Appendix: 3.2

MEETING: DATE: TITLE: LEAD DIRECTOR: AUTHOR: CONTACT DETAILS:

Islington Clinical Commissioning Group Governing Body Wednesday, 3 July 2013 Update on Childhood Immunisations Julie Billett, Director of Public Health Caroline Coen, Senior Public Health Strategist [email protected] 0207 527 1223

SUMMARY: The uptake of childhood immunisation across all ages in Islington has been improving steadily over the past four years. This reflects the significant and sustained work that has been undertaken by health care professionals across primary and community services to increase awareness of and promote immunisation amongst both the public and health professionals, to enhance immunisation data collection, reconciliation and data cleaning, and the proactive work to follow up with individual unimmunised or incompletely immunised children. Although uptake rates are generally on the increase, inequalities persist, with older children less likely to be vaccinated than younger children, and children registered with smaller practices less likely to be vaccinated than those registered with larger practices. Islington’s immunisation action plan sets out the actions being taken to target those children who are likely to have missed or be at risk of missing their vaccinations. Following the recent measles outbreak in south Wales, a MMR catch-up programme targeting 10-16 year olds is being delivered through primary care in Islington, as part of the national MMR catch-up programme led by NHS England. There have been two confirmed cases of measles in Islington between January and April 2013. This compares to two confirmed cases in the whole of last year (Jan-Dec 2012). Vaccination with two doses of MMR provides >95% protection against measles infection. From June 2013, a number of changes are being made to the childhood immunisation schedule. They include changes to the childhood meningitis C schedule, the introduction of rotavirus vaccine for babies and an extension of flu vaccination to children from 2 years – 16 years inclusive, and high risk infants who are 6 months or older. Shingles vaccine will also be introduced for adults aged 70 and over. From April 1 2013, NHS England became responsible for commissioning and monitoring the immunisation programme in England. As these new arrangements are still bedding in, Camden and Islington Public Health team continues to remain closely involved at a local level to ensure the improvements in immunisation uptake are sustained.

SUPPORTING PAPERS: Appendix 3.2a – Summary of Islington annual immunisation returns 2012/13

RECOMMENDED ACTION: The Governing Body is asked to: • NOTE the on-going improvements in uptake of childhood immunisations in Islington; • NOTE actions taken locally to increase MMR vaccination coverage in children aged 10-16; • NOTE the changes to the national immunisation schedule and the new commissioning arrangements for immunisation services.

GOVERNANCE: Members with voting rights Dr Gillian Chair Greenhough Alison Blair Chief Officer Dr Jo Sauvage/Dr Katie Coleman Dr Sharon Bennett Dr Karen Sennett

Dr Rathini Ratnavel Dr Anjan Chakraborty Dr Sabin Khan Deborah Snook Jennie Hurley Sorrel Brookes Anne Weyman Ahmet Koray Martin Machray Dr Mo Akmal

Joint Vice Chairs (Clinical) Central Locality GP Representative South Locality GP Representative

Members without voting rights Simon Local Authority Galczynski Representative Phillip Watson Healthwatch Representative Robbie Bunt LMC Representative Paul Sinden

Director of Commissioning

Julie Billett

Joint Director of Public Health for Camden and Islington

South Locality GP Representative North Locality GP Representative Salaried GP Representative Practice Manager Representative Practice Nurse Representative Lay Member Lay Member Vice Chair (Non-clinical) Chief Finance Officer Director of Quality & Integrated Governance Secondary Care Representative

Objective(s) / Plans supported by this paper: Ensuring high rates of childhood immunisation is an important contribution towards Islington CCG’s strategic priority of ensuring every child has the best start in life. Audit Trail: None.

Patient & Public Involvement (PPI): No specific PPI in the preparation of this report, however there has been engagement with key target population groups with low immunisation coverage to inform and support the development of the Islington immunisation action plan. Equality Impact Assessment: No Equality Impact Assessment has been undertaken for the report. Understanding variations in uptake of childhood immunisations between different population groups and the reasons underlying those variations, and then taking appropriate action and interventions to reduce these inequalities, is the approach that underpins the Islington immunisation action plan. A childhood immunisation equity audit in Islington was published in November 2012. See: http://www.islington.gov.uk/publicrecords/library/Public-health/Quality-andperformance/Profiles/2012-2013/(2012-12-27)-Islington's-Child-Immunisation-Equity-Audit2012.pdf Risks: The transition of responsibilities for commissioning, monitoring and assuring childhood immunisations programmes posed a potential risk to continuity of delivery and to maintaining and improving coverage rates. Although the new arrangements, and in particular recruitment to local Screening and Immunisation Teams within NHSE, have taken a while to bed down, Public Health and local immunisation providers have continued to work together, and with NHSE and PHE colleagues, to minimise these transition risks and sustain the positive progress made in relation to childhood immunisation in recent years. Resource Implications: The commissioning budget for the childhood immunisation programme now sits with NHS England, and this includes funding for the national MMR catch up campaign, as well as for the new vaccinations set out in this paper.

1. EXECUTIVE SUMMARY The uptake of childhood immunisation across all ages in Islington has been improving steadily over the past four years. This reflects the significant and sustained work that has been undertaken by health care professionals across primary and community services and in public health to increase awareness of and promote immunisation amongst both the public and health professionals, to enhance immunisation data collection, reconciliation and data cleaning, and the proactive work to follow up with individual unimmunised or incompletely immunised children. Although uptake rates are generally on the increase, inequalities persist, with older children less likely to be vaccinated than younger children, and children registered with smaller practices less likely to be vaccinated than those registered with larger practices. Islington’s immunisation action plan outlines a number of actions being taken to target those children who are likely to have missed or be at risk of missing their vaccinations. Following the recent measles outbreak in South Wales, Islington is delivering a MMR catchup programme targeting 10-16 year olds, as part of the national MMR catch-up programme. The only way to prevent measles is to be immunised with two doses of MMR vaccine, providing >95% protection against measles infection. From June 2013, a number of changes are being made to the childhood immunisation schedule. They include changes to the childhood meningitis C schedule, the introduction of rotavirus vaccine for babies and an extension of flu vaccination to children from 2 years – 16 years inclusive, including high risk infants who are 6 months or older. Shingles vaccine will also be introduced for adults aged 70 and over. From April 1 2013, NHS England became responsible for commissioning and monitoring the immunisation programme in England. As these new arrangements are still bedding in, Camden and Islington Public Health team continues to remain closely involved at a local level to ensure the improvements in immunisation uptake are sustained.

2. UPTAKE OF CHILDHOOD IMMUNISATIONS IN ISLINGTON The 2012/13 annual immunisation returns (Appendix 3.2a) show that, across all ages, immunisation targets have been met or exceeded in Islington.

Table 1: Uptake of childhood immunisations 12/13 (COVER STATISTICS)

Age

Vaccination

1 year olds

5-in-1 (Diphtheria, Tetanus, Polio, Pertussis, Hib) MMR (1st dose) Hib/MenC Pneumococcal Conjugate Vaccine (PCV) Pre-school booster (Diphtheria, tetanus, Polio, Pertussis) MMR (2nd dose)

2 year olds

5 year olds

% immunised Target (Q4) by birthday 96.1

93.1

91.6 91.9

90.2 90.4

91.1

90.2

86.6

86.0

86.1

85.0

*Targets were set by NHS London and NHS NCL for 12/13.

Quarterly data for 2012/13 show that, across all childhood immunisations, uptake levels have remained steady or increased during the course of the year (see Table 2).

Table 2: Quarterly uptake of childhood immunisations 12/13 (COVER STATISTICS)

Age

Vaccination

1 year olds

5-in-1 (Diphtheria, Tetanus, Polio, Pertussis, Hib) MMR (1st dose) Hib/MenC Pneumococcal Conjugate Vaccine (PCV) Pre-school booster (Diphtheria, tetanus, Polio, Pertussis) MMR (2nd dose)

2 year olds

5 year olds

% immunised by birthday Q1 Q2 Q3

Q4

95.9

95.2

95.9

95.6

89.0 90.3

90.5 90.1

91.5 92.5

92.2 91.3

90.1

90.1

91.5

91.3

81.0

84.8

85.8

92.2

82.2

83.3

84.0

89.9

2.1 Time Trends Childhood immunisation uptake in Islington has been steadily improving since 2009/10. Time trend data are presented in figures 1, 2 and 3 below for the period 2004/5 to 2011/12; comparative data are not yet available for London and England in 2012/13. Each of these

figures shows steady increases in uptake of selected vaccinations by one, two and five years of age. The single largest percentage increase over time has been in the uptake of the second dose of MMR at age five, rising from 43% in 2007/8 to 83% in 11/12 (and most recently to 90% in Q4 12/13).

Figure 1: Uptake of DTaP/IPV/Hib in one year olds, Islington, London and England, 2004/5 -2011/12 Uptake of DTaP/IPV/Hib in one year olds, Islington, London, England, 2004-2012 100 90

Islington

Percentage of children

80

London England

70 60 50 40 30 20 10 0 2004-05

2005-06

2006-07

2007-08

2008-09

2009-10

2010-11

2011-12

Year Note: Data for 2004-05 to 2006-07 for Islington not available; Source: GLA, 2012

Figure 2: Uptake of MMR (first dose) in two year olds, Islington, London, England (2004/5-2011/12) Uptake of MMR1 in two year olds, Islington, London, England, 2004-2012 100 90 80

Percentage of children

Islington London

70

England 60 50 40 30 20 10 0 2004-05

2005-06

2006-07

2007-08

2008-09

Year Note: Data for 2005-06 to 2006-07 for Islington not available; Source: GLA, 2012

2009-10

2010-11

2011-12

Figure 3: Uptake of MMR (second dose) in five year olds, Islington, London, England 2004/5-2011/12

Uptake of MMR2 in five year olds, Islington, London, England, 2004-2012 100 90

Percentage of children

80

Islington

70

London 60

England

50 40 30 20 10 0 2004-05

2005-06

2006-07

2007-08

2008-09

2009-10

2010-11

2011-12

Year Note: Data for 2005-06 to 2006-07 for Islington not available; Source: GLA, 2012

2.2 Comparative Data in 2011/12 2.2.1 One Year Olds For one year olds, Islington is just one of five London boroughs with uptake rates for the ‘five-in-one’ vaccine in one year olds at or above 96%. This compares well with London (91%) and England (95%), and is an exceptionally high vaccination uptake rate for a deprived inner London borough, exceeding the World Health Organisation’s target uptake rate of 95%. Men C and PCV uptake in Islington is higher than in Camden or in London, and is similar to England as a whole. Table 3: Percentage of children immunised by their 1st birthday, 2011/12, Islington, Camden, London and England Percentage of children immunised by their 1st birthday Area

Diphtheria, Tetanus, Polio, Pertussis, Hib, (DTaP/IPV/Hib)

Men C

Pneumococcal Conjugate Vaccine (PCV)

Islington

95.6

94.6

95.2

Camden

89.7

88.1

89.4

London

91.3

89.9

90.4

England 94.7 93.9 94.2 Source: Department for Health, COVER Statistics 2011/12.

2.2.2 Two year olds Uptake of immunisations for two year olds in Islington is generally better than the London average. Uptake of DTaP/IPV/Hib and Men C are also above the England rate.

Table 4: Percentage of children immunised by their 2nd birthday, 2011/12, Islington, Camden, London and England Percentage immunised by their 2nd birthday

Area

Diphtheria, Tetanus, Polio, Pertussis, Hib, (DTaP/IPV/Hib

MMR1

MenC

Hib/MenC booster

Pneumococcal Conjugate Vaccine (PCV)

Islington

96.4

90.7

93.5

90.2

88.4

Camden

94.0

85.0

91.0

86.5

84.9

London England

93.3 96.1

86.1 91.2

90.2 90.2

86.8 92.3

85.3 91.5

2.2.3 Five year olds In general there has been steady progress on the five year old pre-school immunisations. Uptake rates in Islington are now higher than London, and higher than England for the first dose of MMR. Uptake of the 2nd dose of MMR by age 5 now stands at 90% (Q4, 2012/13). Table 5: Percentage of children immunised by their 5th birthday, 2011/12, Islington, Camden, London and England Percentage immunised by their 5th birthday

Diphtheria, Tetanus, Polio, Pertussis

MMR

Booster

first dose

Islington

81.4

93.1

first and second dose 83.0

Camden

70.3

84.4

70.0

London

78.8

89.7

80.2

England

87.4

92.9

86.0

Area

2.3

Islington’s Immunisation Action Plan and tackling inequalities

A range of stakeholders have been working together to strengthen collaboration and improve childhood immunisation uptake in Islington e.g. Children centres, Private, Voluntary and Independent Nurseries (PVI’s), health advocacy services (staff are now trained to promote immunisations in communities with low uptake rates eg workshops have been held in Islington mosques targeting Somali men. Although uptake rates are generally on the increase, inequalities do persist. We know that older children are less likely to be vaccinated than younger children, which is likely to be a result of less contact with health services, particularly after their first year. Coverage in older children is also affected by population mobility and some parents may be less aware that booster vaccinations are needed, and that these are as important as primary vaccinations in ensuring long term protection for their children. Children registered with smaller practices are also less likely to be vaccinated than those registered with larger practices; however, this may account for a very small number of children in the borough. There are also a number of unvaccinated children resident in Islington where the GP is unknown. In many of these cases, it is likely that these children have actually left the borough. To address these issues, Islington’s action plan for improving the uptake of immunisations focuses on ensuring:• good management of information and data with regular data flows between the Child Health information team at Whittington Health and Islington GP practices to ensure accuracy of records. • Identifying unimmunised children with proactive follow-up and immunisation. This involves generating and sharing “defaulter lists” with the Health Visiting teams and ensuring appropriate action is taken to follow up these children and update lists. • Frequent communication between the Immunisations Coordinator and GP practices to ensure timely immunisation administration and correct coding. • On-going training for practice nurses and community staff to address professional and clinical concerns around immunisations, supporting health professionals to feel confident to address parents’ concerns around new vaccines. • Ensuring all immunisation providers have a timely call and recall system in place and process for accurate recording. • Developing a schools immunisation pathway to support schools to identify their unimmunised children and arrange an appropriate response to ensure all children are immunised. The feasibility of running regular immunisation clinics in schools is being considered.

3. Responding to the measles outbreak in South Wales Following the recent measles outbreak in south Wales, Islington Council’s public health team has been working with NHS England (London) and Public Health England (London) to support the roll out of the national MMR catch up programme in Islington. The aim of this programme, launched in April 2013, is to ensure that unvaccinated or partially vaccinated children aged 10-16 years in the borough are offered at least one dose of MMR vaccine by September 2013, in time for the new academic year. The catch-up programme is being primarily delivered through general practice, although NHS England is considering the need for more targeted interventions for specific vulnerable communities. Public health was asked to identify children in particular vulnerable groups (see table 6 below) and what the existing arrangements are for immunising these groups. Table 6: Vulnerable population groups and current immunisation arrangements Children not in formal education

Children in Pupil Referral Units (PRUs) Gypsy / Traveller children

Looked after children (LAC) Children with disabilities

Unregistered children

Approximately 100 Islington children, who are offered the routine immunisation schedule All children in PRUs are offered the routine schedule of immunisations Very low number in Islington and are part of the defaulter lists followed up by Health Visiting teams All LAC are offered the routine immunisation schedule All children in this group are offered the routine immunisation schedule, with paediatrician guidance These children are part of the Islington defaulter list action plan

Although MMR immunisation rates for young children in Islington have improved over the last few years, there were a number of years when immunisation rates were lower than that needed to prevent an outbreak of measles. This means that there is large cohort of schoolage children in Islington who remain at risk of catching measles. The catch-up campaign launched in April is specifically targeting children aged 10-16 years, but children of any age up to 18 years of age who missed, or only partially completed their MMR vaccinations should also be encouraged to have their 'catch-up' vaccination. Under the national catch up campaign, GP practices have been asked to identify and offer MMR to young people aged 10-16 years, whilst continuing to deliver the routine childhood immunisation schedule. To date, the national catch-up programme has resulted in more than 95 per cent of GP practices across England ordering extra doses of the vaccine – over 200,000 extra in total. Data on the number of extras doses of MMR vaccine ordered though general practice is not currently available at regional or local level. In support of the campaign, public health has disseminated information and letters to all nurseries, primary and secondary schools in Islington to encourage uptake of MMR vaccination. It is important to note that London is not in a measles outbreak situation currently. The majority of cases reported recently in London are associated with particular cultural communities and there is no evidence of spread to wider communities. However, in line with trends across the country, the number of cases of measles has continued to rise in London. During the first four months of 2013 there were 103 confirmed cases. This is in comparison to a total of 139 cases in 2012. Whilst measles cases are occurring in all age

groups, they are primarily affecting individuals who have not had any doses of MMR vaccine, especially those young people aged between 10 and 16 years. During the first four months of 2013 (Jan-April) there were two confirmed measles cases in Islington, the same number as in the whole of 2012 (Jan-Dec). In conjunction with changes to the national immunisation schedule, and in particular the introduction of an adolescent dose of MenC (see section 5 below), from January 2014 children in year 9 in Islington will be routinely offered a dose of MMR if they are unimmunised or partially unimmunised with MMR. 4. Changes to the national immunisation programme Starting from June 2013, a number of changes are being made to the childhood and adult immunisation schedule. These are summarised below. From June 2013 - Meningitis C. The second dose of Men C vaccine currently given at four months will stopped, and will be replaced by a booster dose given in adolescence. The initial change will be to cease giving the four month dose from 1 June 2013. Introduction of the adolescent dose is most likely to take place in schools from the Spring term in 2014. From July 2013 - Rota virus Nearly all children will have at least one episode of rotavirus gastroenteritis before reaching five years of age. An estimated 130,000 children with rotavirus gastroenteritis will visit their GP and approximately 12,700 children will be hospitalised in England and Wales every year. Although deaths from rotavirus in the UK are rare and are difficult to quantify accurately, there may be up to three to four a year. Rotavirus infection in children leads to severe diarrhoea, vomiting, stomach cramps, dehydration and mild fever and are likely to last approximately three to eight days. Rotavirus immunisation will be introduced into the childhood immunisation schedule from 1st July 2013. This will be offered routinely to all babies aged two and three months when they attend for their first and second routine immunisations. From Autumn 2013 - Childhood Flu The existing flu immunisation programme will be extended over a number of years to include all children aged two to 16 inclusive. In autumn 2013, immunisation will be initially offered to a limited age range of pre-school-aged children i.e. mostly children with chronic illness or immune suppression. From September 2013 - Shingles – adults To protect against herpes zoster, a shingles vaccine will be introduced to adults aged 70 (routine cohort) and 79 years (catch up cohort). Extension of the pertussis vaccine for pregnant women The existing temporary pertussis (whooping cough) vaccine for pregnant women will be extended until 2014, subject to the findings of an expert review expected in June 2013.

5.

Changes in responsibility for the national immunisation programme

The significant changes set out in the Health and Social Care Act 2012, which came into force from 1st April 2013, introduced substantial changes to the arrangements for

commissioning and assuring delivery of the national immunisation programme. These new arrangements are summarised below.

Organisation

Responsibility

Department of Health

Overall responsibility for the strategic oversight and direction of the national immunisation programme, including:- setting policy based on expert advice - securing the necessary funding - holding Public Health England and the NHS England to account for their roles in ensuring delivery of the programme - Advising Department of Health (DH) on the development of national service specifications - Setting quality assurance (QA) standards and providing independent QA of the immunisation programmes - procuring, storing and distributing vaccines and immunoglobulins - gathering and analysing coverage and surveillance data - developing and providing national communication strategies for immunisation - providing expert public health analysis and advice to the NHS England, and to DH - supporting the independent Joint Committee on Vaccinations and Immunisation - be responsible for the commissioning of immunisation services on behalf of Secretary of State - be supported in its commissioning responsibilities through detailed service specifications for each of the programmes - be accountable to DH for programme delivery and population coverage - be responsible for managing the immunisation data flows acros the system - Have a duty to ensure plans are in place to protect their population including through immunisation - Provide independent scrutiny and challenge of the plans of NHS England, Public Health England and providers - PHE will support Directors of Public Health through the provision of data and information on performance against standards - Directors of Public Health will need to assure themselves that the combined plans of all the relevant organisations will deliver effective immunisation programmes to their local populations - Continue to deliver immunisation programmes under the same contractual arrangements as in 2012-13

Public Health England

NHS England

Local Authority Directors Public

of

Providers of immunisation services

Strong partnership working will be needed at every level to ensure that the system continues to deliver the national immunisation programmes. Local coordination of screening programmes is now done through NHS England’s Screening and Immunisation Teams, which map onto the Local Area Team geographies ie North Central and North East London. This team has both NHS England and Public Health Englanf staff working together. As these new arrangements are still bedding in, Camden and Islington Public Health team continues to remain closely involved at a local level to ensure the improvements in immunisation uptake are sustained.

6.

CONCLUSIONS AND RECOMMENDATIONS

There has been a substantial improvement in the uptake of childhood immunisations in Islington in recent years, and this reflects the sustained focus and hard work of individuals and teams across the borough to improve the accessibility and reach of the immunisation programme, to provide training, as well as to support robust data recording, reporting and monitoring. Information to track progress with the delivery of the national MMR catch-up campaign at a local level is not currently available eg numbers of children aged 10-16 offered and taking up one or two doses of MMR. When this information becomes available through NHS England’s Screening and Immunisation leads, this will be disseminated to Islington Clinical Commissioning Group. The Governing Body is asked to: • NOTE on-going improvements in the uptake of childhood immunisations in Islington. • NOTE actions taken locally to increase MMR vaccination coverage in children aged 10-16. • NOTE the changes to the national immunisation schedule and the new commissioning, assurance and accountability arrangements for immunisation services.