01.01.2014 How is vaccination dealt with in Switzerland's prevention activities?

Lead article. Vaccinations are incontestably among the most effective means of prevention in the healthcare sector. Their history goes back a long way – but has very recent chapters as well.

Pictures How is vaccination dealt with in Switzerland's prevention activities?

TODO CHRISTIAN

The idea of protecting people against a fatal disease by inoculating a harmless form of the causative agent dates back as far as the seventh century, when Buddhists in India were already drinking snake venom to achieve immunity against snake bites. The immunisation technique of variolation is mentioned in Chinese documents dating from the tenth century and was also used in 16th century India. It involved the application of dried pus from smallpox pustules to scratches made on the skin. This form of inoculation was also practised in large parts of Turkey, from where it was exported to England in 1721. It was helpful in reducing the harmfulness of smallpox in the event of infection. But it was not risk-free – two to three per cent of patients thus treated died of the smallpox that had been inoculated into them by variolation. At the end of the 18th century, cattle breeders in Britain observed that people who had contracted cowpox – a disease that is harmless in human beings – were immune to smallpox. One of these farmers had inoculated members of his family with cowpox twenty years before the British physician Edward Jenner published his 1798 studies describing how this benign infection was able to provide protection against the frequently fatal smallpox (which had a mortality rate of 30 to 96%, depending on the strain). Variolation with cowpox could be transferred from person to person, in order to protect additional people. But it was not without risks as other infections such as syphilis were occasionally transmitted as well. A standardised serum was eventually produced, and regularly used from 1890 on. It was made with material obtained from deliberately infected cows and was treated to eliminate any bacteria. This development constituted the actual birth of the first vaccine.

Breakthrough of modern vaccination
Relatively few new vaccines were produced in the 19th century. The method developed by Pasteur was originally intended to target animal diseases (fowl cholera, anthrax and rabies) and was predicated on reducing the virulence of the causative agents. In 1885 there was some resistance to the use of attenuated rabies virus in children who had been bitten by rabid dogs. If a child died, its death was not infrequently blamed on the vaccine rather than the fatal disease. But hundreds of lives were saved. In the meantime, the principle of vaccines employing killed microbes was discovered in the United States, enabling vaccines to be developed against typhus, cholera and plague.
In the 20th century, vaccines were developed against at least 20 other diseases – for instance diphtheria (1923) and tetanus (1926) – using inactivated bacterial toxin. In the second half of the 20th century, not only did development methods change significantly, in parallel with a greater understanding of immune response mechanisms, with the culturing of viruses, molecular biology and genetic engineering, but there was also considerable improvement in the scale of clinical studies, in standards of production quality and in safety monitoring.

An international success story
The implementation of large-scale vaccination programmes had an enormous and well documented effect on mortality and morbidity. Good examples include the programme against diphtheria in Canada in the 1920s, and the eradication of smallpox in 1980, which resulted in the cessation of routine smallpox vaccination. The WHO's "Expanded Programme on Immunisation", established in 1974, resulted in a decline in the number of worldwide cases of diph­theria from a million to fewer than 10,000. Average global vaccination coverage was 81 per cent for three doses administered by the age of one. On the other hand, the discontinuation or interruption of vaccination programmes regularly triggered a resurgence of the disease and fatalities, which goes to show how effective and useful vaccinations are. Such setbacks were caused by political unrest, for instance, or by loss of public confidence due to claims of serious side effects (whooping cough in Japan, 1975; measles in the United Kingdom, 1998) or even to suspicion of nefarious intent (poliomyelitis in Nigeria).
The effect of vaccinations extends beyond protection of the individuals who are vaccinated, when thanks to their immunity, they form a barrier to the spread of the causative agent, and therefore also protect non-vaccinated people or those in whom the vaccine is not effective.

Vaccinations in Switzerland: cooperation among different partners
In Switzerland, authorisation of vaccines and monitoring of adverse reactions are the responsibility of Swissmedic, the Swiss Agency for Therapeutic Products. The Federal Office of Public Health (FOPH) is responsible for issuing recommendations on vaccinations. These recommendations are summarised in the annual National Immunisation Schedule and, in cooperation with the Federal Commission on Vaccination Issues, continually updated to take the latest findings into account. Vaccinations are recommended on the basis of the anticipated benefit to the health of the community as a whole as well as that of individuals. They are divided into three categories. The recommended basic vaccinations are considered essential for individual wellbeing and public health. The recommended supplementary vaccinations are recommended for people who want to an optimal protection against well defined risks. The third category comprises vaccinations recommended for people with a high risk of exposure, transmission or complications. The costs incurred by recommended vaccinations are generally reimbursed by the recipient’s compulsory health insurance cover. This occurs in compliance with the conditions laid down in the Speciality List and the Ordinance of the FDHA on Services Covered by Compulsory Health Insurance, after each one has been assessed by the Federal Medicines Commission and the Federal Commission for General Ser­vices and Key Issues.

Working together to obtain better vaccination coverage rates
The cantons are responsible for implementing measures to achieve public health objectives. For instance, together with school medical services they organise information, checking of vaccination cards and, if necessary, vaccinations in schools. Vaccinations are performed either by physicians themselves or under their responsibility in domiciliary practices and in the framework of the public health service. As a result, broad and easy access is ensured. All members of the healthcare professions make a contribution in accordance with their professional responsibilities. Vaccination measures are evaluated jointly by the FOPH and the cantons. This occurs in the form of studies of the vaccination coverage rate and through mandatory reports of vaccine preventable diseases, and the mandatory adverse event reports that are collected by pharmaco­vigilance centres and analysed by Swissmedic.

High level of acceptance, but still room for improvement
The recommended basic vaccinations generally enjoy a very high level of acceptance in Switzerland: 95 to 96 per cent of children aged two have received three doses of the vaccine against diphtheria, tetanus, whooping cough (pertussis), poliomyelitis (infantile paralysis) and Haemophilus influenzae b (Hib). Certain vaccinations or boosters, however, are affected by delays and shortcomings: at two years of age, only 88 per cent of children have received their fourth dose of the above vaccine and only 86 per cent have received the two doses of the vaccine against measles, mumps and rubella (German measles) that are recommended between the 15th to the 24th month of life. At eight years of age, 95 per cent have received their fourth dose of DPT (diphtheria, pertussis, tetanus) vaccine, but only 80 per cent have also received the fifth dose that is recommended for four to seven year olds. At 16 years of age, 95 per cent have received at least one dose of the anti-measles vaccine, but only 88 per cent have been given the second dose. Hepatitis B vaccination of young people is on target at an average of 70 per cent, but this is not the case with the HPV (human papilloma virus) vaccination of girls that protects against the risk of developing cervical cancer. The aim here is to achieve a vaccination coverage of 80 per cent, but in fact only about 54 per cent of girls are currently vaccinated. There is therefore room for improvement.

Vaccination info box

The Federal Office of Public Health's website offers a wide range of information material on vaccinations:
www.sichimpfen.ch

You will find everything you need to know about measles and vaccination here:
www.stopmasern.ch/

The InfoVac website is an independent information service for questions about vaccination:
www.infovac.ch/

You can create your own electronic vaccination record on the following website:
www.meineimpfungen.ch/

The Federal Vaccination Commission (EKIF/CFV) has drawn up fact sheets on the subject of vaccination that can be downloaded from the following website:
www.bag.admin.ch/themen/medizin/00682/00685/03212/index.html?lang=de

Several vaccination-related flyers, brochures and fact sheets can be ordered free of charge at the Federal Publications Shop.
www.b2cshop.admin.ch/cshop_bbl/b2c/start.do

Contact

Virginie Masserey, Head of the Vaccination Programmes and Control Measures Section, virginie.masserey@bag.admin.ch

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