Marina Conyn-van SpaendonckCentre for Infectious Disease Control

Immunisation Policy in the Netherlands

DG Sanco Workshop Vaccination Strategy | February 13-14, 2008

Immunisation in the Netherlands

• National Immunisation Programme• National Programme Influenza Prevention• Vaccination programme for risk groups:

• hepatitis B: MSM, drug users• BCG for immigrant children

• Immunisation of travellers

Centre for Infectious Disease Control

National Immunisation Programme since 1957

• not mandatory, free of charge• delivered to neonates and toddlers through healthy

baby clinics; to 4-year and 9-year-olds through public health services, often in mass campaigns / immunisation days

• individual invitation and reminders if needed• centrally registered• centrally directed public programme

Vaccination Coverage• >95%• pockets of low coverage

in the so-called bible belt: orthodox reformed peoplerefusing vaccination forreligious reasons (in total± 200,000)

• resistence fromantroposophics, homeopathics and alternative medicine

Centre for Infectious Disease Control

National Immunisation Programme anno 2008

DT-IPV-6 + MMR-2DT-IPV-6 + MMR-29 year

DTP-IPV-5DTP-IPV-5 4 year

MMR-1 + MenCMMR-1 + MenC14 mnth

DTP-IPV-Hib-hepB-4 + Pneu-4DTP-IPV-Hib-4 + Pneu-411 mnth

DTP-IPV-Hib-hepB-3 + Pneu-3DTP-IPV-Hib-3 + Pneu-34 mnth

DTP-IPV-Hib-hepB-2 + Pneu-2DTP-IPV-Hib-2 + Pneu-23 mnth

DTP-IPV-Hib-hepB-1 + Pneu-1DTP-IPV-Hib-1 + Pneu-12 mnth

hepB-0-0 mnth (< 48 uur)

target group hep B onlygeneral immunisationsage

Hib in 1993; Men C in 2002; hepatitis B: target group (children of HBsAg+ mothers, children of parents from high-endemic countries ±15%) in 2006; hep B 0 mnths for children of HBsAg+ mothers added in 2007, pneumococci in 2006, .... HPV? varicella? influenza?

Unrestricted possibilities for vaccination?

The future of the National Immunisation Programme

• Safe and effective• Cost-effective

balance

meticulessness ↔ decisiveness

Expansion of the Immunisation Programme: what stakes?

• Health gains• Interest of individual versus group / population• Acceptation, vaccine coverage• Fit into the programme: logistics• Costs• Credibility of authorities• Pharmaceutical companies

Decision making process in the Netherlands

• RIVM informs Health Council and Ministry of Health on the

possible impact of a vaccine through surveillance, modelling,

scenario analysis, cost-effectiveness studies

• Health Council advises the Minister of Health based on the

state of science

• MoH decides on introduction of a vaccine in the NIP

• Netherlands Vaccine Institute: vaccine production, tender /

purchase of vaccine

• RIVM direction, implementation, evaluation of NIP

HPV vaccination in the NIP? - focus on cervixcarcinomaCurrent planning:

• End of March: advice of the Health Council to MoH• April: decision of Minister of Health

In anticipation MoH, RIVM and NVI prepare forthe possible inclusion of HPV-vaccination in the NIP.

• HPV in NIP for 12-year-old girls?• Catch-up campaign for 13-16 or 13-18-year-old girls?• Immunisation days

HPV in the NetherlandsProgrammatic screening cervixca. since 1976, coverage 75%

Measles age-specific seroprevalence 0-79 years (1995)

0

10

20

30

40

50

60

70

80

90

100

0- 1- 5- 10- 15- 20- 25- 30- 35- 40- 45- 50- 55- 60- 65- 70- 75-

%

national sampleorthodox reformed lvcnon-orthodox reformed lvc

Measles• 1999-2000 outbreak in the bible belt : 3292 cases (0.21 per

1000 inhabitants), 519 with complications of which 3 deceased, 72 hospitalised

→ Risk for not orthodox reformed neighbouring neonates not yetvaccinated; additional MMR immunisation at 9 months?

• Next outbreak anticipated• Surveillance protocol: rash disease, non-invasive

procedures (PCR urine, saliva, nasopharyngeal swab) orless invasive (capillary bleeding, serology)

• Plan for investigation: attack rates according to vaccinationstatus, number of doses, time since vaccination; correlatesof protection

Rubella notifications, the Netherlands, 1952-2006

0

2.000

4.000

6.000

8.000

10.000

12.000

1952 1957 1962 1967 1972 1977 1982 1987 1992 1997 2002

Jaar

Aant

al a

angi

ften

selective rubella vaccination11 year-old girls

universal rubella vaccination: boys and girls, 14 mnth, 9 yr

Surveillance: notifications of rubella 2004/2005effective immunisation programme forms a threat to

non-vaccinated groups due to shift in age distribution?

37 41 45 49 53 3 7 11 15 19 23 27 310

20

40

60

80

num

ber o

f cas

es

week

Netherlands

Orthodox Reformed people, MMR vaccination coverage, rubella outbreak in 2004

Rubella outbreak in 2004-2005 in the Netherlands

Rubella infections 387of which pregnant women 32resulted in:Intra-uterine fetal death 2congenitale rubella syndrome CRS 11congenital rubella-infections CRI 3

Restricted to orthodox reformed groups objecting to vaccination

Rubella outbreak in Canada following outbreak in the Netherlands (notifications 2004/2005)

37 41 45 49 53 3 7 11 15 19 23 27 310

20

40

60

80

num

ber o

f cas

es

week

CanadaNetherlands

0.01

RVi/Linging.CHN/00RVi/Dangshan.CHN/00

RVi/Toyama.JPN/67RVi/EinVered.ISR/92

Isolate INS (Germany 1995)RVi/Gouda.NET/15.05 RVi/Ontario.CAN/27.05

RVi/PAN/99RVi/SLV/02

RVi/Los Angeles.USA/91RVi/Moscow.RUS/67

RVi/Moscow.RUS/97RVi/TelAviv.ISR/68

RVi/Anqing.CHN/00/2RVi/Seattle.WA.USA/16.00RVi/Beijing.CHN/79

RVi/BEL/63RVi/NJ.USA/61

RA 27/3 vaccine strainRVi/Tiberias.ISR/88

RVi/Jerusalem.ISR/75RVi/Beneberak.ISR/79

RVi/Saitama.JPN/94RVi/Dezhou.CHN/02

RVi/MYS/01RVi/Tokyo.JPN/90

RVi/DalyCity.CA.USA/97

Geno group 2(A,B,c)

Geno group 1(a,B,C,D,E,F,g)

Tipples et al. 2005Van Binnendijk et al. 2005

1F

1C

1a1g

1E

1B

1a

1D

1D

RVi/Beijing.CHN/80

2B

2A

2c

Surveillance through molecular-biology of strainsFylogenetic analysis of Dutch / Canadian rubella outbreak

Concluding remarks on the NIP in the Netherlands• Public programme

• central direction, individual invitation (based on pop. registry), reminders and registration

• support with extensive communications: protocols, leaflets, newletters etc.

• continuous surveillance of and reporting on target diseases, adverse events, population's immunity

effective approach → high vaccination coverage

• Opponents: • orthodox reformed people - known, stable, nearly impossible

to influence; • antroposofics, homeopathics etc – impact less known, more

diffuse → herd immunity; growing group?

• What are the consequences of expanding the NIP with HPV, hepatitis B, influenza, varicella, ...

National Programme Influenza Prevention

• target group:chronic conditions of heart, lung or kidney, immunocompromised patients and patients with diabetes, orage > 65 year (next season > 60 year)

• not mandatory, free of charge• delivered in primary care through general practitioners and in

nursing homes• vaccine made available by Netherlands Vaccine Institute• programme co-ordination by RIVM• coverage 76% in primary care, 90% in nursing homes