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Health Protection (Children)

Introduction

Health Protection involves the planning, surveillance and response to incidence and outbreaks of disease. It prevents and reduces the harm caused by communicable diseases and minimises the health impact from environmental hazards such as chemicals and radiation. It also includes the delivery of major programmes such as national immunisation programmes and the provision of health services to diagnose and treat infectious diseases.

The Local Authorities Regulations, 2013 explains the new health protection duty of local authorities. These regulations are made under section 6C of the “NHS Act 2006” (as inserted by section 18 of the Health and Social Care Act 2012). This came into force on the 1st April 2013:

 

  1. The Health Protection team, on behalf of the Director of Public Health (DPH) is responsible for the Local Authorities' contribution to health protection matters including the response to incidents and emergencies. Public Health England (PHE) will provide specialist support and have a complementary role to play.  Both PHE and Local Authority Public Health will work as a single unit.

 

  1. NHS organisations including NHS England (NHSE) and our local Clinical Commissioning Group (CCG) have a legal responsibility under the NHS ACT 2006 to mobilise resources to manage incidents and emergencies.  They also have a legal duty to co-operate with Local Authority Public Health in delivering national and local health protection priorities.

 

The role of Health Protection involves:

  1. Planning and responding to incidents and emergencies;
  2. Surveillance of communicable and notifiable diseases;
  3. Reduction of detriment due to communicable and non-communicable diseases and prevention of infection and infectious diseases;
  4. Minimising the health impact of environmental hazards; and
  5. Reducing premature mortality and morbidity by improving environmental sustainability.

 

The role of Health Protection begins from the day life is conceived until the end stage of life. Most Health Protection issues involve:

  1. Vaccine preventable diseases (measles, mumps, rubella, human papillomavirus),
  2. Gastrointestinal diseases (food poisoning notifications, food hygiene standards),
  3. Respiratory diseases (tuberculosis, pneumococcal disease, seasonal flu, asthma),
  4. Hepatitis,
  5. Sexually transmitted infections (chlamydia, HIV) and
  6. Environmental hazards (radon, skin cancer, air pollution, water quality)

 

This chapter covers Health Protection as it relates to pregnant mothers, children and young people.  For the Health Protection chapter on Adults, please follow this link

 

Infectious diseases screening (Antenatal Screening for Infectious diseases)

All pregnant women in Bedfordshire are offered antenatal screening for HIV infection, Hepatitis B infection, Syphilis infection and susceptibility to Rubella infection. The screening programme aims to ensure that women who screen as positive are offered appropriate assessment and management of their condition and to reduce the risk of mother-to-child transmission. The timely identification of babies born to Hepatitis B positive mothers helps to ensure that babies receive the recommended immunisation doses to protect them against infection. Identifying women susceptible to rubella infection during Antenatal Screening allows for immunisation to be obtained prior to any subsequent pregnancy.

 

In Bedford Borough approximately 97% of pregnant women access maternity services at Bedford Hospital and the remaining 3% access care at surrounding hospitals

 

Facts, Figure and Trends

Two Key Performance Indicators (KPIs) measure the Screening for Infectious Diseases in the Pregnancy programme quarterly and annually – ‘HIV coverage’ and ‘Timely referral of hepatitis B positive women for specialist assessment’.

Screening for HIV

A national target to achieve a 90% uptake of antenatal screening for HIV is in place across maternity services. Figure 1 shows the % coverage of HIV screening (ID1) in Bedford Hospital Trust and Luton & Dunstable Hospital

Figure 1: Figure1: Antenatal infectious disease screening (ID1)– ‘HIV coverage’ 2014/15

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Source: Bedfordshire DPH Screening and Immunisation Programme Report (September 2015). (Data for IDPS is currently available by Acute Trust only. Data relates to screening uptake and outcomes for all pregnant women accessing maternity services at Bedford Hospital and the Luton & Dunstable Hospital, not Bedfordshire women in isolation).

 

Both Bedford Hospital and Luton & Dunstable Hospital Trust are performing above the target of 90% screening coverage (Fig1). It should be noted that not all cases of HIV identified through antenatal screening are newly diagnosed, and in many cases HIV positive status is known prior to antenatal screening. In 2013, the percentage of pregnant women screened positive for HIV nationally in total was 0.25%. The percentage of women newly diagnosed in East of England is 0.05% compared with 0.03% nationally

 

Screening for Hepatitis B

 

All pregnant women should be offered screening for Hepatitis B infection, as part of the antenatal screening programme for infectious disease and a national target is in place to ensure that pregnant women are offered antenatal screening for Hepatitis B infection. The national target is above 90% and the national ‘acceptable’ standard of above 70%. Figure 2 shows that Bedford Hospital Trust screened 68.27 % of its eligible women within the required time frame which is below the accepted target.  It is important to note that there are small numbers of women for referral that can significantly affect the achievement of this KPI.

 

Figure 2: Antenatal infectious disease screening (ID2) – ‘Timely referral of hepatitis B positive women for specialist assessment’ 2014/15

 

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Source: Bedfordshire DPH Screening and Immunisation Programme Report, September 2015 (Data for IDPS is currently available by Acute Trust only- data relates to screening uptake and outcomes for all pregnant women accessing maternity services at Bedford Hospital and the Luton & Dunstable Hospital, not Bedfordshire women in isolation).

 

As the data demonstrates, the provision of antenatal screening to women in Bedfordshire is good, with high levels of uptake for screening for HIV but for Hepatitis B – ‘timely referral for Hep B in women’, screening uptake is below target and the 70% acceptable national standard.

 

Screening to identify Foetal Anomaly, inherited metabolic diseases, cystic fibrosis, congenital hypothyroidism, sickle cell disease, congenital physical and hearing anomalies:

 

Table 1: Other Antenatal and Newborn screening indicators

Screening Indicators

Bedford Hospital Trust

Luton & Dunstable

Q4 England National Average

National Standard/Target

FA1: % Down’s Syndrome Screening – Completion Of Laboratory Request Forms

98.9

98.6

67.9

≥97%

ST1: % Antenatal Sickle Cell And Thalassaemia Screening – Coverage

99.3

99.7

99

≥95%

NB1: % Newborn Blood Spot Screening – Coverage

96.6

98.6

95.9

≥95%

NH1: % Newborn Hearing Screening – Coverage

99.5

99.5

98.3

≥99.5

NP1: % Newborn And Infant Physical Examination – Coverage (Newborn)

no data

no data

93.2

≥95%

 

Down syndrome screening (FA1): Best performer in the region; 174 out of 176 were screened remaining 2 forms incorrect/incomplete. Forms are regularly checked by members of staff prior to sending to Birmingham Lab.

Sickle Cell Thalassaemia (ST1): Have a robust system in place; 798 out of 804 were screened and remaining 6 were exceptionally reported.

Newborn Bloodspot Screening coverage within 17 days (NB1): Uptake is 96.6% with 1261 out of 1306 screened. 45 results were not on System at Day 17 - Exception Report provided

Newborn Hearing test (NH1): 1299 out of 1306 were screened with 99.5% uptake. Exceptional reporting suggests no gaps in the system.

New born Physical Examination (NP): NIPE SMART system has gone live at the end of June however it currently is not being accessed on a regular basis. Plans are being put in place to ensure this is addressed with the aim of Q2 2015/16 data being submitted

 

National & Local Strategies (Current best practice)

 

Antenatal Screening for Infectious diseases

Best practice guidance and evidence used include:

 

      I.        UK National Screening Committee (UKNSCa) (2010) ‘Infectious Diseases in Pregnancy Screening Programme, Programme Standards’ September 2010;

 

    II.        UK National Screening Committee (UKNSCb) ‘Infectious Diseases in Screening Programme Handbook for Laboratories’ September 2010

 

   III.        Department of Health (DoH) ‘Hepatitis B antenatal screening and new-born immunisation programme - Best practice guidance’ makes clear recommendations to improve the uptake rate of existing Hepatitis B immunisation programmes for new-borns who are at risk of Hepatitis B infection (DH, 2011).

 

HIV

Pregnant women are offered antenatal screening for HIV in order to identify infection, to both allow the timely offer of interventions to reduce the risk of mother-to-child transmission and to safeguard the women’s own health. A combination of antiretroviral therapy, appropriate management of labour, and the avoidance of breastfeeding can reduce the risk of mother-to-child transmission from 15-25% to 1% or less (UKNSC, 2010a).

Hepatitis B

 

Hepatitis B infection is caused by the Hepatitis B virus (HBV), which is transmitted through infected blood and other bodily fluids. The risk of perinatal transmission is dependent on the status of the maternal infection, with around 70-90% of mothers testing positive for HBV e-antigen passing the infection on to the infant. The rate of transmission is lower, at around 10%, in women with antibodies to HBV e-antigen.

 

The objectives of the screening programme are:

                      i.        To ensure that all Hepatitis B positive mothers identified are referred for specialist care within 6 weeks of screening results and

                    ii.        To ensure that all infants born to Hepatitis B positive mothers receive vaccination within 24 hours of delivery and at 1, 2 and 12 months. In babies born to mothers with a higher risk of transmission, the additional Hepatitis B Specific Immune Globulin (HBIG) can reduce the risk further. With this strategy, transmission can be prevented in over 90% of infants exposed to maternal infection (UKNSC, 2010a). 

 

The antenatal screening programme for infectious diseases should be delivered in line with ’The Infectious Diseases in Pregnancy Screening Programme Standards’ (UKNSC, 2010a). Specific best practice titled ‘Hepatitis B antenatal screening and new-born immunisation programme’ (DH, 2011) is available in relation to the delivery of neonatal Hepatitis B immunisation. Both Hepatitis B and postnatal MMR vaccination should be delivered in line with the Department of Health ‘Green Book’ recommendations for immunisation (DH, 2009). Screening for each of the four conditions should be undertaken using the nationally agreed screening protocols. Analytical processes which govern the diagnostic sensitivity and specificity of tests are outlined in the IDPS Handbook for Laboratories (UKNSC, 2010b).   

 

What are the unmet needs/ service gaps?

There are, however, a number of gaps identified in relation to the screening pathway for infectious disease in pregnancy, as well as the subsequent management of positive screens.

 

  1. The ability to disaggregate data in order to analyse screening uptake for women living in Bedford Borough. This subsequently prevents the development and implementation of targeted strategies to promote screening uptake within specified populations.
  2. The ability to analyse screening outcome data beyond the level of acute Hospital Trust. This inhibits the compilation of trend data relating to HIV, Syphilis, Hepatitis B and Rubella.
  3. The absence of a locally agreed, multiagency protocol to govern the management of infants born to Hepatitis B positive mothers.
  4. The absence of a locally agreed, multiagency protocol to govern the postnatal management of women identified as Rubella susceptible.

 

Recommendations for consideration: 

There are a number of gaps identified in relation to the screening pathway for infectious disease in pregnancy and newborn screening, as well as the subsequent management of positive screens.

  1. The ability to disaggregate data in order to analyse screening uptake for women living in Bedford Borough. This subsequently prevents the development and implementation of targeted strategies to promote screening uptake within specified populations. The ability to analyse screening outcome data beyond the level of acute Hospital Trust. This inhibits the compilation of trend data relating to HIV, Syphilis, Hepatitis B and Rubella.
  2. The absence of a locally agreed, multiagency protocol to govern the postnatal management of women identified as Rubella susceptible
  3. Sickle Cell Thalassaemia screen: Currently early access is measured at 12 weeks and 6 days against expected 10 weeks’ time.
  4. Newborn Blood spot test: Delay in sample taking, some of the samples are taken at day 17. Also there are issues with avoidable repeat test that has risen nationally due to new National Lab Quality Criteria implementation; and issue with NB coverage for Movers- In where there are delays in maintaining time frame of 21 days from GP notifications to results

 

Newborn physical Examination:  No designated clinical lead at the provider hospital. and  communication gap within the service; no clarity on responsibilities such as who owns the KPI and who is responsible for data entering; exceptional report required, and not clear who will do that

 

Childhood Immunisation

Immunisation protects individuals and the community from serious infectious diseases. As well as being protected themselves, vaccinated individuals are also less likely to be a source of infection to others. This reduces the risk of unvaccinated individuals being exposed to infection, meaning that individuals who cannot be vaccinated will still benefit from the routine vaccination programme.  This concept is called population (or ‘herd’) immunity.

When vaccine coverage is high enough to induce high levels of population immunity, infections may even be eliminated from the country, e.g. diphtheria. If high vaccination coverage were not maintained, it would be possible for the disease to return.

 

Hepatitis B

Mothers are screened during the antenatal period for Hepatitis B infection, as part of the national antenatal screening for infectious diseases programme. Babies born to Hepatitis B positive mothers should receive a complete course of Hepatitis B vaccination in line with the recommendations made by the Department of Health (DH, 2006).

Hepatitis B vaccine (HBV) usually is given as a series of three injections:

1. Shortly after birth

2. at 1-2 months of age

3. at 6-18 months of age

Vaccine creates long-term immunity. Infants who receive the HBV series should be protected from hepatitis B infection not only throughout their childhood but also into their adult years. Eliminating the risk of infection also decreases risk for cirrhosis of the liver, chronic liver disease, and liver cancer. Young adults and adolescents also should receive the vaccine if they did not as infants.

 

Tuberculosis

The UK BCG immunisation programme which protects against infection with Tuberculosis is targeted, seeking to immunise those at increased risk of developing severe disease and/or of exposure to TB infection. The BCG vaccination should be offered to all babies and children who are deemed to be at high risk (babies from countries whose TB incidence is greater than 40/100,000 or babies who have parents or grandparents who were born in a high incidence country (DH, 2006).

 

Routine immunisation schedule for 0-19 year old population  

      i.        At age 2 months, vaccinations offered are:

a.    Diphtheria, tetanus, pertussis, polio and Haemophilus influenza type B (DTaP/IPV/Hib); and

b.    Pneumococcal conjugate vaccine (PCV)

c.    Rotavirus

d.    Meningitis B

 

  1. At age 3 months, vaccinations offered are:

 

a.    Diphtheria, tetanus, pertussis, polio, Haemophilus influenza type B (DTaP/IPV/Hib); and

b.    Meningitis C (Men C)

NB: In June 2013, the vaccination schedule for administering the MenC conjugate vaccine changed and the second priming dose previously given at four months was replaced by a booster dose given in adolescence).

c.    Rotavirus

 

  1. At age 4 months, vaccinations offered are:

 

a.    Diphtheria, tetanus, pertussis, polio and Haemophilus influenza type B (DTaP/IPV/Hib)

b.    Pneumococcal conjugate vaccine (PCV)

c.    Meningitis B

 

  1. Between 12 and 13 months, vaccinations offered are:

 

a.    Measles, mumps and rubella (MMR)

b.    Pneumococcal conjugate vaccine (PCV)

c.    Haemophilus influenza type B (Hib), Meningitis C (MenC)

d.    Meningitis B

 

    v.        Children aged two, three and four years old and school years 1 and 2 are offered the Influenza vaccination (September – January). (NB: the following year will include 7 year olds adding an age group each year and so on and so forth up until the age of 16)

 

  1. At age 3 years 4 months old to 5 years, vaccinations offered are:

•      Diphtheria, tetanus, pertussis and polio (DTaP/IPV)

•      Measles, mumps and rubella (MMR)

 

  1. Girls aged 12 to 13 years are offered Human Papillomavirus (HPV) strains 16 and 18

 

  1. Young people aged around 14 are offered:

 

a.    Tetanus, diphtheria and polio (Td/IPV)

b.    Meningitis ACWY

 

  1. Young people aged around 17/18 are offered:

a.    Meningitis ACWY

 

Meningitis B and Meningitis ACWY

 

A number of changes have been made to the national immunisation programme in 2015-16 in order to protect against meningococcal disease following an increase in cases. The Meningitis B vaccine has been introduced to the UK routine immunisation schedule and offered to Babies at 2 months, 4 months and 12-13 months as well as a one off catch up programme.

The Meningitis ACWY is being offered to young teenagers, sixth formers and university fresher students. It is given by a single vaccination and protects against 4 causes of meningitis and septicaemia (Meningococcal A, C, W and Y). The priority is to vaccinate all teenagers in school years 9 to 13 before they complete school year 13. This is being done by replacing the routine teenage Men C booster given in school years 9 or 10 with the Men ACWY vaccine, and by a series of catch-up campaigns.

The numbers of cases of meningitis and septicaemia due to Men W have been increasing in England, from 22 cases in 2009 to 117 in 2014 and the increase seems to be accelerating in 2015. With early diagnosis and treatment, most people make a full recovery however it is fatal in about 10% of cases and can lead to long-term health problems, such as amputation, deafness, epilepsy and learning difficulties.

 

Facts, Figures, Trends

Childhood Immunisations uptake in Bedford Borough

 Figure 3: Hepatitis B vaccination coverage in 1 and 2 year old children

HP16

Fig 4  Immunisation uptake of DTaP vaccine in 1 year olds, 2 year olds and children aged 3.5 - 5 years old (2014-15)

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Figure 5: Immunisation uptake of Measles, Mumps and Rubella (MMR) vaccine in 2 year olds and children aged 3.5 - 5 years old (2014-2015)

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Fig 6 showing uptake of pneumococcal and Haemophilus Influenzae & Meningitis C Vaccination in children age 2

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 Fig 7 showing uptake of childhood immunisation and its association with deprivation

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Figure 8a showing uptake of Meningitis C and Td IPV vaccination

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Please note This data is collected nationally once per year and published at the end of each academic year. The NHS England Midlands and East Team (Central Midlands) are collecting this data by provider return twice per annum. To date this data is incomplete and therefore figures for this academic year are not a true reflection of vaccine uptake; however it gives an idea of how the programmes are progressing.

 

Figure 8b showing uptake of HPV vaccination

 

 

Total No. of girls in Cohort 12

Dose one

     Dose one and two

   

Number 

%

Number 

%

Hertfordshire And The South Midlands

15743

14676

93.2

14167

90.0

Bedford Local Authority

996

943

94.7

910

91.4

 

      Uptake of childhood immunisations within Bedford Borough  mainly reaches the target of 95%, except the preschool vaccinations that includes DTaP and MMR which is  given to children at the age of approximately 3 years and 4 months (though measured at 5 years) (fig 1) Q312015/16 figures for Bedfordshire Clinical Commissioning Group (CCG) suggest that MMR (dose 2) vaccination and DTaP vaccination uptake at age 5 have improved by 0.8% in comparison to the last quarter of 2015/15, with an uptake of 92.8% (DTaP) and 91.8% (MMR 2). (fig1)

•      Bedfordshire Clinical Commissioning Group is performing significantly better (higher) than both the England and East of England average for MMR 2nd dose vaccination at age 5 at the end of the 2014/15 year.  Nationally, uptake of MMR dose 2 is low, with an average of 88% nationally for the 2014/15 year. Therefore, although uptake of MMR dose 2 falls below the 95% target, performance is above the national and regional average.

•      Bedford local Authority has vaccinated 94.7 % of its eligible young females with HPV vaccination; and 91.4% of them have completed two doses in the school academoic year of 2014-15., which is better than the national average and has also met the national target of 90%.

 

National & Local Strategies

Childhood Immunisation: 

.Best practice guidelines and evidence used are:

      i.        Department of Health (2006) Immunisation against infectious disease London: TSO

    ii.        Department of Health (2009a) Healthy Child Programme: Pregnancy and the first five years of life London: DH

   iii.        Department of Health (2009b) Healthy Child Programme: From 5-19 years old London

   iv.        Department of Health (2011) Hepatitis B antenatal screening and new-born immunisation programme: Best practice guidance  London : DH

    v.        The National Institute for Health and Clinical Excellence (NICE) (2009)Reducing differences in the uptake of immunisations (including targeted vaccines) among children and young people aged under 19 years  London : NICE

 

All childhood immunisations should be carried out in line with the national schedule for immunisations, as specified by the Department of Health (DH, 2006)

 

Best practice guidance for reducing inequalities in the uptake of immunisations makes the following recommendations for implementation:

  1. Focus on reducing of differences in immunisation uptake among children. Ensure there is an identified healthcare professional in each GP practice who is responsible, and provide leadership for the local childhood immunisation programme
  2. Improve access to immunisation services for those with transport, language or communication difficulties. This could include extending clinic times, weekend/ evening clinics, longer appointment times, walk-in vaccination clinics, mobile or outreach services. Ensure children and young people are seen promptly, make sure clinics are child and family friendly and review the role of hospital staff in encouraging immunisation uptake.
  3. Use a variety of approaches to promote uptake of immunisations such as providing literature in a variety of formats on the benefits of immunisation and raising awareness in different settings such as pharmacies, malls, libraries, nurseries, schools and higher education institutions.
  4. Develop processes to ensure children who miss immunisations are identified and followed up. This is particularly important for children who require targeted immunisations such as Hepatitis B and BCG vaccines (NICE, 2009).
  5. Monitor vaccination status as part of a wider assessment of children and young people’s health, through the implementation of the Healthy Child Programme. Other professionals for example those in education have an important role to play in promoting immunisations (DH, 2009a & 2009b). The Healthy Child Programme (HCP) reinforces the importance of childhood immunisation and recommends:

 

·         That immunisations are offered to all children and their parents and calls for local planning to target excluded or at-risk families such as refugees, the homeless, travelling families, very young mothers, those not registered with a GP and those who are new to an area.

·         Every child’s immunisation status should be accessed each time a member of the Healthy Child Programme comes into contact with a family. The role of the health visitor and school nurse is crucial in identifying children with incomplete immunisations and encouraging families and children to attend for immunisation.

   vi.        Promote the importance of childhood immunisations by providing evidence-based information and advice on immunisation.

 

Bedford Borough Council is part of the Midland and East Area Team of NHS England who is now responsible for commissioning Immunisation services and performance monitoring of the activities.  With the support of LA Public Health, PHE will also provide expert quality assurance of the Immunisation through the specialist national Immunisation teams and staff. Local Providers in conjunction with NHSE area team are responsible for delivering services as per recommended best practice guidelines.  Bedfordshire DPH is responsible for overseeing and scrutinising local services and alerts commissioners and providers with any issues identified.

 

What are the unmet needs/ service gaps?

Service provision:.

  1. Improved call and recall systems are required, to highlight areas of improvement within primary care, focusing specifically on practices with the poorest uptake.
  2. Improved failsafe processes need to be developed collaboratively between the primary care provider and the Child Health Records Departments, to ensure the timely and effective follow up of children who fail to attend for immunisations.
  3. A robust system for scheduling Hepatitis B immunisations for babies born to Hepatitis B positive mothers is required, to ensure the timely delivery of the correct and complete vaccine dose schedule in line with the Department of Health recommendations (DH, 2006 & DH, 2011).

 

Access to service:

              i.        All Primary Care practices should be offering flexible and accessible immunisation services specially provision for increasing preschool boosters.

 

Recommendations

Responsibility of delivering childhood immunisation now lies with the NHSE area team of South Midland and Hertfordshire. The public health team in the local authority will be supporting agencies responsible for delivery of the childhood immunisation programme in addressing the gaps and including recommendations in the local plans. The following recommendations have been identified through evaluation of the previous years’ immunisation performance:

i.          A review of call and recall systems and failsafe processes around childhood immunisations should be undertaken, focusing on both Primary Care and Child Health Records Departments.

ii.         Targeted work with specific practices can be undertaken , to reduce the number of infants and children who fail to attend for scheduled immunisations

iii.        Focus should be on improving access for those groups of children who are at risk of not completing their immunisations to address the inequality such as:

a.         Children who have missed a previous vaccination (either through parental choice or otherwise)

b.         Looked after children

c.         Children with physical or learning disabilities

d.         Children of teenage or lone parents

e.         Children not registered with GP practices

f.          Children who are hospitalised or with a chronic illness

g.         Children from minority ethnic groups

h.         Children from non-English speaking families

IV       Vulnerable children such as those whose families are travellers, asylum seekers or are homeless.

v          Primary Care practices should be supported to implement targeted measures to improve immunisation uptake rates specially in preschool boosters, through the provision of flexible and accessible services, appropriate materials etc.

vi.        A local Hepatitis B immunisation pathway should be developed and agreed, to ensure that all affected babies are followed up appropriately and receive timely vaccination

vii.       BCG immunisation provision should be reviewed and included in TB service review and redesign planned to make it NICE complaint and fit for TB current national TB strategy.

 

References

1.    BASSH UK National guidelines on the management of the viral Hepatitis A,B and C 2008

2.    British Thoracic Society (2009) Commissioning TB Services http://www.brit-thoracic.org.uk/

3.    Clinical diagnosis and management of tuberculosis and measures for its prevention and control, NICE).

4.    Department of Health (2006) Immunisation against infectious disease London: TSO

5.    Department of Health (2009) Supply of TB drugs to patients – changes to regulations and advice on implementation [ARCHIVED CONTENT] Supply of TB drugs to patients changes to regulations and advice on implementation : Department of Health - Public health

6.    Department of Health (2009a) Healthy Child Programme: Pregnancy and the first Five years of life London: DH

7.    Department of Health (2009b) Healthy Child Programme: From 5-19 years old London: DH

8.    Department of Health (2011) Hepatitis B antenatal screening and new-born Immunisation programme: Best practice guidance London: DH

9.    Department of Health (DH) (2009) Immunisation against infectious diseases – The Green Book www.dh.gov.uk

10. Department of Health (DH) (2011) Hepatitis B antenatal screening and new-born immunisation programme www.dh.gov.uk/publications

11. ECDC, Importance of Surveillance; Surveillance is essential to understanding the epidemiology of infectious diseases (2011).   http://www.ecdc.europa.eu/ [external link]

12. European Centre for Disease Prevention and Control: Annual Epidemiological Report on Communicable Diseases in Europe 2008. Stockholm, European Centre for Disease Prevention and Control, 2008

13. European Medicines Agency, EU recommendations for the seasonal influenza vaccine composition for the season 2011/2012. Letter of the BWP ad-hoc influenza Working Group, 17 March 2011. EMA/CHMP/BWP/156215/2011.  (http://www.ema.europa.eu/docs/en_GB/document_library/Other/2011/03/WC500103708.pdf)

14. Gamma Release Assays in the screening of contacts and new entrants for TB ThoraxVol. 62: Supp 3, S49A pA22

15. Gray, M. &Ormerod, L.P. (2007) An economic evaluation of the use of Interferon

16. Hirsch P, Hodgson M, Davey V. Seasonal influenza vaccination of healthcare employees: results of a four year campaign. Infection Control and Hospital Epidemiology, 2011; 32: 444-448.

17. HPA Hepatitis C in the UK 2012 report

18. https://www.gov.uk/government/organisations/public-health-england

19. https://www.gov.uk/government/organisations/public-health-england

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/179349/green_book_complete.pdf.pdf

20. managing tuberculosis among hard-to-reach groups  Public Health Guidance 37

21. National Audit Office, Improving patient care by reducing the risk of hospital acquired infection: A progress report, Report by the comptroller and auditor general HC 876 session 2003-4, London Stationary Office, 2004.

22. National Institute of Health and Clinical Excellence (NICE) (2011) Tuberculosis:

23. National Institute of Health and Clinical Excellence (NICE, 2012) Identifying and

24. NICE public health guidance 43. Dec 2012 Hepatitis B and C: ways to promote and offer testing to all people at increased risk of infection.

25. Public Health England https://www.gov.uk/government/organisations/public-health-england

26. Public Health England  http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/HepatitisB/

27. The National Institute for Health and Clinical Excellence (NICE) (2009) Reducing Differences in the uptake of immunisations (including targeted vaccines) among children and young people aged under 19 years London: National Institute of Clinical Excellence

28. UK national guidelines on safer sex advice July 2012 The Clinical Effectiveness Group of the British Association for Sexual Health and HIV (BASHH) and the British HIV Association (BHIVA) July 2012

29. UK National Screening Committee (UKNSCa) (2010) Infectious Diseases in Pregnancy Screening Programme, Programme Standards September 2010

30. UK National Screening Committee (UKNSCb) Infectious Diseases in Screening Programme Handbook for Laboratories September 2010

31. The flu immunisation programme 2013/14. Letter from the Chief Medical Officer, the director of nursing and the chief pharmaceutical officer for England, Available at:www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/Professionalletter

32. Department of Health: seasonal flu plan 2013-2014: http://immunisation.dh.gov.uk/

33. www.nice.org.uk/TA168

34. NICE have published infection Prevention and Control Clinical standard 61 (April 2014). Available at:   http://publications.nice.org.uk/infection-prevention-and-control-qs61#close

 

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