Drs Helen Bedford and David Elliman explain how the NICE public health guidance on immunisation should lead to improved services and increased uptake of vaccines
The overall uptake of childhood vaccines in England and Wales is high—over 90% of 1 year-olds are fully immunised with the primary vaccines. These are the routine infant vaccinations, comprising three doses of diphtheria, tetanus, pertussis, polio, and Haemophilus influenzae type b vaccines and two doses of pneumococcal and meningococcal C conjugate vaccines.1 This figure masks wide variation in uptake between geographical areas. Following the ‘measles, mumps, and rubella (MMR) scare’, which began in 1988, uptake of the MMR vaccine fell, and despite recent increases in uptake,1 further improvement is required if all primary care trusts (PCTs) are to achieve the public health targets and prevent outbreaks of disease. As part of the ‘Vital signs’ targets, at least 95% of children should receive three doses of diphtheria, tetanus, polio, and pertussis in the first year of life; at least 95% should receive a first dose of a measles, mumps, and rubella vaccine by 2 years of age; and at least 90% should receive a booster dose of tetanus, diphtheria, and polio between 13 and 18 years of age.2
With all vaccines there is significant variation in uptake within PCTs; with lower rates among mobile populations, some ethnic minority groups, and disadvantaged groups. Recent guidance issued by NICE entitled Reducing differences in the uptake of immunisations (including targeted vaccines) among children and young people aged under 19 years, should help increase immunisation uptake in groups and settings where immunisation coverage is low.3 The guideline also focuses on improving uptake of hepatitis B immunisation for babies born to mothers who are infected with the disease.3
The guidance was produced by NICE for the NHS and other commissioners, managers, and professionals who have a direct or indirect role in, and responsibility for, the immunisation of children and young people. This includes those working in:
- children’s health services,
- social care
- the wider public, private, voluntary, and community sectors.
It may also be of interest to parents, others with parental responsibility, all those who look after the health and wellbeing of children and young people, and members of the public. The recommendations are set out under six headings:3
- immunisation programmes
- information services
- contribution of nurseries, schools, and colleges of further education
- targeting groups at risk of not being fully immunised
- hepatitis B immunisation for infants.
The Joint Committee on Vaccination and Immunisation (JCVI) advises the Department of Health (DH) on policy for immunisation programmes. Approved policy is issued as guidance in the ‘Green book’4 and updates to this publication should be circulated to all relevant professionals and implemented as quickly as possible.4 Locally, at PCT and general practice level, individuals should have responsibility for implementing the programme.3
Some groups of people are at risk of poor uptake, often due to inaccessibility of immunisation services. The NICE guideline sets out the importance of providing well organised and accessible child and family friendly services, using a multifaceted, coordinated approach across different settings.3 Flexibility of service provision is important and improving access to immunisation services includes such initiatives as:3
- offering extended clinic times
- alternative venues
- reduced waiting times.
Invitations to attend clinics, and reminders for immunisation are effective in increasing uptake rates.5 They should be individualised and followed up by telephone or text message as appropriate.3 The information provided for parents, carers, and young people should be tailored to their needs and should include details of the vaccines offered, the infections they prevent, and the benefits and risks of the vaccines.3 This can be done by enclosing a copy of the relevant DH booklet. Parents, carers, and young people also need opportunities to discuss any concerns they may have and these can be offered either in person or by telephone, by any healthcare professional who is equipped with the necessary skills to advise on immunisation.3
For parents/carers who have not responded to reminders or who have difficulty accessing services, domiciliary immunisation should be considered. This approach may be particularly useful for groups such as travellers, asylum seeker, and mothers with large families or multiple births. It is sensible to check a child’s immunisation status at any opportunity, and if any are outstanding, offer vaccines if appropriate or refer to relevant local services.3
The provision of an effective immunisation service depends on having an accurate database of all the children for whom the PCT and each practice are responsible. Unless their records are transferred appropriately, children who move out of the area will continue to be included when calculating immunisation uptake, resulting in apparently lower rates. Duplicate records should be identified as these also skew the results. Therefore, it is important that details of children moving in and out of practices should be recorded in a timely fashion.3
To maintain consistency of information between databases, each vaccine given should be recorded in patient records, on the child health information system, and in the Personal Child Health Record (PCHR, also known as the ‘Red book’).3 Information on vaccines administered privately will not be collected routinely unless private healthcare providers are encouraged to notify GP practices and PCTs so that this information can be recorded.3 The same data should be used to report to the child health system, for the purposes of providing COVER (Cover of Vaccination Estimated Rapidly) reports, and for submitting data to the PCT for GP payments. This will ensure that the data are consistent across these databases. (NB COVER reports are reports of uptake of vaccination prepared by PCTs on a quarterly basis for children aged 1, 2, and 5 years—they are passed on to the Health Protection Agency, which, acting on behalf of the Department of Health, collates and publishes them).3
Those individuals who are responsible for immunising children and young people should be provided with up-to-date information on vaccine coverage for their caseloads. This will enable them to monitor their performance and reinforces the importance of data collection, which may act as incentive—in terms of feedback—to submit data to the child health system. Feedback in many cases improves performance. These databases should also be used to record any information about why a child or young person is more likely to miss out on vaccines; for example, children who are looked after by the local authority (‘looked after children’) or who have chronic conditions. Contraindications should be noted, and where immunisations have been postponed, there should be a function within the database that triggers a review after a suitable interval.3
Studies report that healthcare professionals’ knowledge of and attitudes towards immunisation are sub-optimal,6–8 yet being knowledgeable, confident, and enthusiastic is key to the success of immunisation services. In view of this, the Health Protection Agency has developed core training for all those involved in immunisation;9 including not only those who are administering vaccines, but also the support staff. The curriculum includes:9
- national policy and schedules
- the workings of the immune system
- the types of vaccines used
- storage of vaccines
- recording of vaccines given
- communicating with parents/carers.
The ability to respond to parents’ questions and concerns effectively is one of the most important aspects of the immunisation process. Therefore, the technique of administering the vaccine is only one of the many skills needed.
Nurseries, schools, and colleges of further education
Although the aim is to ensure children are protected at the earliest possible age, some children miss out. This is often because parents have forgotten or have not managed to attend immunisation clinics for a variety of reasons. However, by adopting a more flexible approach and immunising children in settings other than just healthcare, there will be many opportunities to remind parents and to offer vaccines as appropriate.
Entry to a day nursery, nursery school, playgroup, or Sure Start Children’s centre, or starting primary school all present opportunities to check a child’s immunisation status.3 In this situation parents will often accept the required immunisations. For those parents who prefer not to have their child immunised, it means there is a record of children who will be unprotected in the event of an outbreak of infectious disease. Older children transferring to a new school or starting college should also have their immunisation status checked. This can be done by the Healthy Child Team for children up to the age of 5 years and by the school nursing team for older children.2
Where immunisations are not up to date, appropriate action should be taken to remind parents and to offer vaccines or refer to relevant local services. Schools are being encouraged to take on an extended role, both in terms of the population to whom they offer services and the hours they are open. Part of the role of ‘extended schools’ would be to offer vaccination sessions thus providing greater flexibility in immunisation services.3
Targeting those at risk of not being fully immunised
Some groups are at an increased risk of not being fully immunised and particular efforts are required to ensure they are not missed out. This lack of immunisation may occur because services are not readily accessible, or because parents choose not to have their children immunised.10 These two groups have been described respectively as ‘passive defaulters’ and ‘active resisters’ and need different approaches.11
Consideration should be given to making services more accessible by providing extended hours, walk-in clinics, and vaccination in settings such as the home or children’s centres.3 Parents and young people must be given information about immunisation that is accurate, up to date, and available in different formats and languages. Information could also be made available in a range of settings such as pharmacies and retail outlets.3
Reviewing the immunisation status of children and young people in particular groups (such as new migrants, young offenders, and looked after children) at appropriate opportunities, discussing the need for vaccines and offering any outstanding ones is an important approach to making immunisation more available for these disadvantaged individuals.3
For those parents who would prefer their children to have specific vaccines omitted or to have no vaccines at all, a more individual approach is required. It is important to explore their reasons for making this decision and ensure that they have accurate information on the pros and cons of immunisation.
Hepatitis B immunisation for infants
Infants born to mothers who are hepatitis B positive are at high risk of becoming carriers of the infection and developing serious liver disease in later life. The risk of chronic carriage is significantly reduced in babies who receive a complete four-dose course of hepatitis B vaccine in the first year of life—at birth, 4 weeks, 8 weeks, and 12 months of age. Some children will also require hepatitis B immunoglobulin at birth.3 However, such infants are often socially disadvantaged and, therefore, many do not complete the full course of vaccines.
In areas where there is a dedicated person to oversee this programme, uptake rates of the full four-dose course are higher.12 For maximum effect, good communication between antenatal, postnatal, neonatal, primary care, and community child health services is essential. Having accurate information in the child’s records regarding the mother’s hepatitis B status is also important. Parents need information, advice, and support on the prevention of hepatitis B transmission, emphasising the importance of completing the vaccine course. Where appropriate, the hepatitis B status of the baby’s siblings should be assessed and vaccination offered if necessary.3
Inequalities in immunisation uptake place some children at increased risk of infectious disease. It is important to establish locally whether lower rates are the result of parents’ active resistance or passive default—with this information the appropriate targeted approaches can be instituted.
|NICE implementation tools|
NICE has developed the following tools to support implementation of Public Health Guidance 21 on Reducing differences in the uptake of immunisation (including targeted vaccines) among children and young people aged under 19 years. They are now available to download from the NICE website: www.nice.org.uk
Costing templates are spreadsheets that allow individual NHS organisations and local health economies to estimate the costs of implementation taking into account local variation from the national estimates, and they quickly assess the impact the guideline may have on local budgets.
A costing statement is available, which discusses the costs of implementing the recommendations. The guidance should not have a significant impact on national resources but there may be some local costs, depending on local circumstances.
The slides are aimed at supporting organisations to raise awareness of the guideline and resulting implementation issues at a local level, and can be edited to cater for local audiences. This information does not supersede or replace the guidance itself.
Audit support has been developed to support the implementation of the NICE guideline on improving immunisation services. The aim is to help NHS organisations with a baseline assessment and to assist with the audit process, thereby helping to ensure that practice is in line with the NICE recommendations. The audit support is based on the key recommendations of the guidance and includes criteria and data collection tools.
Guide to resources
The guide to resources provides an overview of information directly related to the guidance either in terms of background, such as government policy documents, or practical help, such as pathways or toolkits.
Frequently asked questions
This document has been produced to help staff in Sure Start Children’s centres implement and further develop their understanding of the guidance.
- PBC collectives and PCTs could help improve immunisation uptake by ensuring primary care clinicians are fully trained in the increasingly complex vaccination program, possibly through protected learning time events for GP practices
- PBC collectives and public health clinicians should ensure that immunisation services are convenient and accessible for hard-to-reach groups in particular
- A domiciliary immunisation scheme or specialised service could be commissioned to address travelling communities or unregistered patients as well as passive defaulters
- Practices could be asked to identify ‘passive defaulters’ and ‘active resisters’ in immunisation returns to help direct any specialised follow up effectively
- Commissioners should consider identifying named individuals to oversee non-standard processes, such as vaccinations for hepatitis B or immunisation for new migrants
- Practices are likely to be highly motivated to engage in increasing immunisation rates as they are financially penalised if they fail to reach standard vaccination targets (and informed dissent is not an allowed exception)
PBC=practice-based commissioning; PCT=primary care trust
- The Information Centre. NHS immunisation statistics 2008–9. The NHS Information Centre for Health and Social Care, 2009. Available at: www.ic.nhs.uk/webfiles/publications/immunisationstats0809/NHS_Immunisation_Statistics_England_2008_09_Bulletin.pdf
- Department of Health. Vital signs. Technical guidance for 2009/10. Available at: www.immunisation.nhs.uk/files/VitalSigns_2009.pdf
- National Institute for Health and Care Excellence. Reducing differences in the uptake
of immunisations (including targeted vaccines) among children and young people aged under 19 years. Public Health Guidance 21. London: NICE, 2009. Available at: www.nice.org.uk/nicemedia/pdf/PH21Guidance.pdf
- Department of Health. Immunisation against infectious disease. London: DH, 2006. Available at: www.dh.gov.uk/en/Publichealth/
- Jacobson Vann J, Szilagyi P. Patient reminder and recall systems to improve immunization rates. Cochrane Database Syst Rev 2005; (3): CD003941.
- Henderson R, Oates K, Macdonald H, Smith W. General practitioners’ concerns about childhood immunisation and suggestions for improving professional support and vaccine uptake. Commun Dis Public Health 2004; 7 (4): 260–266.
- Macdonald H, Henderson R, Oates K. Low uptake of immunisation: contributing factors. Community Pract 2004; 77 (3): 95–100.
- Petrovic M, Roberts R, Ramsey M. Second dose of measles, mumps and rubella vaccine: survey
questionnaire of health professionals. BMJ 2001; 322 (7278): 82–85.
- Health Protection Agency. Core curriculum for immunisation training. London: HPA, 2005. Available at: www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1204100468732
- Samad L, Tate A, Dezateux C et al. Differences in risk factors for partial and no immunisation in the first year of life: prospective cohort study. BMJ 2006; 332 (7553): 1312–1313.
- Fitzpatrick M. Measles returns. Practice Nursing 2008; 19 (4): 189–191.
- Larcher V, Bourne J, Aitken C et al. Overcoming barriers to hepatitis B immunisation by a dedicated hepatitis B immunisation service. Arch Dis Child 2001; 84 (2): 114–119. G