Public Health (1990), 104, 275-278

© The Society of Public Health, 1990

L o w I m m u n i s a t i o n Rates: F a c t or F i c t i o n ? E. A. Scott

Riverside District Health Authority

The uptake rate for primary immunisation against diphtheria in 1987 in the east part of Riverside District Health Authority was 61% for children aged two. A retrospective survey was undertaken of the immunisation records of all children aged two recorded on the Child Health System as not fully immunised: 46% had been immunised; 18.1% had moved out of the district; 15.6% of the children could not be traced; in 13.6% of records, there was no reference to immunisation; and only 2.5% of children were definitely not immunised. Large numbers of omissions were found in the data held on the Child Health System. The reasons for this are discussed and recommendations made for improving the quality of the data held.

Introduction The European Division o f the World Health Organisation has recommended that by the year 1990, 90% o f children aged two should be immunised against diphtheria, tetanus and polio. The uptake rate for p r i m a r y immunisation against diphtheria in 1987 for the east part of Riverside, an inner city district in London, was 61%. This c o m p a r e d with uptake rates o f 81% for N o r t h West T h a m e s Region and 83 o/o for England and Wales, l In order to target p r o g r a m m e s and strategies for improving uptake, an investigation was undertaken o f the reasons for the apparently low uptake rate. Riverside East has been using the Child Health System in the organisation o f immunisation and vaccination since 1978. It is a computerised system designed to m o n i t o r child health and development. It is based on a child register and has three modules, one of which concerns immunisation. When a child is born, the obstetric unit (or in the case o f a domiciliary birth, the midwife) has a statutory duty to notify the birth to the District Health Authority in which the m o t h e r resides. In Riverside East, such notifications are sent to the Child Health Administration. The Child Health Administration is therefore able to notify the Regional C o m p u t e r Centre o f all births to w o m e n resident in Riverside East. The Child Health Administration is also responsible for notifying the Regional C o m p u t e r Centre o f all m o v e m e n t s in and out o f the District, thereby keeping the register updated. The Child Health System identifies children who are due for immunisation. A p p o i n t m e n t cards are sent to the treatment centre chosen by parent or guardian. I f the treatment centre agrees that the child is due for immunisation, the a p p o i n t m e n t is forwarded to the child's home. The clinics and treatment centres inform the Child Health Administration o f all immunisations p e r f o r m e d on children. In turn, the Child H e a l t h Administration forward this information to the Regional C o m p u t e r Centre.

Correspondence to: Dr E.A. Scott, Senior Registrar in Public Health Medicine, Directorate of Public Health Medicine, North West Thames Regional Health Authority, 40 Eastbourne Terrace, London W2 3QR.

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A retrospective survey was undertaken o f the immunisation records of all children who were the responsibility o f Riverside East, were b o r n in 1985 and had not been immunised against diphtheria. A printout was requested from the Regional C o m p u t e r Centre late in December 1987 and so virtually all the children were aged two at the time o f the printout. The records of all children who had not received their third dose o f diphtheria antigen were e x a m i n e d - - t h i s is the criterion for ' n o t fully immunised' used when immunisation rates are calculated. In each case, the clinic records and the records o f the health visitor were examined. G P records were not examined as the identity o f the G P was recorded in only 30.6% o f Child Health System records. The m a n a g e m e n t o f the data concerned was also studied. This was done by a series of informal interviews with key personnel. Results

A total of 1,256 children were identified as being born in 1985 and the responsibility o f Riverside East for immunisation; 487 o f these children were recorded as not having received their third dose o f diphtheria antigen and therefore not fully immunised. The records of these 487 children were examined. The results o f the survey are summarised in Table I. O f the 487 children recorded as not fully immunised, 223 (46.0%) had received a full course of immunisation. O f these, 60 were given their immunisation at the clinic indicated on the computer record and 49 were immunised by their general practitioner. The largest group (63) were imnmnised privately and 31 were immunised abroad. O f the remaining 264, 89 children had m o v e d out o f the District but this information had not been fed into the Child Health System. No trace was found o f a further 76 children. This was despite using various combinations o f surname and forenames, and different years of birth. In an unfortunately large n u m b e r o f c a s e s - - 6 6 - - t h e r e were no details pertaining to immunisation at all. Nearly one third of these children were born in private maternity units. It is possible, but by no means certain, that these children were also immunised privately; 12 children were definitely not immunised. Discussion

There can be no d o u b t that there are large numbers o f omissions in the information held a b o u t Riverside East children on the Child Health System. Recalculation using the information gained f r o m the survey gives an immunisation uptake rate o f 74.6%. This does not take into account any unimmunised child, resident in Riverside but not on the Child Health System. Most previous studies into immunisation rates have looked at specific antigen(s) or groups in society, such as the problems associated with contra indications to pertussis immunisation 2~ and travelling families. 5 Other studies have concentrated on the problems o f information systems for immunisation and vaccination programmes. There is some evidence that a computerised system increases uptake rates. 6 Whichever system is used, it needs to identify rapidly the non-immunised. 7 The Child Health System, as used in Riverside East, does not fulfil the latter criterion. In addition, improving immunisation uptake rates requires motivation on the parts o f health professionals and health authorities. 8

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Table I

Immunisation status or reason for a child being recorded as not fully immunised

Immunisation status/reason for being registered as not fully immunised Complete course of immunisation given --at treatment centre specified --by general practitioner --elsewhere in the UK --abroad --privately - - N H S hospital --private hospital Family moved elsewhere in UK --abroad --address not known No record of the child No immunisation details in record Not immunised --homeopathic remedies only --frequent non-attender --consent refused --recent immigrant --medical contra-indicators Duplicate record Child adopted Child died Child taken into care Family changed GP Total

Number (Percentage of total) 60 (12.3%) 49 (10. ! %) 17 (3.5%) 3! (6.4%) 63 (12.9%) 2 (0.4%) 1 (0.2%) 46 (9.4%) 14 (2.9%) 29 (6.0%) 76 (15.6%) 66 (13.6%) 2 (0.4%) 5 (1.0%) 2 (0.4%) 2 (0.4%) 1 (0.2%) 16 (3.3%) 2 (0.4%) 1 (0.2%) 1 (0.2%) 1 (0.2%) 487 (100%)

The turnaround of information to and f r o m the Child Health Administration is often slow. This is partly as a result of the workload generated by a District such as Riverside East, where the population turnover is particularly high (a factor shown elsewhere to c o m p r o m i s e data quality) 9 and partly as a result of the staff at the Child Health Administration being unfamiliar with the system due to high staff turnover. Inaccurate, out o f date information is then fed back to field staff. This generates frustration and extra p a p e r w o r k for field staff which, combined with uncertainty a b o u t what the Child Health System can and cannot do, acts as a disincentive to field staff to complete p a p e r w o r k fully and quickly. I n f o r m a t i o n sent to the Child Health Administration is often out o f date and incomplete. Naturally, the staff there see no reason to deal with it promptly. A vicious circle thereby develops. There are two points at which this vicious circle can be broken. (i) The turnover of staff in the Child Health Administration is high. To a large extent this is due to the low wages paid relative to what can be earned elsewhere in the City of Westminster for jobs requiring similar skills. This is c o m p o u n d e d by the frustration felt by staff working with out o f date, incomplete data. Furthermore, staff

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are unable to build links with field staff. Staff need a thorough induction programme to ensure that they gain a working knowledge of the Child Health System as rapidly as possible. Their working conditions need to be as pleasant as possible and they need to be encouraged to build links with health professionals and others working in the field so that field staff have a better understanding o f the Child Health System. (ii) Getting information from the field to the Child Health System involves several people and much paper work. It is therefore perhaps hardly surprising that data is out of date and inaccurate. A system o f remote data capture has now been developed for the Child Health System. Terminals can be placed in health centres, G P practices and administrative centres, and data fed directly into the computer. There is also a statistical package being developed, which would enable field staff to obtain directly simple aggregated statistics. Obviously remote data capture would be expensive, both in terms o f installing the hardware and in training staff to use it. Neither solution suggested is likely to work completely if implemented without the other. Both are costly, in terms of effect and finance. But pay related to performance indicators such as immunisation rates may soon be in place for many people. It has been argued that uptake rates should be first adjusted to control for variations in social factors before being used to measure standards o f performance. 1° That is probably true, but in the current political climate, where targets loom as all important, it is only by attention to the quality of data that those who are to be judged by targets will be accurately rewarded.

References I. Begg, N. T., Gill, O. N., White, J. M. (1987). 'Cover' (Cover of Vaccinati0n Evaluated Rapidly): 3. Communicable Disease Reports, 37, 3-5. 2. Stevens, D., Baker, R. &Hards, S. (1986). Failure to vaccinate against whooping cough. Archives of Diseases in Childhood, 61, 382-387. 3. Hull, D. (1981). Interpretations of the contraindications to whooping cough vaccination. British Medical Journal, 283, 1231-1233. 4. Nicholl, A. (1985). Contraindications to whooping cough immunisation: myths or realities. Lancet, i, 679-681. 5. Jefferson, N., Sleight, G. & MacFarlane, A. (1987). Immunisation of children by a nurse without a doctor present. British Medical Journal, 294, 423-424. 6. Newman, C. P. S. (1983). Immunisation in childhood and the computer scheme participation. Public Health, 97, 208-213. 7. Hull, D. (1987). Why are children not immunised? Journal of the Royal College of Physicians, 21, 28-31. 8. Immunisation policy: recipes for success [editorial]. (1987). Lancet, ii, 78-80. 9. Mant, D., Phillips, A. & Knightly, M. (1986). Measles immunisation rates and the good practice allowance. British Medical Journal, 293, 995-997. 10. Jarrnan, B., Bosanquet, N., Rice, P. et al. (1988). Uptake of immunisation in district health authorities in England and Wales. British Medical Journal, 296, 1775-1778.

Low immunisation rates: fact or fiction?

The uptake rate for primary immunisation against diphtheria in 1987 in the east part of Riverside District Health Authority was 61% for children aged ...
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