serious diseases such as measles, meningitis, whooping cough and polio.

Measles-2011

• Eliminated from:– Finland 1996– USA 2000– Australia 2008– Significant declines in

Africa-“….measles has now become so uncommon that some younger West African doctors have never seen a single case” (de Groot 2008)

Gillray 1802

1853-British Vaccination Act

• vaccination compulsory for all infants in first 3 months of life

• monetary penalties or imprisonment

• anti-(compulsory) vaccination movement

• opponents to government intrusion on personal autonomy

• 1890s allowed conscientious objection-increased vaccine uptake

• repealed in 1948

Public concerns about vaccines

Multiple sclerosis & Hepatitis vaccineMercury in vaccines & neurological damage

M Multiple vaccines & immune dysfunction

Whole cell pertussis vaccine and neurological damageMMR vaccine & autism and bowel disease

Public concerns about vaccines

–– Tetanus vaccine contaminated with contraceptives

Polio vaccine contaminated with HIV/contraceptives

0

20

40

60

80

100

120

140

160

180

200

1940 1950 1960 1970 1980 1990 2000

Year

Notifi

catio

ns (t

hous

ands

) Vaccine uptake (%)

Whooping cough cases and vaccine coverage England and Wales 1940-2008

Immunisationintroduced

0

100

50

Source: OPCS/DH

Prepared by: CDSC

Case series of 12 children •suspected autism/ autistic spectrum•In 8 onset of symptoms after MMR vaccine•“ We did not prove an association between measles, mumps and rubella vaccine and the syndrome described.”

•“There is sufficient concern in my own mind for a case to be made for vaccines to be given individually at not less than one year intervals.” (A.Wakefield- press conference)

MMR autism and bowel disease

MMR vaccine-autism and bowel disease• 1998-2011-over 13 robust epidemiological studies

– Shifting hypothesis

• Evidence of no link between MMR vaccine autism and bowel disease

• Original ‘research’ discredited and Lancet paper retracted

• Lead author struck off medical register

British Medical Journal-Jan 2011

• Three part series in which investigative journalist Brian Deer provides evidence that ‘MMR scare’ was a fraud.

• No single case of the 12 reported in 1998 paper can be reconciled with the medical records-i.e. facts altered to provide the results wanted.

Measles confirmed cases England and Wales 1996-2011

0

200

400

600

800

1000

1200

1400

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010*

2011**

2010* (provisional data), 2011** (first quarter)

Source: Health Protection Agency 2011

UK Childhood Vaccination Schedule-2011• Vaccines offered routinely mainly in first two years of life

diphtheria, tetanus, polio, pertussis (whooping cough),Haemophilus influenzae type b (five-in-one) meningococcal C, pneumococcal, measles, mumps and rubellaHuman Papilloma Virus vaccine (HPV)-girls only

• Vaccines offered selectivelyBCGhepatitis Binfluenza

• Vaccines being considered by Joint Committee on vaccination and Immunisation (JCVI)

Universal hepatitis BVaricellaRotavirusMeningococcal b

Vaccine Uptake-England 2009-10

12 months of age– 94% DTaP/IPV/Hib x 3

24 months of age– 88% MMR

5 years of age– 85% Pre school booster– 83% MMR x 2

PCT range81%-98%

73%-95%

58%-94%

58%-92%

Source: NHS Information Centre 2011

Immunisation uptake in UK Millennium Cohort Study

• 18,819 children born in the four UK countries 2000-2002

• Interviewed in home-detailed socio-demographic information gathered. Mothers reported their children’s vaccine status

– 9 months-primary vaccine uptake & reasons if not complete (n=18,488)

– 3 years-MMR uptake & reasons if no MMR (n=14,578)

Samad et al. BMJ 2006 332:1312-3 Samad et al Vaccine. 2006; 24:6823-9Pearce et al., BMJ 2008;336:754-7

What do we know about parents whose children are not fully immunised?

• Children unimmunised-(1%) parents usually made active decision-”active rejectors”– Older mothers, more highly educated mothers

• Children with incomplete immunisations-(3%) often access to services is issue-”passive defaulters”– Younger mothers, lone parents, larger families, baby had a least

one hospital admission

Mothers’ reasons for partial and no primary immunisation n=18,488

Mothers’ reasons

Unimmunisedn=228

1%

Partially immunisedn=697 3%

TotalN=925

Beliefs and attitudes

47% (92) 12% (57) 16% (149)

Practical/ accessibility

12% (29) 32% (235) 28% (264)

Medical 33% (84) 45% (328) 44% (412)

Other 8% (23) 11% (77) 10% (100)

Mothers’ reasons for partial and no primary immunisation

• Beliefs and attitudes– “I’ve read up about it and I just don’t like the side effects

and the ingredients in them”

• Accessibility issues – “. . ..transport problems due to having two small children.

. .the surgery is quite far away and they only do the surgery on Wednesdays and I can’t get from the nursery to the surgery easily”

Approaches for parents with accessibility/practical difficulties

• Enhancing access to vaccination services– timing of immunisation sessions– location of immunisation sessions– child and family friendly setting– opportunistic immunisation

• children’s centres• extended schools• GP surgeries• domiciliary• hospitals

Approaches for parents who actively decline immunisation

• May be little that can be done for this group• Repeated reminders may be of little value• Opportunity to discuss concerns and questions with

well informed health professional/s• Provision of more and more information not

necessarily the answer • Information needs to be tailored to respond to

individual’s concerns• Nature of communication is critical• TRUST is pivotal

Approaches for parents who have concerns and questions re immunisation• ?20-30% parents in USA and European countries

accept vaccines while having concerns and questions about vaccines

• Such parents could change their minds about accepting vaccines

• Questions and concerns to be encouraged• Listen to concerns• Build and sustain trust with this group-immunise

them against more extreme views

Internet and social media

• Parents seeking information search the Internet• “University of Google”• Evidence based sound material alongside

anecdote, personal opinion and misinformation• Social media-”Facebook” and “Twitter”-building of

virtual communities-quick to pick up and amplify concerns from other countries

• We have been slower to engage in these forms of communication

The power of the Internet

• Scullard et al 2010. Looked for advice via Google for 5 common paediatric problems-35% of websites searched gave incorrect information re MMR and autism.

• Betsch et al 2010. Viewing vaccine critical material for 5-10 minutes significantly increased perception of vaccine risk and reduced perception of risk of not having vaccine

Should UK resort to the law?

– Few countries have compulsory vaccination– US requirement for children to be immunised before

entering school– States vary in enforcement – exemptions on religious and philosophical grounds– In UK is we have achieved high uptake without need

to legislate-potential to make more parents reject– Maybe a case for excluding unimmunised children

from school in event of an outbreak

Conclusions• Vaccines highly effective• Accessibility remains an issue for some parents• Real challenge is ensuring we develop a better

understanding of public concerns about vaccines• Demand rigorous evidence of safety, efficacy,

technical issues re vaccines• Same level of evidence required re public’s

attitudes and for effective communication strategies

• Build and sustain trust with the public