Primary immunisations in Liverpool. II: Is there a gap between consent and completion?

Effect of socioeconomic deprivation on uptake of measles, mumps and rubella vaccination in Liverpool, UK over 16 years: a longitudinal ecological study

Suboptimal uptake of the measles, mumps and rubella (MMR) vaccine by certain socioeconomic groups may have contributed to recent large measles outbreaks in the UK. We investigated whether socioeconomic deprivation was associated with MMR vaccine uptake over 16 years. Using immunization data for 72,351 children born between 1995 and 2012 in Liverpool, UK, we examined trends in vaccination uptake. Generalized linear models were constructed to examine the relative effect of socioeconomic deprivation and year of birth on MMR uptake. Uptake of MMR1 by age 24 months ranged between 82·5% in 2003 [95% confidence interval (CI) 81·2-83·7] and 93·4% in 2012 (95% CI 92·7-94·2). Uptake of MMR2 by age 60 months ranged between 65·3% (95% CI 64·4-67·4) in 2006 and 90·3% (95% CI 89·4-91·2) in 2012. In analysis adjusted for year of birth and sex, children in the most deprived communities were at significantly greater risk of not receiving MMR1 [risk ratio (RR) 1·70, 95% CI 1·45-1·99] and MMR2 (RR 1·36, 95% CI 1·22-1·52). Higher unemployment and lower household income were significantly associated with low uptake. Contrary to concerns about lower MMR uptake in affluent families, over 16 years, children from the most socioeconomically deprived communities have consistently had the lowest MMR uptake. Targeted catch-up campaigns and strategies to improve routine immunization uptake in deprived areas are needed to minimize the risk of future measles outbreaks.

The impact of the media on the decision of parents in South Wales to accept measles-mumps-rubella (MMR) immunization

A large measles outbreak occurred in South Wales in 2012/2013. The outbreak has been attributed to low take-up of measles-mumps-rubella (MMR) immunization in the early 2000s. To understand better the factors that led to this outbreak we present the findings of a case-control study carried out in the outbreak area in 2001 to investigate parents' decision on whether to accept MMR. Parents who decided not to take-up MMR at the time were more likely to be older and better educated, more likely to report being influenced by newspapers [adjusted odds ratio (aOR) 3·07, 95% confidence interval (CI) 1·62-5·80], television (aOR 3·30, 95% CI 1·70-6·43), the internet (aOR 7·23, 3·26-16·06) and vaccine pressure groups (aOR 5·20, 95% CI 2·22-12·16), and less likely to be influenced by a health visitor (aOR 0·30, 95% CI 0·16-0·57). In this area of Wales, daily English-language regional newspapers, UK news programmes and the internet appeared to have a powerful negative influence. We consider the relevance of these findings to the epidemiology of the outbreak and the subsequent public health response.

Is there an association between the coverage of immunisation boosters by the age of 5 and deprivation? An ecological study

OBJECTIVE

To determine whether there was an association between the coverage of booster immunisation of Diphtheria, Tetanus, acellular Pertussis and Polio (DTaP/IPV) and second Measles, Mumps and Rubella (MMR) dose by age 5 in accordance with the English national immunisation schedule by area-level socioeconomic deprivation and whether this changed between 2007/08 and 2010/11.

DESIGN

Ecological study.

DATA

Routinely collected national Cover of Vaccination Evaluated Rapidly data on immunisation coverage for DTaP/IPV booster and second MMR dose by age 5 and the Index of Multiple Deprivation (IMD).

SETTING

Primary Care Trust (PCT) areas in England between 2007/08 and 2010/11.

OUTCOME MEASURES

Population coverage (%) of DTaP/IPV booster and second MMR immunisation by age 5.

RESULTS

Over the 4 years among the 9,457,600 children there was an increase in the mean proportion of children being immunised for DTaP/IPV booster and second MMR across England, increasing from 79% (standard deviation (SD12%)) to 86% (SD8%) for DTaP/IPV and 75% (SD10%) to 84% (SD6%) for second MMR between 2007/08 and 2010/11. In 2007/08 the area with lowest DTaP/IPV booster coverage was 31% compared to 54.4% in 2010/11 and for the second MMR in 2007/08 was 39% compared to 64.8% in 2010/11. A weak negative correlation was observed between average IMD score and immunisation coverage for the DTaP/IPV booster which reduced but remained statistically significant over the study period (r=-0.298, p<0.001 in 2007/08 and r=-0.179, p=0.028 in 2010/11). This was similar for the second MMR in 2007/08 (r=-0.225, p=0.008) and 2008/09 (r=-0.216, p=0.008) but there was no statistically significant correlation in 2009/10 (r=-0.108, p=0.186) or 2010/11 (r=-0.078, p=0.343).

CONCLUSION

Lower immunisation coverage of DTaP/IPV booster and second MMR dose was associated with higher area-level socioeconomic deprivation, although this inequality reduced between 2007/08 and 2010/11 as proportions of children being immunised increased at PCT level, particularly for the most deprived areas. However, coverage is still below the World Health Organisation recommended 95% threshold for Europe.

Making sense of perceptions of risk of diseases and vaccinations: a qualitative study combining models of health beliefs, decision-making and risk perception

Background

Maintaining high levels of childhood vaccinations is important for public health. Success requires better understanding of parents' perceptions of diseases and consequent decisions about vaccinations, however few studies have considered this from the theoretical perspectives of risk perception and decision-making under uncertainty. The aim of this study was to examine the utility of subjective risk perception and decision-making theories to provide a better understanding of the differences between immunisers' and non-immunisers' health beliefs and behaviours.

Methods

In a qualitative study we conducted semi-structured in-depth interviews with 45 Australian parents exploring their experiences and perceptions of disease severity and susceptibility. Using scenarios about 'a new strain of flu' we explored how risk information was interpreted.

Results

We found that concepts of dread, unfamiliarity, and uncontrollability from the subjective perception of risk and ambiguity, optimistic control and omission bias from explanatory theories of decision-making under uncertainty were useful in understanding why immunisers, incomplete immunisers and non-immunisers interpreted severity and susceptibility to diseases and vaccine risk differently. Immunisers dreaded unfamiliar diseases whilst non-immunisers dreaded unknown, long term side effects of vaccines. Participants believed that the risks of diseases and complications from diseases are not equally spread throughout the community, therefore, when listening to reports of epidemics, it is not the number of people who are affected but the familiarity or unfamiliarity of the disease and the characteristics of those who have had the disease that prompts them to take preventive action. Almost all believed they themselves would not be at serious risk of the 'new strain of flu' but were less willing to take risks with their children's health.

Conclusion

This study has found that health messages about the risks of disease which are communicated as though there is equality of risk in the population may be unproductive as these messages are perceived as unbelievable or irrelevant. The findings from this study have implications beyond the issue of childhood vaccinations as we grapple with communicating risks of new epidemics, and indeed may usefully contribute to the current debate especially in the UK of how these theories of risk and decision-making can be used to 'nudge' other health behaviours.

Invasive Haemophilus influenzae disease: an ecological study of sociodemographic risk factors before and after the introduction of Hib conjugate vaccine

This study examines the impact of H. influenzae type b (Hib) conjugate vaccine on sociodemographic risk factors for invasive H. influenzae disease in the 2 years before and immediately after the introduction of Hib conjugate vaccine. An ecological study design was used and cases were identified using active surveillance employing several surveillance systems. The study population comprised all children aged < 5 years resident in the West Midlands, an English health region, with laboratory confirmed invasive disease 2 years before (1990-1992) and 2 years after (1992-1994) the introduction of Hib conjugate vaccine. Selected sociodemographic variables derived from the UK census were obtained for all census enumeration districts in the region. Each variable was then ranked and divided into six categories. Linear associations between disease rates and sociodemographic variables were examined. Overall, there was a significant reduction in the incidence of invasive H. influenzae disease. In the pre-conjugate vaccine era there were trends of decreasing disease incidence with increasing child population density (p = 0.012) and total population density (p = 0.0023). In the post-conjugate vaccine period, total population density (p = 0.0275) remained significant and a trend of increasing disease incidence with increasing population mobility (p = 0.0012) was seen. Although Hib conjugate vaccine has resulted in a dramatic reduction in disease incidence changes in sociodemographic risk factors were identified in the post-conjugate vaccine period, particularly population mobility. Our results may have implications for current and future vaccine strategies.

Increases in vaccination coverage for children in child care, 1997 to 2000: an evaluation of the impact of government incentives and initiatives

OBJECTIVE

To compare vaccination coverage of children in child care before (1997) and after (2000) implementation of government immunisation strategies including parent/providers incentives and surveillance of vaccination uptake.

METHODS

Cross-sectional parent surveys of vaccination coverage for children (<3 years old regularly attending child care) in 47 child care centres and 19 councils operating family day care in metropolitan Melboume.

RESULTS

Data were collected for 1,578 (72%) children in 1997 and 1,793 (72%) in 2000. In 2000, 93% were completely immunised, a 9% (95% CI 6%-11%, p<0.001) increase from 1997. Less than 1% of children were unimmunised (0.8% in 1997, 0.5% in 2000). For those >2 years, 94% were completely immunised before their second birthday in 2000 compared with 80% in 1997. Immunisation levels were 10% (95% Cl 6-12) higher in 2000 than in 1997 for those receiving child care benefits compared with a 7% (95% Cl 3-10) increase for families not receiving benefits. In 1997, 8 (17%) child care centres and 4 (21%) councils reported > or = 90% children completely immunised increasing to 33 (70%) and 16 (84%) in 2000 respectively. Fewer families reported delaying immunisations because of minor illness in 2000 (27%) compared to 1997 (44%, p<.001). Updating immunisation data by child care coordinators increased from 51% in 1997 to 98% in 2000.

CONCLUSION

A substantial increase in immunisation uptake has been achieved for this population of young children attending child care. This study provides evidence that the increase in vaccination rates is attributable to some extent to increased surveillance of immunisation rates and both parent and provider incentives to immunise.

Equity of access to health care services: theory and evidence from the UK

The pursuit of equity of access to health care is a central objective of many health care systems. This paper first sets out a general theoretical framework within which equity of access can be examined. It then applies the framework by examining the extent to which research evidence has been able to detect systematic inequities of access in UK, where equity of access has been a central focus in the National Health Service since its inception in 1948. Inequity between socio-economic groups is used as an illustrative example, and the extent of inequity of access experienced is explored in each of five service areas: general practitioner consultations; acute hospital care; mental health services; preventative medicine and health promotion; and long-term health care. The paper concludes that there appear to be important inequities in access to some types of health care in the UK, but that the evidence is often methodologically inadequate, making it difficult to draw firm conclusions. In particular, it is difficult to establish the causes of inequities which in turn limits the scope for recommending appropriate policy to reduce inequities of access. The theoretical framework and the lessons learned from the UK are of direct relevance to researchers from other countries seeking to examine equity of access in a wide variety of institutional settings.

Immunisation uptake, services required and government incentives for users of formal day care

OBJECTIVES

To determine immunisation uptake in children attending formal day care prior to the introduction of certificates (state) and parent incentives (federal), and to document parent and child carers' attitudes to these strategies.

METHOD

In 1997, 60 child care centres and 300 family day carers in suburban Melbourne were randomly sampled. Immunisation dates, service use and preference, and views on government incentives were obtained from parents of children under three years of age.

RESULTS

From 2,454 eligible children, information was obtained for 1,779, of whom 84% (95% CI 82-86) were completely immunised. Low income (OR 1.8, 95% CI 1.2-1.9, p < or = 0.001) and larger family size (OR 1.8, 95% CI 1.2-2.7, p = 0.002) and only ever using a doctor (OR 1.6, 95% CI 1.1-2.3) was associated with incomplete immunisation. Main reasons for delaying immunisation were occurrence of minor illness and work commitments. Families would prefer immunisation services at Maternal and Child Health visits (39%), evening sessions (22%) and at day care (22%). Immunisation uptake could increase to 94% if those receiving Childcare Assistance (67%) immunised their children on time but would increase to 87% if these incentive only motivated those for whom Childcare Assistance was essential (15%). While 98% of day care co-ordinators and 71% of family day care co-ordinators documented immunisation status at commencement of child care, only 51% and 33% respectively regularly updated this information.

CONCLUSION

Providing client-focused, flexible immunisation services and government incentives and legislation may work together to boost immunisation levels for those in formal child care.

A retrospective cohort study of risk factors for missing preschool booster immunisation

AIM

To identify factors associated with non-uptake of preschool booster immunisation.

DESIGN

Data from the computerised child health system was used to study all children born in 1990 and living in South Glamorgan, Wales, on their 5th birthday. Factors associated with preschool booster uptake were investigated using multiple logistic regression.

RESULTS

Preschool booster coverage in the study cohort was 91.4%. After adjustment for other variables, uptake was associated most strongly with completed primary immunisation for diphtheria, tetanus, and polio vaccine or first dose measles, mumps, and rubella vaccine. Identifying children who miss either of these predicts 52.4% of those who miss the preschool booster.

CONCLUSION

Effective targeting of children who have missed previous immunisations could improve preschool booster uptake and ensure maximum uptake of at least one dose of measles, mumps, and rubella vaccine. Achieving optimum measles vaccine coverage is vital to achieve the goal of measles elimination.

Vaccine preventable diseases and immunisations: a qualitative study of mothers' perceptions of severity, susceptibility, benefits and barriers

This study investigated mothers' perceptions of vaccine-preventable diseases and associated vaccines in terms of perceived susceptibility, severity, benefits and barriers. A purposive sampling strategy was used to choose mothers whose only or youngest child was completely, incompletely (behind the recommended immunisation schedule) or partially (parents chose or advised not to have a specific immunisation) immunised or had no immunisations. Semi-structured interviews found that complete immunisers believed the risk of vaccines was lower than the risk from disease and that the likelihood of contracting many of these diseases was low. Incomplete immunisers perceived vaccines to be less effective in preventing disease and were often confused about which diseases the vaccines would protect against. Non-immunisers were more concerned about unknown, long-term side effects of vaccines than the diseases. Many mothers who did immunise believed that preventing diseases was not always possible and for diseases such as measles, mumps and rubella, it was not always necessary nor desirable. Vaccines were perceived as placing stress on the immune system rather than strengthening it. Important themes relating to barriers to the decision to immunise were a lack of 'balanced', detailed information and poor communication between health providers and parents. The major barrier to timely, age-appropriate immunisations was the occurrence of minor illnesses in the target child or the family. This study found that many mothers were balancing the risks of immunising with the risks of not immunising and this must be taken into account, along with factors such as difficulties in obtaining immunisations.

Home vaccination for children behind in their immunisation schedule: a randomised controlled trial

OBJECTIVE

To ascertain the effectiveness of a home vaccination service for children behind in their vaccination schedule.

DESIGN

Randomised controlled trial of nurse-administered vaccination at home. Children were allocated at random to the intervention or the control group before any contact with the parents was made.

SETTING

10 council areas in north-west metropolitan Melbourne defined by 56 postcode zones. Six-week intervention period from November 1996.

PARTICIPANTS

405 children--all those in the study area (n = 2610) 90 days late (age 9 months) for their third diphtheria-tetanus-pertussis/poliomyelitis/Haemophilus influenzae type B (DTP/OPV/Hib) vaccination, or 120 days late (age 16 months) for their measles-mumps-rubella (MMR) vaccination, according to the Australia Childhood Immunisation Register.

MAIN OUTCOME MEASURES

Number of children completing DTP/OPV/Hib or MMR during the intervention period, and number up to date before intervention.

RESULTS

Verification of vaccination status with the parents revealed that 123 (60%) of the children in the intervention group and 113 (56%) of those in the control group were up to date with their vaccinations, leaving a study population of 81 (intervention group) and 88 (control group). Vaccination was achieved in 46 (57%) intervention children and 24 (27%) control children (risk ratio [RR], 2.08; 95% CI, 1.4-3.1; P < 0.001). For DTP/OPV/Hib, 18/32 (56%) intervention children and 12/36 (33%) control children were vaccinated, (P = 0.06). For MMR, 28/49 (57%) and 12/52 (23%) children were vaccinated, respectively (P < 0.001). Home vaccinations were completed with 26 families (including five siblings). The average cost per child vaccinated as a result of the home program was $92.52.

CONCLUSION

Home vaccination for children behind in their immunisation schedule is an effective, acceptable and relatively cheap method of completing recommended vaccinations. We recommend that a home vaccination program be widely implemented and made available, particularly for disadvantaged families.

Primary immunisations in Liverpool. I: Who withholds consent?

The association between parents in Liverpool consenting to their children being invited for primary immunisations and five sociodemographic factors, namely sex, position of child in the family, family type, migration into Liverpool since birth, and local deprivation was examined. Rates of consent to invitation were over 97% for each antigen except pertussis, which had a consent rate of 83%. Consent to invitation for pertussis vaccine was least likely to have been given for boys, children with older siblings, those recorded as living with a single parent, and those in the most deprived areas. Local deprivation also had an effect on consent to the measles, mumps, and rubella vaccine. Migration into Liverpool had a significant effect on consent to invitation for all antigens except pertussis. The child's sex, family type, and local deprivation had no effect on consent to diphtheria, tetanus, and polio immunisations. Maximising pertussis vaccine uptake will require more attention to be paid to those parents who have been identified as being less likely to give consent. It is particularly important that consistent and clear advice about immunisations is made available to parents with two or more children, lone parents, and those living in materially deprived areas. Our findings challenge some of the assumptions underlying the principles of 'first parent visiting', at least so far as pertussis is concerned.