Public Health
(1990), 104, 267-274
© The Society of Public Health, 1990
Improving Immunisation Uptake in the United Kingdom D. N. Baxter
University of Manchester, Department of Community Medicine
Reasons for the non-uptake of vaccination are discussed and proposals to remedy them are considered. It is believed that the proposals outlined in the paper will be as effective in improving vaccine uptake as legislation which has worked well in other cotmtries (e.g. Hungary and the USA). Introduction
In most developed countries, public and professional interest in infectious diseases has declined during the 20th century. This lack o f concern arises from the perception that there is only minimal risk from these diseases and is based on their falling mortality rates. Although such a view is partly correct, it neglects both the potential for transmission and the current incidence o f infection which for some conditions are not inconsiderable. In the U K during 1984 for example, there were just over 60,000 notifications o f measles and 5,500 o f whooping cough (pertussis); in epidemic years the figures might be as high as 100,000 and 60,000 respectively. Numbers alone, however, do not convey the full impact o f these diseases: despite its relatively mild reputation, measles can lead to middle ear damage, bronchopneumonia, encephalitis with permanent brain damage, sub-acute sclerosing panencephalitis and death. Pertussis may result in a prolonged debilitating illness and in more severe attacks, complications such as bronchopneumonia, bronchiectasis, brain damage and death are well recognised. General control measures for infectious diseases include improvements in nutrition, supply o f potable water, safe disposal o f sewage, high levels o f personal hygiene, provision o f adequate housing and effective health education. Specific activities (where appropriate) require immunisation of susceptibles, isolation o f infective sources, control o f vectors and early treatment o f cases. This paper will focus on the use of immunisation. In 1984 the global estimate was that 3,450,000 children died o f infections which were preventable by immunisation: o f these just over 2,000,000 resulted from measles, 803,000 from tetanus, 606,000 from pertussis and 265,000 from polio. 1 Relevant data for England and Wales during the same period are shown in Table I. lmmunisation Rates
Trends in the coverage o f vaccination for Health Regions in England between 1974 and 1984 are shown in Table IIa. With only two exceptions rates in each Region increased over the 10 year period. F o r two-year-old children born in 1984, the estimated overall uptake o f diphtheria, tetanus and polio was 85%; 67% for pertussis, and 71% for measles; the lower correspondence to: Dr D. Baxter, University of Manchester, Department of Community Medicine, Stopford Building, Oxford Road, Manchester MI3 9PT.
268 Table I
D. N. Baxter
Notifications and deaths for selected infectious diseases in England & Wales for 1984 Total
Measles Pertussis Tetanus Diphtheria
Notifications Rate per 100,000 population
62,080 5,517 6 4
124 11 0.01 0.008
Total
Deaths Rate per 1,000 notifications
10 1 3 0
0.2 0.2 500 0
Source: OPCS Series MB2 No. 12 (1985).2
limit was 77% for polio, tetanus and diphtheria, 57% for pertussis and 62% for measles. Variation in uptake both between and within Health Districts (see Tables IIb and IIc) may be just as great as between Regions: an observation that is important in predicting the impact and spread of specified infectious diseases. Some initial caution must be expressed about the reliability of the information on which Tables I I a - c are based, since a preliminary study comparing immunisation data in paired child health and computer records showed a discrepancy o f just over 12% (involving both antigens given/not and demographic information). 6 A larger study is currently being undertaken to assess if the problem is more widespread. Such a level o f inaccuracy (if confirmed) would have considerable implications both locally and nationally for: Use o f immunisation uptake rates as health status indicators; Targeting services to improve overall district uptake; Selective immunisation in the event o f disease outbreaks.
Table Ila
Vaccination and immunisation acceptance rates at 2 years for children born in specified years by Regional Health Authority Pertussis 1974 1984
Northern Yorkshire Trent East Anglia North West Thames North East Thames South East Thames South West Thames Wessex Oxford South Western West Midlands Mersey North Western England
31 42 45 48 38 41 34 40 36 58 42 33 34 30 38
Source: Personal communication (1987).3
66 68 71 72 69 61 68 72 74 74 70 63 57 58 67
Measles 1974 1984 47 46 54 59 44 43 37 49 69 75 62 39 32 35 47
75 75 76 77 71 62 66 72 81 78 78 67 66 66 71
Polio 1974
1984
69 70 76 81 73 84 66 79 85 91 80 73 64 68 75
85 85 88 87 85 77 84 85 91 88 89 82 80 83 85
Improving Immunisation Uptake Table lib
269
Vaccination and immunisation acceptance rates at 2 years for children born in 1984 by Health District: North Western Regional Health Authority
Lancaster Blackpool Preston Blackburn Burnley West Lancs Chorley Bolton Bury North Manchester Cent. Manchester South Manchester Oldham Rochdale Salford Stockport Tameside Trafford Wigan
Diphtheria %
Tetanus %
Pertussis %
Polio %
Measles %
92.1 85.5 65.8 77.3 84.4 96.4 83.3 89.6 91.4 78.4 84.4 81.4 88.5 86.4 81.8 92.6 87.6 94.2 89.5
92.3 85.4 65.9 77.2 84.1 96.1 83.4 89.6 91.4 78.4 84.3 81.4 88.5 86.5 81.9 92.6 87.6 94.2 89.5
74.4 55.3 53.2 60.1 57.4 61.0 64.1 59.9 63.8 52.2 56.1 53.0 57.9 59.4 52.4 65.1 61.7 68.9 62.3
92.2 85.1 65.2 75.4 82.8 95.6 82.9 89.5 91.6 78.8 84.5 81.2 88.4 86.3 81.6 92.5 87.5 94.3 89.7
76.6 58.7 53.4 54.6 60.3 68.8 60.8 76.5 77.8 62.8 63.9 53.9 65.6 71.4 59.5 74.2 74.1 78.5 76.0
Source: Comparative Statistics t986, North Western Regional Health Authority (1987).4
Since uptake figures are valid health status indicators, District Health Authorities (DHAs) should be encouraged to develop accurate monitoring systems. Stockport D H A has created an immunisation database, using D Base III P L U S 7 and Clipper 8 software which runs on an IBM compatible PC and is presently being evaluated. The immediate impressions are that a district-based system has a number o f advantages over the existing Regional set-up. W H O has declared 1990 the year when all children will be immunised and it is clearly evident (even with the above reservations) that in the U K considerable progress will have to be made in order to achieve these targets. This paper seeks to identify the reasons for low uptake and put forward strategies by which they may be overcome. These observations are based on experiences gained as Immunisation Co-ordinator for Stockport D H A . Some problems are c o m m o n to all the immunisation services and will be considered first: others are related more to knowledge or particular vaccines, and discussed later. (a) Service factors Services that are not readily accessible deter a number o f parents. Where this is due to inconvenient clinic times some improvement might result if they were to be extended or rescheduled. In Stockport, immunisation sessions are held either in the morning or the early afternoon and this inevitably causes difficulty for some working parents. Although evening clinics m a y lead to problems (e.g. o f security) their use should be explored and evaluated. Accessibility might be less o f a problem where general practitioners offer immunisation
D. N. Baxter
270 Table IIc
Vaccination and immunisation acceptance rates at 2 years for children born in 1984--for Stockport DHA
Ward name Stockport DHA
Polio %
Measles %
Diphtheria %
Pertussis %
Tetanus %
Brinnington Manor Great Moor Davenport Cale Green Edgeley Heaton Mersey Heaton Moor North Reddish Romiley Bredbury Heald Green Cheadle Cheadle Hulme South Cheadle Hulme North Hazel Grove East Bramhall West Bramhall North Marple South Marple South Reddish
81.4 94.7 91.6 90.7 88.4 88.5 94.9 95.8 91.6 85.5 93.5 92.9 96.1
55.3 76.7 66.5 77.5 66.3 63.5 76.4 80 62.8 66.4 79.6 81.2 81.1
81.4 94 91 91.4 88.4 88 94.9 95.8 91.6 86.3 93.5 92.9 96.1
46.8 60.7 61.1 65.6 50 50 66.3 61.7 58.1 58 65.6 64.3 74.8
81.4 94 91 91.4 88.4 88 94.9 95.8 91.6 86.3 93.5 92.9 96.1
99.2
80.3
99.2
72
99.2
96.9 95.2 94.3 98.6 96.2 92.5 87.3
85.1 78.8 81.3 85.9 82.7 80.8 59.9
96.9 95.7 94.8 99.3 97 92.5 88.3
72 71.9 77.1 83.8 75.2 73.3 51.8
96.9 95.7 94.8 99.3 97 92.5 88.3
Source: National Child Health System Wardtape (1986).5
both in special clinics and during regular surgeries. Adequate back-up should be available for parents in the event o f the child experiencing an immunisation reaction. Problems o f physical access (e.g. poor transport, isolated clinics or long travel times) m a y result in low uptake. The response in Stockport has been to provide a limited domiciliary service for some parents identified by the health visitor. The author's experience has been that the service is o f considerable value, but not cost effective as presently organised: ideally general practitioners or immunisation-trained health visitors and practice nurses should undertake this function (as already happens in some DHAs). Critics would argue that such a proposed system is open to abuse, but so is the present o n e - - i n the majority o f domiciliary immunisations I carry out, the health visitor has called to arrange clinic appointments six or seven times at least before my visit. Use o f the approaches outlined in this article should prevent the emergence o f a 'domiciliary-based service'. I also believe (albeit based on personal experiences in developing countries) that high profile outreach programmes taken into defined areas o f low uptake, would ease accessibility problems: operating from community centres or mobile clinics, such services are cost-effective9 and raise uptake rates) ° Domiciliary immunisations reinforce the need for an effective cold chain since the reduced immunogenicity o f inappropriately stored vaccines has been clearly demonstrated.
Improving Immunisation Uptake
271
It is essential that one person be given responsibility for storage and distribution o f vaccines in a health centre or G P surgery. Training in cold chain management should be provided in all health districts: we currently use a training manual developed by W H O for its own expanded immunisation programme. H The present arrangements for service delivery lead to confusion for some parents as to who is providing the service, and where they should take their baby for immunisation: this may well become more important in certain districts as changing priorities and financial arrangements for Primary Health Care (PHC) mean that General Practitioners are more directly involved in immunisation programmes. Problems can arise where P H C and the D H A duplicate immunisation services. Failure to co-ordinate such activities leads to the confusion identified above: in addition it is an inefficient use of limited resources and can generate conflict between professionals. As services are relocated, continuous monitoring o f both uptake rates and consumer satisfaction is essential. It may be better to concentrate D H A services in areas of low uptake and/or where an inadequate immunisation service is provided by the P H C team. (b) Parentalfactors Lack o f knowledge about the disease and/or vaccine may be a problem for a number of parents. They may also be given conflicting advice (especially for measles and pertussis) by professionals because of the latter's ignorance or reluctance to use particular vaccines (see section c). It is important to give parents all relevant information so that a reasoned decision can be made. The discussion should cover disease severity and individual susceptibility, together with vaccine toxicity and efficacy. Clear recommendations should be given: unequivocal advice doesn't deny parental choice, but states what the health professional (with more knowledge usually) would do in those circumstances. Such an approach allows more informed decision-making and is preferable to the c o m m o n (but inconsistent) practice o f saying ' o f course your child should have diphtheria, tetanus and polio, but the decision regarding measles and pertussis is yours'. One reason for this practice is the fear o f litigation which influences many health professionals. Given that legal action usually arises from the need to fund lifelong care for handicapped children and that the value of immunisation clearly extends beyond the vaccinated individual, adequate provision should be made for these children without their having to resort to lengthy and costly litigation. No-fault compensation does not imply an acceptance that vaccination has caused the damage, rather it reflects the importance o f living in a society with the highest possible vaccine uptake rates. In addition, some parents are unaware o f either the recommended schedule of immunisations, or what immunisations their children have, or should receive. These problems have been addressed in Stockport by sending parents the immunisation history cards o f their two-year-old children, together with comments as to what further immunisations (if any) are needed: this service has only just started and is as yet unevaluated. (c) Professionalfactors Some workers lack good interpersonal skills and are p o o r communicators. Appropriate training should be provided for all health professionals since their attitude and behaviour has a major influence on parental decision making? 2 A number of studies have identified lack o f knowledge among health professionals (HPs)
272
D. N. Baxter
as a major problem. 12-~6This may lead to varying and inconsistent advice which is a source of confusion for some parents. Conflicting advice may also be given when health professionals have pre-determined negative views about the use o f (particular) immunisations in any circumstances. Whilst respect for clinical freedom is important it is necessary to decide whether this should allow professionals to determine their own policy when contrary to (majority) expert advice and government policy. Health workers must know about vaccine properties, side effects and contra-indications. They should be able to assess the benefit-risk ratio o f any immunisation for a particular individual using clear and unambiguous criteria: the new DHSS guidelines ~7 should more adequately fulfill these criteria although inconsistencies between them and the manufacturers' advice notes are a source o f continuing confusion. In Stockport national guidelines are supplemented with a weekly referral immunisation clinic where specialist advice is available to any H P (or parent). It is essential that the process o f referral does not raise doubts or worries in parents' minds: unnecessary referrals should reduce as local education and training programmes become more established. As an additional measure our staff are encouraged to seek immediate assistance if they have problems during routine clinics rather than defer immunisation. We also undertake a monthly clinic audit when the reasons why particular children did not receive a particular antigen(s) are discussed: initial response among staff has been very favourable. Staff may be unaware o f immunisation uptake in their locality and this lack o f feedback can be a disincentive to their supplying accurate data. We send to everyone involved in the immunisation service a monthly newsletter detailing uptake ofimmunisation for cohorts o f children (aged 10 and 15 months, 6 and 11 years). Also included are the district infectious disease notification figures. (d) Disease specific factors (i) Measles. A recent study found that 90% o f parents thought measles was a mild disease causing only a rash and a mild pyrexia: few were aware o f any complications associated with infection; 65% believed that measles vaccine was either ineffective or only minimally protective; 20% o f parents moreover thought the vaccine had significant side-effects.18 The author's experience has been that a number o f HPs also regard measles as a universally mild condition, and by implication not worthy o f immunisation. In addition lack o f knowledge regarding absolute vaccine contra-indications is widespread thus atopic disease (including minor egg allergy and eczema) and seizures (less often in the child or even its 1st degree relatives than in other family members) are the commonest reasons found in Stockport for non-recommendation o f immunisation.19 Offering measles immunisation during the second year o f life undoubtedly causes problems since many parents have got out o f the habit o f ' c o m i n g to clinic'. The age o f first infection, together with interference in the immune response by passively transferred antibody preclude earlier immunisation in the United Kingdom. Lack o f knowledge about the disease or vaccine appear to be the main deterrent to vaccine uptake and our approach therefore has been an essentially educational one. F o r parents we ran a community campaign identifying the impact o f the disease, the morbidity associated with it and the fact that a very safe and effective vaccine was available. We also targeted just over 2,000 children between two and four years o f age who according to the records had not been immunised and these parents were approached directly and invited to come and discuss measles. This campaign ran for 3 months and during that time there was a
Improving Immunisation Uptake
273
7% increase in immunisation. Strategies to maintain community interest and involvement should be incorporated into the overall plan. For professionals a variety o f methods are employed. Written advice is given to all HPs in the monthly newsletter accompanying uptake rates, and individually to those who refer children to the advisory clinic. Regular seminars are held for clinical medical officers, health visitors and practice nurses and an update session is organised annually for all groups (including practice nurses). An attempt is being made to meet with all P H C teams to discuss problems related to immunisation. All groups are involved in organising and implementing the media campaigns. (ii) Pertussis. Following the adverse publicity o f the early 1970s, pertussis immunisation rates declined dramatically: the impact o f 3 recent epidemics has led to a considerable improvement in uptake, although they have yet to reach the pre-1972 levels. In Stockport approximately 25% o f parents currently do not have their children immunised (by 2 years) against pertussis--four years ago the figure was nearly 60%. A disproportionately large number o f non-consentors come from the more socio-economically deprived areas. The main barrier to vaccine acceptance in 1989 remains the perceived causal relationship between immunisation and persistent severe brain damage, despite the lack o f adequate supportive evidence. This is further aggravated by confusion among professionals about pertussis contra-indications. 19 There are no easy answers to improving pertussis uptake. Developing a sub-unit vaccine confers reduced toxicity (theoretically at least) but it is doubtful if such a vaccine will ever be adequately field tested. 2° Using the balanced approach (risk o f the vaccine versus the risk of acquiring the disease and developing side effects) fails for those parents whose perception of risk is all-or-none (rather than incremental). I believe that the approach to improving uptake is (like measles) an essentially educational one: improving rates over the past 5 years suggest that though slow, progress can be made. References
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.
The State of the World's Children (1987). UNICEF: Oxford University Press. OPCS Series MB2 No. 12 (1985). Personal communication, October 1987. DHSS Statistics and Research (SR2B). North Western Regional Health Authority. (1987). Comparative Community Health Statistics 1986. National Child Health System Wardtape 1986. Unpublished data. D. Baxter (Nov. 1987). DBASE III PLUS--Software developed and produced by Ashton-Tate (1986). The Clipper Compiler, Autumn '86: Nantucket Corp. (1986). Baxter, D., Patel, M.S. & Killian, R. (1986). Cost appraisal and management of a mass immunisation programme in Jamaica. Journal of Management in Medicine, 1, 179-194. Loevinsohn, B. & Loevinsohn, M. (1987). Well child clinics and mass vaccination strategies. American Journal of Public Health, 77, 1407-1411. Logistics and Cold Chain for Primary Health Care Series July 1987: EPI, WHO. Riddiough, M., Willems, J. S., Sanders, C. R. & Kemp, K. (1981). Factors affecting the use of vaccine: considerations for immunization programme planners. Public Health Report, 96, 528535. Campbell, A. (1983). Measles immunisation: Why we have failed. Archives of Disease in Childhood, 58, 3-5.
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D. N. Baxter
14. Adjaye, N. (1981). Measles immunisations: the factors affecting non-acceptance of vaccine. Public Health, 95, 185-188. 15. Knowledge about measles. Measles matters, but do parents know. (1985). British Medical Journal, 290, 623-624. 16. Bussey, A. L. et al. (1977). Immunisation levels--needs they all decline? Lancet, ii, 970-971. 17. Immunisation against Infectious Diseases. (1988). DHSS. 18. Baxter, D.N. (1987). The management of measles in the UK. Journal of Management in Medicine, 1, 275-289. 19. Thakker & Baxter: (in preparation). 20. Baxter, D . N . & Gibbs, A. C. C. (1987). How are the new sub-unit pertussis vaccines to be evaluated? Epidemiology and Infection, 99, 477-484.
(1990), 104, 267-274
© The Society of Public Health, 1990
Improving Immunisation Uptake in the United Kingdom D. N. Baxter
University of Manchester, Department of Community Medicine
Reasons for the non-uptake of vaccination are discussed and proposals to remedy them are considered. It is believed that the proposals outlined in the paper will be as effective in improving vaccine uptake as legislation which has worked well in other cotmtries (e.g. Hungary and the USA). Introduction
In most developed countries, public and professional interest in infectious diseases has declined during the 20th century. This lack o f concern arises from the perception that there is only minimal risk from these diseases and is based on their falling mortality rates. Although such a view is partly correct, it neglects both the potential for transmission and the current incidence o f infection which for some conditions are not inconsiderable. In the U K during 1984 for example, there were just over 60,000 notifications o f measles and 5,500 o f whooping cough (pertussis); in epidemic years the figures might be as high as 100,000 and 60,000 respectively. Numbers alone, however, do not convey the full impact o f these diseases: despite its relatively mild reputation, measles can lead to middle ear damage, bronchopneumonia, encephalitis with permanent brain damage, sub-acute sclerosing panencephalitis and death. Pertussis may result in a prolonged debilitating illness and in more severe attacks, complications such as bronchopneumonia, bronchiectasis, brain damage and death are well recognised. General control measures for infectious diseases include improvements in nutrition, supply o f potable water, safe disposal o f sewage, high levels o f personal hygiene, provision o f adequate housing and effective health education. Specific activities (where appropriate) require immunisation of susceptibles, isolation o f infective sources, control o f vectors and early treatment o f cases. This paper will focus on the use of immunisation. In 1984 the global estimate was that 3,450,000 children died o f infections which were preventable by immunisation: o f these just over 2,000,000 resulted from measles, 803,000 from tetanus, 606,000 from pertussis and 265,000 from polio. 1 Relevant data for England and Wales during the same period are shown in Table I. lmmunisation Rates
Trends in the coverage o f vaccination for Health Regions in England between 1974 and 1984 are shown in Table IIa. With only two exceptions rates in each Region increased over the 10 year period. F o r two-year-old children born in 1984, the estimated overall uptake o f diphtheria, tetanus and polio was 85%; 67% for pertussis, and 71% for measles; the lower correspondence to: Dr D. Baxter, University of Manchester, Department of Community Medicine, Stopford Building, Oxford Road, Manchester MI3 9PT.
268 Table I
D. N. Baxter
Notifications and deaths for selected infectious diseases in England & Wales for 1984 Total
Measles Pertussis Tetanus Diphtheria
Notifications Rate per 100,000 population
62,080 5,517 6 4
124 11 0.01 0.008
Total
Deaths Rate per 1,000 notifications
10 1 3 0
0.2 0.2 500 0
Source: OPCS Series MB2 No. 12 (1985).2
limit was 77% for polio, tetanus and diphtheria, 57% for pertussis and 62% for measles. Variation in uptake both between and within Health Districts (see Tables IIb and IIc) may be just as great as between Regions: an observation that is important in predicting the impact and spread of specified infectious diseases. Some initial caution must be expressed about the reliability of the information on which Tables I I a - c are based, since a preliminary study comparing immunisation data in paired child health and computer records showed a discrepancy o f just over 12% (involving both antigens given/not and demographic information). 6 A larger study is currently being undertaken to assess if the problem is more widespread. Such a level o f inaccuracy (if confirmed) would have considerable implications both locally and nationally for: Use o f immunisation uptake rates as health status indicators; Targeting services to improve overall district uptake; Selective immunisation in the event o f disease outbreaks.
Table Ila
Vaccination and immunisation acceptance rates at 2 years for children born in specified years by Regional Health Authority Pertussis 1974 1984
Northern Yorkshire Trent East Anglia North West Thames North East Thames South East Thames South West Thames Wessex Oxford South Western West Midlands Mersey North Western England
31 42 45 48 38 41 34 40 36 58 42 33 34 30 38
Source: Personal communication (1987).3
66 68 71 72 69 61 68 72 74 74 70 63 57 58 67
Measles 1974 1984 47 46 54 59 44 43 37 49 69 75 62 39 32 35 47
75 75 76 77 71 62 66 72 81 78 78 67 66 66 71
Polio 1974
1984
69 70 76 81 73 84 66 79 85 91 80 73 64 68 75
85 85 88 87 85 77 84 85 91 88 89 82 80 83 85
Improving Immunisation Uptake Table lib
269
Vaccination and immunisation acceptance rates at 2 years for children born in 1984 by Health District: North Western Regional Health Authority
Lancaster Blackpool Preston Blackburn Burnley West Lancs Chorley Bolton Bury North Manchester Cent. Manchester South Manchester Oldham Rochdale Salford Stockport Tameside Trafford Wigan
Diphtheria %
Tetanus %
Pertussis %
Polio %
Measles %
92.1 85.5 65.8 77.3 84.4 96.4 83.3 89.6 91.4 78.4 84.4 81.4 88.5 86.4 81.8 92.6 87.6 94.2 89.5
92.3 85.4 65.9 77.2 84.1 96.1 83.4 89.6 91.4 78.4 84.3 81.4 88.5 86.5 81.9 92.6 87.6 94.2 89.5
74.4 55.3 53.2 60.1 57.4 61.0 64.1 59.9 63.8 52.2 56.1 53.0 57.9 59.4 52.4 65.1 61.7 68.9 62.3
92.2 85.1 65.2 75.4 82.8 95.6 82.9 89.5 91.6 78.8 84.5 81.2 88.4 86.3 81.6 92.5 87.5 94.3 89.7
76.6 58.7 53.4 54.6 60.3 68.8 60.8 76.5 77.8 62.8 63.9 53.9 65.6 71.4 59.5 74.2 74.1 78.5 76.0
Source: Comparative Statistics t986, North Western Regional Health Authority (1987).4
Since uptake figures are valid health status indicators, District Health Authorities (DHAs) should be encouraged to develop accurate monitoring systems. Stockport D H A has created an immunisation database, using D Base III P L U S 7 and Clipper 8 software which runs on an IBM compatible PC and is presently being evaluated. The immediate impressions are that a district-based system has a number o f advantages over the existing Regional set-up. W H O has declared 1990 the year when all children will be immunised and it is clearly evident (even with the above reservations) that in the U K considerable progress will have to be made in order to achieve these targets. This paper seeks to identify the reasons for low uptake and put forward strategies by which they may be overcome. These observations are based on experiences gained as Immunisation Co-ordinator for Stockport D H A . Some problems are c o m m o n to all the immunisation services and will be considered first: others are related more to knowledge or particular vaccines, and discussed later. (a) Service factors Services that are not readily accessible deter a number o f parents. Where this is due to inconvenient clinic times some improvement might result if they were to be extended or rescheduled. In Stockport, immunisation sessions are held either in the morning or the early afternoon and this inevitably causes difficulty for some working parents. Although evening clinics m a y lead to problems (e.g. o f security) their use should be explored and evaluated. Accessibility might be less o f a problem where general practitioners offer immunisation
D. N. Baxter
270 Table IIc
Vaccination and immunisation acceptance rates at 2 years for children born in 1984--for Stockport DHA
Ward name Stockport DHA
Polio %
Measles %
Diphtheria %
Pertussis %
Tetanus %
Brinnington Manor Great Moor Davenport Cale Green Edgeley Heaton Mersey Heaton Moor North Reddish Romiley Bredbury Heald Green Cheadle Cheadle Hulme South Cheadle Hulme North Hazel Grove East Bramhall West Bramhall North Marple South Marple South Reddish
81.4 94.7 91.6 90.7 88.4 88.5 94.9 95.8 91.6 85.5 93.5 92.9 96.1
55.3 76.7 66.5 77.5 66.3 63.5 76.4 80 62.8 66.4 79.6 81.2 81.1
81.4 94 91 91.4 88.4 88 94.9 95.8 91.6 86.3 93.5 92.9 96.1
46.8 60.7 61.1 65.6 50 50 66.3 61.7 58.1 58 65.6 64.3 74.8
81.4 94 91 91.4 88.4 88 94.9 95.8 91.6 86.3 93.5 92.9 96.1
99.2
80.3
99.2
72
99.2
96.9 95.2 94.3 98.6 96.2 92.5 87.3
85.1 78.8 81.3 85.9 82.7 80.8 59.9
96.9 95.7 94.8 99.3 97 92.5 88.3
72 71.9 77.1 83.8 75.2 73.3 51.8
96.9 95.7 94.8 99.3 97 92.5 88.3
Source: National Child Health System Wardtape (1986).5
both in special clinics and during regular surgeries. Adequate back-up should be available for parents in the event o f the child experiencing an immunisation reaction. Problems o f physical access (e.g. poor transport, isolated clinics or long travel times) m a y result in low uptake. The response in Stockport has been to provide a limited domiciliary service for some parents identified by the health visitor. The author's experience has been that the service is o f considerable value, but not cost effective as presently organised: ideally general practitioners or immunisation-trained health visitors and practice nurses should undertake this function (as already happens in some DHAs). Critics would argue that such a proposed system is open to abuse, but so is the present o n e - - i n the majority o f domiciliary immunisations I carry out, the health visitor has called to arrange clinic appointments six or seven times at least before my visit. Use o f the approaches outlined in this article should prevent the emergence o f a 'domiciliary-based service'. I also believe (albeit based on personal experiences in developing countries) that high profile outreach programmes taken into defined areas o f low uptake, would ease accessibility problems: operating from community centres or mobile clinics, such services are cost-effective9 and raise uptake rates) ° Domiciliary immunisations reinforce the need for an effective cold chain since the reduced immunogenicity o f inappropriately stored vaccines has been clearly demonstrated.
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It is essential that one person be given responsibility for storage and distribution o f vaccines in a health centre or G P surgery. Training in cold chain management should be provided in all health districts: we currently use a training manual developed by W H O for its own expanded immunisation programme. H The present arrangements for service delivery lead to confusion for some parents as to who is providing the service, and where they should take their baby for immunisation: this may well become more important in certain districts as changing priorities and financial arrangements for Primary Health Care (PHC) mean that General Practitioners are more directly involved in immunisation programmes. Problems can arise where P H C and the D H A duplicate immunisation services. Failure to co-ordinate such activities leads to the confusion identified above: in addition it is an inefficient use of limited resources and can generate conflict between professionals. As services are relocated, continuous monitoring o f both uptake rates and consumer satisfaction is essential. It may be better to concentrate D H A services in areas of low uptake and/or where an inadequate immunisation service is provided by the P H C team. (b) Parentalfactors Lack o f knowledge about the disease and/or vaccine may be a problem for a number of parents. They may also be given conflicting advice (especially for measles and pertussis) by professionals because of the latter's ignorance or reluctance to use particular vaccines (see section c). It is important to give parents all relevant information so that a reasoned decision can be made. The discussion should cover disease severity and individual susceptibility, together with vaccine toxicity and efficacy. Clear recommendations should be given: unequivocal advice doesn't deny parental choice, but states what the health professional (with more knowledge usually) would do in those circumstances. Such an approach allows more informed decision-making and is preferable to the c o m m o n (but inconsistent) practice o f saying ' o f course your child should have diphtheria, tetanus and polio, but the decision regarding measles and pertussis is yours'. One reason for this practice is the fear o f litigation which influences many health professionals. Given that legal action usually arises from the need to fund lifelong care for handicapped children and that the value of immunisation clearly extends beyond the vaccinated individual, adequate provision should be made for these children without their having to resort to lengthy and costly litigation. No-fault compensation does not imply an acceptance that vaccination has caused the damage, rather it reflects the importance o f living in a society with the highest possible vaccine uptake rates. In addition, some parents are unaware o f either the recommended schedule of immunisations, or what immunisations their children have, or should receive. These problems have been addressed in Stockport by sending parents the immunisation history cards o f their two-year-old children, together with comments as to what further immunisations (if any) are needed: this service has only just started and is as yet unevaluated. (c) Professionalfactors Some workers lack good interpersonal skills and are p o o r communicators. Appropriate training should be provided for all health professionals since their attitude and behaviour has a major influence on parental decision making? 2 A number of studies have identified lack o f knowledge among health professionals (HPs)
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as a major problem. 12-~6This may lead to varying and inconsistent advice which is a source of confusion for some parents. Conflicting advice may also be given when health professionals have pre-determined negative views about the use o f (particular) immunisations in any circumstances. Whilst respect for clinical freedom is important it is necessary to decide whether this should allow professionals to determine their own policy when contrary to (majority) expert advice and government policy. Health workers must know about vaccine properties, side effects and contra-indications. They should be able to assess the benefit-risk ratio o f any immunisation for a particular individual using clear and unambiguous criteria: the new DHSS guidelines ~7 should more adequately fulfill these criteria although inconsistencies between them and the manufacturers' advice notes are a source o f continuing confusion. In Stockport national guidelines are supplemented with a weekly referral immunisation clinic where specialist advice is available to any H P (or parent). It is essential that the process o f referral does not raise doubts or worries in parents' minds: unnecessary referrals should reduce as local education and training programmes become more established. As an additional measure our staff are encouraged to seek immediate assistance if they have problems during routine clinics rather than defer immunisation. We also undertake a monthly clinic audit when the reasons why particular children did not receive a particular antigen(s) are discussed: initial response among staff has been very favourable. Staff may be unaware o f immunisation uptake in their locality and this lack o f feedback can be a disincentive to their supplying accurate data. We send to everyone involved in the immunisation service a monthly newsletter detailing uptake ofimmunisation for cohorts o f children (aged 10 and 15 months, 6 and 11 years). Also included are the district infectious disease notification figures. (d) Disease specific factors (i) Measles. A recent study found that 90% o f parents thought measles was a mild disease causing only a rash and a mild pyrexia: few were aware o f any complications associated with infection; 65% believed that measles vaccine was either ineffective or only minimally protective; 20% o f parents moreover thought the vaccine had significant side-effects.18 The author's experience has been that a number o f HPs also regard measles as a universally mild condition, and by implication not worthy o f immunisation. In addition lack o f knowledge regarding absolute vaccine contra-indications is widespread thus atopic disease (including minor egg allergy and eczema) and seizures (less often in the child or even its 1st degree relatives than in other family members) are the commonest reasons found in Stockport for non-recommendation o f immunisation.19 Offering measles immunisation during the second year o f life undoubtedly causes problems since many parents have got out o f the habit o f ' c o m i n g to clinic'. The age o f first infection, together with interference in the immune response by passively transferred antibody preclude earlier immunisation in the United Kingdom. Lack o f knowledge about the disease or vaccine appear to be the main deterrent to vaccine uptake and our approach therefore has been an essentially educational one. F o r parents we ran a community campaign identifying the impact o f the disease, the morbidity associated with it and the fact that a very safe and effective vaccine was available. We also targeted just over 2,000 children between two and four years o f age who according to the records had not been immunised and these parents were approached directly and invited to come and discuss measles. This campaign ran for 3 months and during that time there was a
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7% increase in immunisation. Strategies to maintain community interest and involvement should be incorporated into the overall plan. For professionals a variety o f methods are employed. Written advice is given to all HPs in the monthly newsletter accompanying uptake rates, and individually to those who refer children to the advisory clinic. Regular seminars are held for clinical medical officers, health visitors and practice nurses and an update session is organised annually for all groups (including practice nurses). An attempt is being made to meet with all P H C teams to discuss problems related to immunisation. All groups are involved in organising and implementing the media campaigns. (ii) Pertussis. Following the adverse publicity o f the early 1970s, pertussis immunisation rates declined dramatically: the impact o f 3 recent epidemics has led to a considerable improvement in uptake, although they have yet to reach the pre-1972 levels. In Stockport approximately 25% o f parents currently do not have their children immunised (by 2 years) against pertussis--four years ago the figure was nearly 60%. A disproportionately large number o f non-consentors come from the more socio-economically deprived areas. The main barrier to vaccine acceptance in 1989 remains the perceived causal relationship between immunisation and persistent severe brain damage, despite the lack o f adequate supportive evidence. This is further aggravated by confusion among professionals about pertussis contra-indications. 19 There are no easy answers to improving pertussis uptake. Developing a sub-unit vaccine confers reduced toxicity (theoretically at least) but it is doubtful if such a vaccine will ever be adequately field tested. 2° Using the balanced approach (risk o f the vaccine versus the risk of acquiring the disease and developing side effects) fails for those parents whose perception of risk is all-or-none (rather than incremental). I believe that the approach to improving uptake is (like measles) an essentially educational one: improving rates over the past 5 years suggest that though slow, progress can be made. References
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.
The State of the World's Children (1987). UNICEF: Oxford University Press. OPCS Series MB2 No. 12 (1985). Personal communication, October 1987. DHSS Statistics and Research (SR2B). North Western Regional Health Authority. (1987). Comparative Community Health Statistics 1986. National Child Health System Wardtape 1986. Unpublished data. D. Baxter (Nov. 1987). DBASE III PLUS--Software developed and produced by Ashton-Tate (1986). The Clipper Compiler, Autumn '86: Nantucket Corp. (1986). Baxter, D., Patel, M.S. & Killian, R. (1986). Cost appraisal and management of a mass immunisation programme in Jamaica. Journal of Management in Medicine, 1, 179-194. Loevinsohn, B. & Loevinsohn, M. (1987). Well child clinics and mass vaccination strategies. American Journal of Public Health, 77, 1407-1411. Logistics and Cold Chain for Primary Health Care Series July 1987: EPI, WHO. Riddiough, M., Willems, J. S., Sanders, C. R. & Kemp, K. (1981). Factors affecting the use of vaccine: considerations for immunization programme planners. Public Health Report, 96, 528535. Campbell, A. (1983). Measles immunisation: Why we have failed. Archives of Disease in Childhood, 58, 3-5.
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14. Adjaye, N. (1981). Measles immunisations: the factors affecting non-acceptance of vaccine. Public Health, 95, 185-188. 15. Knowledge about measles. Measles matters, but do parents know. (1985). British Medical Journal, 290, 623-624. 16. Bussey, A. L. et al. (1977). Immunisation levels--needs they all decline? Lancet, ii, 970-971. 17. Immunisation against Infectious Diseases. (1988). DHSS. 18. Baxter, D.N. (1987). The management of measles in the UK. Journal of Management in Medicine, 1, 275-289. 19. Thakker & Baxter: (in preparation). 20. Baxter, D . N . & Gibbs, A. C. C. (1987). How are the new sub-unit pertussis vaccines to be evaluated? Epidemiology and Infection, 99, 477-484.
