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A Decisive Decade in Immunisation

Presentation by Professor John Horvath AO, Chief Medical Officer, Australian Government Department of Health and Ageing, to the NCIRS 10th Anniversary Conference.

PDF printable version of A Decisive Decade in Immunisation (PDF 467 KB)

18 July 2007

Slide 1.

• Last speaker at the NCIRS 10th year anniversary conference
• Pleasure to speak today on a decade in immunisation in Australia

Background:

• At University of Sydney
• The Hon Michael Wooldridge gave the opening address
• You are following Sir Gustav Nossal, who is talking about the decade in international immunisation

Slide 2.

• Before reflecting on the past decade, I will give a brief historical overview and describe what was already in place as we entered the decade in 1997.
• Then I will discuss the Seven Point Plan, many elements of which continue to feature strongly in our immunisation system today.
• I will also discuss the reforms to the immunisation advisory structures, which occurred in 2005.
  
  and
  
  
• I will finish with some brief comments on immunisation in the next few years to come.

Slide 3.

• Australia has a long history of using immunisation in targeted and mass vaccination programs for controlling communicable diseases.
• We have also had a strong record in research and development of vaccines, with Australian scientists and clinicians in the forefront of many developments.
• The tables on this and the next slide have been compiled from a number of sources. The dates are indicative only, but they illustrate our long and proud history in using vaccines.
• Smallpox vaccination was given in NSW to control outbreaks of the disease as early as 1804.
• Routine infant vaccination was established by 1953, but note different schedules were used across jurisdictions.

Slide 4.

• More vaccines were introduced throughout the 40 year period covered by this table.
• A national schedule for infant vaccination with DTP(w) was achieved in 1975.
• Hib was the last vaccine implemented before the beginning of the most recent decade.

Slide 5.

• The NHMRC made national recommendations for vaccines and published the “Immunisation Procedures” handbook.
• Immunisation implementation was considered the responsibility of States and Territories. Jurisdictions provided their own programs or delegated the role to local Government authorities, but GPs also provided immunisation services.
• The mix of public and private immunisation varied among jurisdictions
• Funding arrangements were complex
  • they included a mix of Commonwealth funding to States and Territories for vaccines provided in public programs and PBS funding for a few vaccines prescribed by GPs
  • funds based on historical usage (not population) had been incorporated into the general revenue assistance to States/Territories in 1988, making it difficult for jurisdictions to access funds to increase immunisation coverage
  • State funded vaccines were not generally provided to private practitioners, especially live virus vaccines, due to cold chain concerns
  • As a result, service delivery was fragmented and it was difficult to monitor immunisation programs and coverage at a national level.

Slide 6.

• As a result, Australia had low immunisation coverage.
  • National Surveys of childhood immunisation in 1983 and 1989/90 showed low levels of immunisation
  • Those most at risk of incomplete immunisation were low socioeconomic and minority groups
  • In the 1989/90 survey, only 53% of children in the 0-6 years age group were fully immunised for age
  • This was a lower rate than in some developing countries.
• Thus, while there had been success in controlling some diseases (eg polio, diphtheria etc), notifiable disease and other data indicated that many VPDs were continuing to occur at unacceptable rates, with attendant mortality and morbidity

Slide 7.

• 1993 was the year of two seminal events in immunisation in Australia
• The first was the publication of the NHMRC National Immunisation Strategy, which was endorsed by AHMAC in June 1993
• The strategy established national immunisation coverage targets and recommended a range of strategies and system changes to improve efficiency, quality, coverage and accountability
• The second was the successful introduction of infant Hib vaccination nationally
• Although there were some difficulties, such as a bringing forward of the planned implementation date and the late inclusion of a catch-up program, the Hib Program demonstrated the value of a coordinated, national approach to the introduction of a new vaccine and set the stage for later initiatives
• Aspects that were new and/or important for success included
• An NHMRC recommendation prior to the availability of the infant vaccines (1990)
• Relatively short time (approximately 6 months) between TGA approval for the first infant vaccine and commencement of national implementation
• Commonwealth agreement to fund the vaccine
• National vaccine tender
• Commonwealth/State Hib Implementation Committee

Slide 8:

• The dramatic success of the Hib Program is illustrated by the graph on this slide
• The success continues with only 7 cases of Hib disease notified in the first 6 months of 2007.
  • Four of these cases were in indigenous people
  • Five cases were in children aged 2 years or less. Of these, 3 children (2 of them Indigenous) were unimmunised.

Slide 9:

• As we moved from 1993 to the start of 1997, progress was being made in some areas:
  • Funding for a pilot Immunisation Register was approved in the May 1995 Budget, and operation of the ACIR commenced on 1 January 1996.
  • The NIC was established as, essentially, a continuation of the 1993 State/Commonwealth Hib Implementation Committee, with the vital addition of GP representation.
  • Contract arrangements between States/Territories and the Commonwealth for vaccine funding (for some vaccines) were implemented.
  • Funding was population-based, with a requirement that funded vaccine be provided free to both public and private providers and that vaccine use and wastage be monitored.
  • Nationally agreed purchasing arrangements also placed requirements on manufacturers and distributors to ensure continuity and monitoring of the cold chain
• States and Territories had begun to implement school and childcare entry requirements and the Commonwealth and the jurisdictions were working together to implement NIS recommendations, including promoting and supporting cold chain standards, on-the-spot immunisation, simultaneous immunisation, recalls and reminders, and professional education.

Slide 10:

The second landmark document released in Australia was the Immunise Australia: Seven Point Plan.

The 1997 Seven Point Plan saw:

• the establishment of the General Practice Immunisation Incentives (GPII) Scheme to encourage general practitioners to give age appropriate immunisations,
• linking of “fully Immunised for age” status to child care benefit payments and the maternity immunisation allowance,
• the expansion of role and uses of the Australian Childhood Immunisation Register (ACIR),
• the establishment of NCIRS,
• the development of a plan to eliminate measles in Australia,
• immunisation days, and
• the development of school entry requirements.

Slide 11:

• Posters and brochures from campaigns since 1997
  • Understanding Childhood Immunisation
  • Pneumococcal older Australians poster
  • Influenza older Australians poster
  • Indigenous immunisations poster
  • Measles Control Campaign – Let’s work together to beat measles
  • Cover of 8th Edition Australian Immunisation Handbook

Slide 12:

• The need for NCIRS was established as part of the Seven Point Plan
• The Seven Point Plan identified the need for a research centre to focus on the gaps in immunisation, and to undertake surveillance activities of data relevant to the area of immunisation
• A national tender was advertised to select a suitable organisation to become NCIRS.
• That organisation was based at the Children’s Hospital at Westmead in Sydney, or as it was called then, the Royal Alexandra Hospital for Children
• The first contract was signed in August 1997
• NCIRS has received continuous funding since that time

Slide 13:

• NCIRS has contributed significantly to our understanding of gaps in immunisation knowledge, changing knowledge, attitudes and practices of providers and parents
• Contributed to analysis and understanding of what our vaccination coverage rates from the Australian Childhood Immunisation Register (ACIR) say, compared with results from serosurveys and notifications of vaccine preventable diseases
• NCIRS are contributing to the difficult area of improving timeliness of coverage in Indigenous populations
• NCIRS function as the Australian Technical Advisory Group on Immunisation’s (ATAGI) scientific secretariat, providing technical writers for working parties, and the technical editors of the Immunisation Handbook

Slide 14:

• Another success of the Seven Point Plan
• Point 5 of Seven Point Plan is measles eradication
• Very successful Measles Control Campaign in 1998 with 1.9 million primary school children vaccinated with MMR
• Australia has achieved measles elimination and documentation to announce this achievement is being prepared by NCIRS
• Peak in 2006 related to imported cases linked to a tour of a religious group (AMMA), with spread of disease through non- or under-immunised populations

Slide 15:

• Another success story of our current immunisation program is meningococcal C disease control through vaccination
• Program commenced in January 2003
• Targeted all 1 to 19 year olds over a four year period, and adding routine immunisation to the schedule at 12 months of age
• At the time, it was the largest vaccination program ever undertaken, in terms of population targeted, at a cost of $298 million over four years
• Effect of program has been:
  • There were 213 cases of meningococcal C reported in 2002. In 2005 there were 40 cases reported
  • This means between 2002 and 2005 there was a decrease of 81% in reported meningococcal C cases
  • In 2006, 24 cases of meningococcal C disease were reported with 1 death

Slide 16:

• Graph shows decline in serogroup C disease by age
• Note previous high disease in 15-19 age group, followed by 20-24 year age group
• By end 2006 rates by age show dramatic decrease in those age groups previously experiencing higher rates of disease, and elimination of the bimodal peak distribution of cases
• This is an amazing achievement in a short period of time, and is a testament to Australia’s sophisticated and well functioning immunisation program

Slide 17:

• Australian Government expenditure in vaccine funding has increased substantially in a decade
• Between 1996 and 2006 there has been a 22-fold increase in vaccine expenditure
• Australian Government also contributes to the immunisation program through funding the ACIR, NCIRS, supporting the immunisation committees, enhanced surveillance for disease, and other projects

Slide 18:

• Spike in expenditure over 2002-03 is the commencement of the National Meningococcal C Vaccination Program
• The peak in 2004-05 was the commencement of the National Childhood Pneumococcal Vaccination Program and the National Pneumococcal Vaccination Program for Older Australians
• And the projected expenditure peak in 2007-08 is as a result of the commencement of the National HPV Vaccination Program and adding rotavirus vaccines to the National Immunisation Program

Slide 19:

• Coverage is taken from the ACIR
• Graph shows that after June 2000, coverage has remained fairly stable at 12 months of age, with over 90% of all children fully immunised for age
• It was in December 2003 when, for the first time, the 24 month coverage rate exceeded the 12 month coverage rate. This was because in September 2003, the 18-month dose of diphtheria, tetanus, acellular pertussis vaccine was removed. The 24 month rate has not yet fallen below the 12 month old rate.

Notes:

For children under 7 years of age, we measure immunisation coverage through the Australian Childhood Immunisation Register. The ACIR talks to the Medicare database, which means that 99% of children in Australia have a record on the ACIR, whether they will be or have been vaccinated, giving a very accurate denominator from which to assess immunisation coverage in this age group.

As with all data collection systems there are some problems with this data. The data displayed in the graph do not count immunisations that are reported late, nor immunisations given late. If late notifications and late immunisations are counted in the assessment for coverage, the coverage rates rise by another 2 to 3 percentage points.

The conscientious objector rate in Australia has also been estimated at between 2 and 3 percent. Children not vaccinated because their parents conscientiously object are still included in denominator data.

Slide: 20

• Pressure for reform started in September 2003 when the 8th Edition Australian Immunisation Handbook was released
• The media remarked that the recommended best practice schedule included vaccines which weren’t funded
• The media missed the fact that this had occurred in all previous versions of the handbook
• With multiple new vaccines in the research and development pipeline, many of which expected to reach market within the next 5 years there was a need for change
• The new HPV vaccines are a good example of moving away from the traditional concepts of what a vaccine does and when it does it
• There was recognition within the government of the need for greater transparency in making funding decisions for vaccines
• And there was the realisation that immunisation advisory structures had not changed since the inception of ATAGI in 1997, when vaccine expenditure was only $13 million and 8 diseases were prevented by vaccines included in the routine program. By 2005-06, vaccine expenditure was $283 million for protection against 13 diseases.

Slide 21:

• At a cost of $12.8 million over the next four years, the Australian Government announced that:
  • the responsibility for making funding recommendations to the Minister would transfer from ATAGI to the Pharmaceutical Benefits Advisory Committee
  • vaccine price setting would transfer from the Immunisation Section to the established process used by the Pharmaceutical Benefits Pricing Authority
  • ATAGI’s membership, standard operating procedures and terms of reference would be reviewed, and its role in providing advice on the medical administration of vaccines in Australia would be strengthened
  • increased support for ATAGI, research and surveillance activities would be provided through expanded funding to the NCIRS, and additional money to the States and Territories to enhance surveillance for vaccine preventable diseases
  • the establishment of one immunisation schedule for Australia, the National Vaccine Schedule, which lists only Australian Government funded vaccines
  • These changes came into effect from late 2005, with the relevant legislation coming into force on 1 January 2006

Slide: 22

• Maintaining and improving immunisation coverage rates in hard to reach populations. In some cases it is not only about how to improve them, but how to ensure they are given on time
• Constant schedule change is hard to manage at all levels, national, state and territory and for the workers at the coal face
• It is not about managing the complex and rapid technological change, but managing this in the context of a changing role for vaccines
• And what do we do about the need for a whole of life immunisation register? The feasibility study announced in the 2006-07 Federal Budget should help to answer this question

Slide 23:

This was the immunisation schedule in 1997

Slide 24:

And the immunisation schedule in 2007

Slide 25:

What will be the schedule in another decade?