Improving vaccine uptake: An overview

Abstract

A task group was formed with the aim to improve the quality of the service offered by ensuring that all children waiting for an appointment for vaccination would be offered one at the earliest opportunity. Children aged between 12 mo–5 y that were not completely immunized for their age were identified and included in a pilot catch-up session. Following evaluation of the pilot session, four further immunization sessions were delivered. A total of 398 children attended the four sessions, representing an improved attendance rate of 39%. Most parents brought their children between 11am–3pm and 728 vaccines were administered: 339 MMR; 255 Pre-school boosters; 53 Hib/MenC and 81 PCV. Uptake of MMR vaccine in the PCT at age 24 mo increased by 9% by Q3 2008. For children aged five years, uptake of the first dose of MMR vaccine increased from 91.9% to 94% for the first dose and from 82.3 to 82.5% for the second dose by Q3 2008. This project demonstrates that new ways of delivering immunization sessions can be successfully implemented which can enhance access through the use of alternative venues and subsequently lead to increased vaccine uptake.

Introduction

The childhood immunization program in the UK ensures that children are offered protection from vaccine preventable diseases that could have a significant impact upon their health and wellbeing. To ensure optimum benefit from the childhood immunization program, it is essential to ensure that children are immunized at the appropriate age and that they receive all doses for each course. Although Primary Care Trusts (PCTs) may have agreed local targets for vaccine uptake, most aspired to achieve 95% uptake for each vaccine as recommended in the European operational targets set by the World Health Organization (WHO) during 1996.¹

During November 2012, the UK Vaccine Update² reported that annual MMR vaccine uptake had exceeded 90% for the first time since 1997/98, and while this may be a real change in terms of vaccine uptake, the Health and Social Care Information Centre considered that the quality of the data reported could also impact on the trend observed so a cautious approach was advised when comparing the 2011/12 figures to those published in previous years.³ However, increased uptake was reported for all vaccines given at age 12, 24 and 60 mo both nationally and regionally.

There is no doubt that vaccination saves lives and the UK National Health Service (NHS) constitution enshrined the right to have the vaccines that the Joint Committee on Vaccination and Immunization (JCVI) recommends under a national immunization program. However, in addition to this ‘right’ it is acknowledged that all individuals have a responsibility in relation to vaccination and “should participate in important public health programs such as vaccination.”⁴

PCTs have been encouraged to explore vaccination uptake rates and to identify differences between population groups and geographical areas in terms of completion rates and access to immunization, the aim of which is to reveal variation in uptake and to help to prioritize action for disadvantaged and hard to reach groups.

Although improvement in vaccine uptake has been observed in recent years, further improvement is required because there is still variation in vaccine uptake across England; for example, uptake of DTaP/IPV/Hib at age 12 mo for Q2 2012 varied between 82.3% - 98.8%. In addition, some children do not complete the recommended course of vaccines which may mean that they remain susceptible to vaccine preventable disease. This is clearly demonstrated when reviewing MMR coverage data: during Q2 2012, 93.9% of children aged five years had received the first dose of MMR vaccine but only 87.5% had received their second dose.⁵ To provide optimum protection against vaccine preventable disease, individuals should ensure that they receive all doses of a recommended course.

In the UK, the Health Protection Agency (HPA),⁶ Department of Health (DH)⁷ and National Institute for Health and Clinical Excellence (NICE)⁸ have all made recommendations to enable organizations to improve vaccine uptake and to reduce the differences in the uptake of vaccines. Groups identified as being at particular risk of under-vaccination include: children in care, children with physical or learning difficulties, children of lone parents, hospitalized children, children not registered with a GP, minority ethnic groups and vulnerable adults such as asylum seekers and the homeless population, all of which may not routinely access health care services. In addition, issues such as childcare difficulties or a lack of transport have been described as logistical barriers which are associated with under-vaccination despite parents being motivated to vaccinate their children.⁹

Various strategies to improve childhood vaccine uptake have been reviewed and shown to be effective,¹⁰ but ensuring vaccine accessibility is acknowledged as a key quality criterion for an effective immunization program by the HPA who recommend offering vaccines in the setting that is most likely to achieve the highest uptake in the target group.¹¹

How This Can Work in Practice

During 2008, it was acknowledged that a backlog of children had developed in a PCT in the North West of England who were due an appointment for their immunizations but were waiting for the appointment. This was due to priority being given to the scheduling of appointments for younger children by the Child Health Computer System. A task group was formed with the aim being to improve the quality of the service by ensuring that all children waiting for an appointment for vaccination would be offered one at the earliest opportunity.

The task group identified alternative venues where immunization could be offered to those children waiting for an appointment and scheduled a date for a pilot session to take place. The expected outcomes from the session were that there would be a recorded increase in the uptake of pre-school vaccines, particularly MMR, and that the benefits of delivering immunization services in alternative venues could be explored and any lessons learned could be applied to future sessions.

Methodology

Pilot session

All children aged between 12 mo and 5 y that were not completely immunized for their age were identified from a search of child health records which was completed by the Child Health Systems manager. All General Practices were then sent the details of children registered at their practice for further validation of the data. If any inaccuracies were identified by the general practice, the records held on the child health system were updated. Children that were confirmed by their GP as having outstanding vaccines were then invited to one of the planned sessions.

The team for each session consisted of four immunizers per three hour slot; two nursery nurses; clerical support; the PCT Immunization Trainer; the PCT Immunization co-ordinator and a children’s entertainer. In addition, a named individual was identified at Child Health services that could be contacted using their direct telephone number in case of any queries regarding a child’s immunization history that were raised on the day.

As this was a new way of offering vaccination to children, a pilot catch-up session was planned for delivery in a local shopping center. This venue was selected due to its central location, easy access using public transport and close proximity to the surgery where patients being invited to the immunization session were registered. The venue was risk assessed by the immunization co-ordinator, the immunization lead trainer, infection control, the ambulance service and school health. Essential equipment was sourced and sufficient vaccines were ordered and stored in a local hospital pharmacy. It was agreed beforehand that only MMR or the pre-school booster vaccine would be offered at this session. The session ran from 9am–6pm with PCT immunizers and nursery nurses working three hour slots. The immunization co-ordinator was present throughout the day and a children’s entertainer attended for part of the day. Although attendance was on an appointment basis, children were offered a one hour time band during which to attend the session for vaccination rather than a specific time, this created potential for a large number of children to be waiting at any one time if all attended during their allocated time slot so a children’s entertainer was invited to work alongside the nursery nurses. This enabled all children waiting to be vaccinated to take part in activities such as balloon modeling and plate spinning before and after the intervention. In addition, the entertainer was also able to distract the small number of children that appeared anxious.

In total, 286 children were invited to the pilot session and 67 attended (representing a 24% uptake rate). Five children that had not been invited to the session were brought in and immunized as required on a drop-in basis. Children requiring vaccines in addition to MMR and/or the pre-school booster to bring them up-to-date with the current schedule were referred back to their Health Visitor / GP. Sixty-eight percent of children attended the session between the hours of 11am and 4pm and 139 vaccines were administered, of these, 70 were MMR and 69 were pre-school boosters.

The total cost for this session was approximately £650 (immunizers were working within their contracted hours with the agreement of the service lead). Although this event was not formally evaluated from a parents’ perspective, comments from parents attending the pilot session were positive.

Following evaluation of the pilot session, a recommendation was made to the PCT Board that a further four immunization sessions should be delivered in alternative venues and the recommendation was accepted. Planning took place and a further two sessions were organized for delivery in the same shopping center, and two sessions for delivery in community clinic buildings. Risk assessments were completed for the new venues following discussion with the Ambulance Service and Infection Control, vaccine storage and supply issues were addressed, a staffing rota was developed and equipment requested as necessary (e.g., screens, chairs, desks and children’s toys, etc.).

To promote the catch-up sessions and the pre-school childhood immunization program, postcards were developed and distributed locally. Methods of distribution included two local stores, which at that time were major suppliers of items of school uniform. Staff at these stores added a postcard to carrier bags when items of school uniform were purchased, local hairdressers displayed cards in salon waiting areas and the local library inserted a card in all children’s books borrowed. The postcards were also displayed at customer services desks in the shopping center. Messages used on the cards were taken from Department of Health immunization publications to ensure consistency of information for parents.

The use of postcards in this way to highlight the immunization program had several advantages, including being inexpensive to produce, able to reinforce national immunization campaign messages, being distributed during the time period when the invitations for the catch-up sessions were posted out to parents and, most importantly, they reached the target group. The limitations of this approach were the lack of control over who would receive a postcard once they had been left in the premises where agreement had been gained for their distribution. In addition, one large supermarket required agreement from their Head Office before they could agree to display the postcards.

Immunization Session Delivery

Although a task group steered the project, the Health Visiting Service delivered all clinical sessions with support at one session from the School Nursing Service. All sessions were planned by the Health Visiting Lead, the Immunization Co-ordinator and the Lead Immunization Trainer (HV), and each session was led by the Immunization Co-ordinator. Although sessions were very busy during the peak hours of 11am–3pm, immunizers reported that they felt confident at the sessions due to the peer support that was available. Immunizers were able to ‘pair up’ if required and to take immediate advice when necessary from the Immunization trainer or Immunization co-ordinator. The sessions offered the opportunity for Health Visitors from different teams to work together and for those who were less confident when immunizing to further develop their competency in immunization. Parents were invited to bring their child to attend the appointment by Child Health Computer Services and were allocated to a one hour time band during which they could attend.

Upon arrival at the session, a member of the clerical team collected in the child’s personal child health record and their invitation letter, which identified which vaccines they had been invited for. These were cross-referenced with the clinic list that had been prepared by the Child Health Computer Services Manager. If any discrepancies in the child’s immunization history were identified, a call was made to Child Health Services on a pre-agreed direct number for further clarification and confirmation. Further confirmation of immunization history was also available from the GP surgery at which the child was registered if required. The parent was then given a ticket to ensure they were seen in order of attendance. As no adverse incidents had occurred in relation to vaccine storage or administration at the pilot session, it was also agreed that Hib/MenC and Pneumococcal Conjugate Vaccine (PCV) vaccines would be available at the additional four sessions along with MMR and the pre-school booster. While waiting, children had the opportunity to play in the area set up for this purpose and to join in activities with the nursery nurses and the children’s entertainer.

Details of all vaccines administered were reported back to Child Health Services and to the GP that the child was registered with by fax within 24 h. The vaccine controller allocated vaccines to immunizers to ensure strict control of storage conditions and stock and collected further supplies from the hospital pharmacy as required. Children were immunized following normal PCT consent and pre-vaccination procedures. This involved discussion between the parent and the lead immunization trainer about why the child was attending the session, the vaccines that were being offered and follow-up advice.

Results

Based on the 24% attendance observed at the pilot session, approximately 250 children were invited to each of the four sessions (giving a total of 1,025 children). This gave an expected minimum attendance of 60 children per day over eight hours and between four immunizers. Although this may seem generous in terms of appointment time, it was acknowledged that additional children may attend the session and that extra time should be built into each session to allow for this.

A total of 398 children attended the four sessions (approximately 100 per session), representing a much improved attendance rate of 39%. Children attending were found to be registered with 12 different GP practices in the PCT which clearly demonstrated that parents are willing to travel to alternative venues if they are accessible and convenient. The majority of parents brought their children between 11am–3pm and a total of 728 vaccines were administered: 339 MMR; 255 pre-school boosters; 53 Hib/MenC and 81 PCV (Prevenar^®).

Parents views remained positive and included

“Really good idea, I am up here anyway doing the shopping so only needed to drop in”; “They know there is something wrong when you take them to the Doctors”; “Less stressful”; “More convenient”; “More child friendly”; “Excellent way of doing it.”

Discussion

Prior to the implementation of the project, uptake of MMR vaccine in the PCT at age 24 mo was recorded as being 79.6% during Q4 2007 (Jan–Mar 2008), this increased to 88.5% by Q3 2008 (Oct–Nov 2008) representing a 9% increase in uptake of MMR during the period when the catch-up sessions were delivered.⁵ For children aged five years, uptake of the first dose of MMR vaccine during Q4 2008 was 91.9%, and the second dose of MMR was 82.3%. This increased to 94% for the first dose and 82.5% for the second dose by Q3 2008.⁵

The present study was initiated to ensure that all children waiting for an appointment for vaccination would be offered one at the earliest opportunity and that there would be a recorded increase in the uptake of pre-school vaccines, particularly MMR. As this study was also using non-traditional venues such as a shopping center for some of the planned sessions, the benefits of delivering immunization services in alternative venues could be explored. The pilot sessions and the subsequent four sessions ensured that all children waiting for a vaccination appointment were offered one at the earliest opportunity, 465 children were vaccinated and children that were invited to a session but did not attend were referred back to their GP / HV for further follow up.

Overall Outcome for Five Immunization Sessions

Over the course of the five immunization sessions, 1,311 children were invited to attend for vaccination and a total of 465 children were brought up-to-date with their immunizations. This represented the administration of 867 separate vaccines of which 409 were MMR; 324 were pre-school boosters (dTaP/IPV), 53 were Hib/MenC boosters and 81 were pneumococcal boosters.

This project clearly demonstrates that new ways of delivering immunization sessions can be successfully implemented and that clinics based in venues that are easily accessible to parents, such as shopping centers, can help to reduce logistical barriers to vaccination. The approach to the delivery of immunization sessions for the children in the priority target group was original and novel and by encouraging local retailers and the library to promote the program in the shopping center, awareness of the pre-school vaccination program was raised in the parents of the target group before they received their invitation to one of the sessions. Children were relaxed while waiting to be called through to the clinical area and were also able to relax again following vaccination. The children’s entertainer was also able to participate in the delivery of play and distraction techniques for the very few children who became anxious. With forward planning, the further delivery of immunization sessions in alternative venues such as shopping centers could be sustained and this project could easily be replicated across other areas providing organizational support and commitment is obtained.

All stated objectives were met for this project as all children in the target group received an invitation for immunization. Of these, 39% attended and those who did not attend received further invitations to attend their GP surgery for the outstanding vaccines. Uptake of MMR vaccine increased by 9% following the implementation of the project and definite benefits have been identified in the delivery of immunization sessions in venues such as local shopping centers. Lessons learned from the sessions delivered have been identified and have been fed back to the service providers.

Recommendations

Alternative community venues should be considered for the delivery of childhood vaccination ‘catch-up’ sessions as parents may find them more accessible or be more likely to attend if the sessions are held in areas where parents frequently visit such as shopping centers. Regular review of vaccine uptake and provider performance should continue to be undertaken to ensure high vaccine uptake is maintained, particularly during organizational transition periods.