Immunisation: spreading the word

08 February 2018

Health visitors are vital to achieving full vaccine coverage among children, say Michelle Falconer, Laura Craig, Helen Campbell and David Green of Public Health England.

Immunisation is a key component of the public health offer for all children. It is important that they receive the vaccinations they are eligible for in a timely manner; this will provide them with optimal protection against vaccine-preventable disease that can be a significant cause of morbidity and mortality.

Although there is regional variation in vaccine coverage across the country, data reported for 2015-16 indicated that vaccine coverage in England fell for the third consecutive year and also fell below that of the other UK countries for most routine childhood vaccinations at one and two years old (NHS Digital, 2016).

Healthcare professionals have a key role supporting parents in making decisions about vaccinations. Health visitors, who specialise in providing a public health service to preschool children and their families are vital in achieving parental trust and high vaccine coverage, and have a significant role in supporting the childhood immunisation programme.


Healthy foundations

Vaccination schedules are informed by a number of key determinants, including risk of disease and severity of disease by age. The greatest risk for a number of vaccine-preventable diseases, in the absence of vaccination, is in infancy. 

In England, responsibility for commissioning public health services for children was transferred to local authorities during 2015. Health visitors provide targeted and universal services for the 0 to five years element of the national Healthy Child Programme. This aims to give every child the good start they need to lay the foundations of a healthy life (Public Health England (PHE), 2016a), ensuring a healthy productive adulthood is reached (PHE, 2014).

Commissioning guides describe health visitors’ contribution to this programme (PHE, 2016a; 2016b; 2016c). The transformed service model includes four levels of intervention, five mandated health reviews and six high-impact areas that are critical to improving the health and wellbeing of children. 

The five mandated health reviews provide a unique opportunity for the health visitor to discuss immunisation and refer children and pregnant women for outstanding vaccines, which highlights their role as a key source of immunisation information and support for expecting and new parents. The table (left) includes suggested actions for health visitors during each health review. 

Using health reviews to support childhood immunisation decision-making


Antenatal health-promoting visits from 28 weeks of pregnancy
  • Introduce the benefits of vaccination (for mother and unborn baby)
  • Confirm whether pertussis vaccination has been given and support with decision-making if not yet given
  • Discuss flu vaccination if flu season and support with decision-making
  • Discuss with mother whether it has been advised for baby to be offered hepatitis B vaccine at birth (if mother has an acute hepatitis B infection during pregnancy or is chronically infected)

New baby review: ideally within 10 to 14 days of birth date

  • Confirm whether baby was born to a hepatitis B positive mother. If so remind mother of importance of hepatitis B vaccine and check baby has received dose one (at birth) and is scheduled for dose two (at four weeks)
  • Remind parents of the benefits of all routine childhood immunisations and the importance of vaccination at the recommended ages, starting with the first routine appointment at eight weeks
  • Remind mother of the need for her to check her own MMR immunisation status (for example, with GP) and encourage two doses of MMR vaccine to protect future pregnancies if not documented in her medical notes 
Six- to eight-week assessment
  • Confirm whether the first scheduled vaccines have been given or an appointment has been scheduled as appropriate
  • Remind parents that there is no requirement for the six- to eight-week baby check to be completed before the vaccines scheduled at eight weeks of age are given
  • Confirm that postnatal MMR vaccine for mum has been arranged if required (two doses, one month apart) 
One-year assessment
  • Confirm with parents that baby is up to date with all scheduled vaccines
  • Discuss the importance of booster doses to ensure duration of protection
  • If baby was previously identified as being born to a hepatitis B positive mother, remind mother that baby should have a booster dose of hepatitis B vaccine at 12 months of age and a blood test to check for infection (hepatitis B surface antigen) at the same time. If the infant has developed hepatitis B, they will need to be referred to a specialist 
Two-year to two-and-a-half-year review
  • Review immunisation status, and support with planning an appropriate schedule if incomplete
  • Remind parents that the next scheduled vaccination appointment will be when their child reaches three years and four months of age, for booster doses to extend the duration of protection throughout their school years (for example, second dose of MMR vaccine)


Source of trust

Health professionals are generally highly trusted by parents and are important in communicating immunisation information (Campbell et al, 2015). This trust has increased in recent years, and advice from healthcare professionals appears to be a key factor influencing parental decisions on vaccination. Most parents have access to the internet, but those who trust the information given by health professionals are most likely to have their child vaccinated at the scheduled age (Campbell et al, 2017).

Parental attitude tracking surveys commissioned by PHE have identified health visitors as an important source of information for parents. The authors identified that between 2002 and 2010 these surveys indicated that around half of parents of children up to the age of two recalled discussing immunisation with a health visitor before their children were due to be immunised. 

Although this dropped to just a third of parents having those discussions with their health visitor between 2015 and 2016, a PHE official confirmed there has been a steady increase since and, in March 2017, 41% of parents of children up to two years recalled discussing immunisation with a health visitor.

The role of the health visitor as an expert in communicating with parents about immunisation has been described (Redsell et al, 2010). Some believed their role included the entire process – from the provision of pre-vaccination information to vaccine administration – while others felt their role ended after supplying relevant information, leaving practice-based staff to complete the process.

The knowledge of vaccinations in pregnancy and the perceived roles of nurses, midwives and health visitors in England have recently been explored using an online questionnaire. This found a high level of knowledge around vaccination in pregnancy in all professional groups. However, Vishram et al (2017) reported that ‘practice nurses were significantly more likely to recommend the pertussis and influenza vaccines to pregnant women than midwives and health visitors’.

Groups at risk of not being fully immunised 

  • Those who have missed previous vaccinations (whether as a result of parental choice or otherwise)
  • Those with physical or learning disabilities
  • Those not registered with a GP
  • Children who are hospitalised or have a chronic illness
  • Those from ethnic minority groups
  • Vulnerable children such as those whose families are travellers, asylum-seekers or homeless
  • Looked-after children
  • Children of teenage or lone parents
  • Younger children from large families
  • Those from non-English speaking families. NICE, 2009

Vaccine coverage

Monitoring vaccine coverage is an important part of the ongoing surveillance of national vaccine programmes. Since 2014, there has been a gradual decline in uptake. This includes a fall in coverage for the primary vaccines, the first dose of MMR vaccine and the DTaP/IPV booster given at three years four months of age (NHS Digital, 2017).

The number of children in England getting their first dose of the MMR vaccine by their fifth birthday reached the 95% WHO target for the first time during 2016-17 (NHS Digital, 2017). But a recent study looking at vaccination records of children born between 1995 and 2012 in Liverpool revealed a high proportion of children with no MMR recorded, despite an intensive catch-up campaign at the time of a previous measles outbreak (Keenan et al, 2017).

Ensuring children are immunised on time and those with missing doses are identified and caught up with plays an important role in continued population-level control of vaccine-preventable diseases such as measles. 

Vaccination provides individual and population protection (herd immunity), so high coverage is required. When coverage drops, numbers of susceptible children accumulate and can sustain an outbreak of a vaccine-preventable disease. It is essential that vaccines are administered at the recommended ages, helping to maintain population protection by reducing overall transmission and enabling infants to develop their own direct protection before entering nursery or school where there is increased potential for exposure. 

Every contact with a health professional is an opportunity to ensure that a child is up to date with their vaccinations. 

The NICE guideline (2009) on increasing immunisation uptake in children and young people identifies factors that may influence whether a child is vaccinated or not. Those at risk of not being vaccinated include children living in a more affluent area, those of highly educated parents, and the groups in the panel above. 


The health visitor is in a unique position to assess a child’s status and support parents with immunisation, for example by signposting them to their practice nurse. 

By proactively and positively promoting immunisation, health visitors can continue to make a vital contribution in the delivery of a key public health intervention that prevents disease, prolongs life and promotes health.

Stay up to date

For the latest developments in vaccines, vaccination policies and procedures in England, subscribe to the free monthly vaccination newsletter Vaccine update at bit.ly/ENG_vaccine and access the ‘green book’ (PHE, 2013) which contains national vaccination programme recommendations. Visit bit.ly/SCT_vaccine to access regular Scottish vaccine updates from Health Protection Scotland. Updates for Wales and Northern Ireland can be found on the Public Health Wales and Public Health Agency websites.

Michelle Falconer is an immunisation nurse specialist, Laura Craig is lead immunisation nurse specialist, Helen Campbell is a senior clinical scientist and David Green is nurse consultant for immunisations, all at Public Health England. 


Amirthalingam G, Campbell H, Ribeiro S, Fry K, Ramsay M, Miller E, Andrews N. (2016) Sustained effectiveness of the maternal pertussis immunisation program in England 3 years following introduction. Clinical Infectious Diseases 63(Suppl 4): S236–S243. See: ncbi.nlm.nih.gov/pmc/articles/PMC5106626 (accessed 15 January 2018).

Campbell H, Edwards A, Letley L, Bedford H, Ramsay M, Yarwood J. (2017) Changing attitudes to childhood immunisation in English parents. Vaccine 35(22): 2979-85. See: ncbi.nlm.nih.gov/pubmed/28442229 (accessed 15 January 2018).

Campbell H, Hoek AJV, Bedford H, Craig L, Yeowell A-L, Green D, Yarwood J, Ramsay M, Amirthalingam G. (2015) Attitudes to immunisation in pregnancy among women in the UK targeted by such programmes. British Journal of Midwifery 23(8): 566-73. See: magonlinelibrary.com/doi/10.12968/bjom.2015.23.8.566 (accessed 15 January 2018).

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NICE. (2009) Immunisations: reducing differences in uptake in under 19s. Public Health guideline (PH21). See: nice.org.uk/guidance/ph21/chapter/2-Public-health-need-and-practice (accessed 15 January 2018).

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Pebody RG, Green HK, Andrews N, Boddington NL, Zhao H, Yonova I, Ellis J, Steinberger S, Donati M, Elliot AJ, Hughes HE, Pathirannehelage S, Mullett D, Smith GE, de Lusignan S, Zambon M. (2015) Uptake and impact of vaccinating school age children against influenza during a season with circulation of drifted influenza A and B strains, England, 2014/15. Eurosurveillance 20(39). See: http://www.eurosurveillance.org/images/dynamic/EE/V20N39/art21256.pdf (accessed 15 January 2018).

Public Health England. (2016a) Best start in life and beyond: improving public health outcomes for children, young people and families, commissioning guide 1. See: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/554499/Service_specification_0-19_commissioning_guide_1.pdf (accessed 15 January 2018).

Public Health England. (2016b) Best start in life and beyond: improving public health outcomes for children, young people and families, commissioning guide 2. See: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/518657/Service_specification_CG2_FINAL_12_Feb.pdf (accessed 15 January 2018).

Public Health England. (2016c) Best start in life and beyond: improving public health outcomes for children, young people and families, commissioning guide 3. See: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/493624/Service_specification_0_to_19_CG3_FINAL_19Jan2016.pdf (accessed 15 January 2018).

Public Health England. (2016d) Vaccination against pertussis (whooping cough) for pregnant women. See: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/529956/FV_JUNE_2016_PHE_pertussis_in_pregnancy_information_for_HP_.pdf (accessed 15 January 2018).

Public Health England. (2014) From evidence into action: opportunities to protect and improve the nation’s health. See: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/366852/PHE_Priorities.pdf (accessed 15 January 2018).

Public Health England. (2013) Immunisation against infectious disease (The green book). See: gov.uk/government/publications/immunisation-against-infectious-disease-the-green-book-front-cover-and-contents-page (accessed 15 January 2018).

Redsell S, Bedford H, Siriwardena AN, Atkinson P. (2010) Primary healthcare research and development, Health visitors’ perception of their role in the universal childhood immunisation programme and their communication strategies with parents. Primary Healthcare Research & Development 11: 51–60. See: researchgate.net/publication/228615280_Health_visitors%27_perception_of_their_role_in_the_universal_childhood_immunisation_programme_and_their_communication_strategies_with_parents (accessed 15 January 2018).

Vishram B, Letley L, Van Hoek AJ, Silverton L, Donovan H, Adams C, Green D, Edwards A, Yarwood J, Bedford H, Amirthalingam G, Campbell H. (2017) Vaccination in pregnancy: attitudes of nurses, midwives and health visitors in England. Human Vaccines & Immunotherapeutics. Available at tandfonline.com/doi/abs/10.1080/21645515.2017.1382789 (accessed 15 January 2018).

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