A process evaluation of how the routine vaccination programme is implemented at GP practices in England

Preferences of nurses in the United Kingdom for attributes of pediatric hexavalent vaccines: a discrete-choice experiment

OBJECTIVES

Given the limited evidence on UK nurses' preferences for pediatric hexavalent vaccines, we aimed to evaluate their preferences for these vaccines' attributes.

METHODS

In a discrete-choice experiment study, 150 nurses chose between 2 hypothetical pediatric hexavalent vaccines with varying attribute levels (device type, plastic in packaging, time on the market, and time the vaccine can stay safely at room temperature) in a series of choice questions. Using random-parameters logit-model estimates, conditional relative attribute importance (CRAI) and odds ratios (ORs) were calculated.

RESULTS

Device type (with associated preparation time and risk of dosage errors) was the most important attribute (CRAI, 61%), followed by years on the market (CRAI, 25%). The odds of choosing a prefilled syringe were nearly 3 times the odds of choosing syringe-and-vial combinations requiring reconstitution (OR, 2.80; 95% confidence interval [CI], 1.93-3.68). Vaccines on the market for < 1 year were less likely to be preferred to vaccines available for > 3 years (OR, 0.66; 95% CI, 0.47-0.84). ORs for time a vaccine can stay at room temperature (3 vs. 6 days) (0.94; 95% CI, 0.71-1.16) and plastic blisters in packaging (1.19; 95% CI, 0.80-1.56) were not significant, indicating that these attributes did not influence choices.

CONCLUSIONS

In this survey, nurses' preferences were mainly influenced by device type.

The association of maternal mental health with vaccination coverage and timeliness in early childhood - A historical cohort study in England using electronic health records

BACKGROUND

Maternal mental illness (MMI) affects almost a quarter of mothers and may impact a child's development and physical health. It remains unclear whether MMI is associated with altered utilization of vaccination services. Understanding this association could help to identify families in need of additional support.

METHODS

Using primary care data from England, we conducted a historical cohort study of 397,519 children born in England between 2006 and 2014 with linked maternal records. Associations between different types of MMI (common mental disorders, severe mental illness and alcohol and substance use disorder) with childhood immunisation were explored using logistic regression for differences in coverage and accelerated failure time models for differences in timeliness before the child's fifth birthday.

RESULTS

While there were no differences in vaccination coverage at the age of one, children of mothers with common mental disorders had lower odds of being vaccinated at the ages of two (OR 0.95, 95 %CI: 0.93-0.98) and five (OR 0.86, 95 % CI 0.84-0.89) in comparison to children of mothers with no record of MMI. Vaccination coverage was even lower for children of mothers with comorbid substance disorder and common mental disorder (OR 0.70, 95 % CI: 0.62-0.78 at the age of five). There were no significant differences in timeliness of vaccine receipt by MMI.

CONCLUSIONS

Inequalities in vaccination coverage associated with MMI grow with increasing age of the child. Extending support services for women with MMI beyond the child's first year of life could offer potential to improve vaccination uptake and reduce childhood infections.

A new neonatal BCG vaccination pathway in England: a mixed methods evaluation of its implementation

INTRODUCTION

The introduction of a national evaluation of newborn screening for Severe Combined Immunodeficiency (SCID) in England triggered a change to the selective Bacillus Calmette-Guerin (BCG) vaccination programme delivery pathway, as this live attenuated vaccine is contraindicated in infants with SCID. The neonatal BCG vaccination programme is a targeted programme for infants at increased risk of tuberculosis and used to be offered shortly after birth. Since September 2021 the BCG vaccine is given to eligible infants within 28 days of birth, when the SCID screening outcome is available. We explore the experiences of those implementing the new pathway, and how they made sense of, engaged with, and appraised the change.

METHODS

A mixed-methods evaluation was conducted between October 2022 and February 2023. This involved national online surveys with BCG commissioners and providers and qualitative semi-structured interviews with commissioners, providers, and Child Health Information System stakeholders in two urban areas. Survey data was analysed using descriptive statistics and interview data was analysed thematically. The data was triangulated using Normalization Process Theory as a guiding framework.

RESULTS

Survey respondents (n = 65) and qualitative interviewees (n = 16) revealed that making sense of the new pathway was an iterative process. Some expressed a desire for more direction on how to implement the new pathway. The perceived value of the change varied from positive, ambivalent, to concerned. Some felt well-prepared and that improvements to data capture, eligibility screening, and accountably brought by the change were valuable. Others were concerned about the feasibility of the 28-day target, reductions in vaccination coverage, increased resource burden, and the outcome of the SCID evaluation. New collaborations and communities of practice were required to facilitate the change. Three main challenges in implementing the pathway and meeting the 28-day vaccination target were identified: appointment non-attendance; appointment and data systems; and staffing and resourcing. Feedback mechanisms were informal and took place in tandem with implementation.

CONCLUSION

The new NHS neonatal BCG service specification has created an effective structure for monitoring and managing the BCG vaccination programme, but further work is required to support delivery of the 28-day vaccination target and improve uptake rates.

Timeliness of childhood vaccination in England: A population-based cohort study

INTRODUCTION

Vaccine surveillance for children in England focuses on coverage at ages 1, 2, and 5 years. Previous studies exploring vaccine timeliness have used different arbitrary categories to define whether vaccines were received 'late' or 'on time'. This paper aims to provide more detailed and holistic information on timing and patterns of vaccine uptake across the childhood immunisation schedule in England.

METHODS

We included all children born in England between 2006 and 2014 and registered in the Clinical Practice Research Datalink (CPRD) Aurum, a primary care electronic health record. We described vaccine uptake for representative antigens (pertussis, pneumococcus, measles) by age in days and stratified by ethnicity, region and birth cohort. Alluvial diagrams were used to illustrate common journeys through the vaccination schedule, and we applied survival analysis using accelerated failure time models (AFT) to predict age of vaccine receipt based on timing of previous doses.

RESULTS

573,015 children were followed up until their fifth birthday, when they had 90.16 % coverage for two doses of measles, mumps, rubella (MMR) vaccine and 88.78% coverage for four doses of diphtheria, tetanus, pertussis (DTP) vaccine. Overall, the later the age at which a vaccine was due, the more delay in vaccination. Children of Black Ethnicity or from London showed deviating uptake patterns. If a child received their third DTP dose more than a year later than recommended, they would receive the next dose 2.7 times later than a child who was vaccinated on time. A smaller delay was found for children who did not receive first MMR dose on time.

DISCUSSION

We showed that the risk of vaccination delay increased with the age of the child and significant delay of previous doses. Primary care data can help to promptly identify children at higher risk of delayed vaccination.

Projected health and economic outcomes of extending public funding of pharmacy services to include administration of Pneu23 and Td/Tdap immunizations by pharmacy practitioners in New Brunswick

Background

Although legislation permits New Brunswick pharmacy professionals to administer a wide range of immunizations, public funding for these services is currently limited to immunizations against influenza and COVID-19 and was recently extended to include pneumococcal immunization (Pneu23) in individuals aged 65 years or older. We used administrative data to project health and economic outcomes associated with the current Pneu23 program and with extension of public funding to include: 1) younger adults aged 19 years or older in the Pneu23 program, and 2) tetanus boosters (Td/Tdap).

Methods

Two model scenarios were compared: a Physician-Only model in which physicians remain the only practitioners to administer publicly funded Pneu23 and Td/Tdap, and a Blended model in which this service is also provided by pharmacy professionals. Immunization rates by practitioner type were projected based on physician billing data accessed via the New Brunswick Institute for Research, Data and Training in conjunction with trends observed with influenza immunization by pharmacists. These projections were used along with published data to estimate health and economic outcomes under each model.

Results

Public funding of Pneu23 (65+), Pneu23 (19+) and Td/Tdap (19+) administration by pharmacy professionals is projected to yield increased immunization rates and physician time savings compared with the Physician-Only model. Public funding of Pneu23 and Td/Tdap administration by pharmacy professionals in those aged ≥19 years would result in cost savings, owing primarily to productivity losses avoided in the working age population.

Discussion

Increased immunization rates, physician time savings and cost savings may be realized if public funding were extended to include administration of Pneu23 in younger adults and Td/Tdap, by pharmacy practitioners.

Implementation of a quality improvement programme using the Active Patient Link call and recall system to improve timeliness and equity of childhood vaccinations: protocol for a mixed-methods evaluation

INTRODUCTION

Call and recall systems provide actionable intelligence to improve equity and timeliness of childhood vaccinations, which have been disrupted during the COVID-19 pandemic. We will evaluate the effectiveness, fidelity and sustainability of a data-enabled quality improvement programme delivered in primary care using an Active Patient Link Immunisation (APL-Imms) call and recall system to improve timeliness and equity of uptake in a multiethnic disadvantaged urban population. We will use qualitative methods to evaluate programme delivery, focusing on uptake and use, implementation barriers and service improvements for clinical and non-clinical primary care staff, its fidelity and sustainability.

METHODS AND ANALYSIS

This is a mixed-methods observational study in 284 general practices in north east London (NEL). The target population will be preschool-aged children eligible to receive diphtheria, tetanus and pertussis (DTaP) or measles, mumps and rubella (MMR) vaccinations and registered with an NEL general practice. The intervention comprises an in-practice call and recall tool, facilitation and training, and financial incentives. The quantitative evaluation will include interrupted time Series analyses and Slope Index of Inequality. The primary outcomes will be the proportion of children receiving at least one dose of a DTaP-containing or MMR vaccination defined, respectively, as administered between age 6 weeks and 6 months or between 12 and 18 months of age. The qualitative evaluation will involve a 'Think Aloud' method and semistructured interviews of stakeholders to assess impact, fidelity and sustainability of the APL-Imms tool, and fidelity of the implementation by facilitators.

ETHICS AND DISSEMINATION

The research team has been granted permission from data controllers in participating practices to use deidentified data for audit purposes. As findings will be specific to the local context, research ethics approval is not required. Results will be disseminated in a peer-reviewed journal and to stakeholders, including parents, health providers and commissioners.

Time and labour costs of preventive health care, including vaccinations, in Finnish child health clinics

In Finland all children are entitled to regular health check-up visits at child health clinics (CHC). During the visits public health nurses and physicians follow-up the growth and development of the child, evaluate the welfare of the family, give health counselling and vaccinate the children. The aim of this study was to measure the time used by the nurses and physicians for different tasks during the visits and evaluate the costs of preventive health care procedures. Special emphasis was on time and costs used for administering vaccinations. The study was conducted in four CHCs. Trained observers measured the time used for predefined tasks with a stopwatch application operating on a tablet computer. Labour costs of visits and vaccinations were evaluated by using the gross average salary costs of health care personnel. Time used for vaccine logistics and other administrative tasks was obtained by interviewing the nurses in charge of the vaccine logistics at each CHC. Altogether 325 CHC visits of children <13 months were followed. Public health nurse used for a visit in average 49 (range 12-101) minutes, and the corresponding labour costs were 17 (4-35) Euros. Vaccines were administered at 183 visits. Children got on average 2.4 (1-4) vaccine doses per visit. The observed time used for vaccinations was 10.2 (1.6-25) minutes and the costs 3.58 (0.57-8.62) Euros per visit. The observed time included guidance, preparation, administration, and documentation of vaccinations. Adding one dose into a visit increased the time spent on vaccination on average 2.8 minutes (0.99 Euros). The mean non-observed time used for vaccine logistics outside the visits was 3.4 minutes and cost 1.19 Euros per dose. Administering of the vaccines of the Finnish vaccination programme is relatively simple and inexpensive because Finnish children have regular scheduled visits to CHCs.

Sex and age as determinants of the seroprevalence of anti-measles IgG among European healthcare workers: A systematic review and meta-analysis

INTRODUCTION

The international literature shows good evidence of a significant rate of measles susceptibility among healthcare workers (HCWs). As such, they are an important public health issue.

METHODS

We conducted a systematic review and meta-analysis to estimate the prevalence of susceptible HCWs in EU/EEA countries and in the UK and to explore the characteristics (sex and age differences) and management of those found to be susceptible.

RESULTS

Nineteen studies were included in the meta-analysis. The prevalence of measles-susceptible HCWs was 13.3% (95 %CI: 10.0-17.0%). In a comparison of serosusceptible female vs. male HCWs, the RR was 0.92 (95 %CI = 0.83-1.03), and in a comparison of age classes (born after vs. before 1980) the RR was 2.78 (95 %CI = 2.20-3.50). The most recent studies proposed the mandatory vaccination of HCWs.

DISCUSSION

According to our meta-analysis, the prevalence of serosusceptible European HCWs is 13%; HCWs born in the post-vaccination era seem to be at higher risk. Healthcare professionals susceptible to measles are a serious epidemiological concern. Greater efforts should therefore be made to identify those who have yet to be vaccinated and actively encourage their vaccination.

Model-Based Planning and Delivery of Mass Vaccination Campaigns against Infectious Disease: Application to the COVID-19 Pandemic in the UK

Vaccination plays a key role in reducing morbidity and mortality caused by infectious diseases, including the recent COVID-19 pandemic. However, a comprehensive approach that allows the planning of vaccination campaigns and the estimation of the resources required to deliver and administer COVID-19 vaccines is lacking. This work implements a new framework that supports the planning and delivery of vaccination campaigns. Firstly, the framework segments and priorities target populations, then estimates vaccination timeframe and workforce requirements, and lastly predicts logistics costs and facilitates the distribution of vaccines from manufacturing plants to vaccination centres. The outcomes from this study reveal the necessary resources required and their associated costs ahead of a vaccination campaign. Analysis of results shows that by integrating demand stratification, administration, and the supply chain, the synergy amongst these activities can be exploited to allow planning and cost-effective delivery of a vaccination campaign against COVID-19 and demonstrates how to sustain high rates of vaccination in a resource-efficient fashion.

Keep calm and carry on vaccinating: Is anti-vaccination sentiment contributing to declining vaccine coverage in England?

BACKGROUND

In England, coverage for childhood vaccines have decreased since 2012/13 in the context of an increasingly visible anti-vaccination discourse. We determined whether anti-vaccination sentiment is the likely cause of this decline in coverage.

METHODS

Descriptive study triangulating a range of data sources (vaccine coverage, cross-sectional survey of attitudes towards vaccination, UK-specific Twitter social media) and assessing them against the following Bradford Hill criteria: strength of association, consistency, specificity, temporality, biological gradient and coherence.

RESULTS

Strength of association: compared with well-documented vaccine scares, the decline in childhood vaccination seen since 2012/13 is 4-20 times smaller; consistency: while coverage for completed courses of the hexavalent and meningococcal vaccines decreased by 0.5-1.2 percentage points (pp) between 2017 and 2019, coverage for the first dose of these vaccines increased 0.5-0.7 pp; specificity: Since 2012-13, coverage decreased for some vaccines (hexavalent, MMR, HPV, shingles) and increased for others (MenACWY, Td/IPV, antenatal pertussis, influenza in 2 years of children), with no age-specific patterns. Temporality and biological gradient: the decline in vaccine coverage was preceded by an increase in vaccine confidence and a decrease in the proportion of parents encountering anti-vaccination materials. Coherence: attitudes towards vaccination expressed on Twitter in the UK became increasingly positive between 2017 and 2019 as vaccine coverage for childhood vaccines decreased.

CONCLUSIONS

In England, trends in vaccine coverage between 2012/13 and 2018/19 were not homogenous and varied in magnitude and direction according to vaccine, dose and region. In addition, confidence in vaccines increased during the same period. These findings are not compatible with anti-vaccination sentiment causing a decline in vaccine coverage In England.

What is the cost of delivering routine vaccinations at GP practices in England? A comparative time-driven activity-based costing analysis

Background: The expansion of available vaccines in recent years has increased the overall costs of the vaccine program and put pressure on providers responsible for vaccination. In England in 2016-17, GP practices responsible for vaccinating their local population were paid £227 million. However, the costs to general practice of delivering the program and the factors influencing these costs are unknown. Therefore, the aim of this study was to evaluate the costs of delivering the routine vaccination program at GP practices in England, to identify organizational factors impacting costs, and to compare these to the funding received.Methods: Time Driven Activity Based Costing was undertaken at a convenience sample of nine geographically and socio-economically diverse GP practices in 2017-2018. Cost data were gathered for the preceding year using a survey and clinical and administrative staff kept activity logs for a 2-week period.Results: The mean cost of delivering a childhood vaccination appointment was £18.20 (range £9.71-£25.97) and an adult appointment cost £14.05 (range £7.59-£20.88), of which 75% was for staff, 24% for facility costs and 1% for consumables. Organizational factors contributing to lower costs include: shorter length of allocated appointment; greater use of administrative and reception staff; lower working time for practice manager and practice nurse; and use of health-care assistants for adult vaccinations. The costs identified are lower than payments at all practices.Conclusions: Funding received for vaccination activities was higher than costs at included practices. Several organizational factors have been identified that impact on program delivery costs that could be modified.