Report of the System of Vaccination Uptake 1998 – 2003, in the Health Service Executive Mid-Western Area

Report of the system of vaccination uptake 1998-2003, in the Health Service Executive Mid-Western Area / prepared by Kevin Kelleher ... [et al.]

Item Type Report

Authors Kelleher, Kevin

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Link to Item http://hdl.handle.net/10147/43817

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Report of the system of Vaccination Uptake 1998 – 2003, in the Health Service Executive Mid-Western Area

September 2004

Prepared by Dr Kevin Kelleher Mr Dominic Whyte, Dr Rose Fitzgerald Director of Public Health Surveillance Scientist Specialist in Public Health Medicine Dept of Public Health, Health Service Executive Mid-Western Area, Catherine Street, Limerick

Dr Frank Houghton Ms Esther Connellan Dr Ann Hogan Health Geographer Immunisation Co-ordinator, Regional Child Health Co-ordinator, HSE-MW HSE-MW HSE-MW

Page 1 of 34

Introduction:

Vaccination is offered to all children born in Ireland and other groups. Administration of the vaccines is performed according to the Immunisation Advisory Committee of the RCPI publication – “Immunisation Guidelines for Ireland” (2002).

The primary childhood immunisation programme (PCIP) covers vaccination against diphtheria (D), tetanus (T) and pertussis (P). These have been available as 2-in-1 and 3-in-1 vaccines. Vaccines against polio and Haemophilus influenzae b (Hib) have been added to give 4-in-1 and 5-in-1. These are normally completed within 12 months from birth. The Mumps, Measles, Rubella (MMR) vaccine is given at 12 months now but may have been administered at 15 months. BCG vaccination is given near birth. Vaccination against N. meningitidis group C was introduced in October 2000.

Uptake statistics regionally and nationally depend on all general practitioners returning, in a timely fashion, notification of vaccination in all children. The target uptake desired is 95% of all eligible children. At this level in a homogenous population, there is a good community protective effect which will benefit the remaining unvaccinated population. However, exposure to the disease may still cause infection in those not vaccinated.

Vaccination is a child’s best defence against a range of potentially fatal childhood diseases. Uptake of the PCIP, especially MMR has suffered greatly from adverse and ill-founded scientific and media reports.

Primary childhood immunisation in Ireland is free of charge – for both vaccine and visit to the doctor.

Acknowledgements: The Department of Public Health appreciates the efforts of the public health nurses, area medical officers, senior area medical officers and general practitioners for their role in facilitating the timely collection and collation of vaccination uptake data. The Department is grateful to systems analysts Anne Keane and Margaret Mansell in Management Services for their role in implementing and maintaining the IT infrastructure for recording and reporting of vaccination uptake in the region.

Page 2 of 34 Method:

The CareWorks Immunisation database in the Health Service Executive-Mid Western Area (HSE-MW), formerly Mid-Western Health Board, was utilised to export data concerning three cohorts of children born between July 1st 1998 and June 30th 2003.

These data were stratified by Electoral Division (ED) and by county.

Cohort 1: Children born between July 1st 1998 and June 30th 2000 were examined. Uptake for DTP/Polio/Hib and MMR were computed. This is a two-year cohort and DTP/polio/Hib and MMR vaccinations would be completed. Cohort 2: Children born between July 1st 2000 and June 30th 2002 were examined. Uptake for DTP/Polio/Hib and MMR were computed. This is a two-year cohort and DTP/polio/Hib and MMR vaccinations would be completed. Cohort 3: Children born between July 1st 2000 and June 30th 2003 were examined. Uptake for DTP/Polio/Hib, MMR and MenC were computed. This is a three-year cohort and DTP/polio/Hib and MenC vaccinations only would be completed.

On a quarterly basis the vaccination uptake at 24 months and 12 months is assessed and reported to the Health Protection Surveillance Centre (HPSC). The data used in this report is “live” data and represents the current vaccination status of the cohorts at the end of August 2004 and not when the reports for the HPSC were produced.

Considerable cleaning of systems and data has been carried out by the medical, nursing and management services personnel, to improve the quality of vaccination data in the HSE-MW. Anomalies still occur and data must be regarded as provisional.

The data includes only children eligible for vaccination (those born minus those who died minus those who moved out of the area plus those moved into the area)

Birth rates vary hugely within small areas like EDs from no births to almost 200 births per year. For the 2 year cohort there was an average of 21.6 births per ED (Median=10) and for the 3-year cohort there was an average of 33.6 births per ED (Median=17). The tables in this report include EDs in comparisons, only when over 20 births occurred in the cohort for the ED.

There are 417 EDs in the HSE-MW region. Limerick City – 37 (about 1500 persons/ED) Limerick County – 136 (about 890 persons/ED) Clare County – 163 (about 650 persons/ED) Tipperary North – 81 (about 750 persons/ED) Over the period July 1998 to June 2003, two EDs reported no births – Lackagh in Tipperary North and Clareabbey (part in UD) in Clare.

With 417 EDs it is not always feasible to label areas. Variance in codes, sectors and regions make it difficult to establish contiguous geographical boundaries recognisable to all.

Key Questions: What is the current DTP/polio/Hib vaccination uptake for Cohort 1 and Cohort 2 / Cohort 3? What is the current MMR vaccination uptake for Cohort 1 and Cohort 2? What is uptake like in the HSE-MW and the counties therein? Which EDs perform best and which perform worst with respect to uptake?

Page 3 of 34 Review:

Data on vaccination uptake in the HSE-MW has been reported from the Department of Public Health since 1998. The data illustrate a constant improvement in uptake of DTP/polio/Hib, but uptake still falls short of 95%. Data shown in this section is based on uptake at 24 months.

Data has not always been available for uptake by county. However, recent data suggests that uptake of DTP/polio/Hib is best in Tipperary (often over 90%) compared to Limerick and Clare. Clare has shown improvements in recent months, rising from 82% to 87%.

For MMR the uptake is lower than DTP/polio/Hib and it varies greatly but has improved over the last two years. In 2004, it recovered to levels seen in 2000/2001 (83%).

D3/T3 P3 Hib3 MMR1 Polio3

Uptake % (24months) Uptake % 70

2 01 01 02 000 000 1999 2 2 20 20 20 200 2003 2003 2004 1 3 1 3 1 3 1 3 1 Q Q3 1999 Q1 Q Q Q Q Q Q Q Q Period

Figure 1: Vaccination uptake at 24 months for diphtheria, tetanus, pertussis, Hib, polio (DTP/Hib/polio-3 doses) and measles, mumps and rubella (MMR-1 dose) in the HSE-MW, 1999-2004.

In early 2000, the uptake rates for all vaccinations were very low.

Data for BCG vaccination uptake is available through the Parent Child Health Record and is reported to be between 85 and 88%.

Page 4 of 34 Results:

There are about 4500 births annually in the HSE-MW each year. A number of children move in and move out of the area. Caveat: EDs in rural areas can be large and may have small numbers of births. Uptake in areas with small numbers of births must be interpreted cautiously as variation in uptake from year can be large. Uptake of diphtheria, tetanus and polio is generally 1-2% better than uptake of pertussis and Hib vaccination.

The number of eligible children in the three cohorts examined are shown in the tables below and uptake rates (county rate rounded to 0.5%, HSE-MW to 0.1):

Table 1: Number of eligible children, percentage vaccination uptake, by area (HSE- MW). Eligible children Area 1998 - 2000 2000 - 2002 2000- 2003* Limerick City 1398 1323 2041 Limerick County 3108 3137 4906 Limerick (all) 4506 4460 6947 Clare 2831 2959 4551 Tipperary North 1690 1639 2521 HSE-MW 9027 9058 14019 *Three year cohort

%Uptake Diphtheria, Tetanus Area 1998 - 2000 2000 - 2002 2000- 2003* Limerick City 86 87.5 87 Limerick County 84.5 88 88 Limerick (all) 85 88 88 Clare 84.5 88.5 88.5 Tipperary North 86.5 88 88 HSE-MW 85.1 88.2 88.2

%Uptake Pertussis Area 1998 - 2000 2000 - 2002 2000- 2003* Limerick City 84 85.5 85.5 Limerick County 82 86.5 87 Limerick (all) 82.5 86.5 86.5 Clare 81.5 87 87.5 Tipperary North 85 87.5 87 HSE-MW 82.6 86.6 86.9

%Uptake Polio Area 1998 - 2000 2000 - 2002 2000- 2003* Limerick City 86 88 87 Limerick County 84.5 88 88 Limerick (all) 85 88 88 Clare 84.5 88.5 88.5 Tipperary North 86.5 88 88.5 HSE-MW 85.1 88 88.2

Page 5 of 34 %Uptake Hib Area 1998 - 2000 2000 - 2002 2000- 2003* Limerick City 84.5 87 86.5 Limerick County 84 87.5 88 Limerick (all) 84 87.5 87.5 Clare 84 88 88 Tipperary North 85.5 87.5 87.5 HSE-MW 84.4 87.6 87.7

%Uptake Men C* Area 1998 - 2000 2000 - 2002 2000- 2003 Limerick City - 83 83.5 Limerick County - 85 86 Limerick (all) - 84.5 85.5 Clare - 84 85.5 Tipperary North - 84.5 85.5 HSE-MW - 84.8 85.4 *introduced October 2000

%Uptake MMR Area 1998 - 2000 2000 - 2002 Limerick City 85 85 Limerick County 84.5 86 Limerick (all) 84.5 85.5 Clare 83.5 83.5 Tipperary North 87.5 88 HSE-MW 84.8 85.4

These data show that uptake levels can be slightly higher than reported to HPSC. This may be due to late arrival and input of notification of vaccination. However, there is a consistent 8-12% differential in all cohorts between actual uptake and desired level of uptake. More information is needed on the 15% who do not have vaccination recorded. Table 2 shows the range of births in each region of the HSE-MW as well as mean and median number of births. The frequency of EDs according to a range of births is given. This shows that the Limerick city area is unusual in that there is a large proportion of EDs with high numbers of births. In the Clare, Tipperary North and county Limerick areas there is a high proportion of EDs with very few births, even though two and three year cohorts have been assessed. Care must be taken not to over interpret the uptake proportion in small areas such as EDs. Percentage uptake can vary widely when so few births occur. More analysis will be performed on small area uptake after amalgamation of EDs to allow better inference of trends in vaccination uptake. Current data only illustrates uptake.

Page 6 of 34 Table 2: Total, average and range of births in EDs of Clare, Limerick city, Limerick county and Tipperary North for each cohort and frequency of number of EDs according to birth range Cohort 1 Clare Limerick City Limerick Co Tipperary N HSE-MW Clare Limerick City Limerick Co Tipperary N HSE-MW . Total Births 2831 1398 3108 1690 9027 Minimum 0 3 0 0 0 Mean 17.4 37.8 22.9 20.9 21.6 Maximum 269 151 427 230 427 Median 6 28 11 10 10 No. EDs with births: % % % % % <20 127 14 97 62 300 78% 38% 71% 77% 72% 21-30 13 7 16 6 42 8% 19% 12% 7% 10% 31-40 7 3 9 5 24 4% 8% 7% 6% 6% 41-75 10 10 5 3 28 6% 27% 4% 4% 7% 76-100 1 1 5 2 9 1% 3% 4% 2% 2% >100 5 2 4 3 14 3% 5% 3% 4% 3% Cohort 2 Clare Limerick City Limerick Co Tipperary N HSE-MW Clare Limerick City Limerick Co Tipperary N HSE-MW Total Births 2959 1323 3137 1639 9058 Minimum 0 5 0 0 0 Mean 18.2 35.8 23.1 20.2 21.7 Maximum 295 129 448 187 448 Median 8 28 13 10 11 No. EDs with births: % % % % % <20 134 13 95 62 304 82% 35% 70% 77% 73% 21-30 8 7 22 8 45 5% 19% 16% 10% 11% 31-40 6 8 8 2 24 4% 22% 6% 2% 6% 41-75 9 6 4 4 23 6% 16% 3% 5% 6% 76-100 2 0 2 2 6 1% 0% 1% 2% 1% >100 4 3 5 3 15 2% 8% 4% 4% 4% Cohort 3 Clare Limerick City Limerick Co Tipperary N HSE-MW Clare Limerick City Limerick Co Tipperary N HSE-MW Total Births 4551 2041 4906 2521 14019 Minimum 0 11 0 0 0 Mean 27.9 55.2 36.1 31.1 33.6 Maximum 435 205 738 291 738 Median 11 41 20 16 17 No. EDs with births: % % % % % <20 113 7 70 53 243 69% 19% 51% 65% 58% 21-30 21 5 22 10 58 13% 14% 16% 12% 14% 31-40 6 5 17 5 33 4% 14% 13% 6% 8% 41-75 11 12 17 5 45 7% 32% 13% 6% 11% 76-100 5 5 2 3 15 3% 14% 1% 4% 4% >100 7 3 8 5 23 4% 8% 6% 6% 6%

Page 7 of 34 Cohort 1: Children born July 1998- June 2000, HSE-MW

Table 2: Percentage uptake of DT/MMR in children born July 1998 – June 2000, in EDs showing lowest and highest uptake in HSE-MW.

Only EDs showing more than 20 births included. Worst Uptake % % ED County Uptake (DT) ED County Uptake (MMR) 1. Ennis urban 5 CE 63 Ennis urban 5 CE 70 2. Newcastle rural LK 68 Drumaan CE 71 3. Drumaan CE 71 Ballina TN 72 4. Tulla CE 74 Knocklong LK 73 5. Knockainy LK 75 Scarriff CE 75 6. Knigh TN 75 Ennis urban 2 CE 76 7. Ballycummin LK 76 Corofin CE 76 8. Ballina TN 76 Killaloe CE 76 9. Kilalagh CE 76 Rathkeale Urban LK 77 10. Dock A (City) LK 76 Limerick N rural LK 77 Bruree LK 76 Miltown Malbay CE 77 Galvone B (City) LK 77

Best Uptake % % ED County Uptake (DT) ED County Uptake (MMR) 1. Ballyea CE 100 Kilnamona CE 100 2. Caherconlish LK 97 Newmarket CE 96 3. Pallaskenry LK 97 Nenagh rural TN 96 4. Hospital LK 97 Ballynaclogh TN 96 5. Patrickswell LK 97 Drom TN 96 6. Newmarket CE 96 Castletown TN 96 7. Kildimo LK 96 Templeglentan LK 96 8. Ballynaclogh TN 96 Rathronan LK 96 9. Croagh LK 96 Ballyea CE 95 10. Askeaton East LK 96 Cloghjordan TN 95

For this cohort, there were 150 EDs out of 401 (37%), which recorded DT uptake of over 95%. There were 139 EDs out of 401 (35%), which recorded MMR uptake of over 95%. There were no births in 16 EDs.

Page 8 of 34 Cohort 2: Children born July 2000- June 2002, HSE-MW

Table 3: Percentage uptake of DT/MMR in children born July 2000 – June 2002, in EDs showing lowest and highest uptake in HSE-MW.

Only EDs showing more than 20 births included. Worst Uptake % % ED County Uptake (DT) ED County Uptake (MMR) 1. Twomileborris TN 64 Scarriff CE 54 2. Scarriff CE 67 Ogonelloe CE 55 3. Tobernea LK 68 Twomileborris TN 68 4. Rathkeale urban LK 71 Killaloe CE 69 5. Kilkee CE 76 Kilkee CE 70 6. Ennistimon CE 76 Rathkeale urban LK 71 7. Killaloe CE 78 Tobernea LK 72 8. Newcastle urban LK 79 Ballylanders LK 73 9. Borrisoleigh TN 79 Castle A (City) LK 74 10. Ennis urban 4 CE 79 Borrisoleigh TN 75 Dock A (City) LK 79 Castle D (City) LK 75 Dock C (City) LK 75

Best Uptake % % ED County Uptake (DT) ED County Uptake (MMR) 1. Dromard LK 100 Templemaley CE 100 2. Templemaley CE 100 Hospital CE 100 3. Pallaskenry LK 100 Rathronan TN 100 4. Carrigatogher TN 100 Drumcolliher TN 100 5. Galbally LK 100 Borrisokane TN 97 6. Mountievers CE 100 Bruff TN 97 7. Kilseily CE 100 Templetuohy LK 96 8. Monagay LK 100 Killone LK 96 9. Bruff LK 100 Galbally CE 95 10. Knocklong LK 100 Nenagh rural TN 95

For this cohort, there were 188 EDs out of 410 (46%), which recorded DT uptake of over 95%. There were 148 EDs out of 410 (36%), which recorded MMR uptake of over 95%. There were no births in 7 EDs.

Page 9 of 34 Cohort 3: Children born July 2000- June 2003, HSE-MW

Table 4: Percentage uptake of DT in children born July 2000 – June 2003, in EDs showing lowest and highest uptake in HSE-MW.

Only EDs showing more than 20 births included. Worst Uptake % ED County Uptake (DT) 1. Drumaan CE 63 2. Scarriff CE 69 3. Ballycannan CE 74 4. Rathkeale urban LK 74 5. Twomileborris TN 74 6. Tobernea LK 74 7. Emlygrennan LK 76 8. Galvone B (City) LK 77 9. Prospect A (City) LK 77 10. Lorrha East TN 77 Dock D (City) LK 78

Best Uptake % ED County Uptake (DT) 1. Castletown (Croom) LK 100 2. Ballynaclogh TN 100 3. Templeglentan LK 100 4. Templemaley CE 100 5. Ballymackey TN 100 6. Kilmihil CE 100 7. Galbally LK 100 8. Mountievers CE 100 9. Askeaton West LK 100 10. Ruane CE 100

For this cohort, there were 158 EDs out of 412 (38%), which recorded DT uptake of over 95%. There were no births in 5 EDs.

Page 10 of 34 Within each cohort the ED with the most number of eligible children in each county was examined. With one exception these areas were consistent in returning the largest number of births of eligible children for vaccination.

Table 5: Percentage uptake of DT/MMR three cohorts of children, in EDs showing the highest number of births in HSE-MW.

1998-2000 Area No. Children DT Uptake (%) MMR Uptake (%) Abbey A (Limerick City) 151 91 89 Clenagh (Clare) 269 78 80 Ballycummin (Co Limerick) 427 76 78 Thurles urban (Tipperary) 230 80 85

2000-2002 Area No. Children DT Uptake (%) MMR Uptake (%) Abbey A (Limerick City) 129 94 91 Clenagh (Clare) 295 88 85 Ballycummin (Co Limerick) 448 86 83 Thurles urban (Tipperary) 187 90 86

2000-2003 Area No. Children DT Uptake (%) Abbey A (Limerick City) 194 93 Clenagh (Clare) 435 89 Ballycummin (Co Limerick) 738 86 Thurles urban (Tipperary) 291 88

Note: Ballycummin is classified as a County Limerick ED but the area is a densely populated division adjacent Raheen and the Mid-Western Regional Hospital in Dooradoyle.

Page 11 of 34

Uptake in Clare county: Table 6 shows the EDs reported with best and worst uptake for DT and MMR, and compares uptake in the earlier cohort and the later cohort of children (for EDs with over 20 births in the cohort).

Table 6: Best and worst uptake of DT and MMR in the Clare region for children born July 1998 – June 2000 and for children born July 2000 and June 2002/3.

Clare 1998-2000 2000-2003 1998-2000 2000-2002 Best ED Births %DT Best ED Births %DT Best ED %MMR Best ED Births %MMR 1 Ballyea 22 100 Templemaley 29 100 Kilnamona 100 Templemaley 20 100 2 Newmarket 57 96 Kimihil 21 100 Newmarket 96 Killone 24 96 3 Templemaley 22 95 Mountievers 25 100 Ballyea 95 Mountievers 20 95 4 Kilnamona 21 95 Ruane 24 100 Templemaley 95 Killeely 29 93 5 Sixmilebridge 60 95 Rossroe 42 98 Kilraightis 95 Rossroe 29 93 6 Doora (RD) 39 95 Kilnamona 37 97 Kilrush urban 94 Ennis 2 urban 69 93 7 Corofin 29 93 Killone 31 97 Kilkishen 94 Kilnamona 27 93 8 Kilrush urban 72 93 Liscasey 30 97 Killeely 91 Quin 35 91 9 Mountievers 26 92 Drumline 27 96 Liscasey 91 Liscasey 21 90 10 Liscasey 22 91 Kilraightis 27 96 Ennis rural 90 Ballyglass 154 90 (UD) Worst ED %DT Worst ED %DT Worst ED %MMR Worst ED %MMR 1 Ennis 5 urban 102 63 Drumaan 24 63 Ennis 5 urban 70 Scarriff 39 54 2 Drumaan 24 71 Scarriff 74 69 Drumaan 71 Ogonnelloe 20 55 3 Tulla 34 74 Ballycannan 38 74 Scarriff 75 Killaloe 45 69 4 Killilagh 21 76 Kilkee 42 79 Ennis 2 urban 76 Kilkee 33 70 5 Miltown 48 77 Ennis 4 urban 56 80 Corofin 76 Kiltenalea 62 76 Malbay 6 Quin 31 77 Ennistimon 94 81 Killaloe 76 Ennistimon 62 77 7 Scarriff 40 78 Tulla 58 83 Miltown 77 Ennis 6 urban 184 78 Malbay 8 Clenagh 269 78 Ennis 1 urban147 83 Clenagh 80 Tulla 37 78 9 Ennis 6 urban 200 80 Lisdoonvarna 30 83 Quin 81 Cratloe 37 78 10 Kiladysert 26 81 Ennis 6 urban289 84 Killilagh 81 Kiladysert 28 79 Ennis 1 urban 110 82 Ennis 6 urban 82

The greatest number of births in Clare occurred in areas of Ennis, Ennistimon and areas adjacent to Limerick city (Map 1). In Clare the proportion of EDs with over 95% uptake of DT was 38% (n=62) for children born 1998-2000 compared to 43% (n=70) for children born 2000-2003. The equivalent proportions for MMR were 34% (n=56) and 36% (n=58). For MenC, 58 EDs (36%) had over 95% uptake for children born July 2000 – June 2003. The map of DT uptake in Clare (Map 2) shows substantial progress in improved uptake. This has not been the case with MMR in Clare. Ennis urban and several EDs in north east Clare appear to have very low uptake of DT and in north east Clare, MMR uptake shows deterioration (Map 3). Uptake in Scarriff in the later birth cohort for DT is 9% (MMR 21%) lower than uptake in the earlier birth cohort. Ennis 2 urban area had poor uptake of MMR (76%) in the earlier birth cohort but uptake was 93% in the later birth cohort. MenC uptake in Clare is quite good, outside of north east Clare (Map 4).

Page 13 of 34 Table 7 shows the 10 EDs with the highest number of births, the number born in the cohort, the %DT uptake and the difference in uptake between those born in the earlier cohort (1998- 2000) and later cohort (2000-2003).

Table 7: Percentage DT uptake in EDs with highest number of births in Clare. Late 1998-2000 2000-2003 cohort=reference Clare No. births %DT Uptake %DT Uptake No. births Diff+/-DT 1 Clenagh 269 78 89 435 Clenagh 11 2 Ennis 6 Urban 200 80 89 364 Ennis 5 Urban 26 3 Ballyglass 138 90 84 289 Ennis 6 Urban 4 4 Ennis 1 Urban 110 82 92 250 Ballyglass 2 5 Ennis 5 Urban 102 63 83 147 Ennis 1 Urban 1 6 Clareabbey (RD) 92 89 90 136 Clareabbey (RD) 1 7 Kilrush Urban 72 93 89 107 Ennis 2 Urban 7 8 Ennis 2 Urban 66 82 86 99 Sixmilebridge NA 9 Kiltanenlea 64 91 81 94 Ennistimon -2 10 Ennistimon 64 83 85 91 Kiltanenlea -6 96 Kilrush urban 3 Kilrush rural 89 90 Kilrush rural 1

Table 8 shows the 10 EDs with the highest number of births, the number born in the cohort, the %MMR uptake and the difference in uptake between those born in the earlier cohort (1998-2000) and later cohort (2000-2003).

Table 8: Percentage MMR uptake in EDs with highest number of births in Clare. Late 1998-2000 2000-2002 cohort=reference Clare No. births %MMR Uptake %MMR Uptake No. births Diff+/-MMR 1 Clenagh 269 80 85 295 Clenagh 5 2 Ennis 6 Urban 200 82 89 225 Ennis 5 Urban 19 3 Ballyglass 138 88 78 184 Ennis 6 Urban -4 4 Ennis 1 Urban 110 83 90 154 Ballyglass 2 5 Ennis 5 Urban 102 70 79 95 Ennis 1 Urban -4 6 Clareabbey (RD) 92 87 80 90 Clareabbey (RD) -7 7 Kilrush Urban 72 94 93 69 Ennis 2 Urban 17 8 Ennis 2 Urban 66 76 76 62 Kiltanenlea -8 9 Kiltanenlea 64 84 77 62 Ennistimon -6 10 Ennistimon 64 83 90 60 Kilrush Urban -4

Kilrush rural 89 93 Kilrush rural 4

The latter two tables are more likely to over-represent uptake in urban areas which have highest population density, while the other best/worst uptake table may over-represent rural areas with fewer births.

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Map 1: Absolute number of births in Clare by ED (children born 1998 – 2000 and 2000- 2002).

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Map 2: Percentage uptake of DT in children born 1998-2000 and in children born 2000-2003 in Clare by ED.

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Map 3: Percentage uptake of MMR in children born 1998-2000 and in children born 2000- 2002 in Clare by ED.

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Map 4: Percentage uptake of MenC in children born 2000-2003 in Clare by ED.

Page 18 of 34 Uptake in Limerick city: Table 9 shows the EDs reported with best and worst uptake for DT and MMR, and compares uptake in the earlier cohort and the later cohort of children (for EDs with over 20 births in the cohort).

Table 9: Best and worst uptake of DT and MMR in the Limerick city region for children born July 1998 – June 2000 and for children born July 2000 and June 2002/3.

Limerick city Uptake 1998-2000 2000-2003 1998-2000 2000-2002 Best ED Births %DT Best ED Births %DT Best ED %MMR Best ED Births %MMR 1 Rathbane 61 92 Abbey D 46 93 Johns A 95 Dock D 31 94 2 Abbey D 47 91 Coolraine 45 93 Farranshone 93 Abbey C 22 91 3 Abbey A 151 91 Abbey A 194 93 Abbey B 90 Abbey A 129 91 4 Galvone A 69 91 Singland A 64 92 Glentworth B 89 Abbey D 32 91 5 Ballinacurra A 54 91 Glentworth A 25 92 Abbey A 89 Johns B 21 90 6 Johns A 42 90 Singland B 205 92 Rathbane 89 Singland B 125 90 7 Glentworth B 28 89 Galvone A 84 92 Prospect B 88 Glentworth B 28 89 8 Singland B 127 88 Ballinacurra B 43 91 Singland B 87 Johns A 55 89 9 Singland A 55 87 Glentworth B 40 90 Galvone A 87 Singland A 43 88 10 Castle D 38 87 Rathbane 79 90 Castle D 87 Prospect B 37 86 Worst ED %DT Worst ED %DT Worst ED %MMR Worst ED %MMR 1 Dock A 34 76 Galvone B 94 77 Dock A 65 Castle A 27 74 2 Custom 20 80 Prospect A 26 77 Galvone B 77 Dock C 20 75 House 3 Castle C 41 80 Dock D 49 78 Killeely A 78 Castle D 40 75 4 Killeely A 27 81 Dock A 64 78 Custom House 80 Galvone B 61 75 5 Castle A 49 82 Dock C 37 78 Singland A 80 Ballinacurra B 33 76 6 Galvone B 66 82 Ballynanty 188 80 Castle C 80 Killeely B 27 78 7 Johns B 22 82 Abbey C 32 81 Ballinacurra B 81 Ballynanty 119 82 8 Prospect B 56 82 Shannon B 22 82 Castle A 82 Castle C 22 82 9 Ballynanty 96 82 Castle C 34 82 Ballinacurra A 83 Dock A 39 82 10 Ballincurra B 29 83 Prospect B 54 85 Ballynanty 84 Galvone A 57 82

EDs with the highest number of births in Limerick cluster in a ring around the suburbs of the city – these are still regarded as Limerick county areas. Births in Newcastlewest were also high (Map 5). In Limerick city the proportion of EDs with over 95% uptake of DT was 5% (n=2) for children born 1998-2000 and for children born 2000-2002. The equivalent proportions for MMR were 8% (n=3) and 0%. For MenC, no ED had over 95% uptake for children born July 2000 – June 2003. This reflects the larger birth cohorts in Limerick city EDs. For DT (Map 6), the later cohort appears to have slightly higher uptake compared to the earlier cohort (1998-2000). This is particularly evident in West Limerick and Hospital areas. The picture with MMR is more complex. Map 7 shows the improved MMR uptake in West Limerick but in the south (Garrynderk) and mid-county, uptake is lower in those born more recently. Uptake in two adjacent areas of Limerick city, Galvone A and Galvone B is particularly interesting. Uptake in Galvone B is consistently lower than Galvone A. The Abbey D and Abbey A areas have good uptake of DT and MMR, while Dock A and Dock C have poor uptake. Ballynanty has consistently poor uptake compared to Glentworth B with consistently better uptake. It is relevant to compare relative disadvantage in the populations of these EDs. MMR uptake in Castle D was 12% lower in the later birth cohort compared to the earlier birth cohort (87%). Uptake of MenC in the city and county of Limerick has been good (Map 8).

Page 19 of 34 Table 10 shows the 10 EDs with the highest number of births, the number born in the cohort, the %DT uptake and the difference in uptake between those born in the earlier cohort (1998- 2000) and later cohort (2000-2003).

Table 10: Percentage DT uptake in EDs with highest number of births in Limerick city. Late 1998-2000 2000-2003 cohort=reference Limerick City No. births %DT Uptake %DT Uptake No. births Diff+/-DT 1 Abbey A 151 91 92 205 Singland B 4 2 Singland B 127 88 93 194 Abbey A 2 3 Ballynanty 96 82 80 188 Ballynanty -2 4 Galvone A 69 91 77 94 Galvone B -5 5 Galvone B 66 82 93 85 Abbey B NA 6 Rathbane 61 92 86 85 Johns A NA 7 Prospect B 56 82 92 84 Galvone A 1 8 Singland A 55 87 90 79 Rathbane -2 9 Ballinacurra A 54 91 92 64 Singland A 5 10 Castle A 49 82 78 64 Dock A NA

Table 11 shows the 10 EDs with the highest number of births, the number born in the cohort, the %MMR uptake and the difference in uptake between those born in the earlier cohort (1998-2000) and later cohort (2000-2002).

Table 11: Percentage MMR uptake in EDs with highest number of births in Limerick city. Late 1998-2000 2000-2002 cohort=reference Limerick City No. births %MMR Uptake %MMR Uptake No. births Diff+/-MMR 1 Abbey A 151 89 91 129 Abbey A 2 2 Singland B 127 87 90 125 Singland B 3 3 Ballynanty 96 84 82 119 Ballynanty -2 4 Galvone A 69 87 75 61 Galvone B -2 5 Galvone B 66 77 82 57 Galvone A -5 6 Rathbane 61 89 86 56 Abbey B NA 7 Prospect B 56 88 85 55 Rathbane -4 8 Singland A 55 80 89 55 Johns A NA 9 Ballinacurra A 54 81 88 43 Singland A 8 10 Castle A 49 82 85 40 Ballinacurra A 4

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Map 5: Absolute number of births in Limerick (city and county) by ED (children born 1998 – 2000 and 2000-2003).

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Map 6: Percentage uptake of DT in children born 1998-2000 and in children born 2000-2003 in Limerick (city and county) by ED.

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Map 7: Percentage uptake of MMR in children born 1998-2000 and in children born 2000- 2002 in Limerick (city and county) by ED.

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Map 8: Percentage uptake of MenC in children born 2000-2002 in Limerick (city and county) by ED.

Page 24 of 34 Uptake in Limerick county: Table 12 shows the EDs reported with best and worst uptake for DT and MMR, and compares uptake in the earlier cohort and the later cohort of children (for EDs with over 20 births in the cohort).

Table 12: Best and worst uptake of DT and MMR in the Limerick county region for children born July 1998 – June 2000 and for children born July 2000 and June 2002/3.

Limerick county 1998-2000 2000-2003 1998-2000 2000-2002 Best ED Births %DT Best ED Births %DT Best ED %MMR Best ED Births %MMR 1 Caherconlish 38 97 Castletown 24 100 Templeglantan 96 Rathronan 20 100 west (Croom Rd) 2 Pallaskenry 33 97 Templeglantan 23 100 Rathronan 96 Hospital 29 100 3 Hospital 30 97 Galbally 27 100 Caherconlish 95 Drumcollogher 22 100 west 4 Patricks Well 29 97 Askeaton west 31 100 Abington 95 Bruff 30 97 5 Kildimo 27 96 Pallaskenry 41 100 Pallaskenry 94 Galbally 22 95 6 Croagh 23 96 Kilpeacon 23 100 Hospital 93 Monagay 20 95 7 Askeaton east 45 96 Bruff 43 98 Askeaton east 93 Doon south 28 93 8 Abington 37 92 Hospital 41 98 Kildimo 93 Bruree 28 93 9 Templeglantan 23 91 Knocklong 36 97 Clarina 92 Knocklong 25 92 10 Shanagolden 44 91 Dunnaman 32 97 Cappamore 92 Clarina 37 92 Worst ED %DT Worst ED %DT Worst ED %MMR Worst ED %MMR 1 NCW rural 28 68 Rathkeale urban 89 74 Knocklong 73 Rathkeale 65 71 urban 2 Knockainy 20 75 Tobernea 35 74 Rathkeale 77 Tobernea 25 72 urban 3 Ballycummin 427 76 Emlygrennan 25 76 Limerick north 77 Ballylanders 26 73 rural 4 Bruree 34 76 Glin 45 78 Ballycummin 78 Croom 53 75 5 Knocklong 30 77 Abington 44 80 NCW rural 79 NCW urban 103 79 6 Rathkeale urban 94 78 Bulgaden 20 80 Bruff 79 Fedamore 24 79 7 Kilfinane 28 79 NCW urban 157 80 Bruree 79 Glenstal 24 79 8 Galbally 28 79 Ballybricken 68 81 Drumcollogher 80 Limerick north 205 80 rural 9 Bruff 38 79 Kilmallock 109 83 Ballybricken 80 Kilmallock 77 81 10 Roxborough 29 79 Croom 80 84 Abbeyfeale 80 Ballycummin 448 83

In Limerick county, the children born in the later cohort seem to have higher uptake than those in the earlier birth cohort (1998-2000), but mainly with DT uptake rather than MMR uptake. The proportion of EDs with over 95% uptake of DT was 40% (n=55) for children born 1998-2000 compared to 38% (n=52) for children born 2000-2002. The equivalent proportions for MMR were 35% (n=48) and 34% (n=46). For MenC, 41 EDs (30%) had over 95% uptake for children born July 2000 – June 2003. The Rathkeale urban area has a consistently low uptake and Hospital has consistently high uptake. The difference in DT and MMR uptake in the earlier birth cohort is 4-5% higher than uptake in the later birth cohort in the Rathkeale urban area. Uptake of DT and MMR in the Newcastle rural area was notably low in the earlier birth cohort, but for children born 2000-2003, the uptake is lowest in the Newcastle urban area. Uptake of DT in Abington appears to have got worse while uptake of MMR in Bruree and Knocklong improved.

Page 25 of 34 Table 13 shows the 10 EDs with the highest number of births, the number born in the cohort, the %DT uptake and the difference in uptake between those born in the earlier cohort (1998- 2000) and later cohort (2000-2003).

Table 13: Percentage DT uptake in EDs with highest number of births in Limerick county. Late 1998-2000 2000-2003 cohort=reference Limerick County No. births %DT Uptake %DT Uptake No. births Diff+/-DT 1 Ballycummin 427 76 86 738 Ballycummin 10 2 Limerick North rural 203 81 85 320 Limerick North rural 4 3 Ballysimon 182 83 88 223 Ballysimon 5 4 Kilmallock 110 87 90 182 Ballyvarra 6 5 Abbeyfeale 96 84 80 157 NCW urban -2 6 Rathkeale urban 94 78 87 119 Abbeyfeale 3 7 Croom 92 90 84 113 Castleconnell -3 8 NCW urban 91 82 83 109 Kilmallock -4 9 Ballyvarra 88 84 74 89 Rathkeale urban -4 10 Adare South 55 91 84 80 Croom -6 Castleconnell 54 87 81 68 Roxborough NA NCW rural 68 92 52 NCW rural 24

Table 14 shows the 10 EDs with the highest number of births, the number born in the cohort, the %MMR uptake and the difference in uptake between those born in the earlier cohort (1998-2000) and later cohort (2000-2002).

Table 14: Percentage MMR uptake in EDs with highest number of births in Limerick county. Late 1998-2000 2000-2002 cohort=reference Limerick County No. births %MMR Uptake %MMR Uptake No. births Diff+/-MMR 1 Ballycummin 427 78 83 448 Ballycummin 5 2 Limerick North rural 203 77 80 205 Limerick North rural 3 3 Ballysimon 182 84 86 146 Ballysimon 2 4 Kilmallock 110 86 84 106 Ballyvarra -5 5 Abbeyfeale 96 80 79 103 NCW urban -6 6 Rathkeale urban 94 77 85 81 Abbeyfeale 5 7 Croom 92 83 81 77 Kilmallock 0 8 NCW urban 91 85 85 72 Castleconnell -5 9 Ballyvarra 88 89 71 65 Rathkeale urban -6 10 Adare South 55 89 75 53 Croom -8 Castleconnell 54 85 85 41 Roxborough NA NCW rural 79 89 27 NCW rural 10

Page 26 of 34 Uptake in Tipperary North: Table 15 shows the EDs reported with best and worst uptake for DT and MMR, and compares uptake in the earlier cohort and the later cohort of children (for EDs with over 20 births in the cohort).

Table 15: Best and worst uptake of DT and MMR in the Tipperary North region for children born July 1998 – June 2000 and for children born July 2000 and June 2002/3.

Tipperary North 1998-2000 2000-2003 1998-2000 2000-2002 Best ED Births %DT Best ED Births %DT Best ED %MMR Best ED Births %MMR 1 Ballynaclogh 26 96 Ballynaclogh 24 100 Nenagh rural 96 Borrisokane 32 97 2 Cloghjordan 22 95 Ballymackey 23 100 Ballynaclogh 96 Templetuohy 26 96 3 Borrisokane 40 93 Moyne 22 100 Drom 96 Nenagh rural 64 95 4 Nenagh rural 53 92 Carrigatogher 29 97 Castletown 96 Carrigatogher 21 95 5 Drom 25 92 Ardcroney 23 96 Cloghjordan 95 Nenagh east 63 95 urban 6 Carrigatogher 23 91 Knigh 22 95 Templemore 95 Castletown 40 93 7 Nenagh west 110 91 Loughmoe 21 95 Borrisokane 93 Nenagh west 114 92 urban urban 8 Holycross 35 89 Riverstown 20 95 Borrisoleigh 92 Thurles rural 23 91 9 Thurles rural 34 88 Nenagh rural 87 94 Holycross 91 Cloghjordan 24 88 10 Birdhill 33 88 Castletown 64 94 Carrigatogher 91 Birdhill 28 86 Worst ED %DT Worst ED %DT Worst ED %MMR Worst ED %MMR 1 Knigh 20 75 Twomileborris 35 74 Ballina 72 Twomileborris 22 68 2 Ballina 88 76 Lorrha east 22 77 Newport 84 Borrisoleigh 52 75 3 Thurles urban 230 80 Borrisoleigh 73 79 Roscrea 84 Littleton 26 77 4 Borrisoleigh 39 85 Roscrea 259 81 Knigh 85 Newport 77 81 5 Roscrea 196 86 Newport 110 82 Thurles urban 85 Templemore 60 83 6 Littleton 28 86 Borrisokane 45 87 Littleton 85 Ballina 99 84 7 Nenagh east 80 86 Nenagh west 186 87 Nenagh east 89 Roscrea 168 85 urban urban urban 8 Templemore 60 87 Holycross 40 88 Nenagh west 89 Holycross 26 85 urban 9 Newport 62 87 Thurles urban 291 88 Birdhill 91 Thurles urban 187 86 10 Castletown 24 88 Templemore 98 88 Thurles rural 91

The pattern of births in Tipperary North shown in Map 9 clearly illustrates the radial proximity to urban conurbations of Nenagh, Roscrea, Thurles and Templemore. In Tipperary North the proportion of EDs with over 95% uptake of DT was 38% (n=31) for children born 1998-2000 compared to 35% (n=28) for children born 2000-2002. The equivalent proportions for MMR were 40% (n=32) and 46% (n=37). For MenC, 19 EDs (23%) had over 95% uptake for children born July 2000 – June 2003. Uptake of MMR in Tipperary North is good, contrasting with Clare and Limerick. This may reflect the traditionally higher uptake generally achieved in this region compared to Clare and Limerick. The Nenagh rural area has consistently high uptake, while uptake in Uptake of DT in Twomileborris and MMR in Borrisoleigh is quite different when uptake in the earlier and later birth cohorts are compared, the later cohorts having a much lower uptake. Uptake of DT in Tipperary North is good in proximity to the large towns (Map 10). A similar pattern is seen for MMR and MenC vaccination (Map 11 and Map 12).

Page 27 of 34 Table 16 shows the 10 EDs with the highest number of births, the number born in the cohort, the %DT uptake and the difference in uptake between those born in the earlier cohort (1998- 2000) and later cohort (2000-2003).

Table 16: Percentage DT uptake in EDs with highest number of births in Tipperary North. Late 1998-2000 2000-2003 cohort=reference Tipperary North No. births %DT Uptake %DT Uptake No. births Diff+/-DT 1 Thurles urban 230 80 88 291 Thurles urban 8 2 Roscrea 196 86 81 259 Roscrea -5 3 Nenagh West Urb 110 91 87 186 Nenagh West Urb -4 4 Ballina 88 76 89 152 Ballina 13 5 Nenagh East Urb 80 86 82 110 Newport -5 6 Newport 62 87 89 98 Nenagh East Urb 3 7 Templemore 60 87 88 98 Templemore 1 8 Nenagh rural 53 92 94 87 Nenagh rural 2 9 Borrisokane 40 93 79 73 Borrisoleigh -6 10 Borrisoleigh 39 85 94 64 Castletown NA 87 45 Borrisokane -6

Table 17 shows the 10 EDs with the highest number of births, the number born in the cohort, the %MMR uptake and the difference in uptake between those born in the earlier cohort (1998-2000) and later cohort (2000-2002).

Table 17: Percentage MMR uptake in EDs with highest number of births in Tipperary North. Late 1998-2000 2000-2002 cohort=reference Tipperary North No. births %MMR Uptake %MMR Uptake No. births Diff+/-MMR 1 Thurles urban 230 85 86 187 Thurles urban 1 2 Roscrea 196 84 85 168 Roscrea 1 3 Nenagh West Urb 110 89 92 114 Nenagh West Urb 3 4 Ballina 88 72 84 99 Ballina 12 5 Nenagh East Urb 80 89 81 77 Newport -3 6 Newport 62 84 95 64 Nenagh rural -1 7 Templemore 60 95 95 63 Nenagh East Urb 6 8 Nenagh rural 53 96 83 60 Templemore -12 9 Borrisokane 40 93 75 52 Borrisoleigh -17 10 Borrisoleigh 39 92 93 40 Castletown NA 97 32 Borrisokane 4

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Map 9: Absolute number of births in Tipperary North by ED (children born 1998 – 2000 and 2000-2002).

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Map 10: Percentage uptake of DT in children born 1998-2000 and in children born 2000- 2003 in Tipperary North by ED.

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Map 11: Percentage uptake of MMR in children born 1998-2000 and in children born 2000- 2002 in Tipperary North by ED.

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Map 12: Percentage uptake of MenC in children born 2000-2002 in Tipperary North by ED.

Page 32 of 34 Discussion:

Uptake of vaccination against diseases like diphtheria tetanus and polio has improved 5-7% across the HSE-MW since 1999. This improvement is seen in all areas, Limerick City, Limerick county, Clare county and Tipperary North. It appears that more children in the most recent cohorts have vaccination uptake recorded than in earlier birth cohorts. One possible cause of any reversal in uptake level in a birth cohort may involve new entrants to the cohort and who do not have their vaccination status actively recorded on the system.

The combined vaccine 5-in-1 may improve uptake of pertussis and Hib in future.

There is clearly a wider acceptance of the DTP/polio/Hib vaccine over MMR vaccine but uptake of MMR vaccine in Tipperary North is better than Clare or Limerick. However, the difference between DTP/Hib/polio and MMR uptake seen here are not as great as apparent when uptake reports are run immediately after the birth cohort was due the vaccination. This suggests that either MMR vaccine is given late or data on MMR are delayed.

Uptake of MMR is better than might have been thought. Levels of 60-70% were reported in other regions of Ireland. Uptake of 70% was seen in the HSE-MW in early 2000 and 2002 during the first quarter of the year but this improved steadily in subsequent quarters. Presently, quarter 2 2004, the uptake level for MMR in the HSE-MW is 84%. Uptake of MMR in the east Clare region is reaching hazardously low levels with three EDs reporting very low uptake (50-70%). The risk of an outbreak of mumps, measles or rubella must be regarded as high for these areas. The consequences of the parental choice not to vaccinate may have implications for these children in the long term – where pregnancies are involved. Maximising the number of children immunised against measles, mumps and rubella will minimise the risk of a non-immune mother or infant encountering the disease. Antenatal screening for rubella antibody is available to expectant mothers.

The report highlights areas with low or falling uptake that need remedial action.

The uptake of MenC vaccine is not as high as desired despite the success of the vaccine in reducing meningococcal group C disease by 90% since its introduction. This disease is associated with high morbidity and mortality and must be encouraged.

Anecdotal reports suggest the PCIP may be a victim of its own success. The elimination of smallpox and virtually eradication of polio means that potential killer diseases are no longer considered a threat. Infections like diphtheria, mumps, measles and rubella are not commonly encountered as they were 40 years ago in Ireland. It should be remembered that the diseases are associated with serious sequelae and morbidity – the risks of these complications are greater than the risk from any adverse reaction to vaccination. In an outbreak of measles in the Eastern region affecting over 2000 children, there were three deaths in infants recorded attributed in part or totally to the infection. These diseases can be imported from countries where the infection is much more common and may be acquired when visiting such countries.

Quarterly uptake rates for all the Health Boards are published by the HPSC and are freely available at their website – www.hpsc.ie

Further analysis of the uptake by ED region according to urban-rural classification or by deprivation index might point to some useful information. Does the number of times a child needs to go to a general practitioner for a vaccine affect uptake – organisation of such visits might prove a deterrent in some areas more than others. The introduction of the regional immunisation co-ordinator and a regional child health co- ordinator has assisted in getting vaccination status data collected and collated in a timely

Page 33 of 34 manner. Difficulties in the system can be assessed and addressed at the Regional Immunisation Committee of the HSE-MW.

Further information on vaccination: Information leaflets on the 4-in-1, the 5-in-1 and MMR vaccines are available through the HSE Mid-Western Area website www.mwhb.ie Alternatively, please contact the Department of Public Health, HSE-MW, 31-33 Catherine Street, Limerick.

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