The Australian Immunisation Program is a government policy that incorporates many different aspects of government and industry. Today we will be discussing an analysis on the perceived health outcomes achieved by the Australian Immunisation policy and how this assists in ensuring a healthier Australia.
Immunisations are utilised in two ways in Australia. Firstly, they provide protection for each individual that is vaccinated against the disease, and then there is also the concept of herd immunity. Herd immunity is the scenario where by stopping the spread of disease by having most of the population vaccinated. This large density of vaccinated persons means that those who are unable to be vaccinated, such as pregnant women or new born babies, are still protected from the disease as it has extremely limited opportunity to spread through the community. This leads to a decrease on the burden of our health services, as less and less people require treatment for disease once they are immunised or herd immunity is achieved. Thus, leading to an increase in our economy output as attendance at work and education are higher, and more of the population is healthy enough to work, with less disability or long term impairment from complications of vaccine- preventable diseases. This presentation will look at how the incidence of disease has been reduced through the introduction of a vaccination program in Australia. This analysis was chosen as there are no clear goals in any of the publicly available government documents to analyse performance indicators, but there is a lot of external supporting documents on the reduced incidence of disease since vaccination programs began in Australia. We will begin the analysis with a brief quantitative analysis of the policy documents that are publicly available from the Australian government websites though, to give an indication of how the Immunise Australia policy compares with information needed to perform an informed analysis.
Firstly, we will go through a brief overview of he National Immunisation Program. This is a program that is managed by co-operation between all three levels of government- federal, state and local. Advisory bodies are involved in the creation, implementation, review and alterations of the policy, and also assist in the running of the program. The program is fully government funded, with all the population receiving the immunisations as set out of the program schedule for free. If they are unable to meet the immunisation schedule, they must apply for exemptions to qualify for free immunisations at other points, or to receive incentive payments, if applicable. The chart here shows part of the latest immunisation program schedule to be implemented in approximately one months time. This details all immunisations required from birth, right throughout life, and is used in conjunction with the Immunisation Handbook 10 th Edition to ensure accurate vaccinating. The data base of immunisations given is known as the National Immunisation Register, which is considered to be one of the best record keeping systems of immunisation worldwide.
The first stage of the analysis was a review of the policy literature available from the Australian government websites. The included data was assessed using an adapted model from a model of analysis designed by T Collins in 2005, which assessed how well you can use policy documents for policy analysis. For this analysis a grade scale was applied from 1 to 5. The policy was broken down into different parts to assist with analysis, then each part has requirements that are essential for effective analysis of the policy. Part A looks at the background information for the necessity of the policy being developed. The Australian immunisation program contained strong scientific data that proves the importance of developing an immunisation policy.
In part B the goals of the policy are looked at. For the Australian Immunisation program, the goals are not defined with much detail, rather there is just brief mentions of the hope that the program will reduce disease incidence and that herd immunity and ultimately eradication of diseases on the register are achieved. In part C the resources of the policy are assessed. There is no mention of the financial resources allocated, except for a line in the federal and state budgets for overall immunisation funding allocation. The area that is covered in some detail in various places on the government websites is the incentive payments, one for the GPs for achieving 100% immunisation of children at their clinic, and the other for parents. The parent payments total $2100 over 3 years for having their child fully immunised according to the schedule. The use of human resources in a program like the Australian immunisation program is huge, but there is only a brief mention of all the people involved in the program in the literature.
The monitoring and evaluation of the immunisation program in Australia is barely mentioned throughout the government websites, though it is inferred that this is left to the independent advisory bodies, which are discussed in some detail. The lack of information on outcome measures, combined with the lack of goals, does make this a more difficult analysis to accurately perform. The opportunities for public involvement are indicated within the policy, with public comment reviewed and incorporated where appropriate, and the stakeholders involvement in policy creation and the advisory boards is acknowledged. There is question and answer sections in the handbook which assist in the recognition of the stakeholders concerns.. The final part of the analysis of the policy documents is of the obligation of implementers of the policy. This is discussed in detail as to the government and advisory board obligations, but from there on the obligations of other parties, such as health services, are not as clearly defined. Overall the grading for the Australian Immunisation policy was 51 out of 100, indicating that the policy documents do not allow for accurate analysis, therefore leading to a review of external literature to assist in analysing how effective the immunisation program in Australia has assisted in reducing the incidence of disease for diseases included on the vaccination schedule.
Before looking at the outcomes of the Australian immunisation program, we will look at a quick snap shot of global success of immunisation. The reduction in child mortality is linked to immunisation, and the continued introduction of new vaccines, along with the improved programs of immunisation in lower-class and middle-class countries is continuing to reduce this rate, with a predicted value of only 4.3 million deaths per year by 2015, which is a massive reduction from 17 million in 1970. Small pox was a major health burden worldwide, costing the US along US$1.3 billion per year in treatment and prevention. An immunisation program has led to complete eradication of the disease, which now means that $1.3 billion dollars can be spent elsewhere to further improve the health of the residents of America. The rotavirus causes the majority of cases of acute gastroenteritis, which is now vaccinated against. For Europe and North America, the reduction in doctor visits and hospital admissions for acute gastroenteritis has reduced by 95% with the introduction of the vaccine on their immunisation schedule.
An analysis of the reduce incidence of disease was not possible using the government documents available, but the Immunisation Handbook 10 th Edition has an extensive literature review attached, which was utilised in conjunction with my own literature search to determine outcomes. While the incentive payments are not one of the outcome measures being analysed here, it is worthwhile noting these payments offered to parents, as they have a big impact on reducing the incidence of disease. These payments have been offered since 1998, and currently are three payments of $726 per year for 3 years, in the child in question has been fully immunised according to the immunisation schedule. This payment goes towards encouraging parents to ensure timely immunisations, therefore assisting in achieving herd immunity, thus improving the health of the total population.
In Australia, this table indicates just how successful some of the immunisation programs have been. The reduction in numbers for all but pertussis have been consistent with the introduction of routine vaccinations. Polio is considered eradicated from Australian society, but is still immunised against as it is not eradicated worldwide as yet. Pneumococcal and Meningococcal are two of the newer vaccines introduced, both in 2001, and in that decade we have seen the cases drop dramatically, indicating success of the immunisation program. Pertussis is causing some concerns for health authorities, with a prolonged outbreak occurring. Research into the outbreak is continually being performed, looking at the effectiveness, timeliness and number of shots necessary to ensure individual immunity, and from there herd immunity within the Australian population.
We will now look at some of the individual outcomes of the diseases vaccinated against in Australia. Chicken pox was introduced to the immunisation schedule in 2003, which saw hospitalisations reduce from 1200 per year prior to immunisation schedule inclusion to 9.4 per 100000 in 2010. This is one of the more recent additions, and has only recently been made available to all children and included in the incentive payments, therefore the incidence of disease rates of chicken pox are still continuing to lower. For Rubella, Australia is considered to be in an elimination phase, meaning we are nearing complete eradication of the disease. The success of the immunisation program has meant we have gone from 1 in 2000 live births being born with congenital rubella syndrome to only 5 reported cases in the last 15 years, with only two of them to Australian born mothers.
As mentioned earlier, pertussis is one of the diseases on the vaccination schedule that is proving to be problematic for creating herd immunity in the Australian community. There was a period of time in the 1970s and 1980s where pertussis was not routinely vaccinated against, which has led to outbreaks in adolescents and adults over the last two decades. The outbreaks are continuing though, so immunisation against pertussis is being reviewed to assist in reducing the burden of disease from pertussis on the Australian community. Measles has been one of the more controversial vaccine, with different media coverage at different times linking the Measles-Mumps-Rubella (MMR) vaccine to different conditions, including autism. To this day, it is still one of the most common vaccines to be caught up in controversy, even though there is no evidence on any issues with the MMR. The immunisation of measles was first introduced on the schedule in 1969, which led to an 85% immunisation coverage by 1989. An epidemic starting in 1993 led to a review of the measles immunisation, which then introduced the MMR vaccine being offered twice in the schedule to improve immunity. From then, the reported cases dropped dramatically, with 27 cases per 100000 in 1994, 7 cases per 100000 in 1995 and only 2 cases per 100000 in 1998.
HPV is the newest vaccine to be introduced on the immunisation schedule, which occurred in 2007. Females only were vaccinated against HPV to begin with, and this led to a decrease of 59% in females under the age of 27 presenting to health clinics with HPV. The great success of the immunisation program was the subsequent decrease of 28% in males presenting with HPV, indicating that herd immunity is already occurring. Secondary school males are now also immunised along with the females to continue to develop the herd immunity. Rotavirus, as discussed before, causes acute gastroenteritis. At the Royal Children’s hospital in Victoria in 1994 the attendance rate at the emergency department for acute gastroenteritis was 53 per 1000 attendances. The introduction of the rotavirus vaccine in 2007 has led to a 58% reduction in admissions to the Royal Children’s hospital for acute gastroenteritis, and the presentations to the emergency department has dropped to 34 per 1000.
The immunisation policy of Australia has proven to be successful in reducing the incidence of disease for all diseases on the schedule, except for pertussis. This leads to improved overall health of the Australian population, and reduced burden on our health system and economy. The advisory bodies involved in the Australian immunisation program assist in ensuring that the program remains current and effective, with the correct checks and balances done by these independent bodies, even if the government does not do them. The immunisation policy itself could be better improved if it had clear goals and performance indicators, which would allow for more accurate analysis. The lack of alternative strategies also is a potential failure, and events such as the pertussis outbreak show that alternatives need to always be considered.
Australian Immunisation PolicyAn AnalysisBy Tracey Collins 15065065
Immunise Australia Program• The aim of the Immunise Australia Program is to protect individuals in thecommunity by providing individual vaccines, which will also lead to herdimmunity.• This leads to a stronger population with less burden on our healthservices, and ultimately, economy• This presentation will analyse how the Immunise Australia programperforms in reducing incidence of disease through immunisationsfollowing the National Immunisation Program Schedule.• This analysis strategy was selected due to the lack of clear goal indicatorsto compare against. The data available from external sources is able toindicate health benefits without goals for comparison.• A brief overview of the policy information that is publicly available will alsobe performed, to show how it meets some of the criteria of policyimplementation“With the exception of safe water, no other modality,not even antibiotics, has had such a major effect onmortality reduction” (WHO, 2009)
National Immunisation Program Schedule• The whole program is managed by the federal, state and localgovernments, with advisory bodies also.• The records of immunisation are managed through the NationalImmunisation Register.• This schedule is routinely updated, so only the current one is shown.• The schedule details the immunisations that should be given routinelythroughout life from birth.
Brief Policy Overview Analysis• This analysis covers a brief overview of the policy documents availablefrom the government websites detailing the Immunisation program inAustralia.• This analysis is manipulated from a policy analysis that is written by TCollins (2005)• Each part is graded according to the amount of literature available:• 1= Not mentioned at all• 2 = Briefly mentioned• 3 = Discussed in minor detail• 4 = Discussed with enough detail to answer question• 5 = covered in lengthy detail• PART A- Policy Background• Scientific grounds are established: The literature covers the diseasesindividually, with the data as to why the immunisation works. GRADE 5• There is a conclusive review of literature: Yes, the literature review is detailedthoroughly, with the full reference list given also. GRADE 5• The source of the health policy is explicit: Yes, multiple sources are given, andquantitative and qualitative data are used to support. GRADE 5
Brief Policy Overview Analysis• Part B: Goals• Goals are explicitly stated: No, they are only briefly mentioned. Grade B• Goals are concrete: There is no data given on what goals actually are. Grade A• Goals are intended to improve health of population: Yes, and is clearlyindicated as such through herd immunity. Grade C• Policy is supported by internal validity: No information for internal validitygiven, but can be inferred when reading supporting documents. Grade B• Part C: Resources• Cost of condition to community given: Not mentioned. Grade 1• Estimated financial resources stated: Not mentioned. Grade 1• Allocated financial resources stated: Not mentioned. Grade 1• Rewards and/ or sanctions of policy discussed: Payments through parentincentive payments and GP incentives discussed in some detail. Grade 4• Human resources discussed: Only mentioned very briefly. Grade 2
Brief Policy Overview Analysis• Part D: Monitoring and Evaluation• Monitoring and evaluation discussed: Not mentioned. GRADE 1• Nominated a committee or independent body: Multiple nominated, anddiscussed in some detail. GRADE 4• Outcome measures are identified: Not mentioned. GRADE 1• Other alternatives to policy identified: Not mentioned. GRADE 1• Part E: Public Opportunities• The population supports the action: Only discussion on population support isthrough consultation section, where public comment was reviewed. Doeshave a Question and answer section for public concerns though. GRADE 3• Primary concerns of stakeholders are recognised: This is covered in thequestion and answer sections. Grade 3• Part F: Obligations• The obligations of various implementers are specified: Yes, these arediscussed in various detail in many documents available. GRADE 5Total Score: 51 out of 100 for document content
Global Immunisation Outcomes• The World Health Organisation’s data on immunisation shows that globalimmunisation has reduced the global child mortality rate, and theirprediction for 2015 indicated they believe this is to reduce further.• Other data from WHO indicates that the eradication of small pox throughvaccination saves US$1.3 billion a year that would have been spent ontreating and preventing the illness (WHO, 2011)• In Europe and North America, there has been a 95% reduction in doctorvisits and hospital admissions from rotavirus diarrhoea since theintroduction of the rotavirus vaccine
Australian Immunisation Program Outcomes Analysis• The policy documents themselves do not contain much detail on how theprogram has reduced the incidence of disease, but it does reference theliterature that supports this.• The evidence that follows is all from this literature, and from my ownliterature search for supporting documents that discuss the healthbenefits of the Australian immunisation program• The incentive payment program for parents is aimed to encourageimmunisation by offering payments dependent on whether the child ofconcern is fully immunised. These payments have differed over the years,but started in 1998 as two different incentive payments (Lawrence et al.,2004 )• The current incentive payment is three individual payments of $726 perchild per year for each of the immunisation checkpoints. (DOH, 2012)• This payment is to increase the immunisation rates so as to increase herdimmunity, as the government aims to reach near 100% immunity for 5year old, and the current rate is 89% (DOH, 2012)
Australian Immunisation Program Outcomes Analysis• The reported number of cases for the diseases immunised against hasgenerally dropped dramatically in Australia.• The only outlier is Pertussis, which is being assessed by the relevantauthorities as to the reasoning for the rises in reported cases in a diseasethat should have a high immunisation rate within the population• Data from NCRIS (2012), WHO (2012), Dept of Health Australia (2012)Disease Year VaccineIntroducedReportedcases in1980 (per1000population)Reported casesin 1990 (per1000population)Reported casesin 2000 (per1000population)Reported casesin 2011(per1000population)Diptheria 1940 1 7 0 0Tetanus 1953 9 6 1 0Polio 1966 0 0 0 0Measles 1969 - 9 - 1.5Mumps 1980 - 2 - 0.4Rubella 1971 - 8 - 0Pneumococcal 2001 - - 27 11Meningococcal 2001 - - 8.1 2.2Pertussis 1942 124 892 16 411
Australian Immunisation Program Outcomes Analysis• CHICKEN POX (ZOSTER) OUTCOMES• Prior to being included on the vaccination schedule, there were onaverage 240,000 cases, 1200 hospitalisations and 4.2 fatalities peryear from chicken pox in Australia (Scuffham et al., 2000)• Once introduced on the vaccination schedule in 2003, the varicellahospitalisation rate for children aged 1-4 reduced to 9.4 per 100000by 2010 (Ward et al., 2013)• RUBELLA• Australia is now noted as being at an elimination phase for rubella,with only five reported cases since 1998, with only two of those beingAustralian born and unimmunised. The other three cases were bornoverseas (Song et al., 2012).• Prior to immunisation being offered as part of the immunisationschedule, the incidence of congenital rubella syndrome was 1 per2000 live births (Song et al., 2012).
Australian Immunisation Program Outcomes Analysis• PERTUSSIS• In the 1970s and 1980s pertussis was not routinely immunisedagainst, which saw a large increase in pertussis outbreaks inadolescents and adults over the last couple of decades (Quinn &McIntyre, 2011). This pertussis outbreak is still ongoing, and is beingreviewed by the immunisation authority bodies to assess how best toreduce the incidence in the community.• MEASLES• Measles has been on the immunisation schedule in varying degreessince 1969, with a immunisation coverage of 85% in 1989. Anepidemic of measles occurred in 1993-94 with 10000 notified casesand 4 deaths, which led to the government reviewing the policy, andintroducing a second dose of the measles vaccine (Turnbull et al.,2001)• From here, in 1994 there were 27 cases per 100000, then only 7 per100000 in 1995, and 1998 the reported cases was 2 per 100000(Turnbull et al., 2001)
Australian Immunisation Program Outcomes AnalysisAustralian Immunisation Program Outcomes Analysis• HPV• In 2007 HPV vaccine was introduced on the Australian ImmunisationProgram• Since then there has been a 59% decline in HPV presentations infemales aged less than 27 years and a 28% decline in HPVpresentations in unvaccinated males, indicating herd immunity iscommencing (Garland et al., 2011)• ROTAVIRUS• Rotavirus causes acute gastroenteritis (AGE), which in 2004 causes 53per 1000 attendances at the emergency department of the RoyalChildren’s hospital in Victoria (Akikusa et al., 2013)• The rotavirus immunisation was introduced in Australia in 2007, andsince then there has been a 58% reduction in admissions to the RoyalChildren’s hospital due to AGE, and the presentations to theEmergency department dropped to 34 per 1000 presentations(Akikusa et al., 2013)
Australian Immunisation Program Outcomes AnalysisAustralian Immunisation Program Outcomes Analysis• Success of the Policy• The data shown on previous slides indicates that the immunisationprogram in Australia has been successful in improving the health ofthe Australian population through individual and herd immunity• The use of the different advisory bodies assist in ensuring that theAustralian Immunisation Program is a government policy that will beupdated according to accurate literature and correct data• Failures of the Policy• The limitation of available data on the exact goals that thegovernment wishes to achieve and the method of evaluationindicates that the policy is one that is just believed to be successful,and not necessarily using any particular policy implementationtechnique that could assist in ensuring the best possible outcomes• The lack of a mention of alternatives strategies for each of thediseases covered under the immunisation schedule indicates that thepolicy assumes that this is the best method for all diseases, but theremay be potential alternatives not yet explored.
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