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 1 April 2013:

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.

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
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) 
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. The Chapter on Health Protection for Adults is here. 

Antenatal and newborn screening

All pregnant women in Bedfordshire are offered antenatal screening for HIV infection, Hepatitis B infection, and Syphilis 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.

Public Health England (PHE) on 27 January 2016 announced and ended rubella (German measles) susceptibility screening in pregnancy from 1 April 2016 on UK National Screening Committee (UK NSC) recommendation.

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

Facts, figures 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.

Source: Bedfordshire DPH Screening and Immunisation Programme Report (September 2016). (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 and Dunstable Hospital, not Bedfordshire women in isolation).

Both Bedford Hospital and Luton and Dunstable Hospital Trust are performing above the target of 90% screening coverage. 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%. Bedford Hospital Trust screened 78.3 % of its eligible women within the required time frame which has met the national acceptable standard but did not meet the national target.  It is important to note that there are small numbers of women for referral that can significantly affect the achievement of this KPI.

Source: Bedfordshire DPH Screening and Immunisation Programme Report, September 2016 (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 and 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 as for Hepatitis B – ‘timely referral for Hep B in women’, screening uptake is below target national target.

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

Antenatal Screening for Infectious diseases

Best practice guidance and evidence used include:

1. NHS Infectious Diseases in Pregnancy Screening Programme Standards valid for data collected from 1 April 2018
2. NHS Infectious Diseases in Pregnancy Screening Programme: Laboratory Handbook 2016 to 2017 (PDF)
3. Neonatal hepatitis B immunisation programme, 2013 (PDF)
4. Department of Health (DH) ‘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). (PDF)

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:

1. To ensure that all Hepatitis B positive mothers identified are referred for specialist care within 6 weeks of screening results and
2. 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’ (NHS infectious disease standards 2016). 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 (if given) vaccination should be delivered in line with the Department of Health ‘Green Book’ recommendations for immunisation (DH, 2013).

Screening for each of the 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 (NHS infectious disease in pregnancy-lab 2016).  

 What are the unmet needs/ service gaps?

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 and Hepatitis B.
2. Sickle Cell Thalassaemia screen: Currently early access is measured at 12 weeks and 6 days against expected 10 weeks’ time.
3. 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.
4. Newborn physical Examination: The Trust is currently working on NIPE Service Specification requirements for 2016-17 which is monitored via the Programme Management Board. The following are being reviewed: NIPE local process to follow up all non-attendance of appointments after referral. No designated clinical lead at the provider hospital; communication gap within the service.

 Recommendations for consideration: 

1. Develop and implement a local protocol for the management of infants born to Hepatitis B positive mothers.
2. Data quality improvements should be sought, in order to improve local knowledge of screening uptake and trends in relation to screening outcomes. Access to this level of data will need to be negotiated with Acute Trusts.
3. Improving early access to Antenatal and newborn screening so that results are available by 10 weeks
4. Bedford CHRD to have robust process in place to ensure that all NIPE results and outcomes of screening are communicated to relevant Child Health Record Departments (CHRD).

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, eg 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 

At age two 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

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

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

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)

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)

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

Young people aged around 14 are offered:

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

b.    Meningitis ACWY

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.

Childhood Seasonal Flu Immunisation programme:

Following a recommendation in 2012 by the Joint Committee on Vaccination and Immunisation (JCVI) that the routine annual influenza vaccination programme should be extended to include children, the phased introduction of this extension began in 2013. In the 2014/15 flu season, flu vaccine was offered to all two, three and four year old children and those aged four to 10 years (up to and including pupils in school year 6) in seven different geographical pilot areas.

In the 2015/16 flu season, flu vaccine was offered to all two, three and four year old children, to all children of school years 1 and 2 age and to all primary school-aged children in former primary school pilot areas.  The target population for the national primary school age childhood influenza vaccination programme is defined as all children school year 1 (aged 5 rising to 6 yrs) and year 2 (aged 6 rising to 7 yrs) born between 1 September 2008 and 31 August 2010, as defined by child age on 1 September 2015.

The strategic intentions in 2015/16 were:

• to increase immunisation uptake rates, in accordance with the vaccine uptake ambitions set out in the annual flu letter, for all children aged 2 to 6yrs, aiming to maximise uptake, raise the performance in the lowest performing areas, and ensure an even spread across these age cohorts
• that the programme will run either in general practice for pre-school children, or usually in schools for school-aged children. Immunisation of children in these cohorts will improve protection for them and the wider community

Facts, figures and trends

Childhood Immunisations uptake in Bedford Borough

• 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). Figures for Bedfordshire Clinical Commissioning Group (CCG) suggest that MMR (dose2) vaccination and DTaP vaccination uptake at age 5 have improved by 0.9% in comparison to the last year of 2014/15, with an uptake of 91.8% (DTaP)(fig 4) and 90.9% (MMR 2). 
• 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 2015/16 year.  Nationally, uptake of MMR dose 2 is low, with an average of 88%.  Therefore, although uptake of MMR dose 2 falls below the 95% target, performance is above the national and regional average.
• Bedford Borough uptake for pneumococcal conjugate vaccine has fallen by 0.7% and falls  below the national target of 95%.
• The uptake of childhood immunisation in the 20% most deprived practices within Bedford Borough council is lower than the practices with 20% least deprived population, suggesting deprivation as one of the factors influencing uptake.
• 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 academic year of 2014-15., which is better than the national average and has also met the national target of 90%.
• In 2015, Public Health England (PHE) reported a continued, year on year increase in meningococcal capsular group W (MenW) cases in England. The rise was initially recorded in 2009 and since this time, cases have steadily increased, rising from 11 cases in 2009 to 117 cases in 2014. In February 2015, the Joint Committee on Vaccination and Immunisation (JCVI) agreed that the current increase in meningococcal W cases in England and Wales constituted an outbreak situation and recommended a vaccination programme aimed at protecting adolescents against meningococcal capsular groups ACW and Y strains. The MenC vaccination programme for adolescents was replaced by the MenACWY from August 2015. Fig 8a shows that Bedfordshire has exceeded the national target of 90% in both year 10 catch up and year 11 groups. It has also achieved its target for Tetanus/diphtheria and polio teen age booster(93.5%).

 Childhood Seasonal Flu Immunisation programme:

• Bedford Borough flu data figures showing final influenza vaccine uptake for children school years 1 and 2 age bench marked with England and former area team (south midland and Hertfordshire demonstrates and uptake of BBC is higher than the England average, but lower than BCCG and the PHE area averages. 
• The 2015 to 2016 winter season saw the successful roll out of the national childhood influenza vaccination programme to children school years 1 and 2 age. For BBC children, this was offered via a school-based programme, good uptake levels were achieved across Bedfordshire, demonstrating the success of the national roll out of the programme locally.
• This is the second year where all children aged 2, 3 and 4  have been offered flu immunisation and the first year where children in school year 1, 2 and children aged 4 were offered flu vaccination. Uptake of immunisation in children aged 2, 3 and 4 residing in BBC exceeds England and NHSE area Midland and East with exception to 4 year old which is lower than Midland and East average but higher than England. Bedford has vaccinated 41.1% of 2 year olds, 43.1 % of 3 year olds and 34.2% of 4 year old children.
• Bedford Borough Council also has its 55.5% of children in school year 1 and 55.9% in school year 2 vaccinated,comparing better than the England but lower than the NHE midland and East averages.