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Immunisation is one of the most important public health initiatives of the last 60 years. According to the World Health Organisation “the two public health interventions that have had the greatest impact on the world’s health are clean water and vaccines.”(1) Ensuring and encouraging high rates of uptake of vaccines from across the community is essential, as immunisation protects the individual, the family and the community.

Population immunity (also called herd immunity) is achieved when immunisation programmes reach sufficiently high coverage in the target population to interrupt transmission within the community. A successful immunisation programme therefore protects the most vulnerable groups, including babies too young to be vaccinated.

Sustaining population immunity through high uptake of vaccination remains a priority in NHS Lothian. This is especially so as there have been changes to the immunisation schedule throughout 2006 and 2007 and there remain significant challenges in ensuring parental confidence in uptake of the Measles, Mumps, and Rubella (MMR) vaccine.

Immunisation rates

Uptake rates across Lothian are excellent. Uptake of primary immunisation at 24 months of age is generally >98%, exceeding both the Scottish average and the 95% target. Uptake of pre school boosters for the cohort reaching five years of age by end September 2007 was 89.4% (on a par with the Scottish average). These figures demonstrate the confidence shown by parents in vaccination. However, continuing effort is required by health professionals, largely through the provision of accurate, tailored and timely information to parents to maintain such good uptake.

As Box 1 shows, MMR uptake rates are generally good, but further work is required to reach the Government’s 95% target.

Box 1: MMR vaccination in Lothian

In 2006 the Government set a target of 95% uptake of at least one dose of MMR by five years of age. This target has not yet been reached nationally.

West, East and Midlothian CHPs have exceeded this target and West and East Lothian have been top ranking CHPs within Scotland for MMR1 uptake. During 2006 five cases of measles were investigated within Lothian. These were the first cases for three years. Two were acquired abroad but three were acquired locally, and in two the source was undetermined. Of note, three were too young to have received MMR and one had received one dose only (two doses are necessary for immunity).

An in-depth study of MMR2 uptake in Lothian over the nine year period 1998 to 2006 demonstrated:

• Significant variation in uptake by area. Uptake was consistently lower within Edinburgh and lowest in south central Edinburgh;
• Children from the most affluent areas (SIMD 1-3) and those in the most deprived areas (SIMD 10) were significantly less likely to receive the MMR 1 vaccine and significantly less likely to receive the MMR2 vaccine even after having the MMR1 vaccine;
• Children from affluent areas in south central are significantly less likely to receive MMR2 than children from affluent areas elsewhere;
• Children from the most deprived areas were more likely to receive their MMR1 and MMR2 at a later age;
• GP practices with <500 children registered had significantly lower uptake of MMR1 and MMR2 than larger practices; and
• There was an association between MMR uptake and the appointment system used.

Further work is progressing within Edinburgh CHP on maximising MMR uptake.

Remember: MMR: it’s Never Too Late!

The new childhood vaccination schedule

From 4 September 2006 significant changes were made to the national immunisation schedule. These were:

• The introduction of pneumococcal conjugate vaccine (PCV) at two, four and 13 months of age;
• A booster dose of Hib and men C combination vaccine at 12 months; and
• A PCV catch up campaign for all children under two years of age.

The practical implications of these changes were that infants are now offered different combinations of vaccines at two, three and four month visits. There are now three injections at the four month visit and a new 12 month vaccination visit has been included in the programme. The new programme was successfully rolled out across NHS Lothian. The catch-up campaign resulted in a total of 19,000 children being called for pneumococcal vaccinations between September 2006 and end of March 2007.

The first data on uptake of PCV were released in December 2007. Uptake for Lothian children who reached 12 months of age by end September 2007 was excellent at 96%. Uptake of PCV doses appropriate to age for the catch-up campaign was 84.9%.

The Haemophilus Influenza (Type b) catch -up campaign

A national Haemophilus Influenza (Type b) (Hib) catch-up campaign was introduced in November 2007. This affects children born between 4 April 2003 and 3 September 2005 who were either too young to be part of the Hib booster campaign in 2003 or too old to have the new booster at 12 months. This booster will give these children the extra protection they need against diseases such as meningitis, blood poisoning and pneumonia caused by Hib infection.

For most children the booster will be given at the same time as their routine pre-school immunisation so a separate appointment is not required. In addition, as the vaccine used for the pre-school immunisation has been changed temporarily to a Hib containing preparation, most children do not need an extra injection. Until now the routine call up for pre-school immunisation in Lothian was at four-and-a-half years of age. In line with the catch-up, the age at which this is offered will be progressively reduced so that by March 2009 all children will be called up from three years, four months of age.

Keeping vaccines effective

Maintenance of the cold chain throughout the entire life of a vaccine is essential to maintaining its effectiveness. A NHS Lothian policy ‘Handling and storage of vaccines’ was developed in 2006 and distributed widely both in 2006 and 2007. Regular training sessions are held on vaccines handling and storage. During 2007 an audit was completed of adherence to cold chain in all GP fridges throughout Lothian. This showed a high level of adherence.