Immunisation

An infectious disease is an illness, due to a pathogen (an organism that causes disease) or its toxic product, which arises through transmission from an infected person, an infected animal, or a contaminated, inanimate object, to a susceptible host.

Immunity is the ability of the human body to protect itself from infectious disease. Immunity can be innate and present from birth, e.g. physical barriers such as intact skin or chemical barriers such as gastric acid. Immunity can be passive (protection provided from the transfer of antibodies from immune individuals) or active (resulting from exposure to a pathogen that triggers the immune system to produce antibodies to that disease). Active immunity can naturally occur or be delivered via administering a vaccine (vaccine acquired immunity).

Herd immunity occurs when a large proportion of a population are immune to a pathogen. A vaccinated population makes it unlikely for an infection to spread as only a few individuals, dispersed through a population, are potentially vulnerable.  This important outcome provides protection for vulnerable groups, such as newborns.  The percentage of a population required to be immune to achieve herd immunity varies for each disease/pathogen. For example, herd immunity against measles requires about 95% of a population to be vaccinated, whereas for polio the threshold is about 80%.

Immunisation is the process of making you immune or resistant to an infectious disease, typically via vaccination.

Vaccination stimulates your immune system to protect you against infection, disease and/or death and is one of the most cost-effective health interventions available, saving millions of people from illness, disability and death each year. Childhood vaccinations help to prevent disease and promote child health from infancy, creating opportunities for children to thrive and get the best start in life.

• The Joint Committee on Vaccination and Immunisation (JCVI) advises the Secretary of State for Health in England, and Welsh ministers on matters relating to the provision of vaccination and immunisation programmes. Advice is scientific and evidence based and used by Government to inform, develop and construct policy.
• The current national immunisation schedule sets out the national immunisation programme.
• Nationally commissioned immunisation programme specifications are available from: NHS Service Specifications for Immunisation Programmes
• Public Health England published Immunisation Inequalities Strategy, a national strategy to address inequalities in immunisation. Developed in 2019, strategy proposals will ensure equity in delivery of the national immunisation programme.
• NICE has produced supporting guidance and shared learning documents on Immunisations.  Of particular relevance is Flu Vaccination: increasing uptake [NG103] and Immunisations: reducing differences in uptake in under 19s [PH21]. Alongside this, guidance is expected in 2022 covering Vaccine uptake in the general population
• The Green Book has the latest information on vaccines and vaccination procedures, for vaccine preventable infectious diseases in the UK.
• The Vaccine Knowledge Project aims to be a source of independent, evidence-based information about vaccines and infectious diseases from a health risk perspective; they also aim to dispel common myths that can become barriers to uptake.

There is evidence of inequality in the reach of immunisation programmes across a range of characteristics including age, geography, socioeconomic status (deprivation, employment, income/occupation, education), ethnicity, religion, disability and health status (learning disability, physical disability, chronic physical illness), underserved and hard to reach (travellers, migrants, prisoners, children in care) and parental factors (lone parents, large families, parental age). Data specific to Lincolnshire is not currently available.

Overall, there appears to be a relationship in vaccine uptake between the most and least deprived in society (Source: LGA). Small populations of some ethnic groups can skew numbers in some cases. This has most recently been observed with the COVID-19 vaccination programme in Lincolnshire. Local data from this programme has also shown the inequality to be most pronounced in those of “White – Other” ethnicity and, more noticeable still, in those aged under 65. Research is currently being undertaken to understand the barriers and hesitancy related to vaccination uptake amongst adults from deprived communities and from certain ethnic backgrounds in Lincolnshire.

Influenza is often implicated in winter deaths as it can cause complications such as bronchitis and pneumonia, especially in vulnerable groups such as the elderly. Respiratory diseases cause the majority of excess winter deaths however these include a range of diseases and not solely influenza (Source: ONS). “Uptake of flu vaccinations amongst 2-3 year olds in Lincolnshire is comparable to the rest of the country, and uptake amongst older people (aged 65 and over), individuals at risk and primary school aged children is better than the regional and national uptake (Source: Gov)”

For immunisation programmes for children aged 2-years-old, there is a downwards trend regarding levels of vaccination. This includes MMR, Hip/Men C and Dtap/IPV/Hib vaccinations. However, immunisation programmes for 5-year-olds have not displayed a significant change (including MMR vaccinations and Hip/Men C boosters). Uptake of HPV vaccinations for males and females in Lincolnshire is comparable to regional and national levels.

NHS England (NHSE) is responsible for commissioning national immunisation programmes, directly supported by UK Health Security Agency (UKSHA) which has the specialist knowledge needed to ensure this complex area is commissioned and managed safely. The Director of Public Health (DPH) provides independent scrutiny and challenge to the plans of NHSE, UKSHA and providers; this assurance function is a statutory function of the DPH.

The complete routine immunisation schedule includes programmes for childhood immunisation, for populations at particular risk, for older people and, the seasonal flu programme.

In Lincolnshire, most immunisations are provided through GP practices.  The Lincolnshire Community Health Service is commissioned to deliver the school-aged/childhood seasonal flu programme, teenage booster and HPV.  This offer includes electively home educated children.  United Lincolnshire Healthcare Trust (ULHT) delivers neonatal hepatitis B and BCG vaccine.

The Lincolnshire Immunisation Programme Board includes stakeholders involved in delivering, commissioning and assuring immunisation programmes, and provides a mechanism to explore and address issues around the delivery, outcomes and outputs of programmes in Lincolnshire.  The Lincolnshire Health Protection Board provide additional oversight.

Working in partnership with the local NHSE office, the Local Medical Council (LMC), Clinical Commissioning Group (CCG) and GP practices, the Local Authority Public Health team are developing strategies to improve the quality of immunisation uptake data and uptake, and to reduce inequalities. An improvement plan for childhood immunisations is now in place for Lincolnshire. There is also a programme being developed alongside schools to deliver education around the availability and importance of immunisation. The team are also actively engaged in promoting flu vaccine uptake amongst its own staff, frontline health and social care staff and contracted providers.

The focus for COVID-19 vaccinations has three key priorities. To,

• deliver continued access to COVID-19 vaccination where advised;
• plan for delivery of future winter COVID-19 vaccinations if advised by JCVI;
• have contingency plans to rapidly increase capacity should this be required.

The Healthwatch Lincolnshire patient engagement report, regarding  immunisation and screening programmes in the county, is available here.

Key partner organisations and services in this field include NHSE, UKSHA, CCG, GPs, schools, LCHS, and the 0-19 Service, LCHS Child Health Information System, LCC Children’s Services, childcare providers, universities, carer organisations, residential/social/nursing care providers and healthcare trusts.

• Caravan dwellers and transient communities can be registered with a GP outside of Lincolnshire, or not registered at all, so may be missing from available local GP data.
• There is sometimes a gap in understanding needs relating to ethnicity. Findings of research into understanding a hesitancy in COVID-19 vaccination could help if translated to other immunisation programmes. This would likely include working alongside community champions, groups and faith leaders to ensure culturally appropriate messaging.
• Immunisation programmes work effectively, but data about numbers of children living in high-risk homes is unavailable.
• Preschool children – children attending nurseries, Childrens Centres etc. could be a key environment for immunisation activities/promotion.
• Improvement in the uptake of childhood immunisations. Alternative delivery locations, such as children’s centres, are currently being explored for 5-11 year old COVID-19 vaccinations.
• Uptake in the flu vaccine for frontline domiciliary and residential/nursing care staff is low due to access issues and hesitancy.

Work will continue to improve uptake around all vaccination and immunisations. We will:

• Look at ways to address inequalities of access e.g. traveller communities/transient populations.
• Improve links with communities to maximise opportunities to promote uptake of national programmes e.g. provide more information to Children’s Centres, nurseries etc.
• Work with practices on their call and recall systems, e.g. the timing of invites, to try and improve uptake/coverage.
• Assist the LCHS team to help schools deliver direct education on the availability and importance of childhood immunisations.
• Continue to develop and deliver an improvement plan for uptake in childhood immunisations, including a focused pilot in the Boston area of Lincolnshire.