Vaccines have saved more lives worldwide than any other public health intervention apart from providing clean water. They have had a major impact on the health of Irish children.
Since the middle of the 20th century, serious disease such as smallpox, polio and diphtheria have become a thing of the past, while in recent decades, the burden of other vaccine preventable diseases such as pertussis, measles, meningococcal and Hib infections has been greatly reduced in Ireland. The cost of treating a case of measles has been shown to be 23 times the cost of vaccinating one child against measles.
16.2.2 Rationale, Objectives and Continuing Relevance
A well functioning National Immunisation Programme is essential for any country (as outlined by the World Health Organisation). The National Immunisation Programme is
consistent with Government policy as it aims to promote health by preventing death and disability from vaccine preventable diseases.
The Programme provides infant and school immunisation programmes which are free of charge to all children. From September 2011 the National Immunisation Programme will administer a cervical cancer vaccination catch-up programme for all girls in secondary school.
The objectives of the programme are to:
• Prevent disease in individuals and groups through safe and effective immunisation.
• Implement all publicly funded immunisation programmes in a coordinated standardised way.
• Monitor vaccine uptakes rates and provide surveillance of vaccine preventable diseases in order to achieve internationally determined targets.
• Provide evidence-based information for health professionals and the general public.
National immunisation programmes exist worldwide regardless of economic or social circumstances. Each country determines their individual programmes based on international standards and resources. Immunisation is one of the most cost effective health interventions available. A well functioning national immunisation programme has been shown to be critical in preventing disease and disability from vaccine preventable diseases.
16.2.3 Programme Effectiveness
National Immunisation Programme objectives have been met as follows:
• National diphtheria, tetanus, polio and pertussis (DTP) vaccine uptake rates at 24 months of age have increased from 83% in 2001 to 94% in 2010 (WHO target is 95%).
• National measles, mumps and rubella (MMR) vaccine uptake rates at 24 months of age have increased from 69% in 2001 to 94% in 2010 (WHO target is 95%).
• Preliminary uptake rates for human papilloma virus (HPV) vaccine (introduced in September 2010) show many areas have exceeded the HSE target uptake of 80% for a completed course of three doses of vaccine.
• Pneumococcal vaccination has resulted in an 83% reduction in numbers of cases of invasive pneumococcal disease in children under 2 years of age.
• A national uptake of over 70% for the MMR vaccine catch up programme for senior cycle students in second level school in 2009, resulted in stopping a national mumps outbreak of over 3,000 cases.
Not all objectives of the programme have been met. The National MMR uptake has not reached the WHO target of 95%, resulting in children not being protected from measles, mumps and rubella. This may be due to adverse publicity in 2000/2001. A Measles catch up campaign is required for school children. In addition, seasonal influenza vaccine uptake rates for those aged 65 years and older have not met the WHO target of 75%. The highest rate to date was 70% in 2008/2009. A possible reason for this low uptake could be that non GMS patients are required to pay the GP for the administration of the vaccine.
Vaccine uptake rates are measured in accordance with WHO and European Union standards. The National Immunisation website (www.immunisation.ie), which is accredited to the WHO, provides credible accurate information for health professionals and the general public.
16.2.4 Programme Efficiency
A number of new vaccines have been introduced into the national programme since 2008.
In addition, catch up campaigns have also been implemented. The number of births has
increased by 25% since 2005. Increased vaccine supplies were purchased at no overall increased cost due to procurement and distribution efficiencies.
Table 16.5: Trend in Expenditure - National Immunisation Programme Uptake Rates 2008-2011
2008 (€m) 2009 (€m) 2010 (€m) 2011 (budget allocated)(€m) Non-Pay Vaccines 30 Vaccines 40 Vaccines 40 Vaccines 40 Estimated total budget €90-100m which includes estimated as part of the ongoing Value for Money and Policy Review of Immunisation Programmes. In terms of administration costs, the overall trend is decreasing due to greater efficiencies and standardisation.
Table 16.6 below shows the trend in outputs of the programme. Overall these outputs for the programme can be classified as:
• Implementation of national immunisation programmes.
• Introduction of new vaccines to national programmes.
• Implementation of catch up immunisation programmes.
• Uptake rates.
Table 16.6: Trend in Outputs - National Immunisation Programme 2008-2011
2008 2009 2010 2011 (budget allocated)
Quarterly vaccine uptakes are collated by Health Protection Surveillance Centre (HPSC).
Efficiency of the programme can be improved through:
• Validated temperature control of all vaccines from time of manufacture to time of delivery to site.
• Development of medication protocols for nurse administration of school vaccination programmes.
• Process all GP payments through the PCRS.
• Review of fees for seasonal influenza vaccination campaign.
Changes in delivery methods of the programme are being considered as part of the Value for Money and Policy Review which is due for completion in 2012. Examples of such changes are a move to standard school based immunisation programmes which result in better vaccine uptakes and vaccines being administered by pharmacists e.g. seasonal influenza vaccine.
Currently there is no national immunisation register. Immunisation records are maintained on over 50 different databases countrywide, with no relationship between them. This leads to vaccine errors with them being duplicated or incorrectly given. A national immunisation
register would streamline data entry and require less administrative resources. However, the development of a National Immunisation Register would require an IT investment to be put in place.
The National Immunisation Programme is free to all families. The introduction of any charges would be a barrier to uptake and would result in children not being protected against vaccine preventable diseases. Non GMS or doctor only card holders in the recommended at risk groups must pay their GP for the administration of seasonal influenza vaccine resulting in lower vaccine uptake.
16.2.5 Additional Demands
A further influenza pandemic, increased incidence or outbreak of vaccine preventable disease will create additional demands on an already stretched service.
16.2.6 Conclusions
Reducing or discontinuing the National Immunisation Programme is not an option.
However, savings and greater efficiencies can be achieved through:
• The annual review of the Health Professionals (Reduction of Payments to General Practitioners) (Immunisations) Regulations 2011 (currently being drafted in the Attorney General’s Office).
• Nurse led immunisation programmes, particularly for schools.
• Standard school based immunisation programmes.
• Administration of seasonal influenza vaccines by pharmacists.
• Development of National Immunisation Register. (IT investment required. It would, however, result in a more efficient and streamlined system).
• The processing of all GP payments through the PCRS.
16.3 CONCLUSIONS, SAVINGS AND REFORM
The continuation of Health Promotion services is essential in order to assist in the reorientation of the health services away from disease treatment programmes towards health promotion, health improvement and prevention.
The services provided by the National Immunisation Programme are of critical importance and must be continued. International evidence points to immunisation services being among the most cost effective health interventions.
A unified IT based National Immunisation Register to replace the current 50 separate databases would lead to improvements in effectiveness. Efficiencies would also be driven by reducing the requirement for administrative resources.
Key Savings:
• Administration of Seasonal Flu Vaccine: The Department is currently exploring options in relation to the administration of seasonal flu vaccine by community pharmacists, including legal issues in this regard. This would involve setting a lower fee than is currently paid to GPs, while still allowing GPs to administer the vaccine.
Key Reforms:
• Health Promotion Strategic Framework: Efficiencies and effectiveness will be driven through the implementation of the Health Promotion Strategic Framework. This will result in a greater degree of consistency in practice across the country,
improvements in skill mix and increased capacity.
• Performance Monitoring: A new suite of performance indicators for health promotion
will be introduced for 2012.
• Review of Health Promotion Structures: A review of health promotion structures in the HSE will be undertaken to ensure that teams are organised to achieve optimal effectiveness and efficiencies.
• Efficiencies: Consideration will be given to implementation of the following measures to drive efficiencies in the Immunisation Programme:
o Nurse, as opposed to doctor, led immunisation programmes;
o Development of a National Immunisation Register;
o All immunisation related payments to GPs to be administered through the PCRS.
CHAPTER 17
SOCIAL INCLUSION