Immunisation in the UK: protected for the future

New vaccines and campaigns

The list of new vaccines that have been introduced since 1988 is exhausting (Table 1). In each case, the vaccine introduction has involved new national supplies, communication materials, disease surveillance, adverse event surveillance, impact evaluation and adjustment to the programme when necessary. The impacts of these vaccine introductions have been impressive. After the introduction of the measles/mumps/rubella (MMR) vaccine in 1988, coverage rose 10% compared with the previous single measles vaccine, numbers of cases of measles fell considerably, and most importantly, the number of rubella infections in pregnancy fell as pregnant women were no longer infected by their own or their friends’ children.⁵ Despite a perception that the purpose of the introduction of MMR related to control of measles, the main reason was to interrupt rubella transmission among young children, thereby protecting their pregnant mothers, and this was achieved.

The introduction of Haemophilus influenzae b (Hib) vaccine was especially challenging since the existence of Hib as a cause of meningitis and other systemic infections was not well known. Nevertheless, high coverage of Hib vaccine was achieved almost immediately, despite a separate injection being required. For the best part of a decade, Hib disease was almost eliminated. When Hib cases started to recur in the early 2000s, catch-up programmes were put in place and Hib is again back at extremely low levels.⁶ The development and introduction of meningitis C conjugate vaccine was a world leader for the UK. In the mid-1990s, it was evident that along with high levels of group B meningococcal disease, group C disease was increasing in some European countries, especially the UK.⁷ Working with three vaccine manufacturers, a programme of accelerated vaccine development was driven forwards with the result that a full national campaign could be implemented using meningitis C conjugate vaccine – the UK being the first country in the world to do this. The results were spectacular: group C disease melted away, not just in vaccinated individuals but also in non-vaccinated individuals in and outside of the age groups targeted for vaccination.⁸ In 1998/9, the year before the campaign was launched, there were 78 deaths in those less than 20 years. In 2006/7 and 2007/8, there was not a single death in that age group. The benefits of this campaign, especially the catch-up programme, are expected to be felt for many years to come.⁹ In a similar fashion, the introduction of pneumococcal conjugate vaccine along with its catch-up programme has already impacted significantly on the group targeted for immunisation.¹⁰

Vaccine supplies

It almost goes without saying that for a vaccine programme to be fully effective, adequate supplies of vaccines must be available. Yet, despite contracts that should assure this, shortages can occur because vaccines are biological products whose consistency of manufacturing cannot be guaranteed. In 1991, some vaccines were purchased centrally by the Department of Health (DH), some were purchased by health authorities against local birth cohort numbers using money devolved by DH against centrally negotiated prices, some were purchased by health authorities on behalf of general practitioners (GPs), some were purchased by practices and some were provided on prescription. In 1992, responsibility for purchasing all childhood vaccines was brought under the DH's control using central funds. Over the last seven years, the US programme has faced numerous ‘stock outs’ that have on several occasions meant that either schedules had to be changed or complete courses of vaccination could not be achieved^11,12: during the same time the routine UK childhood programme has had no vaccine shortages that impacted on the ability to vaccinate. In the UK, all childhood vaccines are purchased and supplied centrally. In the USA, half of the childhood vaccines are purchased by the private sector. The UK programme attempts to always maintain a six-month stockpile of vaccines; if shortages are anticipated, central release of vaccine stocks can be managed through a process of ‘allocation’ by which all practices get an equal share of stocks according to predefined estimates of their weekly needs, based on patterns of previous use, down to individual practice level. Similarly, in the case of new campaigns, each practice or trust's needs can be fine tuned to match supply and demand. As an example, throughout the complex meningitis C vaccine campaign, no vaccine ordering was necessary by any level. In the USA, frequent stock outs bedevilled the introduction of pneumococcal conjugate vaccine introduction: the UK contract between the DH and the pneumococcal vaccine supplier included penalty clauses that would be invoked in the event of supply failure and there has been none. Currently in the USA, the Hib vaccine schedule has been compromised because of vaccine shortages; a resurgence of cases in Minnesota has been linked to this lack of vaccine.¹³

Communications

The UK immunisation programme has a long history of promotion through different media. In a 1950s information film, the actor John Le Mesurier, smoking a cigarette as he examines a child, berates the parents for not vaccinating their child who has smallpox. In another film from the 1930s, a child with diphtheria is put into the back of a black ambulance and as the door shuts, the voiceover says, ‘Every year, tens of thousands of mothers see their child taken away to the fever hospital and every year, three thousand do not come back’. Certainly present day advertising has to be very different both in content and in the routes by which parents are accessed. Seventy per cent of parents obtain information on immunisation from the internet, where material is unregulated and its probity and accuracy hard to establish. Advertising through television has very high penetration to the target audience but is very expensive. We routinely pre-test all communication materials and evaluate their impact through qualitative and quantitative research.¹⁴ In addition to learning about knowledge, attitudes and beliefs about immunisation, such work allows estimates to be made of the relative cost effectiveness of different routes of advertising. For example, the cost of producing paper bags, to be used in pharmacies, that carry advertising on seasonal influenza vaccination, is very cheap compared with television advertising. While the overall impact is smaller, the cost per point of awareness gained is inexpensive compared with each point gained through television advertising.

As infectious diseases become less common and hence awareness of their potential severity becomes a memory only for grandparents, so new fears arise, such as those of vaccine safety. In the absence of disease or its imminent threat, raising fears over disease seriousness is not a useful counter to fears over vaccine safety since such a strategy leaves parents with two fears instead of one. In developing strategies for communicating over vaccine safety, the most effective communicator is the well-informed primary care professional: GPs and practice nurses are consistently rated as highly trusted by their patients.

Challenges

As technological advances bear fruit, there are going to be new vaccines not just against infectious diseases but against malignant disease (we already have hepatitis B and human papillomavirus (HPV) vaccines) and also against chronic diseases and even substance abuse. The immunisation programme will need to change as epidemiological circumstances dictate, and flexibility and responsiveness will be indicators of healthy programmes. Vaccine safety concerns are likely to arise, irrespective of the real risks, and communicating a proper balance of risk and benefit will remain challenging. The UK immunisation programme is well-placed to face the challenges of the future.