Professor Helen Bedford on the importance of improving childhood vaccine uptake rates.
Childhood vaccination rates are generally high in the UK, but there is considerable room for improvement. Two major issues are currently a cause for concern. The first is a small but gradual decline in uptake each year since 2012/13, and the other, persistent inequalities in uptake, with large variation between geographic areas and population groups. In this article, current vaccine uptake and possible causes of the decline will be reviewed. The importance of improving rates and ways of increasing uptake will be discussed.
The childhood vaccine programme and vaccine uptake
The childhood vaccination programme has expanded significantly since the late 1980s, when only five vaccines (diphtheria, tetanus, polio, pertussis and measles) were routinely offered to all pre-school children (Lang et al, 2020). In 2022, protection is offered against 14 serious diseases, including four types of bacterial meningitis by the age of five years, with additional vaccines offered in adolescence. Vaccine uptake too has increased significantly over the past decades as the vaccine programmes have become more organised and systematic. Parents appreciate the value of vaccination (Sherman et al, 2022; Campbell et al, 2017), and our high vaccine uptake has resulted in very low levels of disease.
The most recent UK vaccine uptake figures for the year 2020/21 for the completed primary course at 12 months of age and for the first dose of MMR vaccine (measles mumps and rubella) at 24 months and first and second doses at five years of age are shown in Table 1 overleaf. The target for vaccine uptake is 95%, and while Scotland and Wales meet those targets for uptake of the 6-in-1 vaccine, uptake in Northern Ireland and England is lower. The average uptake in England for the 6-in-1 is brought down by uptake in London, which is only 86.5%.
The decline in MMR vaccine uptake
Although Scotland, Wales and Northern Ireland achieve the 95% target for the first dose of MMR vaccine for five-year-olds, no country achieves 95% uptake for the first dose at 24 months and, even more importantly, of two doses at five years of age. As the aim of the MMR vaccination programme is to eliminate these diseases, which requires sustained 95% uptake of two doses of MMR, this is a cause for concern.
Vaccine uptake varies by area. The latest figures show that a quarter of five-year-old children in London are not fully protected against measles, mumps and rubella, and across England an estimated three-quarters of a million children between one and six years have not had two doses of the vaccine. The potential for outbreaks has already been demonstrated, with only one confirmed case of measles in the first quarter of 2022, but 23 in the second quarter (April to June), 10 of which were imported or associated with an importation. All cases were unvaccinated and, as measles can be more severe in very young children – who are also at increased risk of developing the severe late complication sub-acute sclerosing pan-encephalitis – it was of concern that six cases occurred in infants under one year of age (UK Health Security Agency (UKHSA), 2022a). These infants were too young to be vaccinated and dependent for their protection on population (herd) immunity.
All three diseases, measles, mumps and rubella, are potentially serious, but in view of its high infectivity, outbreaks of measles are always the first concern as only a small decline in vaccine uptake is needed to spark outbreaks. There are numerous examples of a decline in vaccine uptake leading to resurgence of disease. Most recently, we saw this when, after the WHO declared the UK to have eliminated measles in 2017 (UKHSA, 2022b), a significant increase in measles cases resulted, with almost 1000 confirmed cases in 2018, and the measles-free status was lost. The majority of these cases occurred in young adults or older adolescents who had missed out on the vaccine when they were young.
To prevent such outbreaks, in September 2022, NHS England launched a campaign in which reminders in various forms were sent to parents, encouraging them to book MMR vaccination appointments for their child and reminding them of the importance of vaccination (NHS England, 2022). Health visitors and school nurses should be aware of this campaign and use their opportunities to reinforce the importance of vaccination with families. There is no upper age limit for MMR vaccine and the second dose can be given even after a lengthy interval.
Increased concern about polio
Some recent media headlines reporting that polio is back in the UK after 40 years, although somewhat misleading, are a ‘wake-up call’ for us all (see Big story on page 10). Routine surveillance of sewage in London has identified circulating vaccine derived polio virus (cVDPV). This originates from the live attenuated polio virus found in the oral polio vaccine (OPV) still used in some countries. After circulating in a population for some time, it changes its character and behaves more like wild polio virus and so is more likely to cause paralytic polio than the original weakened virus in the OPV. While the inactivated polio vaccine in use in UK since 2004 protects a fully vaccinated individual from being affected by polio, it does not prevent infection and so it is vital to keep vaccination levels high. The virus found in sewage has probably been circulating in London since February 2022. So far, we have seen no cases of polio due to this in the UK, but a case has occurred in a part of New York state in the US, where there is a particularly low level of vaccine uptake and cVDPV has been found in sewage. It has also been found in sewage in Israel. Genetic analysis of the viruses found in all three countries suggests they have a common origin (Hill, 2022). Unless uptake of polio-containing vaccine increases in London, and other parts of UK, it is only a matter of time before we see children paralysed by this disease again. The US Centers for Disease Control (CDC) now recommends a polio vaccine booster for travel to the UK (CDC, 2022).
In view of high infectivity, measles is a concern as only a small decline in vaccine uptake is needed to spark outbreaks
What is the cause of the decline in uptake?
Each year since 2012/13, there has been a small but steady decline in vaccine uptake. This has been exacerbated by the Covid-19 pandemic (UKHSA, 2021). For example, UK uptake of both completed courses of the primary vaccines at 12 months and of MMR vaccine at 24 months fell by almost 3% between 2012/13 and 2021/22 (NHS Digital, 2022). It is difficult to pinpoint any single main cause for this decline, which is likely to be due to a number of interrelated issues. One factor that has been identified is the impact of the major NHS reforms introduced in 2013. Public health services, including some which oversaw immunisation, were relocated in local government, disrupting the smooth running of services and resulting in a lack of clarity over roles and responsibilities (Edelstein et al, 2020).
As pre-school vaccines are predominantly given in general practice, clarity of responsibility for ensuring good uptake is not always clear in practice. The combination of a shortage of GPs and practice nurses at a time of increasing demand for healthcare has placed great pressure on general practice (Health Foundation, 2022), with anecdotal reports of difficulties getting vaccination appointments. General practice is under even more pressure this winter with an expanded influenza vaccine campaign, Covid vaccine boosters for some, the additional polio vaccine dose for children in London and the MMR vaccination campaign.
Shortages of HVs are well documented, and this may also have impacted on vaccine uptake (Wilkinson, 2022a). However, despite some media headlines, and a reported increase in parents’ questions about vaccination, there is little evidence of a surge of anti-vaccine sentiment being responsible for the decline (Edelstein et al, 2020). While we should not ignore or minimise the impact that misinformation about vaccines, particularly via social media, may have on parents’ vaccination decisions, neither should its influence be magnified. Where parents are uncertain about vaccines, misinformation may be particularly potent and it has been suggested that anti-vaccine messages about Covid vaccine may have also impacted on uptake of other vaccines (Wilkinson, 2022b). However, this doesn’t explain the decline in uptake since 2012/13.
Why we need to improve vaccine uptake
It is often said that vaccination is a victim of its own success: the absence of disease resulting from a successful vaccination programme may lead people to conclude vaccination to be no longer necessary. However, as described above, it is critical to improve UK vaccine uptake if outbreaks of disease are to be prevented. This may involve reminding ourselves, as healthcare professionals as well as the public, about the seriousness of childhood infectious diseases. Recent outbreaks of measles have provided a sharp reminder of that. In the first six months of 2018, 42,170 measles cases and 57 measles-related deaths were reported in the WHO European region (WHO, 2018). Concerns about polio have resulted in a campaign to give all children between one and nine years old in London, an extra dose of polio-containing vaccine, even if fully immunised (UKHSA, 2022c).
In an online survey in 2022 of 2000 parents of children aged 0 to five years in England, it was clear that many parents are unaware that measles, mumps and rubella remain a threat (Freuds, 2022). Almost half (48%) were not aware that measles can lead to complications including pneumonia and encephalitis. Importantly, some parents had not had their child vaccinated during the pandemic as they didn’t want to be a burden on the NHS or were unaware that routine vaccines were still being offered during the pandemic. This, together with only one in five of the parents surveyed aware that if the MMR vaccine has been missed it can still be given at any time, highlights the need to ensure parents are reminded of the seriousness of the diseases and that there is no upper age limit for many vaccines, including MMR vaccine (UKHSA, 2019).
Many children who may have missed out on their vaccines during the pandemic need to catch up, but it can be complex working out which vaccines are due and when they should be given. UKHSA provides a useful algorithm which lays out what children in different age groups need in order to catch up with their vaccines (UKHSA, 2022d).
How can vaccine uptake be improved?
As a core component of child public health programmes, HVs, community practitioners (CPs) and school nurses have an important role to play in improving and sustaining vaccine uptake. In May 2022, NICE published guidance on increasing uptake of all vaccines. Recommendations fell under three categories: organisation of services; identification of eligibility, giving and recording vaccination status; invitations, reminders and escalation of contact (NICE, 2022). The guidance is extensive and addresses many issues which have relevance for HVs and CPs in their daily work.
Some parents report that their child is not up to date with vaccines because they are not aware of what is due and when. Making parents aware of vaccinations should start with the pertussis, influenza and Covid vaccines during pregnancy. At the same time, the childhood programme can be introduced, and eligibility for the selectively given hepatitis B and BCG vaccines ascertained. At the new birth and six- to eight-week contacts with a HV, the childhood vaccination programme should be described, any questions answered and information leaflets published by UKHSA provided. This means that by the time the baby is taken for their first vaccines at eight weeks their parents are well prepared.
Sending invitations and reminders is known to be an effective method of improving vaccine uptake. Any appointment communications should be personalised and state which vaccines are due. They should be accompanied by information about the relevant vaccines or links to such information. HVs and CPs can also show parents the immunisation pages in the personal child health record. These show the routine schedule and provide links to more information as well as being the place to record vaccines given.
NICE recommended the need for healthcare staff who have contact with people who are eligible for vaccination to have ongoing training in vaccination, even if they are not administering the vaccines. This is to ensure they are equipped to have discussions about vaccination. HVs are well placed to check vaccination status of, for example, pregnant women, young children and people with chronic health conditions who may need additional vaccines. Influenza vaccine is recommended for all people aged six months to 65 years with chronic health conditions (UKHSA, 2022e), yet at only 14.4%, uptake among children aged six months to two years is very poor (UKHSA, 2022f), an issue that HVs are well placed to address.
HVs are well placed to check the vaccination status of pregnant women, young children and people with chronic conditions
Although there has been a decline in vaccine uptake recently, compounded by the pandemic and raising concerns about the potential for disease outbreaks, taking action now can prevent this. While recognising the current pressures on health services, HVs and general practice, preventing outbreaks will not only mean that children and their families do not have to experience the impact of a serious disease which may result in complications or even death, but will in the long term save precious NHS resources.
Helen Bedford is professor of children’s health, University College London Great Ormond Street Institute of Child Health.
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