Differences in risk factors for partial and no immunisation in the first year of life: prospective cohort study
BMJ 2006; 332 doi: https://doi.org/10.1136/bmj.332.7553.1312 (Published 01 June 2006) Cite this as: BMJ 2006;332:1312All rapid responses
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Dear Sir,
As pointed out by Samad et al(1), there are several factors that may play
a role in partial or no immunization in the first year of life. Factors
for not being fully immunised have been looked for in Flanders, Belgium,
in the recent 2005 vaccination coverage study funded by the Flemish
government. According to the two cluster sampling technique recommended by
the World Health Organization (2), a sample of 1354 infants aged 18-24
months was identified, of whom the parents were interviewed at home. In
this study, particular attention was paid to the validity of coverage
data: only vaccine doses that were documented in a vaccination leaflet at
home or in the medical file of the vaccinating doctor have been considered
for analysis.
The coverage rate of recommended vaccines (polio, tetanus, diphtheria,
pertussis, H influenzae type b, hepatitis B, measles, mumps, rubella and
meningococcal C) reached 93%, including booster dose at around 15 months
of age. The coverage for the primary doses was comparable to what was
found in UK children in the Millenium Cohort Study(1).
However, a logistic regression analysis for risk factors associated
with partial or no immunisation identified differences with the UK
situation: maternal age or education and ethnicity of the parents were not
found to be significantly associated, neither was family size, but being
the youngest child in rank was associated. Similarly to the UK findings,
working mothers were associated with more fully immunised children. A
particular finding was that the risk of being not fully immunised was
associated with whom the parents chose to immunise the child: GP,
paediatrician or youth doctor at well baby clinic. Full results will be
published in the near future.
(1) Samad L; Tate AR, Dezateux C, Peckham C, Butler N, Bedford H.
Differences in risk factors for partial and no immunisation in the first
year of life: prospective cohort study.
(2) Salmaso S, Rota MC, Ciogi ML et al. Infant immunization coverage
in Italy: estimates by simultaneous EPI cluster surveys of regions.
Bulletin of the World Health Organisation, 1999, 77(10): 843-85
Heidi Theeten, Center for the Evaluation of Vaccination, University
of Antwerp, Universiteitsplein 1, 2610 Antwerp, Belgium
heidi.theeten@ua.ac.be
Corinne Vandermeulen, dienst Jeugdgezondheidszorg, Katholieke
Universiteit Leuven, Kapucijnenvoer 35/1, 3000 Leuven, Belgium
corinne.vandermeulen@med.kuleuven.be
Competing interests:
None declared
Competing interests: No competing interests
Dear Editor,
Samed et al.’s(1) important findings on the relationship between
ethnicity and immunisation status in infants under one year – notably,
that infants of black Caribbean mothers were more likely to be unimmunised
than were those of white mothers - indicate the need for the routine
collection and reporting of ethnicity in immunisation statistics. Their
analysis of the millennium cohort study data has provided for the first
time evidence of ethnic disparities in a large national sample. The fact
that the papers cited on the role of ethnicity in uptake of immunisation
in the UK date from the 1980s belies the sparsity of ethnically coded
data. Indeed, in the last two or three decades only a handful of studies
have appeared, most on ethnic differences in the rates of selective
neonatal BCG immunisation. These new findings - together with obligations
in the Race Relations (Amendment) Act 2000 - present a case for the ethnic
coding of the COVER (Cover of Vaccination Evaluated Rapidly) data
collected as a central return(2), a step which might also catalyse wider
ethnicity data collection in primary care trusts. The NHS has indicated
that, as a general rule, all central return submissions relating to
patients and the services provided to patients should include
consideration of the case for collecting ethnic origin information (and
that this should be the norm in cases where personal profile information
such as age and gender is collected)(3). With reference to the national
contexts referred to by Crampton and Carr(4), the National Immunization
Survey in the USA includes data on race(5) and the data requirements for
the National Immunisation Register, set up in New Zealand in 2004,
incorporate ethnic group.
1.Samad L, Tate AR, Dezateux C, Peckham C, Butler N, Bedford H.
Differences in risk factors for partial and no immunisation in the first
year of life: prospective cohort study. BMJ 2006; 332: 1312-3.
2. Health & Social Care Information Centre. NHS Immunisation
Statistics, England: 2004-05. Bulletin 2005/05/HSCIC. Leeds: HSCIC, 2005.
3. Health & Social Care Information Centre. Dealing with race
information in the ROCR approval process. Leeds: HSCIC, 2005.
http://www.ic.nhs.uk/rocr/approval/dealingwithrace
4. Crampton P & Carr J. Socially or materially marginal children
are less likely to be fully immunised – a systems response. BMJ 2006; 332:
1314.
5. Smith PJ, Hoaglin DC, Battaglia MP, Khare M, Barker LE.
Statistical methodology of the National Immunization Survey, 1994-2002.
Vital Health Stat 2 2005; Mar (138): 1-55.
Yours sincerely,
Peter J Aspinall
Senior Research Fellow,
University of Kent
Competing interests:
None declared
Competing interests: No competing interests
You state partial or no immunisation status can be attributed to
deprived, ethnically diverse or education of populations. I suggest that
this is a popular myth that is often quoted (Baker, MR, Bandaranayake,
R,Schweiger, MS,1984) and one that I wish to dispel.
Heart of Birmingham Teaching Primary Care Trust (HOB) has extremely
high levels of ethnic diversity with 7 out of 10 being Asian or Black. We
also have the highest levels of deprivation with populations living in the
lowest 10% nationally. Until recently, HOB had the worst coverage for MMR
(2004 = 80% aged 24 months) and influenza (2004 = 49%). We now have the
best coverage that ranks in the top ten nationally (MMR = 95%) and
(Influenza = 78%).
Hitherto, our attempts to improving immunisations coverage, we
assumed myths that inequalities in immunisation uptake are persistent and
result in lower coverage in poorer families. Recently, our focus has been
providing support for underperforming General practices by implementing a
variety of failsafe activities.
To resolve the issue of partial or non immunisation, an active
patient management system should be implemented. This should include:
• professional leadership and commitment to good performance
• an accurate, up to date list of registered patients
• a personalised system of call up e.g. letter signed by GP
• a schedule of dedicated clinics
• active follow up and direct contact with defaulters
• a system of “opportunistic visits”
In summary, gross poor performance should not be attributed to
culture, education or deprivation. Three things matter; Organisation,
organisation & organisation.
The good news is that 2/3 of poor performance is artefactual (ghost
patients or non reporting; and easy and cheaply addressed)
We would like to invite you and your team to Birmingham to discuss
the detail of our innovations and see the systems that we utilise.
Competing interests:
None declared
Competing interests: No competing interests
Working in the east end of London a number of years ago, frequently
came across families who were either unsure or were completely against the
idea of immunisation. I always made a point to spend time sympathetically
talking to these parents and was delighted that almost all of these
families agreed to immunise their children minus, ofcourse, the pertusis.
As you would recall during the 80's the pertusis immunisation rates had
dropped significantly due to the scare of brain damage that was
passionately debated in the media I believe in the 70's. My discussions
wih the parents revealed that there main concern was around pertusis
vaccine and therefore agreed to go ahead with other jabs once proper
explanation was given. A few parents, even agreed for pertussis. This
extra time spent talking to these parents proved rather rewarding both for
me and the children.
Interestingly, one of the common explanation given by caucasian young
mothers including single parents was - they saw no reason for immunising
their children as they themselves were not immunised and their own parents
and grand parents were also not immunised. As nobody was harmed, they
found it difficult to understand why their child should be subjected to
immunisations. Happily, most of these mothers did agree for some form of
immunisation after a chat.
In those days the majority of immunisations were done in community
clinics rather than in GP surgeries and the health visiting service was
excellent which helped enormously with opportunistic immunisations
process.
I also remember coming across a few mothers who were intelligent and
articulate - with strong views about the dangers of immunisation. It was
almost impossible and rather challenging, to get through to these
individuals as their minds were already made up.
Competing interests:
None declared
Competing interests: No competing interests
Samad et al. regard better education and greater age as risk factors
for mothers who do not vaccinate their children.
Perhaps we just aren't as gullible, trusting or foolish as younger
mothers with a poorer education; not as likely to succumb to outrageous
scare tactics, and are entirely capable of doing our own research, asking
questions and making our own decisions in the best interests of our
children.
As a woman with a Master of Science, and as a first time mother at
the age of 35, I made clear, researched and rational decisions about my
children's health from before conception. That the majority of pro-vaccine
medical papers were funded in some way by the pharmaceutical industry did
not escape me. Such conflict of interest has been widely discussed in the
pages of this journal, albeit regarding drugs in general, rather than
vaccines specifically.
This paper is not the first to characterise non-consenting mothers -
those that make an informed and conscious decision not to vaccinate (as
opposed to those who only partially vaccinate their children) - as more
highly educated and older.
Among several others, an Israeli study (Maayan-Metzgera, A., Kedem-
Friedrichc, P. and Kuinta, J., 2005: To vaccinate or not to vaccinate-
that is the question: why are some mothers opposed to giving their infants
hepatitis B vaccine? Vaccine, Vol. 23, Is. 16, 14 March 2005, pp 1941-
1948) is worth mentioning. The authors found that in addition to the above
characteristics, mothers who decided not to vaccinate expressed more
knowledge about the vaccine, and held more naturalistic and less
conventional medical attitudes than did the women who complied and had
their babies vaccinated. The non-consenters also planned to breastfeed for
a longer period than the control group, and one of the most telling
characteristics of the non-consenting mothers was that approximately 20
percent of them had careers in health/medical professions, while only 2%
of the consenting group had such a background.
Perhaps it was altogether too scary for the authors of this most
recent BMJ paper to ask their UK cohort about their occupation. After all,
it is bad enough to find educated women rejecting the one-size-fits all
vaccination model of child health, how much worse would it be to discover
that women with medical training were over-represented in this group?
Mothers, such as myself and many other women I know, are blessed with
a brain that works, and the intestinal fortitude to not only use it but to
question a medical dogma that is increasingly driven by drug industry
profits. We have the strength and the independence to make decisions in
the best interests of our families. Among other things, these decisions
usually involve long term breastfeeding and excellent post-weaning
nutrition.
In an age in which it is slowly being recognised that the industry is
over-medicalising life, and pharmacuetical companies are pushing "cradle
to the grave" medication (e.g. the new adult adolescent pertussis boosters
which the manufacturers are pushing for adults to get at least every ten
years) achieving a constant market in the "worried well", an age in which
ever more people are turning to so-called alternative medicine (in reality
holistic medicine which treats the body as a whole) does it really
surprise anyone that increasing numbers of us reject such a model for the
health of our children?
Until both the medical community and the pharmaceutical industry
recognise that child health does not come through a needle, but from good
diet/nutrition and a reduction in exposure to toxins such as tobacco smoke
and environmental contaminants no amount of "different interventions" is
going to make a blind bit of difference.
Regards
Sue Claridge
Competing interests:
None declared
Competing interests: No competing interests
Affluent parents refusing routine immunisations.
Samad et al in their study suggest that factors influencing childhood
immunisation uptake may have changed over time.
In Gwent, South Wales the highest immunisation uptakes for both
primary and MMR vaccines in recent years have been in the most deprived
areas with lower rates in the more affluent areas.
These findings are supported by an ecological study of ' no consents
to vaccines ' entered onto the Child Health computer (CH2000) in Gwent
between 2000 and 2004(1).
(A 'no consent' is a disclaimer form completed by a parent and health
care professional after full consultation. The CH2000 system changes the
consent of the specific antigen as requested on the disclaimer to 'no
consent' and no further immunisation appointments are sent. The 'no
consent' can be revisited anytime by the parent attending surgery or
contacting the HV/PN/GP.)
In this study using the CH2000 system all postcodes with a recorded
no consent to routine childhood immunisations were identified n = 4778.
Non consenting postcodes were then compared to postcodes with recorded
consents to the same immunisations n = 168537.
When the proportion of no consents to immunisations were calculated
by quintile of social deprivation using Townsend scores, the highest rates
of 'no consents' figures were significantly associated with the most
affluent quintile and lowest rates with the most deprived quintile. This
was confirmed geographically using Arc View maps. The maps highlighted
that the more affluent areas had higher rates of 'no consents' and
sometimes bordered one another in Gwent. Chi-Squared test for the
proportion of parents refusing consent for both MMR and Polio vaccines and
social economic status as measured by the Townsend index were
statistically significant at p < 0.001.
This study looked at intentions to consent to immunise and not actual
uptake. Nevertheless it supports the view that different approaches may be
needed to maximise immunisation rates especially with regard to training,
support and access to timely information enabling staff to meet the needs
of the 'no consenting' parents.
Factors associated with low immunisation uptake have been well
described with a body of evidence reporting that deprivation is associated
with reduced immunisation uptakes. It is hypothesised that in recent years
there has been a reverse of this finding that the uptakes in the more
deprived areas are higher than the uptakes in the more affluent areas.
Samad's et al study and this ecological study in Gwent suggest that
different interventions are needed to promote uptakes in the more affluent
areas where primary immunisations are declined by a concerned minority of
parents.
Anne McGowan
Nurse Immunisation Co-ordinator
Oakfield House
Torfaen
Wales
NP44 8YN
anne.mcgowan@gwent.wales.nhs.uk
(1) Are there socio- economic factors which determine consent to
immunisations in Gwent?
M.P.H. dissertation Cardiff University 2005
Competing interests:
None declared
Competing interests: No competing interests