Vaccination remains one of the most cost-effective health interventions in the prevention of disease and is estimated to save 2–3 million lives each year (World Health Organization (WHO), 2019). In the UK, the introduction of a variety of vaccines over the past 70 years has resulted in a dramatic decline in infections that were once commonplace. For example, before the introduction of a vaccine in the 1950s, cases of diphtheria in England were in the tens of thousands (Public Health England (PHE), 2013), compared with only 11 reported cases in 2018 (PHE, 2019). Based on the burden of disease, the emphasis of vaccination programmes is largely on children under 5 years old (WHO, 2018a). In the UK, immunisation is a fundamental and significant part of the role of nurses working in general practice. However, such programmes can only be successful if enough individuals are vaccinated.
Vaccination is not mandated in the UK and parents have the right to decide whether or not to have their children vaccinated. This stresses the importance of monitoring uptake and providing accurate and up-to-date information and advice for parents to ensure sufficient coverage. This article explores vaccination uptake in children and the importance that evidence-based information has in influencing decision-making.
Vaccine uptake rates
It is recommended by the European Region of WHO that UK coverage for all routine childhood vaccinations should achieve a 95% uptake rate (WHO, 1999). Not only does this provide direct protection for the majority of individuals receiving the vaccine, but it also provides herd immunity. Herd immunity (also referred to as population immunity) describes how unvaccinated individuals can still benefit from a vaccination programme. This is seen when enough individuals are vaccinated, meaning that they are less likely to be a source of infection to unvaccinated individuals (PHE, 2018a). In England, the childhood vaccination programme offers protection against 14 diseases to children under 5 years old, and uptake rates are considered to be high (Bedford, 2017). While there are variations between vaccines and geographical locations, data from PHE reported an uptake of 94.3% in 2013/2014 for the diphtheria, tetanus, pertussis, polio and Haemophilus influenza type b (DTaP-IPV-Hib) at 12 months; however, by 2017/2018 this had dropped to 93.1%.
‘Not only does [immunisation] provide direct protection for the majority of individuals receiving the vaccine, but it also provides herd immunity. Herd immunity (also referred to as population immunity) describes how unvaccinated individuals can still benefit from a vaccination programme. This is seen when enough individuals are vaccinated, meaning that they are less likely to be a source of infection to unvaccinated individuals’
In some areas, these figures are as low as 75.6%, while others achieve an uptake of 98.2% (NHS Digital, 2018a). However, the latest coverage data from across England reports a decrease of 1.2% over a 5-year period, a moderate but nonetheless concerning decline in uptake. A similar picture is seen with the first measles, mumps and rubella (MMR) vaccine: 2013/2014 data show an uptake across England of 92.7%, compared to 91.2% in 2017/2018 (NHS Digital, 2018a).
Reasons for uptake decline
The term ‘vaccine hesitancy’ is frequently linked to uptake, and is used to describe a delay in acceptance or refusal of vaccines even where vaccine services are available (WHO, 2018b). Although, it has been argued that the phenomenon is much more complex than this definition suggests (Bedford et al, 2018), it is a vital consideration in light of the decline in uptake seen in recent years. It is also important to acknowledge the anti-vaccination movement (with followers known as ‘anti-vaxxers’), described as ‘minority groups who vocally oppose vaccinations’ (Dowden, 2019: 35).
While this movement represents a potential threat to public confidence in vaccination, there is no published evidence to demonstrate that it has had a direct impact on vaccination uptake. Frontline staff should focus their efforts on those who are vaccine hesitant in order to prevent the decline in uptake.
Published evidence
McKee and Bohannon (2016) reviewed empirical studies to explore why parents might refuse or delay vaccination, or were vaccine hesitant. They identified four categories:
- Religious beliefs
- Personal beliefs or philosophical reasons
- Safety concerns
- A desire for more information.
The prominent categories of safety concerns and the need for more information were associated with many of the studies included in the review. Therefore they are especially relevant areas for nurses working in general practice who respond to questions about vaccination and who are perhaps discussions with vaccine-hesitant parents. Furthermore, these findings emphasised the availability of accurate and contemporary resources for both nurses and parents, so that any discussions and decisions that are made are fully informed (McKee and Bohannon, 2016).
It is important that nurses are aware of vaccine uptake data in their own practice area. This allows them to identify any groups of patients at risk of being under-vaccinated or even unvaccinated, and strategies can be developed to address this. The cover of vaccination evaluated rapidly (COVER) programme gathers immunisation uptake data for children aged 1, 2 and 5 years old (PHE, 2018b) and publishes reports on a quarterly basis. NHS Digital (2018a) has recently collaborated with PHE to produce an interactive dashboard through which COVER data can be viewed, and this information is available at a regional and local authority level.
NHS Digital is piloting a system that reflects the current dashboard but provides more detailed Clinical Commissioning Group and general practice data (NHS Digital, 2018b). Similarly, more granulated data is accessible via PHE's ImmForm system, which is also the ordering system for vaccines used in the UK schedule. Users of the system must first register, then they are able to view vaccine uptake rates relative to their own practice area and this is especially relevant to general practices (ImmForm, 2016).
Immunisation information
Parents may obtain information about immunisation from a variety of sources (Ames et al, 2017). The internet can be a source of both substantiated and unsupported information, therefore it is vital that parents are directed to online information that is evidence-based. The internet can also be a useful place to access vaccination information, not only due to its convenience, but also because any information on it can be regularly updated. This is especially important to reflect the latest guidance around the UK vaccination programme, as changes to the schedule occur based on the development of new vaccines and epidemiological data.
In their survey on parental attitudes to vaccination in England, Campbell et al (2017) found that 84% of parents used the internet daily, and that 34% of these parents used the internet to access immunisation information. The most commonly accessed websites were NHS Direct/Choices (36%) and Mumsnet (29%). Social media sites (such as Facebook, Twitter, chat rooms and discussion forums) were also highlighted as a source of information used by a notable proportion of parents surveyed (Campbell et al, 2017).
It was reported that parents were more likely to have doubts about immunising their child based on something they had seen in a chat room or discussion forum (Campbell et al, 2017). This finding is supported by a report published by the Royal Society for Public Health (RSPH) (2018), in which parents, adults and health professionals were questioned. The report stated that 41% of parents had been exposed to negative vaccination messages on social media, a finding that was reported by health professionals to have also had an impact on parental views about vaccination. However, the impact of online information was not always negative. It was highlighted how positive vaccination messages in the media could have an equally positive affect in promoting the value of vaccines. There was also a call to apply the NHS Information Standards to vaccination information, and a clamp down on ‘fake news’ on social media platforms (RSPH, 2018).
Ames et al (2017) studied parents' views on communication about childhood vaccination. They found that in addition to the internet, parents cited other sources of information available to them, which included (but were not limited to) nurses, doctors and other health professionals, medical publications, leaflets, posters, peers and friends. This review also found that parents wanted help from health professionals to find relevant information, and that they found the amount of information they received to be inadequate.
These studies reiterate the essential role that practice nurses have in knowing which credible sources to direct parents to when more information is required. This is also a reminder for nurses to remain up-to-date, so that discussions with parents can be evidence-based and informed and conducted with confidence. Table 1 outlines some of the key resources, for both parents and health professionals.
Table 1. Key immunisation resources
| NHS – vaccinations https://www.nhs.uk/conditions/vaccinations/ | Aimed at the public providing an overview of the schedule (child and adult) and answers some common concerns around vaccine safety |
| Public Health England – immunisation https://www.gov.uk/government/collections/immunisation | Available to both the public and health professionals but probably most useful for health professionals as it hosts the Green Book and provides practice guidance |
| Oxford Vaccine Group – vaccine knowledge project http://vk.ovg.ox.ac.uk/ | Provides evidence-based information on vaccines and diseases. Designed for both the public and health professionals |
| e-Learning for Healthcare – immunisation https://www.e-lfh.org.uk/programmes/immunisation/ | A training resource for health professionals involved in vaccination |
| Public Health England – vaccine update https://www.gov.uk/government/collections/vaccineupdate | A monthly newsletter for health professionals highlighting developments in vaccines, policies and procedures |
Conclusion
Sufficient uptake rates are essential for vaccination to continue to be successful in preventing disease. It is vital that practice nurses are aware of coverage in their own areas so that shortfalls can be addressed and successes celebrated. An awareness of credible, evidence-based resources is vital so that accurate and up-to-date advice is given, and to ensure that parents are directed to information that facilitates decision-making.
KEY POINTS
- Vaccination is a vital activity in the prevention of disease
- Sufficient coverage is key to the success of the childhood vaccination programme and knowledge of vaccination uptake rates is essential
- There is an excessive amount of vaccination information available to parents from a variety of sources
- Parents should be directed to credible, evidence-based resources so that they can make informed decisions