1. Health Council of the Netherlands More than 100 years of scientific advice on public health issues

2. Growth of NVP in the Netherlands 2003Hepatitis B – children at risk 2006Pneumococcal disease 2002Meningococcal C infections 1993Haemophilus influenzae type b 1989Hepatitis B – mother HBsAg+ 1974Rubella 1987Mumps 1976Measles 1957Polio 1957Tetanus 1957Pertussis 1957Diphtheria

3. National Vaccination Programme (10-2006,*mother HBsAg+, & population at risk) MMRdTP9 Influenza (yearly)>65 aPdTP4 years MMRMenC14 PnDaPTPHib (HepB* & )11 PnDaPTPHib (HepB* & )4 PnDaPTPHib (HepB* & )3 PnDaPTPHib (HepB* & )2 HepB*0 months Injection 2Injection 1Age

4. Organization of NVP in the Netherlands Linkage to population register Embedded in neonatal care and infant welfare Voluntariness Recalls, outreaching activities High quality information and health education Continuous education of infant welfare workers

5. Organization of NVP in the Netherlands National Institute of Public Health (RIVM) –Runs the programme, information, evaluation of effectiveness, adverse effects Netherlands Vaccine Institute (NVI) –Produces or buys the vaccines Health Council (Gezondheidsraad, GR) –Independent, scientific advice

6. Vaccination coverage, Netherlands (Source: RIVM)

7. Committees of the Health Council Independent Based on scientific state-of-the-art Multidisciplinary, including ethical and legal aspects Personal membership, not representing organizations Disclosure Deliberations confidential, reports publicized Advisors from RIVM, Inspectorate, Ministry Hearings for social organizations, industry

8. Request for advice from the Minister of Health in response to report of National Institute of Public Health (RIVM, 2000) Need for new vaccinations in the NVP? Choice of specific (combinations of) vaccines with respect to side effects? Starting points and assumptions used for cost-utility analysis? Number of injections that can be administered at one visit (acceptability in the population)? Total number of vaccinations that can be safely given, risk of overburdening the immune system? Possibility or desirability to stop certain vaccinations now in the NVP?

9. NVP Review Committee Composition of NVP –Criteria for inclusion –Prioritization Risk perception and risk communication, health education Vaccination and maturation of the immune system (Th1/Th2; innate immune system)

10. Recent reports on NVP Universal vaccination against hepatitis B (2001) Programmatic vaccination of adults (2001) Universal vaccination against meningococcal serogroup C and pneumococcal disease (2001) Vaccination of children against hepatitis B (HBsAg+ mothers) (2003) Immunisation against tetanus (2003) Yearly reports on adverse events Pertussis (1997, 2000 and 2004) Pneumococcal vaccination (2005)

11. Purpose of NVP To protect the population and societal life against serious infectious diseases through vaccination Subtargets: 1.To eradicate or eliminate a certain disease 2.To reach and maintain herd immunity 3.To protect as many individuals as possible

12. Emphasis on children in current NVP 1. Children’s diseases are the diseases against which good immunity, also through vaccination, is possible 2. A NVP targeted at children offers the best chances of establishing a high vaccination coverage. A high coverage is important for establishing herd immunity

13. NVP is becoming a programme for infectious disease control at all ages 1. Children’s diseases become diseases of adolescents and adults (pertussis) 1. Long-term protection? (diphtheria, tetanus) 1. Vaccination in the elderly (influenza, zoster) 1. Vaccination against STD (HPV)

14. Criteria for inclusion of a vaccination in a public vaccination programme Disease burden 1. The infectious disease is serious for individuals and affects a sizeable group Effectiveness 1. Vaccination is effective in preventing disease or reducing symptoms 2. Adverse effects do not detract from the favourable health effects in considerable measure

15. Criteria for inclusion of a vaccination in a public vaccination programme Acceptability 1. The inconveniences of vaccination bear a proper proportion to the health effects to be gained 2. The inconveniences of the vaccination programme as a whole bear a proper proportion to the health effects to be gained Efficiency 1. The cost-effectiveness ratio is favourable to other means of prevention Urgency 1. Vaccination serves a (potentially) urgent public health problem

16. Example: vaccination against chickenpox in the Netherlands? Mostly seen as innocent, but 200 hospital admissions and 2.3 deaths/yr Vaccination aimed at all children Goal is to prevent complications Vaccines available: separate (one dose), MMRV (two doses) Linkage of epidemiology of chickenpox and shingles

17. Assessment of vaccination against chickenpox, Netherlands (ongoing) 1. Is c. serious for individuals and does it affect a sizeable group? 1. C. affects almost whole year classes, but is only rarely serious. Peaks at a relatively young age and incidence of complications relatively low compared to neighbouring countries. Incidence of complications could be underestimated in hospital discharge data.

18. Assessment of vaccination against chickenpox, Netherlands (ongoing) 1. Is vaccination effective in preventing disease or reducing symptoms? 2. Do adverse effects detract from the favourable health effects in considerable measure? 1. Yes, VE about 90% in studies abroad 1. Possibly: effects on shingles unclear, incidence might rise

19. Assessment of vaccination against chickenpox, Netherlands (ongoing) 1. Do inconveniences of vaccination bear a proper proportion to the health effects to be gained? 1. Do inconveniences of the vaccination programme as a whole bear a proper proportion to the health effects to be gained? 1. Not certain: inconveniences of one or two dose vaccination are limited, but health effects to gained probably as well 1. Not certain: inconveniences of extra jab are limited, but health effects to gained probably as well

20. Assessment of vaccination against chickenpox, Netherlands (ongoing) 1. Is the cost- effectiveness ratio favourable to other means of prevention (or no prevention)? 1. Does vaccination serve a (potentially) urgent public health problem? 1. Not certain: most of the benefits are less loss of productivity of the parents 1. C. is a mostly innocent disease; it is uncertain how vaccination will encroach upon the dynamic equilibrium with shingles; most parents don’t see a need for vaccination

21. Assessment of vaccination against chickenpox, Netherlands (ongoing) Assess underreporting of complications of chickenpox Possible influence on incidence of shingles will not become clear in short term Rather vaccinate against shingles? Reconsider vaccination against chickenpox for inclusion in NVP when new data on incidence of complications become available

22. The NVP put to the test All 15 current vaccinations meet the 7 criteria Of 23 candidate vaccinations: –No unqualified recommendation for extension of NVP right now –Reconsider within 2-3 yrs: shingles, chickenpox, rota, meningB, hepatitis B (all children), influenza (children, 50-65 yrs), HPV, RSV, CMV (hepatitis A?)

23. Topics of future advisory reports Future of the National Vaccination Programme BCG vaccination Influenza: children <2 yrs, 50-65 yrs, risk groups Hepatitis B vaccination (adolescents) Protection of young infants against pertussis Longer term NVP prospects

24. Statutory task "… to advise the government and the parliament on the current level of knowledge with respect to public health issues..." Health Act 1956, 1997

25. Present day fields Health care MTA Preven- tive medi- cine Envi- ron- mental health Eco- toxi- cology Occu- pationa l health Food & Nutri- tion Advisory Council on Health Research (RGO) MTA Preven- tive medi- cine Envi- ron- mental health Eco- toxi- cology Occu- pationa l health Food & Nutri- tion Health care

26. Structure President Vice-presidents (2) Members ~ 200 Standing committees (9): Review Work programme Standing committees (9): Review Work programme Standing committees (8): Review Work programme Autonomous ad hoc committees (~40): Advisory reports Autonomous ad hoc committees (~40): Advisory reports Autonomous ad hoc committees (~40): Advisory reports Secretariat: Exec. Director ~35 scientific staff ~35 adm. staff