No 16/17 - 2019
Annual report on the Danish childhood vaccination programme
This week, the World Health Organization (WHO) celebrates the 14th European Immunization Week.
Under the slogan “Protected Together, #Vaccines Work”, the WHO also this year wishes to place vaccines in the spotlight as a very effective means for the prevention of infectious diseases. The WHO also spotlights so-called “vaccine heroes”, i.e. the healthcare workers who give the vaccines, all the parents who opt in and have their children vaccinated, and anyone who makes an effort to access evidence-based knowledge about vaccines and pass such knowledge on to others.
In Denmark, the National Health Authority, the Danish Medicines Agency and Statens Serum Institut have jointly and for the fifth time prepared an annual report on the Danish childhood vaccination programme.
The annual report describes the vaccination programme and the activities associated with the programme in 2018.
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.
Vaccination coverage increased in 2018
The coverage of all vaccinations under the Danish vaccination programme increased or remained at par with their 2017 level. This should be interpreted in the light of the fact that all vaccination coverages increased from 2016 to 2017.
In 2018, we have even seen a considerable increase in cervical cancer vaccination (HPV vaccination) among girls who turned 12 and 13 years old in 2018. Coverage rose by 14% for the first vaccine and 16% for the second vaccine in the 2005 birth cohort.
Concurrently, we have observed that 20% more girls aged 14-17 years have been vaccinated compared with 2017. For some birth years, we are now close to the high HPV vaccination coverage recorded before 2015 (approx. 90% coverage).
In 2018, we also studied the MMR coverage at school level. By linking data from the Danish Vaccination Register to other data from Statistics Denmark, we obtain a more fine-grained image than previously when we were able to obtain the vaccination coverage only at the municipal level.
The statement shows that nearly half of all children (44%) attend schools where the MMR vaccination coverage falls in the 90-100% range. Even so, relatively few children attend a school where more than 95% of the children enjoy full measles protection (1.8%), which is the WHO objective. Very few pupils attend a school where the coverage falls in the 50-60% range (658 children), and no children attend schools where the coverage is lower than 50%.
We have identified seven municipalities where the coverage is particularly high at two or more schools (more than 95% coverage). Four of the seven municipalities are located in West Jutland. These municipalities were contacted and asked if they make special efforts to achieve their high coverage. In the cases where the municipality has, indeed, made special efforts in 2018, health visitors’ systematic and dialogue-based efforts towards parents are pivotal.
Please find the list of MMR2 vaccination coverage at the school level here (in Danish).
The municipalities may use the school-level statement as a tool to target their initiatives, if they decide to make a special effort to underpin their vaccination coverage. If the vaccination coverage is low at several schools in the municipality, the health visitors may, e.g., run an information campaign or initiate outreach efforts at these schools to pinpoint unvaccinated children and initiate a dialogue with their parents.
In 2018, vaccination received much attention
In 2018, the Danish government earmarked means for new initiatives in the vaccination field for the next four years. The objective is that even more people should be vaccinated at the recommended time, that novel and even more effective vaccines are given and that everyone who may benefit from this may be offered vaccination.
Specific examples of initiatives include that health visitors will be trained to serve as vaccination ambassadors, that parents will now receive vaccination reminders before the vaccination time through the reminder scheme, and that boys will also be offered HPV vaccination from mid-2019.
In April 2018, a permanent MMR vaccination offer for adults was introduced. The offer is aimed primarily at people born after 1974. These people have a higher risk of not having had the condition during their childhood, as opposed to the older generations, who have typically had the disease in childhood. In 2018, a total of 3,614 adults received measles vaccination, among whom 1,435 were born in or before 1974.
In 2018, a focus was placed on informing about HPV vaccination and on increasing coverage. The HPV information initiative Stop HPV - Stop cervical cancer continued in 2018 with a dedicated website, Facebook page and information materials for parents and health workers. This initiative has helped convince more parents to have their daughters vaccinated.
Furthermore, in 2018 the Copenhagen Municipality implemented a pilot project on HPV vaccination at eight selected public primary and lower-secondary schools as part of which all 6th-grade-girls were offered vaccination in school hours. A total of 229 parents have received the offer and 34 girls were vaccinated. The municipality has earmarked funds allowing the offer to be extended to all schools in Copenhagen for a 2-year-period.
Status quo on the number of reports of presumed side-effect in 2018
In 2018, the Danish Medicines Agency received a total of 661 reports of side effects to vaccines in the childhood vaccination programme. That corresponds to a 13% decline compared with 2017 when another decrease in the number of notifications was recorded compared with the previous year. Of the 661 notifications made in 2018, the Danish Medicines Agency categorised 78 as serious.
The vaccine for which presumed side effects have most frequently been reported is the vaccine that protects against diphtheria, tetanus, whooping cough, polio, infection with the Haemophilus influenzae (hib) bacterium (+ hepatitis B) and the vaccine against pneumococcal infection. The most frequently reported side-effects are granuloma (an itchy, persisting, lump formation at the injection site). In 2018, the Danish Medicines Agency received a total of 417 notifications of granuloma, of which the majority concerned vaccines given in 2015 and 2016. Granuloma following vaccination with vaccines containing aluminum salts is a known and, in most cases, not a severe side effect.
Adverse events provide important information
An unintended event is an error that occurs if health workers accidentally harm or possibly harm a patient. Both health workers and parents can report adverse events to the Danish Patient Safety Authority where the report is anonymised, and the authority ensures that all stakeholders may learn form the event. In the childhood vaccination programme, unintended events are more frequently seen by GPs, as children are typically vaccinated by their GP.
In 2018, a total of 121 unintended events were reported relating to the vaccines used in the Danish childhood vaccination programme. In all, 46 of these unintended events were categorised as having caused mild harm to the child, and 75 were categorised as having caused no harm to the patient. In the majority of cases, the consequence of the unintended event was that the child needed an extra vaccination, which in some cases triggered an additional doctor’s appointment.
The three most frequently identified complaints among the unintended events were: “Incorrect vaccine given (73 adverse events), “Same vaccine given several times” (12 adverse events) and “Powder and fluid not mixed before injection” (10 adverse events).
We vaccinate against 10 diseases in the Danish childhood vaccination programme
In the childhood vaccination programme, we vaccinate against 10 serious infectious conditions: diphtheria, tetanus, whooping cough, polio, inflammation of the lining of the brain or the epiglottis caused by the Haemophilus influenzae type b bacterium (Hib bacterium), inflammation of the lining of the brain and other serious conditions caused by 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. Even so, all health authorities recommend that children receive vaccination in accordance with the Danish childhood vaccination programme. Vaccinations are typically given by the GPs.
Ambitious vaccination coverage objectives
The WHO has established objectives for measles, whooping cough and polio vaccinations. For measles, the WHO recommends a measles coverage of 95% or more in the entire population. In Denmark that means that a minimum of 95% of all children need to receive both MMR vaccines.
The WHO also recommends that a minimum of 95% of all children should receive the DiTeKiPol/Hib vaccines. That coverage ensures a good level of protection against whooping cough, polio and the other diseases included in the vaccine.
Furthermore, the Danish health authorities recommend “timely” vaccination. That means that children should be vaccinated when they reach the age at which the Danish Health Authority recommends vaccination. This ensures that every vaccine provides the child with the optimal protective effect.
Vaccination is an effective and safe prevention method
The Danish childhood vaccination programme is extremely effective. Transmission of conditions like 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 shortly after the vaccination was introduced, e.g. after the introduction of Hib vaccination.
Even so, we still need to have our children vaccinated. Unvaccinated children risk becoming infected during travels abroad and bringing the infection back to Denmark. Unvaccinated people from other countries can also introduce the infection into Denmark. But we will be protected against that if children are vaccinated. Furthermore, we will protect any children who are currently too ill or too young to be vaccinated.
Generally, vaccination is one of the most safe and effective preventive methods available. The effect of the majority of vaccines is long-lasting, and vaccination prevents infection in the vaccinated people and reduces community transmission.
Commentary
2018 was a good year for the childhood vaccination programme. The coverage of the programme increases, and in 2018 considerably more girls and young women received HPV vaccination and thereby achieved adequate protection against cervical cancer. Various authorities are engaged in raising the coverage. The government is earmarking more means than previously. The health authorities are developing new tools and training materials. And more health visitors are engaged in the vaccination dialogue with parents.
Furthermore, the health authorities monitor the programme closely to understand how the programme is doing. We monitor the transmission of the diseases that we vaccinate against and assess any notifications of suspected adverse events and unintended events to vaccination. All of these efforts are made to increase the safety of the childhood vaccination programme for parents and children alike.
(The Danish Health Authority, the Danish Medicines Authority and Statens Serum Institut)