Immunisation is one of the most effective ways to improve public health next to clean drinking water. While smallpox has been eradicated through immunization, other infectious diseases remain threats. The only way to protect against avoidable death and complications from diseases is through high immunization rates in the population. Barnet faces the risk of a measles epidemic as immunization rates, particularly for MMR, have fallen below the required safety levels. Key activities to increase rates include improving record accuracy, strengthening reminder systems, providing immunizations in various community locations, and promoting immunization through community leaders and education.

1. Immunisation
Immunisation is second only to a clean drinking water supply as a way of improving and
maintaining the health of the population. Whilst smallpox has been eradicated from the world,
by immunisation, all other infectious diseases remain. The only way to protect children and
adults from avoidable death and serious, often long-term, complications from such diseases is
to maintain high levels of immunisation in the population.1
The risk we face
Barnet, in common with all other London boroughs, now faces the likelihood of a measles
epidemic. In the last year or so the number of children and adults catching measles – the most
contagious disease that there is – has been much higher than in past years and there have
been several outbreaks, as shown in . Figure 1
Figure 2: The number of reported cases of measles in Barnet in recent years
90
80
70
The 60
50
40
30
20
10
0
2005/06 2006/07 2007/08
reasons for the alarming increase in people catching measles in Barnet are outlined below
demonstrating that MMR immunisation rates in Barnet are substantially below the level required
for safety.
The reason that so many people have caught measles and the fact that we now face the very
real risk of a measles epidemic is because there are now so many children whose parents have
refused consent for them to be 1mmunizat with measles, mumps and rubella vaccine. The
‘herd immunity’ of the population is now sufficiently low to enable each person with measles to
infect more than one other person. The problem of measles is more widespread in other parts
of London, as shown below.
1
The main exception to this is TB. Whilst BCG vaccine is an important way to protect people most at risk the way this disease
affects the population has changed.

2. Source: Health Protection Agency. Measles and MMR uptake in London, 2008 Cover data and trends in vaccine
uptake 2005-2008
MMR uptake at age 2 years for London and UK – January 1996 – March 2008* signify that
immunisation rates are beginning to decline significantly
.

3. 95.0
90.0
85.0
80.0
75.0
% 70.0
65.0
60.0
55.0
Hib primary MenC
DTP/Polio primary
50.0
MMR 2nd dose DTaP/IPV booster
MMR 1st dose
45.0
Q3 05/06 Q4 05/06 Q1 06/07 Q2 06/07 Q3 06/07 Q4 06/07 Q1 07/08 Q2 07/08 Q3 07/08 Q4 07/08 Q1 08/09
Quarter in each year
Immunisation rates in children in Barnet for:
first course of diphtheria, tetanus, pertussis and polio;

first dose of Haemophilus influenzae B;

meningococcus C;

first dose of measles, mumps and rubella (MMR);

second dose of MMR; and

diphtheria, tetanus and pertussis and inactivated polio booster.

This shows clearly that MMR 3mmunization rates in Barnet are very substantially below the level
required for safety, i.e. to avoid measles outbreaks and to avoid a measles epidemic, although they are
beginning to increase
Local targets
In common with other London PCTs, Barnet has agreed to increase all of its childhood
immunisations to 90% by 2010/2011. The trajectory for immunisation rates for MMR by the age
of two years shows the trajectory for MMR, which is the most challenging as all other childhood
immunisation rates are currently in the high eighties and thus closer to the target.
The trajectory for immunisation rates for MMR by the age of two years
Proportion (%) of 2-year olds with first MMR immunisation
actual estimate trajectory
100
90
90
80
77
75.6 76.4
80 74.5
73.9
70
60
50
40
30
20
10
0
2004_05 2005_06 2006_07 2007_08 2008_09 2009_10 2010_2011

4. Source: Barnet PCT Operating Plan
The key activities required are:
• ensuring the accuracy of immunisation records – it is apparent that a lot of children have
been immunised but the fact has not been recorded on the PCT’s child health surveillance
system;
• bolstering the immunisation call system to ensure that all children who need immunisation
(because it is due or have, apparently, been missed) are invited for immunisation;
• providing immunisations in various sites, e.g. GP surgeries, community pharmacies, A&E
departments, walk-in centres, children’s centres, children’s outpatient departments;
• promoting immunisation widely, using social marketing techniques, to better ensure that the
right message is received; and
• working with local community and religious leaders, and in schools, pre-school facilities,
children’s centres, NHS facilities and other places to promote immunisation.
Data on ethnicity and religious belief are not currently routinely recorded in the context of
childhood immunisation. However, it is apparent that in the North East and North central
London area, the majority of people affected by measles have been Jewish. The reasons for
this need to be explored further.

5. Jewish
White: British
White: Eastern European
Black: African
White: Irish
Any Other ethnic group
White: Other
Asian: Bangladeshi
Black: Caribbean
Mixed: Other Mixed
Asian: Indian
Asian: Other
Chinese
Not known
Mixed: White & Black African
Mixed: White & Asian
Black: Other
Asian: Pakistani
0 50 100 150 200 250 300
Number of reported measles cases
Teenage pregnancy
Barnet has one of the lowest rates of teenage pregnancy (TP) in London, and this is also lower
than similar boroughs (including those matched for deprivation) such as Merton, Hounslow and
Enfield. Not only is it lower than the London average, but it is also lower than the national
average. The graph below summarises the his trend and the comparison between Barnet,
London and England.
Approximately 68% of teenagers who conceived in Barnet in 2006 had a termination of
pregnancy (TOP), the remainder having had either a live or still birth. Data on the residential
postcodes of all TOPs performed by Marie Stopes, the PCT’s main provider of abortion
services, on women in Barnet aged under 18 years show that 15.2% of teenage abortions were
performed on young women who had had at least one previous TOP. Teenagers who have had
one TOP are a high risk group for further unplanned pregnancy.

6. Under 18 conception rate per 1000
10
20
30
40
50
60
0
March
June
1998
Sept
Dec
March
June
1999
Sept
Dec
London
England
March
June
2000
Sept
Dec
Barnet rolling average
March
June
2001
Sept
Dec
March
June
2002
Sept
Dec
March
June
2003
Sept
Dec
March
June
2004
Sept
Dec
March
June
2005
Sept
Dec
March
June
2006
Sept
Dec
March
2007
June

7. Quarterly rate
45
Rolling average
40
Under 18 conception rate per 1000
35
30
25
20
15
10
5
0
March
March
March
March
March
March
March
March
March
March
Sept
Sept
Sept
Sept
Sept
June
June
June
June
June
Sept
Sept
Sept
Sept
Dec
Dec
June
June
Dec
June
Dec
June
Dec
June
Dec
Dec
Dec
Dec
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Sexual health
Sexual health is an important aspect of physical and mental well-being. Poor sexual health can
have a long-lasting and severe impact on people’s lives, for example through unintended
pregnancies and abortions causing physical disease and poor educational, social and
economic opportunities; Sexually transmitted infections (STIs) and HIV/AIDS; ectopic
pregnancies leading to infertility; cervical and other genital cancers; and hepatitis, chronic liver
disease and liver cancer.
The risk we face
Sexually transmitted infections
Nationally, diagnoses of sexually transmitted infections (STIs) have been steadily rising in the
UK since 2001. The most recent Health Protection Agency (HPA) data indicate that this trend is
continuing: between 2005 and 2006 there was a 2% rise in both new diagnoses and total
numbers of STIs (recurrent and follow-up presentations) in genito-urinary medicine (GUM)
clinics. The overall increase in STIs masks a more complicated picture for specific infections
and in specific age and other risk groups.i
The incidence of Genital Chlamydia, Gonorrhoea and other STI’s are explored further in
Appendix 8.

8. The true incidence of STIs in Barnet is not known, since figures on the numbers of people with
a STI are rarely presented on the basis of a person’s residence. Most data are reported at
GUM clinic level, but since these clinics see people regardless of their place of residence,
figures from clinics include diagnoses made on people living outside of the ‘host’ PCT area
where the clinic is situated. Data can also be distorted when the place of residence of a patient
attending a clinic is unknown and this varies between GUM clinics. Appendix 8 discusses the
GUM clinics most likely to be attended by Barnet residents and the types of STI’s which are
presented at the GUM clinics.
Although local GUM clinic data are a poor indication of the local incidence and prevalence of
STI, they do give a reasonable idea of trends and these continue to rise in Barnet, as
elsewhere.
HIV/AIDS
The number of people in Barnet known to have HIV infection has increased steadily since
2002. Appendix 8 contains data showing this increase, as well as the ethnicity and age of
HIV/AIDS patients
In common with many other areas, HIV is more common in people in Black African and African
Caribbean ethnic groups. However, unlike most of the other PCTs in the north central part of
London, especially the inner-city ones, HIV infection is becoming increasingly common in Black
women in Barnet rather than in the Black MSM group. It is possible that the male partners of
many of these women contract the infection abroad. But the important point is that it is
heterosexual transmission of HIV that is becoming a larger issue that it is in MSM in Barnet. In
2005, 132/504 (26.2%) of known cases of HIV in Barnet were in MSM, 316/504 (62.7%) were in
heterosexual men or women, 26/504 (5.2%) were acquired by mother-to-child transmission,
and the remainder were acquired through other or unknown means.
Abortion services
In terms of access to abortion services for all women of child-bearing age, there were 2444
TOPs performed on Barnet residents in 2006. This is above the national average rate and
probably reflects either better access to termination services or lack of access to contraception
services. As Barnet has such a low number of teenage conceptions (which include abortions as
well as births) relative to most other PCTs in London, this latter possible explanation is unlikely.
1.0.1 The relationship between diversity and deprivation and sexual health problems
There is a clear relationship between rates of sexual ill-health, poverty and social exclusion.
Certain groups are particularly at risk of poor sexual health, including:
young people, especially those in, or leaving, care;

people from Black and ethnic minority groups;

gay and bisexual men;

injecting-drug users;

adults and children living with HIV and other people affected by HIV;

sex workers; and

people in prisons and youth offending establishment.


9. People in these groups are not only more likely to engage in sexually risky behaviour, but will
often make only poor use of existing services and are therefore hard to reach.ii
Ethnicity is relevant to the planning of sexual health services in several ways. First, certain
communities are more likely to experience a high incidence of specific STIs, for example HIV is
much more common in the Black African community, and the majority of women with HIV in
Barnet are from this community. Secondly, services may need to be modified so that that can
be made religiously and/or culturally acceptable to certain communities, for example sex and
relationships education (SRE) programmes for young people from certain orthodox Jewish and
Islamic communities. Thirdly, cultural values and ethnicity may affect health beliefs and
behaviours and health-seeking activities and can be important influences on health and well-
being. There is limited evidence on this issue, but for instance there is some indication that
men from the Black African community are less likely to attend GUM clinics.iii,iv,v
Knowing people’s ethnicity is also important in terms of designing services: there is evidence
that many people from the African community are uncomfortable visiting GUM clinics, and that
in this community a different approach is needed. Since in general sexually active women of all
communities are more likely to attend health services, increasing testing in these settings is an
important method for increasing uptake of HIV screening in women, for example in antenatal or
family planning clinics. For men, however, a more community-orientated approach is most likely
to achieve results.
In terms of age and general sexual health services, the greatest numbers of people seen in the
main GUM clinics serving Barnet’s population are aged 15-35 years (77% of attendees) and
60% of attendees are women.
1.0.2 Local targets
There are two main targets. The first is to screen people aged 15-24 years for genital
Chlamydia infection. The target for 2008/09 is to screen 6,699 people.
The other main target is to reduce the number of teenage pregnancies. The trajectory for this is
shown in Figure 2.
Figure 2: Teenage pregnancy rates in Barnet – current and future trajectory
actual estimate trajectory
Conception rate per 1,000 females aged 15-17
35
30
25
20
168 149
167
15
10
131 107 84
5
0
2005 2006 2007 2008 2009 2010
1.0.3 Key things that need to be done
The key activities required are:

10. increasing the provision of sexual health services in GP practices;

increasing the number of young people screened for genital Chlamydia infection; and

ensuring that all sexual health services (including sexual health promotion and sexual

relationship education) are designed to enable access by people from different ethnic and
religious backgrounds.
1.0.4 Key things that need to be done
The key activities required are:
enabling more people with mental health problems to give up smoking;

identifying and acting on any common factors that there may be in people who are

currently receiving or who have recently received care from mental health services and
who attempt or succeed in killing themselves;
10mmunizatio that there will be an increased need for services to care for people with

dementia in the coming years.
1.0.5 Over the next few years, in terms of health services, Barnet needs to:
.


11. i
HPA (2007). Testing Times - HIV and other Sexually Transmitted Infections in the United Kingdom: 2007
London: Health Protection Agency, Centre for Infections. November 2007.
ii
Downing J, Jones L, Cook PA et al (2006) Prevention of sexually transmitted infections (STIs): a review of
reviews into the effectiveness of non-clinical interventions. Evidence Briefing Update. London: National
Institute for Health and Clinical Evidence.
iii
National Survey of Sexual Attitudes and Lifestyles II, National Centre for Social Research
iv
Sadler KE, McGarrigle CA, Elam G et al (2007) Sexual behaviour and HIV infection in black-Africans in
England: results from the Mayisha II survey of sexual attitudes and lifestyles. Sexually Transmitted Infections
2007;83:523-529.
v
Fenton KA et al. Ethnic variations in sexual behaviour in Great Britain and risk of sexually transmitted
infections: a probability survey. The Lancet 365: 1246 - 1255, 2005.