UK (Scotland) childhood influenza
vaccination programme –
experience from seasons 2013/14
and 2014/15
Dr Beatrix v. Wissmann
Epidemiologist
Respiratory Viral Team
Health Protection Scotland
2
Overview
• Scotland: Demography
• NHS Service Delivery Model
• Scottish Immunisation Programme (SIP)
• Extension of the SIP to offer Live Attenuated Intranasal Influenza Vaccination (LAIV) to children
• Uptake & determinants of uptake
• Impact (positive or negative) on the existing seasonal programme?
• Challenges overcome & lessons for next season
• Summary results across the UK for season 2014/15
2
854,000 of Scotland’s
5.3 million population
are children
Scotland: Demography
& health
General Register Office of Scotland. Population Pyramids of Scotland. December 2013. Available at:
http://www.gro-scotland.gov.uk/statistics/theme/population/projections/scotland/population-pyramids.html
Main population
within ‘central
belt’
The average number of
people per square
kilometre in Scotland is
68, among the lowest
of the EU countries (i.e.
similar to Ireland and
Bulgaria). There are
huge variations across
the 14 health boards.
• Universal free vaccination at the point of access
• General Practice model of delivery for majority of immunisation programme
– Reimbursement under the global sum paid to General Practices + item of service payment and vaccine cost for selected vaccines (e.g. seasonal influenza vaccine)
• Exceptions offered in the main through secondary school-based programme, e.g.
– Td/IPV, MMR, MenC – school boosters
– HPV programme for adolescent girls
NHS model of immunisation
service delivery across UK
NHS Health Scotland. 2013 National Primary Care Workforce Survey. Available at: http://www.show.scot.nhs.uk
NHS Health Scotland. Your guide to immunisation and vaccines. Available at: http://www.immunisationscotland.org.uk
• All Health issues are devolved from the UK Government to the
Scottish Parliament (a Devolved Administration – DA).
• Health service policy & delivery increasingly different across
UK within each of the three DA’s (Scotland, NI, Wales), e.g.:
– Policy: Minimum pricing for alcohol in Scotland
– Delivery: Health protection within NHS in Scotland c.f. PHE
model in England
• However, whilst Scottish Government set their own
immunisation policy, the risk-based immunisation criteria are
identical to those adopted in England in response to serial
JCVI recommendations made over more than a decade ago
Scottish Immunisation
Programme (SIP)
JCVI, Joint Committee on Vaccination and Immunisation
NHS Health Scotland. Your guide to immunisation and vaccines. Available at: http://www.immunisationscotland.org.uk/
Scottish Immunisation
Programme: Quarterly primary
and booster immunisation uptake
rates by 24 months – reports to 31
December 2013
SIP: Annual primary and booster
immunisation uptake rates by 24
months – reports to 31/12/2014
Source: NHS Scotland Information Services Division.
75
80
85
90
95
100
19
95
19
96
19
97
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
20
10
20
11
20
12
20
13
20
14Perc
en
tag
e V
acc
ine
Up
tak
e
Calendar Year
Primary and Booster Immunisation Uptake Rates by 24 Months of Age, by Calendar Year, Scotland
Diphtheria Tetanus Pertussis Polio Hib DTP/Pol/Hib
MenC PCV MMR1 Hib/MenC PCVB
The decrease in MenC uptake at 24 months of age in year ending December 2014 (children born January to December 2012)
is due to the removal of the second dose (given at four months) from the routine schedule from 1 June 2013.
Seasonal flu programme
policy prior to childhood
extension (season 2012/13)
Annually
• All those aged 65 or more
• All those under the age of 65 in clinical risk groups at
increased risk of clinical complication defined by the Chief
Medical Officer (identical CMO groups across the UK)
• All pregnant women (all trimesters)
• All carers
7Chief Medical Officer and Public Health. Season Influenza Vaccination Programme 2012–13. July 2012. SGHD/CMO(2012)6.
Available at: http://www.sehd.scot.nhs.uk/cmo/CMO(2012)06.pdf
Seasonal flu vaccine
uptake 2000/01 to 2012/13
8
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Infl
ue
nza
va
cc
ine
up
tak
e
Influenza season
65 and over (2000/01 to 2004/5 based on HPS surveillance data, 2005/6 onwards based on GP claimsfor payment)
Under 65s in an at risk group (not available prior to 2004/05; 2004/05 to 2010/11 based on HPSsurveillance data, 2011/12 onwards based on GP claims for payment)
WHO target for seasonal influenza vaccine uptake
Source: Health Protection Scotland (HPS).
JCVI June 2012:
Recommendation for Fluenz
• Extension of seasonal influenza programme to
include all children age 2–17 in annual vaccination
with Live Attenuated Influenza Vaccine (LAIV)
– Implementation over a number of seasons...
– “... does not adversely affect the (immunisation)
programme as a whole”
9JCVI. Positioning statement on the annual influenza vaccination program, July 2012. Available at:
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/224775/JCVI-statement-on-the-annual-influenza-vaccination-
programme-25-July-2012.pdf
Rationale for decision
• Modelled data: Even with only 30% uptake, Live
Attenuated Intranasal Influenza Vaccine (LAIV)
estimated to be cost effective in children aged 2 to
17 years1,2
• Based upon:
– Direct patient protection
• Vaccine effectiveness of LAIV better than
inactivated vaccines3–7
– Indirect public health benefits
• Reduction in transmission to susceptible groups1
10
1. Baguelin M, et al. Vaccine 2012;30:3459–3462.
2. Baguelin M, et al. PLoS Med 2013;10:e1001527.
3. Belshe RB, et al. N Engl J Med 1998;338:1405–1412.
4. Fleming DM, et al. Pediatr Infect Dis J 2006;25:860–869.
5. Vesikari T, et al. Pediatrics 2006;118:2298–2312.
6. Bracco Neto H, et al. Pediatr Infect Dis J 2009;28:365–371.
7. Tam JS, et al. Pediatr Infect Dis J 2007;26:619–628.
2012/13 Benefit realisation –
flu: Then, now and next?
IMPACT*
(Whole
population)
Measure Prior to
vaccination
programme
No programme
Standard
Programme (to
12/13) (inactivated
vaccine for 65+
and at risk groups)
Programme
extension to
children (add
LAIV for all
2–17 years)
Burden* Annual deaths 900 500 300
Levels of
infection/risk of
transmission
Consultation rates High Moderate Low
Vaccine uptake
(and effectiveness)
Not applicable 75% (30–70%) 75% (50–80%)?
Transmission High Moderate? Low
Health care
utilisation*
Annual
hospitalisations
4,700 2,700 1,600
Annual GP
consultations
100,000 75,000 42,000
*Extrapolation and application to Scotland of Public Health England/London School of Hygiene and Tropical Medicine (PHE/LSH&TM)
assumptions for JCVI June 2012: 1. Uptake limited to 30% in 2–16 years; 2. Modelling includes indirect benefit through “herd-immunity”
protection of adult groups; 3. Census data 2010/11 England & Scotland population estimates as 53 million & 5.3 million, respectively. Societal
burden/health economic costs were also estimated by PHE/LSH&TM.1,2
1. Baguelin M, et al. Vaccine 2012;30:3459–3462; 2. Baguelin M, et al. PLoS Med 2013;10:e1001527.
Recommendation into
UK Government policy
• Recommendation accepted by each DA and policy
implementation followed for year 1 & 2 (seasons 2013/14 and
2014/15) as follows:
• single dose (two doses for < 9years old if naïve & in clinical risk
group)
– Pre-school offer of LAIV
• 2013/14 all UK: vaccination of all 2 & 3 year old children
• 2014/15 all UK: all 2-4 year olds (and 5 year olds not yet in school)
– Children of school age
• Different policy implementation for each DA in year 1 and 2
• Scotland: 2013/14 primary school pilots in all boards (~1/4 primary
school aged children), 2014/15 full primary school roll out.
Chief Medical Officer and Public Health. Important changes to the Scottish immunisation programme in 2013-14 – extension of the
seasonal influenza vaccination programme to children (2–17 years). September 2013. SGHD/CMO(2013)17.
Available at: http://www.sehd.scot.nhs.uk/cmo/CMO(2013)17.pdf
13
Preschool children
• 2013/14 vaccine uptake for 2 & 3 year olds: 50.7%– 2 & 3-year-olds at risk (n=3,669): 66.5%
– 2 & 3-year-olds not at risk (n=116,311): 50.1%
• 2014/15 vaccine uptake for 2 to under 5 year olds (not yet in school): 56.4%– 2 to under 5 year olds at risk (n=5,352): 61.3%
– 2 to under 5 year olds not at risk (n=144,468): 56.2%
13
Source: Health Protection Scotland.
1414
Preschool children
uptake by practice
Source: Health Protection Scotland.
2013/14 - proportion of practices achieving uptake
in 2&3 year olds
2014/15 - proportion of practices achieving uptake in 2 to under 5 year olds not yet in
school≥75% uptake 5.2% 15.0%≥65% uptake 15.9% 34.6%≤40% uptake 19.5% 14.5%
School-age children:
Scottish programme
2013/14 & 2014/15
• 2013/14: Pilot implementation to maximum of 190,000 doses
of LAIV purchased - > offer to ~ ¼ Scottish primary school
children across all NHS boards
– A limited number of whole primary schools AND/OR single year-
group cohorts (e.g. all children in Primary 6 and or Primary 7)
– Nested within these approaches a small number of self-
administration pilots
• 2014/15: Full primary school roll out of LAIV offer
• Contraindication to LAIV – asthma: Severity BTS 4 or above
– TIV offered instead
Source: Scottish Immunisation Programme.BTS, British Thoracic Society
• 2013/14 Primary school pilots
– mean uptake: 67.2%
– range between NHS boards: 60.2 - 76.8%
• 2014/15 Full primary school roll out
– mean uptake: 71.8%
– range between NHS boards: 62.6 – 83.1%
• Good acceptance for offer of LAIV in the primary school setting
• Lower uptake associated with delivery out with school hours (in school setting) or in GP setting
• Self-administration was difficult for 10 to 12 year olds
• Less than 1% wastage in school setting
16
Source: Health Protection Scotland.
Primary school:
2013/14 pilots &
2014/15 full roll out
17
• Scottish Index of Multiple Deprivation (SIMD) 2012 quintile
• Increasing uptake most deprived to least deprived (statistically
significant)
• Caveat: By postcode not catchment area
Primary school:
Uptake by SIMD quintile
Source: Health Protection Scotland.
18
Proportion of pupils from an ethnic minority
• Decreasing uptake: with increasing proportion of pupils from ethnic minority
Statistically
significant
independent of
SIMD 2012 quintile
Porcine gelatine?
(offer of TIV in
school did not
compensate)
Language?
Caveat: No data on
religion or details of
ethnicity
composition
Primary school:
Uptake by ethnic minority
Source: Health Protection Scotland.
Seasonal flu vaccine
uptake 2000/01 to 2014/15
Source: Health Protection Scotland.
*Data for 2014/15 based on HPS surveillance estimates at week 13
Seasonal programme at
Week 13 compared to prior
seasons
• 65+: 76.3% – in line with previous seasons (13/14: 76.9%; 12/13: 76.8%)
• At risk: 54.0% – lower (denominator inflation) (13/14: 57.5%; 12/13: 56.1%)
• Pregnant at risk: - 65.0% – in line with previous season (13/14: 65.0%; 12/13: 68.7%)
• Pregnant no risk: - 49.5% – higher (13/14: 47.9%; 12/13: 52.9%)
20
Source: Health Protection Scotland.
Interim estimated seasonal flu
vaccine uptake by each devolved
administration
2014/15
1. PHE Weekly National Influenza Report, England, data to 31 January 2015.
2. HPS National Influenza Report, Scotland, data to 29 March 2015.
3. Influenza Weekly Surveillance Bulletin, Northern Ireland, data to 31 March 2015.
Country Age 65 &
over
Age under 65 in
an “at risk group”
Preschool Primary school
aged
England1 72.8% 50.3% 38.5% – 2 years
41.3% – 3 years
32.9% – 4 years
-
Scotland2 76.3% 54.0% 56.4% - 2 to
under 5 year olds
not yet in school
71.8% - all primary
schools
Northern
Ireland3
73.4% 71.8% 54.4% - 2 to 4
year olds
79.7% - all primary
schools
Conclusions & lessons
for next season
• Offer well accepted in schools, less so in preschool &
wastage low (<1%)
• Resources – staff intensive!
• Pilot 13/14 feedback: “Exhausting effort feels like you have
just managed a 12-week outbreak”
• Self – administration not suitable for primary school age
• Consent – consent form optimisation to reduce
administrative burden
• IT development to integrate child health and GP records to
allow call and recall, and facilitate invitation
• Porcine gelatine concerns acknowledged – parent choice:
offer of inactivated injectable vaccine for belief reasons 22
23
Acknowledgements
• Scottish Primary School pupils, parents & staff
• Scottish Local Authority Council Education departments
• National Services Scotland, Health Protection Scotland: Flu, Immunisation, Statistical & IM&T teams
• NHS Boards: School Nursing staff, General Practitioners & their staff, SIP leads
• Scottish Government: Nicola Kerr, Jacqueline Campbell, Dr Nicola Steedman
• Public Health England
• Northern Ireland Department of Health, Social Services and Public Safety
• Welsh Government, Directorate for Public Health 23