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A vaccination programme for children with learning difficulties

Elizabeth Kinsella RGN RSCN RM
Immunisation Coordinator/Flu Lead
Liverpool Community Health NHS Trust

Pauline Morris RGN DN HV MSc
Immunisation Lead Nurse/Training Lead
Liverpool Community Health NHS Trust

A unique initiative in Liverpool is using an Active Patient Management Team approach to protect unimmunised children with complex care needs attending special education schools

Flu vaccination uptake continues to rise nationally, but only about half of those eligible aged between six months and 65 years in clinical risk groups currently receive the vaccine. This falls far short of the World Health Organization (WHO) target set at 75%.1 This is especially important for children who remain unimmunised despite having medical conditions that place them at higher risk of contracting a disease.

The benefits of vaccinating these groups are clear. Anecdotal evidence from the school nurses in Liverpool responsible for meeting the health needs of children in special schools points to the benefits of a more flexible approach for those attending these schools and their families. Having to wait for vaccination at GP surgeries or clinics often causes distress to children with multiple and complex medical conditions, as well as to their parent or caregiver.

The National Institute for Health and Clinical Excellence (NICE) produced public health guidance on reducing differences in the uptake of immunisations, including targeted vaccinations, among children and young people aged 19 years and under.2 Focusing on increasing immunisation uptake in groups and settings where immunisation coverage is low, the document sets out actions to improve uptake by adopting a multi-faceted and coordinated approach brought together by a strategic immunisation plan.

Like the rest of the country in November 2010, Liverpool was experiencing post-flu pandemic fallout, dealing with a higher than normal rate of seasonal flu cases caused predominantly by the H1N1 virus. It was agreed that provision of flu vaccination should be prioritised to prevent further outbreaks.
Liverpool Primary Care Trust (LPCT) expressed concern at the extremely low uptake of influenza vaccine by children attending a ‘special school' - a cohort of approx 500 children who would normally access the flu vaccine through their GP. School nurses working in Liverpool's special schools did not routinely administer preschool or flu vaccinations, instead generally advising children to go to their GP. It was agreed that provision of flu vaccination should be prioritised to prevent further outbreaks.

The immunisation coordinator identified that additional resources were required to achieve this and developed an operational plan using an already successful ‘active patient managed' approach. This consists of clerical analyst and clinical collaborative working with special school leads and school nurses to support current service provision. It also provided the opportunity to cleanse and update the data held locally by Health Solution Wales (HSW), the child health information system.

In December 2010 there was an increase in mortality and morbidity as influenza activity escalated. The special school action plan was put in place to administer influenza vaccine within the special schools while ensuring that any children missing vaccines according to the national schedule were immunised. A meeting took place with the special school lead manager and team leader to obtain their support and discuss any operational issues.

Training tailored to the specific needs of the staff was planned by the vaccination and immunisation training lead and immunisation coordinator, and was undertaken to ensure the school nurses were fully competent to vaccinate the children across the entire national schedule.

Emphasis was given to the Health Protection Agency (HPA) algorithm for ‘vaccination of individuals with uncertain or incomplete immunisation status' to enable the staff to identify which vaccines were required for each child not fully immunised. The training session also included a review of the consent and capacity process, patient group directives and patient specific directive if required. Further discussions took place around the relevant Green Book 2006 chapters including the influenza flow chart.3

Liverpool Community Health (LCH) took a pragmatic approach to vaccinate all special school children but encouraged a two-pronged approach from the health visitors and primary care to improve uptake in both flu and all the vital signs targets. A letter was given to the parents of all children with long-term medical conditions advising that the influenza vaccine was recommended as the best way to protect their child and that the vaccine was available from their GP.

With the school Christmas holidays fast approaching, information about the plan to offer flu and all other missing vaccinations in special schools was communicated to primary care via the GP e-bulletin to make them aware of the plan and help reduce the risk of over immunisation.

Documentation of any vaccines undertaken in primary care is recorded on an unscheduled immunisation form and posted, faxed or transferred electronically to Liverpool Community Health's child health team on the day the vaccine is administered.

The school nurses confirmed with the headteachers in the nine special schools included in this cohort the dates and an adequate venue for the planned school vaccination sessions in January 2011. It was also agreed that during the sessions we would have the assistance of the educational support workers.
Parents received a consent form and letter informing them of the plan to offer all vaccinations in school sessions during the second week in January. This was given to parents by the school nurses with the DH information and easy-to-read leaflets staff had ordered locally from NHS publications.

The consent form included questions about childhood and any recent vaccination history, including Pandemrix and seasonal flu, to capture any vaccination administered in the GP surgery and not recorded on HSW at child health information. The consent form also included the ethnic monitoring information required to enable the child health team to record on the patient information system to comply with information governance.

The Active Patient Management (APM) team administrative
team process:

  • List of children attending each of the nine schools received.
  • Checked the HSW child health system for children already on the system.
  • Moved children not on HSW.
  • Printed a screen shot of immunisations for all children on lists.
  • Printout given to immunisers.
  • On receipt of consent form, immunisations inputted onto system.
  • Demographics and ethnicity updated to match information on consent forms.
  • For ethnic coding still missing, lists sent to individual school nurses and updated on receipt.

Due to the complexity of the 2010/2011 flu campaign and the preschool national schedule the immunisation coordinator and vaccination and immunisation strategy training lead gave specialist support to the staff throughout enabling them to respond to parental queries. The APMT immunisers gave clinical immunisation support to all nine schools involved. Vaccines and other equipment were ordered and stored in a central location.

At the end of the project all the vaccination information held at the GP, the child health information and the children's school records had been updated. The school health nurses have confidence that all their school records are now updated and are aware of any children who are unimmunised and the reason why. Each school will develop their own local strategies to address this gap.

As a result of this project, this approach is now to be mainstreamed and the special school nurses are able to provide influenza vaccination to the children attending special school.

The feedback from parents was extremely positive. It was evident that there was an increasing trend not to access vaccines in primary care due to a variety of reasons experienced by these special school children and their parents.
The parents had confidence that their children were supported in school by staff they were familiar with, who had an understanding of their family and any physical, social or emotional needs with knowledge of their complex medical conditions and vaccinated by competent immunisers. The project was successful in:

  • Offering a bespoke service for children and families to receive vaccination in a familiar environment in a timely manner.
  • Responding to the individual needs of special school children and their families by improving flexibility, increasing access and breaking down barriers.
  • Providing teenage children leaving special school education who will not access higher education the opportunity to complete all relevant vaccination schedules.
  • Contributing towards herd immunity and the reduction of health inequalities in vaccination.
  • Collaborative working across school/neighbourhood and primary care.
  • Providing staff with the appropriate specialist support to improve and develop their skills in vaccination.
  • Mainstreaming into practice as an integral part of the Vaccination & Immunisation Strategy.

References
1.    Department of Health (DH). Preparation and Assurance for 2011/12 Seasonal Influenza immunisation Programme. London: DH; 2011. 
2.     National Institute for Health and Clinical Excellence (NICE). Reducing differences in the uptake of immunisations (including targeted vaccines) among children and young people aged under 19 years. London:
NICE; 2009.
3.     Department of Health (DH). Immunisation against infectious diseases (the ‘Green Book'). London: DH; 2006.