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Childhood immunisation

Immunisation against infectious disease is a vital public health intervention, which has greatly reduced the burden of communicable disease and made a major contribution to reduced childhood mortality.

The BMA has long highlighted the importance of immunisation for population health, and our members have made the case for extending vaccination programmes to achieve maximum population benefit. Recently this has included support for the introduction of Hepatitis B in the routine childhood immunisation schedule, as well as calls to extend the Human Papillomavirus vaccination programme to boys.

Doctors have expressed concern about declining coverage rates for childhood vaccinations in some areas of the UK, and the potential for this to lead to outbreaks of disease.

In recent years, there have been significant measles outbreaks, associated with lower vaccine coverage rates. This includes:

  • In South Wales in 2013 (affecting 1,200 people and leading to a fatality)
  • Across several parts of England (particularly the North) in 2017
  • Across some European countries between January 2016 and October 2017 (nearly 19,000 measles cases were reported in the EU, including 44 deaths)

There are a range of factors that may influence vaccine coverage rates. The increasing pressure on services delivering vaccination may undermine efforts to achieve high vaccine coverage rates. This may be compounded by cuts to community services and local authority public health functions.

Some evidence has shown that that certain populations groups in the UK are at increased risk of not being fully immunised. For example, among looked after children, among children from large families or with single parents, and among certain ethnic groups (eg those from some Black and Asian Minority Ethnic (BAME) backgrounds and Traveller communities).

To protect against future outbreaks of vaccine-preventable disease there should be a continued focus on:

  • Maintaining and improving vaccine coverage rates across the UK, including targeting certain population groups where coverage is lower. This might include increasing efforts to improve awareness of the benefits of vaccination, particularly among parents.
  • Ensuring there is sufficient funding to deliver fully-resourced vaccination services, including for general practice, community and local authority services.
  • Recognising the importance of childhood vaccination globally, by adequately resourcing vaccination initiatives and promoting adherence to immunisation schedules for diseases that have global public health impact.

 

In detail

  • The effectiveness of vaccination

    Vaccines included in the childhood immunisation programme protect against a number of communicable diseases, many of which were previously associated with substantial morbidity and mortality.

    Since the meningitis C vaccine was introduced in the UK in 1999, there has been a 99% reduction in cases among those aged under 20. Since vaccination against measles was introduced in the 1960s, the number of measles cases has declined substantially.

    Childhood immunisation graphic Source: Health Protection Agency archive 16x9
    Source: Health Protection Agency archive

    The level of vaccination required to have a protective effect at population level (herd immunity) varies, depending on the disease. For example, because measles is highly contagious, the WHO recommends vaccine coverage rates of 95% to achieve herd immunity, underlining the significant risks associated with small reductions in vaccine coverage.

    In England in 2016/17, coverage with the first dose of the MMR vaccine as measured at age 2 was at 91.6%, which has decreased for the third year consecutively. However, when measuring the first dose at age 5, coverage reached the WHO recommended rate of 95% for the first time.

    In 2016, the WHO reported that for the past three years, the number of measles cases has been low enough to stop the disease circulating around the country.

     

    Cost effectiveness

    As highlighted in the BMA’s work on cost effectiveness in public health, vaccination is particularly cost effective and often cost saving, through substantially reducing the costs of treating serious diseases.

    For example, for the childhood flu vaccine, modelling data shows an incremental cost-effectiveness ratio of £251/QALY (quality-adjusted life years) (NICE considers less than £20,000/QALY gained cost effective).

  • Exploring the ethics

    Ethically, the use of vaccination gives rise to a number of issues. For individuals, there is the question, which few find taxing, as to whether they should accept, for themselves or their children, the very small risk of vaccination as a prophylaxis against future illness. Given the issues around population immunity, it also raises questions about whether we are all under some ethical obligation to be vaccinated – private decisions can have public consequences. And lastly there is the more political question as to whether there is a role for the state in mandating or even compelling vaccination.

    Although vaccines are regulated and tested thoroughly, as with all health interventions, they may still carry small risks for an individual. A person’s decision to vaccinate either themselves or their child requires balancing these risks against the benefits accrued through vaccination. As the risks are relatively small, vaccination can benefit large numbers of people in return for a small degree of risk to individuals.

    In contrast, individual choices not to vaccinate can expose others to risk. If sufficient numbers refuse immunisation and population immunity collapses, epidemics can sweep through the community. Not all people at risk have made the decision not to vaccinate, for example neonates, people for whom vaccination is contraindicated, and those whose immune systems are compromised.

    There are several issues that may lead people to question the advantages of being vaccinated. At an individual level, it can be difficult to weigh up the respective costs and benefits of vaccination. Public perceptions regarding the prevalence and severity of a disease can also influence the decision making of individuals. In this respect, vaccination programmes have become the victims of their own success. As the mortality and morbidity associated with their target diseases have become so unusual as to fall out of popular memory, so public perception has begun to focus on potential threats from vaccines, which are comparatively minor.

    Reflecting the high value placed on autonomy and individual liberty, routine vaccination is voluntary in the UK. Individuals can choose whether to vaccinate themselves and parents are viewed as the best people to make health decisions for their children. It is important that these decisions are informed. Public health campaigns are therefore used to encourage take-up of vaccination programmes and provide parents and individuals with reliable and consistent information about their safety and importance.

    Outbreaks of communicable disease either in the UK or Europe can lead some to question whether there is a need for a different approach.

    There are jurisdictions that mandate vaccination for some diseases (e.g. France, Italy, Czech Republic). Other countries while not mandating childhood vaccination, go beyond a purely voluntary system. These approaches use financial or other benefits as incentives, apply penalties, or prevent school enrolment for non-vaccinated children (e.g. Australia, USA). Exceptions exist for people with a genuine reason for not being vaccinated. Although there is evidence to suggest that these schemes may increase uptake, there are also drawbacks: punitive systems can lead to a lower uptake in voluntary vaccinations and the cost effectiveness of incentive-based programmes can vary.

    Switching to a mandatory or quasi-mandatory scheme may also have unintended consequences. The consensual approach in the UK has helped to ensure public approval and a high take-up of programmes. A move away from this may be seen by the public as confrontational and could lead to public mistrust of government public health interventions and messages more generally.

  • The global picture

    Immunisation is the most significant intervention to influence global health in modern times. It has substantially reduced the burden of ill health due to communicable diseases worldwide, resulting in 2-3 million fewer deaths each year. Highly effective vaccination programmes are responsible for the global eradication of smallpox, and the near-elimination of polio. The WHO’s Global Vaccination Plan 2011-2020 aims to ensure that all people receive a full schedule of vital immunisations by 2020.

    At present, global vaccinations rates are stagnant at 86% overall, with coverage much lower for certain diseases such as Rubella. Over half of all children missing vital vaccines live in just 10 countries: Angola, Brazil, the Democratic Republic of the Congo, Ethiopia, India, Indonesia, Iraq, Nigeria, Pakistan and South Africa. Increasing conflict in many regions, particularly in the global south, since 2010 has made vaccination programmes more challenging to administer, resulting in interruption of optimal vaccine schedules or lack of uptake altogether.

    Polio has been eliminated in all but three countries: Afghanistan, Pakistan and Nigeria. In addition to conflict and state instability, mistrust of healthcare workers and inaccurate beliefs about the benefits and risks of vaccination are cited as significant barriers to eradication in these countries. Movement of people globally risks reintroducing the virus to countries where it has been successfully eliminated. All countries must therefore remain vigilant in ensuring high rates of polio vaccination to maintain herd immunity and avoid significant outbreaks of the disease if cases are imported.

    Understanding perspectives and barriers to vaccination among populations with low vaccine uptake is crucial to designing interventions that successfully increase coverage. WHO/Europe has developed guidance and toolkits to support a TIP (tailoring immunization programmes) approach, which has been used in the UK and elsewhere in Europe to engage with underserved populations.

     

    Global policy recommendations

    • Scale-up and adequately resource childhood and adult vaccination initiatives globally
    • Promote adherence to optimal immunisation schedules for diseases that have global public health impact
    • Increase efforts to improve awareness of the benefits of vaccination, particularly among parents.
  • Further resources