No 15/17 - 2017

Annual report on the Danish childhood vaccination programme

In this week, the WHO celebrates the 12th European Immunization Week. As previously, the WHO aims to promote vaccinations as an effective means of prevention against infectious diseases, and the week is marked in various ways in each of the member countries.

In Denmark, the National Health Authority, the Danish Medicines Agency and Statens Serum Institut have jointly and for the third time prepared an annual report on the Danish childhood vaccination programme for 2016.

The annual report describes the vaccination programme and the activities associated with the programme in 2016. The annual report is thus designed to serve as a one-stop reference on the childhood vaccination programme that is available on the websites of all three organisations.

In 2016, the coverage of nearly all vaccines in the childhood vaccination programme rose. Nevertheless, the coverage of the HPV dropped markedly.

Why do we vaccinate in Denmark?

Vaccination is one of the most effective preventive methods available. The effect of the majority of vaccines is long-lasting, and vaccination may prevent both infection in the people vaccinated and reduce community transmission.

Many of the infectious diseases forming part of the childhood vaccination programme will run an epidemic course in unvaccinated populations every few years, but these epidemics can be avoided through a high population vaccination coverage. Many of the diseases that are prevented through vaccination in the childhood vaccination programme may, despite modern treatment, cause deaths and permanent sequelae in children.

The Danish childhood vaccination programme has been extremely effective. Transmission of conditions like diphtheria and polio has not been observed in Denmark for quite a few decades; and for several of the other conditions, a considerable reduction in the incidence is evident already the year after or briefly after the vaccination was introduced, e.g. after the introduction of Hib vaccination. Even so, there is no basis for discontinuation of the vaccines: in addition to continued risk of infection in Denmark, there is also a risk that unvaccinated children may become infected during travels abroad and bring back the infection to Denmark, or that unvaccinated foreigners may introduce the infection into Denmark.

Therefore, it is important to continue vaccination against conditions for which we have seen no cases in recent years. Unless the condition is eradicated completely, it will invariably reappear if we stop vaccinating.

What does the childhood vaccination programme comprise?

The childhood vaccination programme includes vaccination against the following conditions: diphtheria, tetanus, whooping cough, polio, meningitis or epiglottis caused by the Haemophilus influenzae type b bacterium (Hib bacterium), meningitis and other serious conditions caused by the pneumococcal bacteria, measles, mumps, rubella and cervical cancer (girls).

The vaccinations are given free of charge and it is optional whether you want your child to be vaccinated. Vaccinations are typically given by the GPs.

How is the childhood vaccination programme monitored?

Constant monitoring is in place to ensure that the childhood vaccination programme serves its purpose.

A record is kept of the number of disease cases observed for each of the conditions we vaccinate against in the childhood vaccination programme. Furthermore, it is recorded how many vaccinations are administered by doctors, and the Danish Medicines Agency monitors possible side effects of the vaccines.

Statens Serum Institut is responsible for ensuring the supply of vaccines for the childhood vaccination programme and monitors the vaccination coverage in the population and the incidence of the conditions vaccinated against.

International vaccination coverage recommendations

For most vaccines, there is a direct association between their introduction in the childhood vaccination programme and the incidence of the conditions that the vaccines prevent.

Measles is the most infectious of the childhood conditions and therefore requires a very high coverage in the population for outbreaks to be avoided. The World Health Organization’s (WHO’s) objective for measles vaccination is a minimum coverage of 95%. Therefore, a minimum of 95% of all children should receive both MMR vaccines. Nevertheless, this objective has not been reached for any birth year since the vaccine was introduced into the childhood vaccination programme in 1987.

For polio, the WHO assesses that at least 90% of all children need to be vaccinated in order to prevent outbreaks. In the Danish childhood vaccination programme, this corresponds to 90% of a birth year receiving the three initial DTaP-IPV/Hib vaccinations. This objective was reached for the birth years 2012-2015.

The WHO has not established specific goals for the coverage of any of the other vaccines comprised by the childhood vaccination programme. In general, though, the health authorities find that a high vaccine coverage is needed to protect the population against the conditions prevented by the vaccines.

2016 vaccination coverage

Apart from the coverage of the HPV vaccination, the coverage of all vaccinations in the childhood vaccination programme rose in 2016.

The increase was owed, among others, to the reminder letters that Statens Serum Institut started sending out in May 2014 to the parents of children who had not received the vaccinations recommended in the childhood vaccination programme.

In 2016, the coverage of the vaccinations against measles, mumps and rubella (the MMR vaccination) was 2-3 percentage points higher than in 2015. For the first MMR vaccination at 15 months, the coverage was 91%, and for the second vaccination at 4 years of age coverage reached 85%. Despite the increase, the coverage of the measles vaccination remains below the WHO’s 95% coverage goal for both vaccinations.

In 2016, the coverage of the vaccinations against diphtheria, tetanus, whooping cough, polio and the Hib bacterium was 91% or higher for the three primary vaccinations given at 3, 5 and 12 months of age. The coverage of the polio vaccination thus exceeded the WHO’s 90% recommendation.

The coverage of the vaccination against pneumococcal disease was 94%, 93% and 91%, respectively, for the vaccinations given at 3, 5 and 12 months. This is a 3-5% increase from 2015.

In 2016, the coverage for booster vaccination against diphtheria, tetanus, whooping cough and polio at five years of age was 81%. This constitutes a 3-5% increase from 2015.

2016 saw a distinct decrease in the coverage of the HPV vaccination. In 2003, the coverage was 47% for the initial HPV vaccination and 15% for the second vaccination (and thus for full vaccination). This constitutes a distinct drop in relation to 2015, when the coverage for birth year 2002 was 73% and 57%, respectively. It is also an additional decrease in comparison to previous birth years, where the coverage was at 90% or higher for the first HPV vaccination, and where almost 80% of the girls concluded their vaccination.

The authorities are taking very seriously the considerable decrease in HPV vaccination and will focus the effort on restoring a high coverage in the years to come.

Enhanced efforts to increase HPV vaccination coverage in 2016

The coverage of the HPV vaccination dropped further in 2016 compared with 2015. This has made the Danish authorities initiate extraordinary efforts to increase the coverage of the HPV vaccination.

Thus, 7M DKK were earmarked for this purpose by the parties of the so-called Satspulje (Danish Fund for social purposes) in the Danish Parliament. The means are to be used for research projects in the 2016-18 period and will contribute to increase our knowledge about any causal relation between HPV vaccination and serious symptoms that are perceived as adverse vaccine reactions.

In 2016, the Danish Health Authority conducted a thorough analysis that will serve as the basis for a large-scale information campaign about HPV vaccination to be launched in 2017. The analysis focused on knowledge, attitudes and decision processes related to HPV vaccination among girls and parents to girls aged around 12 years and demonstrated that parents demand more factual knowledge of HPV vaccination. The upcoming information measure must prepare parents better to decide about vaccination of their daughter by providing medical information about the vaccination. Additionally, the relevant authorities and organisations in the field, including the Danish Cancer Society and the Danish Medical Association, will join forces to restore the population’s trust in the HPV vaccine.

In 2016, the health authorities also established closer cooperation and dialogue with the World Health Organization (WHO) about the Danish and international efforts related to HPV infection and HPV vaccination. Among others, meetings were held with international experts who provided advice to Denmark.

Notification of suspected adverse reactions in 2016

In 2016, the Danish Medicines Agency received a total of 1,073 reports of suspected adverse reactions to vaccines in the childhood vaccination programme. This figure should be interpreted in relation to the fact that approximately 620,000 vaccinations were administered under the programme.

Of the 1,073 notifications, a total of 307 concerned suspected adverse reactions for the HPV vaccines, which constitutes a distinct decrease from the 822 notifications received in 2015. In addition, there were 632 reports of granulomas. The vast majority of the notified granulomas were presented before 2016, but were notified in 2016. A limited number of granulomas were notified as having presented more than 8 years previously.

The increase in the number of notifications of granulomas can probably be attributed to the attention given to granulomas and aluminum-containing vaccines in recent years.

(The Danish Health Authority, the Danish Medicines Authority and Statens Serum Institut)

Meningococcal disease - How to avoid further cases among acquaintances?

The Danish Health Agency has published “Guidelines on prevention for cases of meningococcal disease” (in Danish).

The statutory basis of the guideline is “Executive Order on the Management of Infections (in Danish language: Bekendtgørelse om håndtering af infektioner)”.

The guideline describes how to respond when a case of meningococcal disease has been detected among your circles. The guideline is an update of previous regulations.

In the 1990s, the number of notified cases of meningococcal disease decreased from about 250 annual cases to approx. 100. Subsequently, the number of cases has continued to follow a decreasing trend, and currently about 50 annual cases are notified.

Nevertheless, the disease remains very serious and it is associated with an excess mortality of 5-10%. Life-threatening meningococcal disease can develop in a matter of hours.

Therefore, rapid information and, if relevant, preventive treatment among the patient’s acquaintances is essential. This guideline specifies who is responsible for the various tasks in this connection.

The Danish Patient Safety Authority, Supervision & Guidance East/South/North (previously the Medical Officers of Health) ensures that the precautionary measures are implemented.

The Danish Health Authority has published an Information Leaflet on Meningococcal Disease (in Danish).

Furthermore, the Danish Patient Safety Authority has published a guideline describing early treatment of patients presenting with symptoms of meningococcal disease: Guideline on GPs’ and on-call doctors’ treatment of meningococcal disease (in Danish).

(Danish Health Authority)

Link to previous issues of EPI-NEWS

26 April 2017