Immunisation Policy in the Netherlands
DG Sanco Workshop Vaccination Strategy | February 13-14, 2008
Marina Conyn-van Spaendonck
Centre for Infectious Disease Control
Immunisation in the Netherlands
•
National Immunisation Programme
•
National Programme Influenza Prevention
•
Vaccination programme for risk groups:
•
•
hepatitis B: MSM, drug users
•
BCG for immigrant children
Immunisation of travellers
National Immunisation Programme since 1957
• not mandatory, free of charge
• delivered to neonates and toddlers through healthy
baby clinics; to 4-year and 9-year-olds through public
health services, often in mass campaigns /
immunisation days
• individual invitation and reminders if needed
• centrally registered
• centrally directed public programme
Centre for Infectious Disease Control
Vaccination Coverage
• >95%
• pockets of low coverage
in the so-called bible belt:
orthodox reformed people
refusing vaccination for
religious reasons (in total
± 200,000)
• resistence from
antroposophics,
homeopathics and
alternative medicine
National Immunisation Programme anno 2008
age
general immunisations
target group hep B only
0 mnth (< 48 uur)
-
hepB-0
2 mnth
DTP-IPV-Hib-1 + Pneu-1 DTP-IPV-Hib-hepB-1 + Pneu-1
3 mnth
DTP-IPV-Hib-2 + Pneu-2 DTP-IPV-Hib-hepB-2 + Pneu-2
4 mnth
DTP-IPV-Hib-3 + Pneu-3 DTP-IPV-Hib-hepB-3 + Pneu-3
11 mnth
DTP-IPV-Hib-4 + Pneu-4 DTP-IPV-Hib-hepB-4 + Pneu-4
14 mnth
MMR-1 + MenC
MMR-1 + MenC
4 year
DTP-IPV-5
DTP-IPV-5
9 year
DT-IPV-6 + MMR-2
DT-IPV-6 + MMR-2
Hib in 1993; Men C in 2002; hepatitis B: target group (children of HBsAg+ mothers, children
of parents from high-endemic countries ±15%) in 2006; hep B 0 mnths for children of
HBsAg+ mothers added in 2007, pneumococci in 2006, .... HPV? varicella? influenza?
Centre for Infectious Disease Control
Unrestricted possibilities for vaccination?
The future of the
National Immunisation Programme
• Safe and effective
• Cost-effective
balance
meticulessness ↔ decisiveness
Expansion of the Immunisation Programme:
what stakes?
•
Health gains
•
Interest of individual versus group / population
•
Acceptation, vaccine coverage
•
Fit into the programme: logistics
•
Costs
•
Credibility of authorities
•
Pharmaceutical companies
Decision making process in the Netherlands
•
RIVM informs Health Council and Ministry of Health on the
possible impact of a vaccine through surveillance, modelling,
scenario analysis, cost-effectiveness studies
•
Health Council advises the Minister of Health based on the
state of science
•
MoH decides on introduction of a vaccine in the NIP
•
Netherlands Vaccine Institute: vaccine production, tender /
purchase of vaccine
•
RIVM direction, implementation, evaluation of NIP
HPV in the Netherlands
Programmatic screening cervixca. since 1976, coverage 75%
HPV vaccination in the NIP? - focus on cervixcarcinoma
Current planning:
•
End of March: advice of the Health Council to MoH
•
April: decision of Minister of Health
In anticipation MoH, RIVM and NVI prepare for
the possible inclusion of HPV-vaccination in the NIP.
• HPV in NIP for 12-year-old girls?
• Catch-up campaign for 13-16 or 13-18-year-old girls?
• Immunisation days
Measles age-specific seroprevalence 0-79 years (1995)
%
100
90
80
70
60
50
national sample
orthodox reformed lvc
40
non-orthodox reformed lvc
30
20
10
0
0-
1-
5-
10-
15-
20-
25-
30-
35-
40-
45-
50-
55-
60-
65-
70-
75-
Measles
• 1999-2000 outbreak in the bible belt : 3292 cases (0.21 per
1000 inhabitants), 519 with complications of which 3 deceased,
72 hospitalised
→ Risk for not orthodox reformed neighbouring neonates not yet
vaccinated; additional MMR immunisation at 9 months?
• Next outbreak anticipated
• Surveillance protocol: rash disease, non-invasive
procedures (PCR urine, saliva, nasopharyngeal swab) or
less invasive (capillary bleeding, serology)
• Plan for investigation: attack rates according to vaccination
status, number of doses, time since vaccination; correlates
of protection
Rubella notifications, the Netherlands, 1952-2006
12.000
Aantal aangiften
10.000
selective rubella vaccination
11 year-old girls
8.000
6.000
universal rubella vaccination:
boys and girls, 14 mnth, 9 yr
4.000
2.000
0
1952
1957
1962
1967
1972
1977
Jaar
1982
1987
1992
1997
2002
Surveillance: notifications of rubella 2004/2005
effective immunisation programme forms a threat to
non-vaccinated groups due to shift in age distribution?
num ber of cases
80
Netherlands
60
40
20
0
37
41
45
49 53
3
7
week
11
15 19
23
27
31
Orthodox Reformed people, MMR vaccination coverage,
rubella outbreak in 2004
Rubella outbreak in 2004-2005 in the Netherlands
Rubella infections
387
of which pregnant women
32
resulted in:
Intra-uterine fetal death
congenitale rubella syndrome CRS
congenital rubella-infections CRI
2
11
3
Restricted to orthodox reformed groups objecting to vaccination
Rubella outbreak in Canada
following outbreak in the Netherlands (notifications 2004/2005)
80
Canada
n u m b er o f c a s e s
Netherlands
60
40
20
0
37
41
45
49
53
3
7
week
11
15
19
23
27
31
Surveillance through molecular-biology of strains
Fylogenetic analysis of Dutch / Canadian rubella outbreak
1F
1a
1g
RVi/Linging.CHN/00
RVi/Dangshan.CHN/00
RVi/Toyama.JPN/67
RVi/EinVered.ISR/92
Isolate INS (Germany 1995)
RVi/Gouda.NET/15.05
RVi/Ontario.CAN/27.05
RVi/PAN/99
RVi/SLV/02
RVi/Los Angeles.USA/91
RVi/Moscow.RUS/67
RVi/Moscow.RUS/97
RVi/TelAviv.ISR/68
RVi/Anqing.CHN/00/2
RVi/Seattle.WA.USA/16.00
RVi/Beijing.CHN/79
RVi/Beijing.CHN/80
RVi/BEL/63
RVi/NJ.USA/61
RA 27/3 vaccine strain
RVi/Tiberias.ISR/88
RVi/Jerusalem.ISR/75
RVi/Beneberak.ISR/79
RVi/Saitama.JPN/94
RVi/Dezhou.CHN/02
RVi/MYS/01
RVi/Tokyo.JPN/90
RVi/DalyCity.CA.USA/97
Tipples et
Geno group 1
(a,B,C,D,E,F,g)
1C
2c
2B
Geno group 2
(A,B,c)
2A
1a
1B
1E
1D
0.01
1D
al. 2005
Van Binnendijk et al. 2005
Concluding remarks on the NIP in the Netherlands
• Public programme
• central direction, individual invitation (based on pop. registry),
reminders and registration
• support with extensive communications: protocols, leaflets,
newletters etc.
• continuous surveillance of and reporting on target diseases,
adverse events, population's immunity
effective approach → high vaccination coverage
• Opponents:
• orthodox reformed people - known, stable, nearly impossible
to influence;
• antroposofics, homeopathics etc – impact less known, more
diffuse → herd immunity; growing group?
• What are the consequences of expanding the NIP with HPV,
hepatitis B, influenza, varicella, ...
National Programme Influenza Prevention
• target group:
chronic conditions of heart, lung or kidney,
immunocompromised patients and patients with diabetes,
or
age > 65 year (next season > 60 year)
• not mandatory, free of charge
• delivered in primary care through general practitioners and in
nursing homes
• vaccine made available by Netherlands Vaccine Institute
• programme co-ordination by RIVM
• coverage 76% in primary care, 90% in nursing homes