Immunisation policy

Dr Rosemary LesterAsst Director, Health ProtectionCommunicable Disease Prevention and Control Unit & Deputy Chief Health OfficerDepartment of Health

Immunisation Policy

National Immunisation Program

–Program of vaccines delivered at no cost to the population

–Extends from birth to old age

–Collaborative agreement between Cwlth and states/territories

Role of NHMRC

–Publish recommended immunisation schedule and handbook (on advice from Australian Technical Advisory Group on Immunisation (ATAGI))

–changes according to new vaccines, new combinations, changing epidemiology of disease, cost effectiveness assessment

Immunisation Policy

Role of ATAGI

Determine whether vaccine is suitable for NIP, PBS etc based

on efficacy, epidemiology of disease, whether population based immunisation will lead to additional positive outcomes for the community, eg herd immunity effect

Write handbook for endorsement by NHMRC

Role of PBAC

Take ATAGI recommendation and perform cost-benefit analysis

Make recommendation to Australian government as to whether fits cost-benefit criteria for NIP or PBS.

Immunisation Policy

National Immunisation Committee

Australian Government

States and Territories

Local government

RACGP

ADGP

Role is to implement the NIP

Australian Government

Policy development

central co-ordination and secretariat services to NIC

encourage research

report to the Health Minister and AHMAC

Funding

Vaccines

Some service delivery

Part ACIR notification payment

Parent and GP incentive payments

Australian Government

Immunisation Hotline 1800 671 811

http://immunise.health.gov.au/

Education and Research

National Centre for Immunisation Research & Surveillance of

Vaccine preventable diseases

www.ncirs.usyd.edu.au

National Immunisation Program (NIP) 1 July 2011

• birth hepatitis B

• 2 months DTPa/IPV/Hib/hep B, 13vPCV, ORV

• 4 months DTPa/IPV/Hib/hep B, 13vPCV, ORV

• 6 months DTPa/IPV/Hib/hep B, 13vPCV, ORV

• 12 months MMR, Hib, MenC

• 18 months varicella

• 4 years DTPa/IPV, MMR

National Immunisation Program (NIP) 1 July 2011

• 10-13 years hepatitis B, varicella, HPV (girls

only)

• 15-17 years dTpa

• 50 years ADT

• adults 65+ influenza (every year)

pneumococcal

States and Territories

• implement the National Immunisation Program

• allocate funds for free vaccine in efficient and effective

manner

• ensure services equitable, acceptable and appropriate

to the population

• Provide funding to local government to conduct

immunisation – both fee for service and incentive

payments

• appropriate management systems

States and Territories (cont.)

• purchase and provide vaccines to all immunisation

providers

• establish vaccine distribution system which maintains

cold chain standards

• surveillance of

– immunisation coverage (ACIR, school

coverage)

– incidence of VPD’s (including

outbreak investigation)

States and Territories (cont.)

• surveillance of

vaccine wastage levels

adverse events following immunisation

• liaise with the Australian Government through the NIC

• develop regional targets for immunisation coverage

Immunisation in Victoria

• Immunisation is provided by:

local government (pre-school) 45%

– Community sessions

– small number M&CH nurses

– School based 90%

general practitioners 50% under school age

others eg.hospitals, Aboriginal Health Services 5%

General practitioners vast majority of vaccines in older adults

Immunisation in local government

• Legislative framework

Public Health and Wellbeing Act 2008

non-delegable statutory obligation on Victorian councils

• “The function of every council under this Act is to seek to prevent diseases......through organised programs....by co-ordinating and providing immunisation services to children living or being educated within the municipal district”

• All local governments provide immunisation services for under school age children, and school based programs in secondary schools.

School entry certificate

• school entry immunisation status certificate is required

to be produced on entry to primary school

• Can be issued by local government, medical

practitioner or any immunisation provider

• ACIR Child History statement is accepted as an

immunisation status certificate

Australian Childhood Immunisation Register (ACIR)

• enrolment via Medicare, children 0-6 years

• data on child, vaccine/s, provider

• payment $6 per completed immunisation encounter

• cost shared between Australian Government/States

Australian Childhood Immunisation Register (ACIR)

• immunisation program evaluation

• measure coverage in terms of national goals and

targets

• assist with opportunistic immunisation

• child history statements

5 year old statement acts as the SEIC in Victoria

Immunisation coverage

Immunisation coverage Victoria

12 months 91.6% (rank 3)

2 years 93.4% (rank 2)

5 years 91.1% (rank 1)

Source ACIR (30 June 2011)

Immunisation coverage 1999 -2010

ACIR coverage data Victoria 1999 to 2010

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Year

Perc

en

tag

e c

overa

ge

12-<15 months

24-<27 months

72-<75 months

60-<63 months

Immunisation coverage - indigenous

Immunisation coverage - indigenous

12 months 84.1% (rank 5)

2 years 93.0% (rank 3)

5 years 86.5% (rank 5)

Source ACIR (30 June 2011)

Improving Victoria’s program

New immunisation strategy 2009-2012

Key action areas

Whole of life immunisation

– Advocate for WoL register

– Improve data and coverage for key groups, eg older adults

Immunisation of high risk groups

– Occupational groups, eg HCWs, carers of elderly

– ATSI people, chronic medical conditions, juvenile justice/prisoners

– Address inequalities and gaps

Service quality

– Cold chain

– Right vaccine at right time

Immunisation strategy

• Public communication and participation

Public communication campaigns, including culturally relevant

Support consumer involvement and advocacy

• Partnerships

Encourage regional partnerships between providers, eg local

government, GPs, AMS

Stakeholder conference & recognition

• Research and development

Local research priorities, especially best practice service

delivery

SAEFVIC

Surveillance of Adverse Events Following Vaccination In

the Community (SAEFVIC)

Rationale:

Promote community confidence in immunisation

Rapidly detect & research vaccine safety concerns

Monitor & feedback adverse events local/nationally

Broad referral service

– Infants and children

– Adolescents and adults

Timely follow up and feedback for the reporter and the public

SAEFVIC

Enhanced passive reporting system

RCH lead agency for SAEFVIC

Referral service to:

• Royal Children’s Hospital – child AEFI

• VIDS - Royal Melbourne Hospital – adult AEFI

• Monash Medical service – child/adult AEFI

Question

• You are the newly appointed immunisation co-ordinator

for your local shire council

How would you go about setting up and monitoring

the immunisation program?

Some ideas

Current immunisation coverage?

Current incidence of VPDs?

Immunisation providers – your council immunisation

nurses, MCH nurses, GPs, local hospital?

Geographic accessibility of sessions?

Community “feel” of sessions?

Equipment for vaccine storage, administration, consent,

recording, reporting to ACIR

Adverse events management and reporting

Some ideas

Evaluation of sessions – consumer feedback

Evaluation of sessions – coverage achieved

Process for following up overdue children?

School immunisation certificates – process to check?

School immunisation- relationship with schools

Invasive Meningococcal Disease

Meningococcal C vaccine

• Meningococcal C conjugate vaccine

• Given as single dose at 12 months

• Phase 1 commenced 1 January 2003

Children 1 to 5 years

Adolescents 15 to 19 years

• Phase 2 commenced 1 July 2003

Children 6 to 14 years

Meningococcal disease

Confirmed and probable invasive meningococcal disease notifications by serogroup,

Victoria, 1995 to 2011

0

50

100

150

200

250

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Year of notification

Nu

mb

er

of

no

tifi

ed

ca

se

s

Unknown

29E

Group Y

Group W135

Group C

Group B

Group A

MenCCV for 1-5 &

15-19 years

(Jan 2003)

MenCCV for

6-14 years

Pneumococcal disease

Meningitis

Septicaemia

Pneumonia

Otitis media

Invasive pneumococcal disease

Notified cases of confirmed invasive pneumococcal disease by age, 1

January 2002 to present

0

10

20

30

40

50

60

70

80

90

100

Jan

02

Apr 0

2

Jul 0

2

Oct 0

2

Jan

03

Apr 0

3

Jul 0

3

Oct 0

3

Jan

04

Apr 0

4

Jul 0

4

Oct 0

4

Jan

05

Apr 0

5

Jul 0

5

Oct 0

5

Jan

06

Apr 0

6

Jul 0

6

Oct 0

6

Jan

07

Apr 0

7

Jul 0

7

Oct 0

7

Jan

08

Apr 0

8

Jul 0

8

Oct 0

8

Jan

09

Apr 0

9

Jul 0

9

Oct 0

9

Jan

10

Apr 1

0

Jul 1

0

Oct 1

0

Jan

11

Month of notification

Num

ber o

f not

ified

cas

es

65+

4 to <65

1 to <4

<1

NIP 01/05:

7vPCV for

children born

2003 onwards

Pertussis

• Bacterial respiratory illness caused by Bordetella pertussis

Infants less than 6 months of age are at highest risk of severe

illness

50% of infants under 6 months hospitalised and some require

ICU admission

Protection not adequate until after 3 doses at 6 months of age

Combat increased incidence with “cocoon” strategy

Boostrix (adult DTPa vaccine) offered free to all parents of

infants born since 15 June 2009

Program currently running until June 2012

Pertussis notifications 1997 - 2011

Notified cases of pertussis by month and age group,

Victoria, 1 January 1997 to present

0

200

400

600

800

1000

1200

Jan 9

7

Apr

97

Jul 97

Oct

97

Jan 9

8

Apr

98

Jul 98

Oct

98

Jan 9

9

Apr

99

Jul 99

Oct

99

Jan 0

0

Apr

00

Jul 00

Oct

00

Jan 0

1

Apr

01

Jul 01

Oct

01

Jan 0

2

Apr

02

Jul 02

Oct

02

Jan 0

3

Apr

03

Jul 03

Oct

03

Jan 0

4

Apr

04

Jul 04

Oct

04

Jan 0

5

Apr

05

Jul 05

Oct

05

Jan 0

6

Apr

06

Jul 06

Oct

06

Jan 0

7

Apr

07

Jul 07

Oct

07

Jan 0

8

Apr

08

Jul 08

Oct

08

Jan 0

9

Apr

09

Jul 09

Oct

09

Jan 1

0

Apr

10

Jul 10

Oct

10

Jan 1

1

Apr

11

Month of notification

Nu

mb

er

of

no

tifi

ed

cases

25+

18 to <25

15 to <18

5 to <15

1 to <5

<1

Jan 04: dTpa for

Year 10s

Newer programs - HPV

• virus with over 100 different types

40 to 50 types affect the genital area

Classified as low-risk and high-risk types

– Low-risk types cause genital warts and/or changes to cervical cells

– High-risk types (~15) are linked to cervical cancer

• The virus can lie dormant in the body for a long time without causing a problem; often no noticeable symptoms

• 70-80% of cervical cancer cases in Australia are linked to HPV virus types 16 & 18

• Gardasil® protects against types 16 & 18 as well as types 6 & 8 (genital warts)

Newer programs - Rotavirus

• Characterised by sudden onset of fever,

vomiting and watery diarrhoea

• Highly contagious

• Generally transmitted by oral-faecal route

• Infects and replicates in cells of small intestine

• Average disease duration 6 days (3 - 8 days)

• Multiple infections in first few years of life

• Most Australian families will experience

rotavirus infection before their child turns five

References: Clark FH, Rotavirus Vaccines, WB Saunders, 1999; Parashar et al., Emerg Infect Dis, 2003.

Newer programs - Rotavirus

• Rotateq

Direct, serotype-specific protection against

all five common serotypes

• 98% efficacy against severe RGE

• 96% efficacy against hospitalisations

• 3 doses given at 2, 4 and 6 months of age

• Time limits for doses – all doses by 32 weeks; no catch

up

• TGA approved for all infants aged 6-32 weeks,

including pre-term

Reference: RotaTeq PI, May 2006

Immunisation website

www.health.vic.gov.au/immunisation