Evaluation of the vaccination programs in France

The vaccine cover

There are various means to evaluate the programs of vaccination:
– exploitation in routine of certificates of health for the 2 year old children;
– periodic investigations by survey in educational circle;
– more punctually, of the local or national investigations are organized, generally by random sampling or cluster sampling;
– the study of the figures of sales of vaccines can also give an idea of the evolutionary tendencies of the vaccine cover. 

Methods evaluation

At the 2 years age
To the 2 years age, the vaccine cover is followed by the analysis of the certificates of 24 ^2nd month health . The certificate is filled for each child by the doctor during the obligatory examination of nourrisson before 2 years. This certificate comprises a heading vaccination in which all vaccinations carried out must be deferred. The expert carrying out the examination addresses this certificate duly filled to the doctor responsible for the departmental service with mother and infant welfare, under confidential and closed fold. The exploitation of the certificates of health is carried out in each department by the departmental services of SME which provide the results of them since 1985 to the ministry in charge of health by the means of the annual statistical form on health of the mother and the child. The national annual results are obtained by analysis of these forms by the Management of research, the studies, the evaluation and statistics (DREES).

Within the framework of the annual evaluation of the vaccine cover, is carried out to the exhaustive analysis of all the antigens mentioned on the 24 ^2nd month old certificates : DT 3 and 4 amounts, Cock 3 and 4 amounts, Polio 3 and 4 amounts, BCG, Measles and Rubella. The results are available by department.

Vaccinations against the mumps, hepatitis B, the infections with  Haemophilus influenzae  standard B are mentioned in light since the diffusion of the new health record in 1995 and the adaptation of the certificates to the new calendar of vaccination in 1996.
The results are available only eighteen months to two years afterwards.
Figures 1 and 2 summarize the results between 1985 and 2000 for vaccinations DTPolio and Rougeole- Rubella.

Figure 1:  Vaccine cover Diphteria, tetanus, poliomyelitis, children 24 months old, France, 1985-2000

Figure 2:  Vaccine cover Measles-Rubella, children 24 months old, France, 1985-2000

However, the figures obtained must be interpreted with precaution, because the interest of the 24 ^2nd month old certificates  is limited by three factors which affect the results: the quality of the filling of the certificate, the transmission circuit of the certificates and exploitation of the data in each department. Moreover, exhaustiveness is not complete: in 1999 for example, 740 083 births were declared. In 2000, 427 721 certificates of 24 ^2nd month health  were exploited, i.e. 57% of the awaited certificates. This same year, 83 on the 96 metropolitan departments transmitted their data to the national level.

One in addition has data of vaccine cover collected on the health records during medical check-ups in nursery school carried out by the services of SME and concerning the children from three to four years. The evaluation relates to the BCG, vaccination against measles, rubella and the mumps. The sample of children studied was 354 713 in 1999.
Certain departments proceeded to the study of the 24 ^2nd month old certificates  not received and/or not filled. This active search for additional information makes it possible to supplement the data.

Local investigations of validation, carrying in particular into the preschool childs, were led to residence in several departments. Information collected was validated by the health records. The sample includes/understands 210 children divided into thirty sites, (cluster sampling, method WHO) or 400 children selected on the lists of marital status. The major disadvantages of these investigations are related on the absenteeism of the residence in the first method and to the strong mobility of the families in the second.

Between 6 and 16 years

- Until 1999, at the 6 years age, an investigation was carried out in theory every two years (1985, 1987, 1989, 1991, 1993, 1996, 1999) in the children in last year of nursery school, by the doctors and nurses of national Education in charge of the promotion of health in favour of the pupils, at the time of the first school medical check-up. The sample of investigation consisted of schools public or deprived drawn with the fate which one studied all the 6 year old children. The sample size was calculated so that the results are representative at the national level, regional and departmental, with a minimum manpower of 100 children per department. The total staff complement was about 30 000 children. The base of survey was ordered to control the disparities between rural medium and urban environment. The analysis was carried out by the service of the statistics, the studies and the information systems of the ministry for Health (DREES). It related to the antigens measles, rubella, mumps (ROR) and, for the 2 last investigations, into the BCG, and gave information on the cover rates, like on the sources of vaccination, the antecedents of measles and the causes of nonvaccination at the time of the first investigations. The results were available at the end of the year following.

- From 2000, was set up a triennial cycle of investigations in educational circle coordinated by the ministry for employment and solidarity (DGS, DREES) and the ministry for national education, research and technology (DESCO, DPD) with like partner the medical Institute of day before. It is about a series of surveys carried out by the doctors and nurses of school health, near three generations of children resulting from the classes of great section of nursery school, middle prices 2 ^2nd  year (CM2) and of class of 3 ^2nd. The sample size is calculated so that the results are representative at the national and regional level. The investigation relates to a sample of approximately 250 pupils with academy, obtained by drawing of lots of a sample of establishments, then of a subsample of pupils within the selected establishments (by drawing of random lots of the pupils within the whole of manpower of the classes concerned). The total staff complement is about 7 000 children. The investigation relates to all the antigens of the vaccine calendar that the child should have received at this age.

- specific investigations were led to the departmental level, in the town of Paris in 1991, in Drôme and Indre and the Loire in 1993, in Guadeloupe in 1994, the Seine St Denis in 1999, Guyana in 2000. These studies are carried out in educational circle, the results obtained are limited to the population of the children provided education for in possession, the day of the investigation, of the documents attesting made vaccinations; they are able to be extrapolated apart from the population of study, neither with the local population children of the same age bracket, nor, of course, at the regional or national level.

In the teenagers of more than 16 years and the adults

The national vaccine cover counters the diphteria, tetanus and the poliomyelitis is known currently only thanks to the investigation into the living conditions Sesi-INSEE going back to 1989.
In 2000, a steering committee on the vaccine cover coordinated by InVS proposed several tracks of investigations as a population: thus, at the time of the decennial survey carried out by INSEE during the year 2002, questions concerning the vaccine cover of the old population of more than 16 years were associated. In the same way, survey SPS (Health social protection) carried out in 2002-2003 by the CREDES (, study and documentation Research center in economy of health) comprises a module on vaccinations of the old people of more than 16 years. Investigation SPS is carried out every 2 years into a sample of 20 000 people, representative of the population covered by the 3 principal insurance systems disease (general mode, agricultural social reciprocity and mode of the independent professions, are 95% of the general population) 

At the young recruits: a survey carried out in 1994 starting from 534 vaccine documents showed that the vaccine cover was higher than 90 % for the DTPolio antigens until the 6th amount (11-13 years) and about 75 % for the 7th amount (16-18 years). This fully justified the administration of a recall alone to the young recruits. The cover for coquelucheuse vaccination is high during the first two years of life, and 10 % received a recall at 6 years. Lastly, 96 % had received the BCG at the 6 years age.With the reform of the national service, this type of investigation will not be possible any more and the up to date handing-over of the vaccine statute will relate to only one limited number of young recruits.

Investigations in the whole of the population

National surveys into sample are carried out each year to evaluate the vaccine cover against the influenza, and until the end of 1998, against hepatitis B the vaccine cover against hepatitis B was studied each six-month period at the request of a producer by an institute of survey (medical Sofres), which sent a questionnaire requiring of information on the vaccine state with respect to hepatitis B, the prescriber, the vaccinator and the indications of vaccination. The sample was calculated to be representative by age brackets one year in the child and of 5-10 years in the adult, for a total of about 20000 families.
This method is also usually used to evaluate the vaccine cover against the influenza of the old people.
It was also used in 1998 to know the vaccine cover measles-rubella-mumps in the children from 0 to 15 years as well as the number of received amounts.
The major disadvantage of this type of investigation is its cost price and also an uncertainty on its precision: reason of –the non-responses, skew related to the family character of the sample. But its major advantage is that it gives results in real time almost.
Lastly, a manner of evaluating the evolution of the vaccine cover is to study the number of sold amounts (vaccine triples measles-rubella-mumps) or numbers it amounts refunded by the social security (influenza). If one cannot draw from these figures of the highly reliable percentages, one can nevertheless observe the tendencies.

Results

·         BCG
Vaccination BCG is managed, within the framework of the obligation to vaccinate all the children at the entry in community, to 83% of the 24 month old children, 93 % of the children of average section of nursery school (given DREES 2003 for the year 2000). 

·         DTPolio and Coqueluche
Associated vaccination DTPolio is managed with a great proportion of children as of 24 months: 98% received three amounts before the 2 years age, and 88% received three amounts and a recall. The coquelucheuse component is also received by respectively 97% per 3 amounts and 87% per three amounts and a recall (given DREES 2003 for the year 2000).
Estimates carried out on a departmental scale on the covers at 11 years show that in Paris, 91 % of the children received their 6 years recall in 1991 and, in Drôme, 97 % of children the 11 year old and 90 % of those 15 years are up to date of their tetanic vaccination in 1993.
On the other hand, at the adulthood and at the old people, protection is insufficient: 70 % of the men of 18-20 years are vaccinated since less than five years, against 67 % of the women. 20 % of the men of 60-69 years had a recall since less than five years; less than 15 % of the 70-79 years and 6 % only of more than 80 years.
On the whole, ten million adults would never have been vaccinated against tetanus, in particular the reprocessed farmers, workmen, tradesmen and craftsmen.
At the time of a survey carried out in 1988-1989, 94 % of the 20 year old adults declared antecedents of vaccination, 80 % of the 40 year old adults, 36 % of those 50 years and less than 10 % of those 70 years. Only 35 % of vaccinated received a recall since less than five years. These rates are weak in comparison with the recommendations of the calendar of vaccinations. 

·         Measles-Rubella-mumps
The vaccine cover with respect to measles, rubella and the mumps, is for 2000 of 84% for in 24 months. In middle class of nursery school, it reaches for the 3 antigens 91% (data DREES 2003 for the year 2000).
A study carried out on a sample of the population of the children with 6 and 15 years in January 1998 shows that the administration of the second amount did not concern whereas approximately 20 % of them. The studies of vaccine cover in progress and to come in CM2 will make it possible to follow the evolution of the cover by the second amount. 

·         Hepatitis B
The cover of the children of less than 2 years is 26% (data DREES 2003 for the year 2000).
At the end of 1998, the last estimate of the vaccine cover with respect to hepatitis B by institute of survey showed the following results: 36 % for the children from 0 to 12 years, with an increase by 88 % from 13 to 15 years and 84 % between 16 and 20 years, then a decrease, 62 % between 21 and 24 years, 39 % between 25 and 34 years, 27 % between 35 and 44 years, 20 % between 45 and 54 years and 10 % with the 55 year old top.

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