Immunisation |
Published on: 26 June 2009 |
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COVER programme: January to March 2009
This report of the COVER programme presents quarterly coverage data for children in the United Kingdom (UK) who reached their first, second or fifth birthday during the evaluation quarter, January to March 2009.
Children who reached their first birthday in the quarter (born January to March 2008) were the seventh quarterly birth cohort to have been scheduled to receive their primary vaccinations according to the new schedule introduced on 4 September 2006 [1] (three doses diphtheria, tetanus, acellular pertussis, polio, and Haemophilus influenzae type b vaccine (DTaP/IPV/Hib vaccine) two doses each of meningococcal serogroup C conjugate vaccine (MenC vaccine) and pneumococcal conjugate vaccine (PCV), completing between May and July 2008.
Children who reached their second birthday in the quarter (born January to March 2007) would have been scheduled to receive their third dose primary vaccinations between May and July 2007 and first measles, mumps, and rubella (MMR) vaccination between February and July 2008. These children are the sixth quarterly birth cohort to be routinely scheduled to receive a booster dose of Hib and MenC vaccine (given as a combined Hib/MenC vaccine) at 12 months, and a PCV vaccine at 13 months of age [1].
Children who reached their fifth birthday in the quarter (born January to March 2004) would have been scheduled to receive their third dose primary vaccinations between May and July 2004, their first MMR between February and July 2005, their pre-school diphtheria, tetanus, acellular pertussis, inactivated polio (DTaP/IPV) booster and second dose MMR from May 2007 onwards, and a catch-up dose of a Hib-containing vaccine from September 2007 [2].
Methods
Methods of data collection for COVER, sentinel MMR coverage and neonatal hepatitis B vaccination coverage are described on the HPA website at: http://www.hpa.org.uk/webw/HPAweb&Page&HPAwebAutoListDate/Page/1209454766294?p=1209454766294.
Results
Data were received from all Health Boards (HBs) in Scotland and Northern Ireland, Administrative Regions (ARs) in Wales, and all but one of Primary Care Trusts (PCTs) in England. This is the second quarter (since January to March 2004) that all 31 London PCTs have submitted a return. However, ongoing data quality concerns mean that there is a continued need for caution when evaluating the vaccination programme in London. Caveats have been issued by eight London PCTs; for three of these and four other PCTs unreliable data for some antigens have been excluded from the analysis presented in this report. One PCT in the South East Coast region and one in Yorkshire and Humber have also issued data quality caveats. Additionally, data for one PCT in the North West region that recently moved to a new child health system has not been included in this report.
Individual PCT data for this quarter are published on the HPA website at http://www.hpa.org.uk/infections/topics_az/cover/default.htm.
Coverage at 12 months
UK coverage at 12 months for DTaP/IPV/Hib3 and PCV2 increased by 0.2% to 92.6% and 92.1% respectively compared with the previous quarter, and MenC2 increased by 0.3% to 92.1% (table 1) [3]. Country-specific comparisons at 12 months show Scotland and Northern Ireland achieved at least 97% coverage and Wales at least 95% for all three immunisations. In England, three regions (North East, West Midlands and South West) achieved 94% coverage for all three immunisations, and London was the only English region to report coverage below 91% for any immunisation at 12 months (table 1) [3].
70 of the 172 participating PCTs/HBs/ARs (41%) achieved at least 95% coverage at 12 months for DTaP/IPV/Hib3 and PCV2 vaccine. 65 (38%) achieved 95% for two doses of MenC vaccine.
Table 1. Completed primary immunisations (all antigens) by 12 months: January to March 2009Strategic Health Authorities (SHAs)/Country |
PCT/HB/AR* (total) |
DTaP/IPV/Hib3 % |
MenC2 % |
PCV2 % |
English SHAs |
|
|||
North East |
12 (12) |
94.9 |
94.5 |
94.3 |
North West |
23 (24) |
93.9 |
93.6 |
93.6 |
Yorkshire and the Humber |
14 (14) |
93.4 |
92.8 |
92.6 |
East Midlands |
9 (9) |
94.1 |
93.6 |
93.6 |
West Midlands |
17 (17) |
94.4 |
94.2 |
94.5 |
East of England |
14 (14) |
94.1 |
93.4 |
93.6 |
London |
31 (31) |
82.7 |
81.3 |
81.4 |
South Central |
9 (9) |
94.9 |
93.8 |
94.6 |
South East Coast |
8 (8) |
91.6 |
91.4 |
91.1 |
South West |
14 (14) |
94.9 |
94.7 |
94.9 |
England (Total) |
151 (152) |
91.8 |
91.2 |
91.3 |
Wales |
3 (3) |
96.0 |
95.7 |
95.8 |
Northern Ireland |
4 (4) |
97.1 |
97.0 |
97.0 |
Scotland |
14 (14) |
97.2 |
97.1 |
97.2 |
United Kingdom |
172 (173) |
92.6 |
92.1 |
92.1 |
Coverage at 24 months
Compared to the previous quarter, UK MMR coverage increased by 1.0% with all countries and all English regions showing improvement. Half of the English regions reported coverage increasing by over 1% with the greatest improvement in London (1.9% increase) [3] (table 2). UK PCV booster coverage, reported for the sixth time this quarter, increased by 1.7% to 85.8% and Hib/MenC booster increased by 1.9% to 88.6% when compared to the previous quarter (table 2) [3]. London reported the greatest increase in PCV coverage (4.9%) and Yorkshire and Humber had the greatest increase in Hib/MenC (5.5%) with London reporting the next highest increase of 3.3%.
UK coverage for DTaP/IPV/Hib at 24 months increased by 0.5% to 94.7%, and infant MenC increased by 0.7% to 93.2%. Country-specific comparisons for these two immunisations show Scotland, Northern Ireland and Wales still achieved at least 95%, whilst in England coverage was 94.1% for DTaP/IPV/Hib (eight regions achieved at least 95%) and 92.7% for infant MenC coverage (seven regions achieved at least 95%) (table 2) [3].
95% coverage at 24 months was achieved by 114 of the 172 PCTs/HBs/ARs (66%) for DTaP/IPV/Hib3, by 111/172 (65%) for MenC, by 16 for the PCV booster, and 15 for the Hib/MenC booster, and by three Scottish Health Board and three English PCTs for MMR.
Table 2. Completed primary immunisations (all antigens) by 24 months: January to March 2009Strategic Health Authorities (SHAs)/Country |
PCT/HB/AR* (total) |
DTaP/IPV |
Infant MenC% |
PCV Booster% |
Hib/MenC% |
MMR1% |
English SHAs |
|
|||||
North East |
12 (12) |
96.5 |
96.5 |
89.2 |
92.7 |
89.0 |
North West |
23 (24) |
95.7 |
94.0 |
87.4 |
90.1 |
88.8 |
Yorkshire and the Humber |
14 (14) |
95.7 |
95.9 |
87.5 |
91.4 |
87.6 |
East Midlands |
9 (9) |
95.9 |
95.9 |
87.9 |
90.3 |
87.7 |
West Midlands |
17 (17) |
96.7 |
95.0 |
88.8 |
91.4 |
89.1 |
East of England |
14 (14) |
95.7 |
95.8 |
86.0 |
91.5 |
85.6 |
London |
31 (31) |
86.7 |
82.7 |
73.4 |
75.7 |
76.7 |
South Central |
9 (9) |
96.6 |
95.0 |
88.5 |
91.6 |
89.3 |
Sth. East Coast |
8 (8) |
93.5 |
92.3 |
84.0 |
87.5 |
84.3 |
South West |
14 (14) |
95.8 |
95.3 |
87.8 |
90.4 |
88.5 |
England (Total) |
151 (152) |
94.1 |
92.7 |
84.7 |
87.9 |
85.6 |
Wales |
3 (3) |
97.3 |
95.9 |
88.6 |
92.7 |
89.6 |
North. Ireland |
4 (4) |
98.2 |
95.9 |
91.8 |
91.3 |
90.8 |
Scotland |
14 (14) |
98.0 |
96.1 |
93.8 |
93.7 |
92.9 |
United Kingdom |
172 (173) |
94.7 |
93.2 |
85.8 |
88.6 |
86.5 |
Coverage at five years
All countries and English regions, except for London, achieved 90% coverage for DTP/Pol3, Hib3 and MenC, with Scotland and two English regions (North East and South West) reporting at least 95% coverage for all three immunisations (table 3).
Compared to the previous quarter, UK MMR1 coverage increased by 0.6% to 90.4%, with Scotland and Northern Ireland achieving at least 95%. UK MMR2 coverage increased by 2.2% to 81% [3]. In England, coverage increased by 2.6% for MMR2 to 80% and by 3.3% to 82.5% for DTaP/IPV coverage; for both booster vaccines coverage increased in all regions. In London, MMR2 coverage increased by 5.5% (data from 4 PCTs excluded) and for DTaP/IPV coverage increased by 8.7% (data from 6 PCTs has been excluded from these estimates due to problems with child health systems). Despite this, London coverage is still lower than corresponding values for other English regions and in particular, pre-school booster coverage for MMR2 and DTaP/IPV is at least 10% lower than other regions.
Table 3. Completed primary immunisations and boosters (all antigens) by 5 years: October to December 2008Strategic Health Authorities (SHAs)/country |
PCT/HB/AR* (total) |
Primary |
Pre-school booster |
||||
| DTP/Pol3 % | Hib3 % | MenC % | MMR1 % | MMR2 % | DTaP/IPV % | ||
| English SHAs | |||||||
North East |
12 (12) |
96.7 |
96.3 |
97.0 |
93.7 |
86.4 |
89.1 |
North West |
23 (24) |
95.6 |
94.1 |
94.4 |
93.2 |
83.9 |
86.0 |
Yorks. & Humber |
14 (14) |
95.1 |
94.6 |
95.1 |
92.4 |
82.5 |
83.8 |
East Midlands |
9 (9) |
95.3 |
94.9 |
95.6 |
91.6 |
84.0 |
86.6 |
West Midlands |
17 (17) |
95.9 |
95.0 |
94.9 |
92.3 |
84.4 |
88.0 |
East of England |
14 (14) |
94.3 |
93.8 |
94.4 |
88.7 |
80.1 |
83.5 |
London |
31 (31) |
82.7 |
81.5 |
80.9 |
81.2 |
66.7** |
65.2 |
South Central |
9 (9) |
93.5 |
93.0 |
92.9 |
90.5 |
80.7 |
84.9 |
Sth. East Coast |
8 (8) |
92.3 |
92.5 |
91.6 |
88.3 |
76.8 |
81.4 |
South West |
14 (14) |
96.5 |
95.8 |
95.9 |
92.7 |
84.3 |
88.4 |
England (total) |
151 (152) |
92.8 |
92.2 |
92.1 |
89.6 |
80.0 |
82.5 |
Wales |
3 (3) |
96.1 |
95.2 |
93.6 |
92.0 |
83.4 |
88.4 |
North'n Ireland |
4 (4) |
97.0 |
93.6 |
94.5 |
95.6 |
89.7 |
91.6 |
Scotland |
14 (14) |
98.4 |
97.6 |
97.6 |
95.6 |
87.2 |
89.6 |
Unit'd Kingdom |
172 (173) |
93.5 |
92.8 |
92.7 |
90.4 |
81.0 |
83.7 |
MMR sentinel surveillance scheme coverage in England
For methods of data collection see http://www.hpa.org.uk/webw/HPAweb&Page&HPAwebAutoListDate/Page/1209454766294?p=1209454766294
Data collected from March 2009 to May 2009 for children in the four age cohorts is summarised in table 4, and ranged from 70.1 to 72.2% at 16 months, 82.1 to 82.7% at 20 months, 85.3% to 85.9% at 24 months, and 89.5% to 90.4% at 36 months.
Table 4. Monthly sentinel estimates of measles, mumps and rubella (MMR) coverage at 16, 20, 24 and 36 months: March 2009 to May 2009Evaluation month |
Proportion of children vaccinated at each age |
||||
Number of PCT/trusts |
16 months |
20 months |
24 months |
36 months |
|
March 2009 |
34 |
70.1 |
82.1 |
85.3 |
89.5 |
April 2009 |
35 |
71.0 |
82.7 |
85.9 |
90.4 |
May 2009 |
34 |
72.2 |
82.3 |
85.7 |
89.8 |
The figure shows observed and projected MMR coverage at 16, 24 and 36 months in England for birth cohorts from October 2002 to December 2007. Projections of coverage at 24 and 36 months were made using the most recent coverage data for the same birth cohort and an estimate of the proportion, p, of those unvaccinated at each earlier age who were subsequently vaccinated by the later age. The proportion was estimated using the most recent 18 months data where final coverage was known. 95% confidence intervals were calculated based on the variability of p in the past data. The estimates of p were as follows: 50.8% for 16 to 24 months, 64.5% for 16 to 36 months, 21.2% for 20 to 24 months, 45.8% for 20 to 36 months and 33.3% for 24 to 36 months. Projections make the assumption that p remains constant over the period of the projection, however, this assumption is likely to be affected by the current MMR catch-up campaign and therefore the projections will probably be under-estimated. Data at 20 months is not shown to simplify the graph as the line is close to that plotted for the 24 month data.
Observed and projected MMR coverage at 16, 24, and 36 months by birth year and month in England
Neonatal hepatitis B vaccine coverage data in England
The data presented in table 5 represents coverage for three doses of hepatitis B vaccine in those infants born to hepatitis B surface antigen-(HBsAg)-positive mothers who reached the age of one year in this quarter (ie those born between January and March 2008), and coverage of four doses of vaccine in infants who reached two years of age (i.e. those born between January to March 2007).
Region |
Returns with 12 month data |
12 month denom- inator |
Coverage at 12 months |
Returns with 24 month data |
24 month denom- inator |
Coverage at 24 months |
| North East | 6 (12) |
11 |
100% |
7(12) |
8 |
25% |
| North West | 17 (24) |
17 |
71% |
17 (24) |
30 |
47% |
| Yorkshire & the Humber | 12 (14) |
34 |
88% |
12 (14) |
28 |
79% |
| East Midlands | 7 (9) |
13 |
77% |
7 (9) |
9 |
44% |
| West Midlands | 13 (17) |
41 |
63% |
13 (17) |
54 |
28% |
| East of England | 12 (14) |
43 |
77% |
12 (14) |
55 |
80% |
| London | 25 (31) |
320 |
64% |
25 (31) |
383 |
41% |
| South Central | 7 (9) |
41 |
95% |
7 (9) |
26 |
81% |
| Sth. East Coast | 6 (8) |
4 |
100% |
6 (8) |
8 |
50% |
| South West | 11 (14) |
11 |
9% |
11 (14) |
17 |
0% |
| Total | 116(152) |
535 |
69% |
117 (152) |
618 |
46% |
Data were received from 116/152 (76%) PCTs in England, 6% fewer than reported in the last quarter [3]. Some of the returns may relate to only part of the PCT due to mergers [4]. Coverage in England for three doses in those aged one year increased 2% to 69% [3] (Table 5). Coverage in England for four doses in those aged 24 months increased by 5% to 46% compared to the last quarter [3].
Commentary
The increase in a range of childhood immunisations rates over the last three quarters may indicate the positive impact that the Vital Signs immunisation indicators [5] is having. In addition, the ongoing MMR catch-up programme targeting all unvaccinated children up to 18 years of age in England, announced by the Chief Medical Officer in August 2008 [6], may be impacting on MMR coverage for children up to five years of age. Local efforts to increase MMR coverage in all unvaccinated children followed the widely reported rise in measles incidence across England and Wales during 2008 when a total of 1383 cases were reported, with continued activity in 2009 (626 cases to the end of April) [7].
UK MMR coverage at 24 months is now 86.5%, up 1% compared to the previous quarter and at a level last recorded in January to March 2001 [3, 8]. This upward trend was observed in all countries (except N Ireland) and all English regions, particularly in London, South Central and the East of England regions where increases of 1.9%, 1.6% and 1.5% respectively were reported.
UK coverage of two doses of MMR at five years of age also increased, up 2.2% to 81.0%, achieving the highest level recorded since the COVER programme started evaluating MMR2 in April to June 1998 [9]. Again, increased coverage was observed in all English regions, particularly in London where a 5.5% rise to 66.7% was reported. MMR2 coverage data in London was calculated using data from 27 of the 31 PCTs; data from four PCTs was excluded due to quality concerns indicating there is a continued need for caution when evaluating the vaccination programme in London. UK coverage of at least one dose of MMR at aged five increased by 0.6% to 90.4%; coverage in Scotland and Northern Ireland exceeded 95% [3].
Children reaching their second birthday in the quarter (born January to March 2007) were the sixth quarterly birth cohort recorded by COVER to be offered (at 12 months and 13 months respectively) the new booster Hib/MenC and PCV vaccines, introduced in September 2006. UK coverage for both booster vaccines evaluated at 24 months continues to increase; PCV coverage was up 1.7% to 85.8%, and Hi b/MenC booster was up 1.9% to 88.6% compared to the previous quarter's estimates [3].
Increases were also observed in UK coverage for the pre-school booster (DTaP/IPV) at five years (up 2.8% to 83.7%), for DTaP/IPV/Hib at 24 months (up 0.5% to 94.7%) and infant MenC (up 0.7% to 93.2%), and for all antigens at 12 months (up between 0.2% and 0.3%).
Relevant links for country-specific coverage data are as follows:
England
http://www.ic.nhs.uk/statistics-and-data-collections/health-and-lifestyles/immunisation
Northern Ireland
http://www.cdscni.org.uk/surveillance/Coveragestats/default.asp
Scotland
http://www.show.scot.nhs.uk/scieh/
Wales
http://www.wales.nhs.uk/sites/page.cfm?OrgID=368&PID=2278
Other relevant links
http://www.hpa.org.uk/infections/topics_az/cover/default.htm
http://www.mmrthefacts.nhs.uk/
References
1. Department of Health. Important changes to the childhood immunisation programme. PL CMO (2006) 1. London: DH, 2006. Available online at: http://www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/Professionalletters/
Chiefmedicalofficerletters/DH_4137171
2. Department of Health. Haemophilus influenzae type b (Hib) vaccine for young children catch-up programme. PL/CMO/2007/5, PL/CNO/2007/3, PL/CPHO/2007/2. 23 July 2007.London: DH, 2007. Available at: http://www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/Professionalletters/
Chiefmedicalofficerletters/DH_076964
3. HPA. COVER programme: October to December 2008. Health Protection Report [serial online] 2008 [cited 23 June 2009]; 3(12): immunisation. Available online at
http://www.hpa.org.uk/hpr/archives/2009/hpr1209.pdf
4. HPA. COVER programme: January to March 2007. Health Protection Report [serial online] 2007 [cited 24 March 2009]; 1(26): immunisation. Available online at
http://www.hpa.org.uk/hpr/archives/2007/hpr2607.pdf
5. Vital Signs: Childhood immunisation. NHS Immunisation Information website. http://www.immunisation.nhs.uk/Local_coordinators_toolkit/
Commissioning_and_providing_immunisation_services/Vital_Signs
6. Department of Health CEM/CMO/2008/1 2: MMR catch-up programme [online]. London: Department of Health, 6 August 2008. Available online at: www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/Professionalletters/
Chiefmedicalofficerletters/DH_086837.
7. HPA. Confirmed measles cases in England and Wales – an update to end of April 2009. Health Protection Report [serial online] 2009 [cited 23 June 2009]; 3(22): news. Available at http://www.hpa.org.uk/hpr/archives/2009/news2209.htm#msls.
8. CDSC. COVER/Korner: January to March 2001. Vaccination coverage statistics for children up to five years of age in the United Kingdom. Comm Dis Rep CDR Wkly 2001; 11(25): immunisation . Available online at http://www.hpa.org.uk/cdr/archives/2001/cdr2501.pdf
9. CDSC. COVER/Korner: April to June 1998. Comm Dis Rep CDR Wkly 1998; 8: 345-6. Available online at:http://www.hpa.org.uk/cdr/archives/1998/cdr3998.pdf.
Laboratory-confirmed cases of pertussis reported to the enhanced pertussis surveillance programme in 2008
There were 903 laboratory confirmed cases of pertussis (culture, PCR, serology) reported to the pertussis enhanced surveillance programme in 2008 (table 1). This represents a 46% increase on the 618 cases reported in 2007 [1].
Table 1. Laboratory confirmed cases of pertussis in England and Wales in 2008, by quarter |
|||||
Quarter |
Culture |
PCR only |
Serology only |
Serology and PCR |
Grand total |
1 |
37 |
11 |
129 |
|
177 |
2 |
50 |
19 |
176 |
|
245 |
3 |
72 |
36 |
195 |
1 |
304 |
4 |
9 |
14 |
154 |
|
177 |
Total |
168 |
80 |
654 |
1 |
903 |
Since mid-2006 there has been greater use of serology testing compared to previous years due to both increasing awareness of pertussis occurring in older children and adults [2], and increased awareness of the availability of this diagnostic method [3]. In 2008 serology confirmations made up 72% of laboratory confirmed cases. Culture and PCR confirmations have also increased compared to 2007 (by 50% and 90% respectively). These increases can be seen in Figure 1 in the <6 month age groups in particular and are in line with 3-4 year cyclical peaks observed in previous years. Careful monitoring of these age groups continues.
Figure 1. Whooping cough notification rates in England and Wales 1998-2008, by age group
The laboratory test used is dependent on the age of the patient and the stage of the illness; this is reflected in the distribution seen in table 2. Culture has high specificity but loses sensitivity as the time post-onset of illness increases. PCR testing is offered for acutely ill children aged less than one year old admitted to a paediatric intensive care unit or paediatric ward with respiratory illness compatible with pertussis [4]. In contrast, serology testing is offered for samples taken more than two weeks after onset for any individuals with prolonged cough. However, as recent vaccination (primary and pre-school booster) can confound the serological results, these investigations are not usually recommended for infants within one year of immunisation (primary or pre-school booster).
Table 2. Age distribution of laboratory-confirmed cases of pertussis in England and Wales in 2008Age group |
Culture |
PCR only |
Serology only |
Serology and PCR |
Grand total |
<3 months |
113 |
62 |
3 |
|
178 |
3-5 months |
23 |
14 |
|
1 |
38 |
6-11 months |
7 |
|
1 |
|
8 |
1-4 years |
6 |
3 |
18 |
|
27 |
5-9 years |
|
|
24 |
|
24 |
10-14 years |
6 |
1 |
126 |
|
133 |
15+ years |
13 |
|
482 |
|
495 |
Total |
168 |
80 |
654 |
1 |
903 |
PCR and serology services are provided by the Centre for Infection's Respiratory and Systemic Infection Laboratory (RSIL). Further information is available on the HPA website at http://www.hpa.org.uk/cfi/rsil/bordetella.htm.
References
1.1. HPA. Laboratory confirmed cases of pertussis reported to the enhanced pertussis surveillance programme in 2007. Health Protection Report [serial online] 2008; 2(26): immunisation. Available at: http://www.hpa.org.uk/hpr/archives/2008/hpr2608.pdf.
2. Harnden A, Grant C, Harrison TG, Perera R, Brueggemann AB , Mayon-White R, et al. Whooping cough in school age children with persistent cough: prospective cohort study in primary care. BMJ. 2006; 333: 174-7.
3. Fry NK, Tzivra O, Li YT, McNiff A, Doshi N, Maple PA, et al. Laboratory diagnosis of pertussis infections: the role of PCR and serology. J Med Microbiol. 2004; 53: 519-25.
4. Fry NK, Duncan J, Wagner K, Tzivra O, Doshi N, Litt DJ, et al. Role of PCR in the diagnosis of pertussis infection in infants: 5 years' experience of provision of a same-day real-time PCR service in England and Wales from 2002 to 2007 J Med Microbiol. 2008, 58, 1023-1029.