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Vaccination and Immunisation

Jane RentonPrincipal Pharmacist

NHS Lothian

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“ The two public health interventions that have had the greatest impact on the worlds health are clean water and vaccines” WHO

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History of Vaccination

1796 -Jenner – cowpox 1885 - Pasteur – cholera, diphtheria, chickenpox, rabies 1911 - first typhoid vaccine 1927 - first tetanus vaccine 1931 - Calmette & Guerin – first crude BCG 1936 - influenza Modern era of vaccination 1940 - diphtheria national programme in UK 1950’s - polio, pertussis, modern BCG 1960’s - measles, mumps & rubella, modern tetanus 1980’s - H. Influenzae B (Hib) 2000’s - Meningitis C, Human papilloma virus (HPV)

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Terminology!

Vaccination: the process of administering a vaccine

Immunisation: the process of inducing immunity to disease

Immunity is usually acquired naturally, but can be induced by vaccination

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Immunity

Active

An antibody response formed by the body

Induced by vaccine or natural infection

Passive

Antibody is donated e.g. immunoglobulin or

maternal antibody passed to infant

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Why immunise?

To prevent or protect against serious disease

To eliminate a particular disease from a defined population

To eradicate a disease entirely e.g. smallpox

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However it is not possible to eradicate all vaccine-preventable diseases: Asymptomatic carriage Mutating organisms e.g. influenza Animal reservoirs e.g. SARS, avian influenza Environmental reservoirs e.g. tetanus Global travel/mass immigration

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Population (herd) immunity

“Population immunity is the state achieved when immunisation programmes reach sufficiently high coverage of the target population to interrupt transmission within the community”

Depends on: Degree to which disease is infectious Efficacy of vaccines Vulnerability of population Environmental factors

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Herd Immunity

Protects people unable to be vaccinated i.e too young, have health problems, pregnant.

Thresholds (% of population that needs to be immune) are quite high. Polio 80-86% Diphtheria 85% Measles 95%

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UK Vaccination Guidance

JCVI WHO DOH & SGHD EU HB SIRS SUPPLIES

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Vaccine preventable diseases(bacterial)

Diptheria ♦ Haemophilus influenzae B (Hib) ♦ Meningococcal (meningitis) ♦ Pneumococcal disease ♦ Tetanus ♦ Tuberculosis ♦ Whooping cough (pertussis) ♦

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Vaccine preventable diseases (viral)

Chickenpox ‘flu ♦ Measles ♦ Mumps ♦ Polio ♦ Rubella ♦ HPV ♦

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UK Childhood Vaccination schedule

When to immunise What is given2 months old DTaP/IPV/Hib (Pediacel) & PCV (Prevenar 13)3 months old DTaP/IPV/Hib (Pediacel) & Men C4 months old DTaP/IPV/Hib (Pediacel) & PCV & MenC

Between 12 and Hib/ Men C & PCV & MMR13 months old 3 years and 4months or dTaP/IPV or DTaP/IPV &As soon after. MMR

13 to 18 years old Td/IPV (Revaxis)Girls aged 12-13yrs HPV (Cervarix)

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SIRS

Scottish Immunisation Recall System File opened at birth Should have complete immunisation record

up to school leaving Records immunisations which are scheduled Unscheduled attendee form to be completed

for all non-recall vaccinations

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Successes

Efficacy of National Childhood Immunisation Programme Cases of Measles notified in under 15’s in

Scotland ↓ from over 12,000 in 1976 to 147 in 2007.

Rubella ↓ from 6,000 cases in 1989 to 131 in 2007.

Pertussis ↓ from 4,000 cases in 1982 to 62 in 2007.

Data: ISD

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Challenges

Breaking down barriers to immunisation uptake.

Cold chain issues Preventing immunisation errors

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Barriers to Immunisation Uptake

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Barriers to Immunisation Uptake

Poor information/ misconceptions/ myths Conflicting advice: family, media etc Inconvenience: time, transport, lack of

flexibility in system Vaccine supply issues

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Poor information/ misconceptions/ myths

Misconceptions have always been around e.g Vaccines can give you the infection e.g ‘flu Multicomponent vaccines overload the immune

system Giving vaccines singly is safer Risk from vaccine is worse than the infection –

no-one dies these days from measles! etc.etc.etc…………..

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Conflicting advice: family, media etc

Provocative media headlines e.g “Autism: new risk in NHS vaccine”

(Scotsman 13 March 2004)

Anecdotal parental reports of autism after MMR vaccination

Emotional impact – creates confusion/ concern in parents

Once damage done is difficult to rectify despite evidence

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Inconvenience: e.g time, system inflexibility

Working parents have difficulty in attending fixed daytime immunisation clinics.

Yellow fever vaccines only available from designated clinics

Changes being made – ‘flu clinics on Saturdays, Community pharmacies undertaking ‘flu vaccines.

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Vaccine supply issues

Can affect uptake of immunisation Clinics cancelled – patients forget to return for

next dose Increased number of injections having to be given

puts people off!

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Vaccine Production

Two main stages Biological - antigen preparation Pharmaceutical - ready to use product

Production cycles are long Tetanus vaccine - 9-10 months Diphtheria vaccine - 11 months

Rigorous QA checks

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Cold Chain

System of transporting and storing vaccines within the recommended temperature range of 2 – 80C

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Why is the cold chain important?

Effectiveness of vaccines cannot be guaranteed if exposed to temperature extremes.

Ensures compliance with manufacturers’ SPC/MA

Provides assurance/ confidence in potency of the product

Ensures patient obtains maximum benefit from immunisation

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Risks associated with incorrect vaccine storage

Financial Vaccine costs/ disposal costs

Repevax £11.98/dose Revaxis £7.25/dose Pediacel £19.94/dose Infanrix IPV £18.88/dose Prevenar £34.50/dose Cervarix /Gardasil £80.50/dose

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Risks associated with incorrect vaccine storage

Risk to patient Risk of acquiring infection due to ineffective

vaccination Risks associated with possible re-vaccination

Risk to NHS/ Healthcare professionals Loss of confidence in service

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Immunisation administration errors

e.g. Administration of the wrong vaccine Administration of extra/ unnecessary vaccines Administration of out of date vaccines Most are avoidable! All should be reported using medication

incident reporting systems Reports should be reviewed and analysed

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Travel Vaccines

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Travel Vaccination

Increased risk of transmission of infectious disease due to dramatic ↑ in global travel

Study revealed 67% of travellers to high/medium risk areas had not taken medical advice

Need consultation at least 1 month before travel

Are two compulsory vaccinations – yellow fever/ meningitis

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Travel Vaccines

Cost – is an area of much debate!. Some vaccines can be prescribed on a GP10

Td/IPV, MMR, Hep A, typhoid

Others require private prescription Rabies, Japanese encephalitis, tick borne

encephalitis, yellow fever

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And finally….

“ Protection from infectious diseases is one of the greatest benefits that any government can ensure for each generation”

KA Annan

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References and Resources

‘The Green Book’, www.dh.gov.uk www.immunisation.nhs.uk www.hps.scot.nhs.uk www.immunisationscotland.org.uk www.uvig.org (UK Vaccine Industry Group) www.hpa.org.uk