WHO child immunisation targets are now regularly missed, with the pandemic and inequality of access taking the blame. Wiliam Hunter investigates initiatives to tackle the problem and looks at the importance of nursing expertise in any potential solutions
The outbreak of the Covid-19 pandemic saw the topic of vaccination gain huge importance in the lives of patients and clinicians. However, a glance at the statistics for routine childhood and adolescent vaccination tells another story.
While the rollout of the Covid-19 vaccination has been praised as a success in public health policy, uptake of other vaccinations has been in near-freefall, with the UK health security agency (UKHSA) recently warning that young people are now at risk of disease due to declining immunisation rates.
Data released by UKHSA show that, during the 2021/22 academic year, uptake of Td/IPV and MenACWY vaccines for children in Year 9 (age 13-14) was 69%, around 7% lower than the previous year and well below pre-pandemic levels.1 The two vaccinations protect children from tetanus, diphtheria, polio and four types of meningococcal disease.
Now, with uptake well below the 95% target set by the World Health Organization, Professor Helen Bedford, professor of children’s health at UCL Great Ormond Street Institute of Child Health, says ‘there is a real risk of having big outbreaks’ of these diseases.
She cites recent incidents to illustrate her point. ‘We’ve had diphtheria in asylum seekers, and polio in sewage water. These are really striking demonstrations that if we don’t keep vaccinations up, these diseases can get a hold.’
Why is uptake continuing to fall?
Based on the changes in uptake since 2019, one common response has been to ascribe falling rates to missed appointments during the national lockdowns.
A study published by researchers at the University of Oxford found pandemic-related disruption had led to a global drop in uptake.2
However, as Professor Bedford and many others have pointed out, the decline in uptake started well before the arrival of Covid-19.
‘The decline has been going on for 10 years now,’ Professor Bedford tells Nursing in Practice. She attributes the beginning of the decline in England to the NHS reforms in 2013, which changed the way immunisation services were commissioned. This included the introduction of CCGs and the transfer of responsibility for the health service from the Department of Health and Social Care to NHS England.
Crucially, the 2013 reorganisation also removed the role of immunisation coordinator in England. This position carried responsibility for ensuring nurses were trained to national minimum standards for immunisation, as well as for supporting surgeries that had lower uptake.
RCN professional lead for primary care Heather Randle explains the importance of the role and why it has been missed: ‘They would run the programmes and then go out to do the assessing. That built their relationship with the nurses so that when nurses had problems, they could go to them.
‘They would also support practices where rates had dropped to get their immunisation rates back up, and I feel that there is a really big gap now.’
There are also growing concerns that Covid-19 might have had a long-term impact on uptake rates by damaging trust in healthcare services and increasing rates of hesitancy.
Sharon White, chief executive of the School and Public Health Nurses Association (SAPHNA), tells Nursing in Practice school nurses are being asked more questions by parents, teachers and pupils around ‘anti-vax propaganda information’.
Ms White believes ‘mixed and sometimes contradictory’ messaging around vaccinations during the pandemic has ‘dented confidence significantly’.
Likewise, Professor Bedford says parents now have more concerns and questions in relation to vaccinating their children than a decade ago, because of the rise in ‘misinformation or even disinformation’ around the subject of vaccinations.
Similarly, GP partner Dr Priya Kumar, who is NHS health inequalities lead for Slough, says a lack of clear communication over the Covid vaccines may have harmed public confidence.
She says some patients who had a Covid-19 vaccine but still contracted the virus may not now see the value of routine immunisation, perhaps due to a lack of understanding of the different function of those immunisations.
‘We’ve had families who think that because of the vaccine their loved ones have died, and people who think “I’ve had Covid, I didn’t die. So, what are all these other vaccines, and do we really need them?’’’
Yet a number of experts, including Professor Bedford, are not convinced that anti-vax sentiment or vaccine hesitancy have been significant drivers of reduced immunisation uptake.
Furthermore, as Ms White points out, patients asking questions about their own healthcare is not a bad thing, provided there are trained professionals available to answer those questions.
Ms White says: ‘There is a healthy debate to be had and, particularly with adolescents, we should be encouraging people to take responsibility for their own health and ask those questions.’
Helen Donovan, nurse consultant and vaccination expert, tells Nursing in Practice that while people might be asking more questions, this does not necessarily mean they are ‘vaccine hesitant’.
‘It’s quite normal for people to have questions,’ she says, ‘but that just means they are normal parents who want to make sure they are doing the right thing for their children. Studies done year on year show the number of people refusing vaccines is actually very low.
‘We cannot underestimate the importance of staff who are really well trained and educated. If you don’t have a good education within the staff, then you lose confidence from the public very quickly.
‘Staff need to feel confident to go the extra mile when having those conversations, so education is critical.’
Improving vaccine access
When discussing how to improve vaccination uptake clinicians may reference the ‘Three Cs’ model: Confidence, Complacency, Convenience.
An educated workforce with time to speak to patients can help bring down complacency and boost confidence, but that has little effect if patients can’t access those services and workforce to begin with.
For Dr Kumar, increasing convenience was her primary goal when she implemented a multigenerational home-visiting service in Slough, where most practices were missing their target for preschool boosters and 14% of the population live in multigenerational households. Funded by the local vaccination board, local primary care networks identified all such households with children who had not had their booster.
Dr Kumar says more than 150 different languages are spoken in Slough, so it is hard to achieve an increase in uptake of immunisation services by simply sending out invitation letters as normal.
Home visits were arranged to create an opportunity to offer vaccinations in peoples own homes. Initially, a total of 103 homes were visited and an additional 68 vaccinations were administered, alongside other health checks for older household members.
‘This disproves that it is only vaccine hesitancy,’ says Dr Kumar, ‘because when we reached out, we were able to do many more injections.
‘Some of these people are working zero-hours contracts; they can’t afford to miss work to come for an appointment. They want to get their child immunised, but they can’t actually afford to miss work or get the bus to come to town. It’s really small things sometimes that are compounding why these people aren’t accessing us.’
Given the challenges some families face, Lorraine Meadows, head of service and clinical lead for the Child Health Information Service (CHIS) for South Central and West NHS, says it is ‘no wonder families weren’t accessing services’.
Yet, while Covid-19 may have impacted negatively on vaccine confidence, Jane Lambert, chief executive of ECG Healthcare, which provides vaccination training for primary care staff, says it has also given healthcare leaders the freedom to work more flexibly to improve access.
‘I don’t think that children going into their GP practice for immunisations is sustainable, that could be the first choice of location but there need to be other options to access.’
Ms Lambert, a registered nurse, describes a project she is undertaking with Northampton Council to provide a mobile vaccination bus.
The council provides the bus and drivers while ECG Healthcare staffs the bus with nurses. Currently the service is commissioned to carry out Covid-19 and flu vaccinations as well as health checks, but Ms Lambert hopes to expand the service to catch-up immunisations.
‘The point of the bus is to get to people in hard-to-reach communities, and to give people another opportunity.
‘Sometimes we’re in a really deprived area, sometimes we’re outside Tesco, but it’s about actually trying to make healthcare more convenient.’
Immunisation into the future
There remains little consensus on how to go about making healthcare access more convenient. While immunisation uptake rates in England fell during lockdown, research from 2022 found that uptake of infant and preschool immunisations in Scotland was improved during this time.3 This was thought to be due to active measures taken to promote immunisation at local and national levels.
Programmes like Dr Kumar’s outreach service achieve good results by targeting the proportion of the population considered least likely to access immunisation services in traditional settings.
Likewise, Ms Meadows and her colleague Charlotte Marshall, CHIS inequalities insights lead at South Central and West NHS, tell Nursing in Practice they have achieved significant improvements through targeted support for struggling practices.
But, while Ms Meadows believes ‘GPs need to get into the community more’, such programmes are costly in terms of resources and time, and require lots of data.
On the other side of debate, Ms Lambert says she would like to see immunisation move further out
into the community. In a view that was recently supported by health minster Maria Caulfield, she suggests nurse-led immunisation could also be run out of community pharmacies, which she says have an excellent model of access.
‘They’re open evenings, they’re open weekends, and people have developed a good rapport and trust with their community pharmacist over years.’
Ms Lambert says these advantages, if combined with nurses’ experience and confidence with patients, could mean nurse-led immunisation from venues such as community pharmacies becomes a valuable future option.
Falling rates of immunisation could ultimately be tackled in a number of ways, and it is clear nurses will continue to have a central role to play.
- UK Health Security Agency. Young people at risk of disease as concerning numbers miss out on life-saving vaccines. 2023. tinyurl.com/UKHSA-imms
- Heneghan C et al. The impact of COVID-19 restrictions on childhood vaccination uptake. Preprint. DOI: 10.1101/2021.06.25.21259371
- McQuaid F et al. Uptake of infant and preschool immunisations in Scotland and England during the COVID-19 pandemic. PLoS Med 2022;19:2:e1003916. tinyurl.com/McQuaid-uptake