Why is the UK falling short of immunisation targets?

Last year, the UK was stripped of its WHO measles-free status, just two years after eliminating the virus. This is a result of rising measles cases which are, in turn, linked with lower uptake of the measles, mumps and rubella (MMR) vaccine — beneath the WHO’s 95% coverage target.

Measles is of particular concern because it is highly contagious and can be serious, yet NHS Digital’s latest annual report confirms that the drop in MMR coverage is part of a larger trend. There has been a year-on-year decline in coverage for routine childhood vaccinations since 2013.

The NHS interactive dashboard on vaccines includes a coverage map at the local authority level, illustrating large differences across the country. While many London boroughs and large cities have lower coverage rates, the devolved nations, North East, and North West are often at or above targets.

Last year, the UK was stripped of its WHO measles-free status, just two years after eliminating the virus.

Karen Guest-Humphries is the Clinical Lead at Harrogate NHS Foundation Trust’s Childhood Immunisation Team, a nurse-led service providing routine immunisations for children and young people. The areas served by Karen’s team are consistently among those with the highest uptake.

“We cover six local authorities, and every school has a named nurse responsible for that school,” Karen says. “We make a big effort with consent forms and create plenty of opportunities to get them signed — including school assemblies, parents’ evenings, and community events.”

Karen says that, despite offering the same services across local authorities, certain approaches work better than others depending on local circumstances. And she says that socioeconomic deprivation and ethnicity are among the important predictors accounting for differences in uptake.

London and larger cities, meanwhile, face the additional challenge of high population mobility. When families move around, they are less likely to receive follow-up vaccine doses when these are needed. This also has an effect on the ability to keep track of uptake rates, and lowers the accuracy of data.

Dr Jennie Evans at the British Society for Immunology says: “We have been pushing to make sure that people have access to easy-to-understand, evidence-based information. And, ultimately, trying to understand the issues affecting vaccine uptake so that we can reach the WHO’s 95% targets.”

Jennie says that three main factors can influence whether someone accepts vaccines — confidence, complacency and convenience. Although this approach can be interpreted as placing responsibility on parents and carers, it primarily seeks to understand people’s attitudes towards vaccines, and the degree to which they can access them.

Vaccine nation: understanding barriers to access

Routine vaccinations are available throughout the UK. Infant vaccines are mainly offered through GP clinics, meanwhile school-age vaccines are offered at schools. Different approaches taken at the local level can, however, lead to varying rates of uptake.

“Historically, reminders for the MMR vaccine have been at the discretion of GPs,” says Jennie. “Making these reminders mandatory would ensure that parents and carers are aware of services and when their child needs a dose.”

Jennie also comments on the loss of local expertise and its impact on service delivery. In particular, NHS restructures that led to the replacement of immunisation coordinators, who played a key role in delivering immunisation programmes, with a smaller number of screening and immunisation leads.

Professor Andrew Pollard chairs the Joint Committee on Vaccination and Immunisation and leads the Oxford Vaccine Group at the University of Oxford: “Health visitors, immunisation coordinators, and outreach teams are in short supply — but they are a key part of delivering crucial messaging on vaccinations.

“We also need to make the most of opportunities that already exist. When, for example, a midwife is assessing a pregnant mother, this is a chance to give routine pregnancy vaccines to her rather than writing a referral to the immunisation clinic in primary care. Immunisation should be a priority for all healthcare professionals.”

Andrew also notes how organisational structures can affect service delivery. While it might be possible to quickly roll out a new programme and get high uptake rates in the devolved nations, the relative size of England and the way in which institutions are organised can make this more exacting.

“Immunisation should be a priority for all healthcare professionals.” — Professor Andrew Pollard, the Oxford Vaccine Group

Dr Alice Forster is a UCL psychologist who investigates why people choose to embrace or avoid health interventions like vaccinations: “Improving access to services and support for families are two areas where we are likely to make the greatest gains.”

Alice’s research, cited in our 2020 State of Child Health report, discusses the role of practical issues that disproportionately impact lower socioeconomic groups. This includes the cost of travelling to a clinic, difficulties in arranging childcare for other children, and competing demands for parents’ time.

“Societal barriers are important,” she says. “But we also need to understand motivations and attitudes. This is relevant at the moment, with many parents potentially missing vaccine appointments due to concerns about COVID-19. But other concerns existed before the pandemic.”

Wars of perception: misinformation and the role of belief

In Moving the Needle, the Royal Society for Public Health included tackling public misconceptions as a recommendation for improving uptake. The research found incorrect beliefs about side effects and “body load” as some of the reasons why parents and carers may be unsure about vaccinations.

A recent editorial from the College’s Immunisation Lead, Professor Helen Bedford, quoted research from the Institute of Health Visiting reporting that in May this year 60% of families had considered cancelling or postponing their child’s vaccinations because of fears about COVID-19. And that families concerned about vaccine safety could be influenced by strongly voiced opinion and misinformation.

Imran Ahmed is CEO at the Center for Countering Digital Hate: “The number of people producing misinformation is small — but the audiences they reach are large. And our recent study shows how prominent groups have been exploiting the pandemic to grow their online following.”

Imran’s report also cites psychological research showing how uncertainty in the face of new information can cause people to become more susceptible to misinformation. This highlights the need to address the concerns of parents and carers with clear, evidence-based information.

While this is already challenging with routine vaccinations, COVID-19 poses a particular challenge — scientific inquiry is ongoing and public health messaging is often changing. Understanding the role of psychology in belief, therefore, will allow better framing of messaging for parents and carers.

“The number of people producing misinformation is small — but the audiences they reach are large. And our recent study shows how prominent groups have been exploiting the pandemic to grow their online following.” — Imran Ahmed, CEO at the Center for Countering Digital Hate

“When it comes to preventative interventions, the psychology is counter-intuitive,” says Andrew. “If people are not already informed, they will generally take the ‘no intervention’ option and avoid having their child vaccinated. Educating people at the point of the needle is too late. We need to have better understanding through the education system of the key role of immunisation in defending our health.

“If your child is unwell, you’ll do anything to make them better. But preventing illness is a different conversation. Vaccinations have done such a good job of reducing disease that we’re a victim of our own success — we need to be better at communicating the message that immunisation is still critical.”

Andrew leads the Oxford Vaccine Group, whose Vaccine Knowledge Project provides independent information about vaccines and infectious diseases. The content is designed to help people make more informed decisions about vaccines and addresses common concerns expressed by parents and carers.

In addition to the more general concerns that extend across vaccines, there are also aspects of particular vaccines that can affect uptake rates, including the nature of the diseases they prevent and the ingredients they contain.

“We need to keep in mind the specific concerns of communities,” says Alice. “HPV is a sexually transmitted infection. The vaccine is offered at ages 12 to 13 because it works best if it is given before the onset of sexual activity. So although some parents may feel that their child is not at risk of an HPV infection, it is for this very reason that the vaccine is given at a young age.”

“ The flu vaccine contains porcine gelatine from collagen in pigs,” says Karen. “While we’ve done our best to engage with religious communities, there are certain cultural beliefs that simply make it impossible to have any meaningful effect on uptake rates.”

“ Although the government has refused to rule out compulsory vaccinations as a way of improving uptake, we think it is best to avoid enforcement,” says Jennie. “It is preferable to establish an ongoing relationship between parents and providers founded on trust and conversation.”

Jabs of concern: disrupted routines and new vaccines

Although routine vaccinations have been available during the pandemic, the number of MMR vaccines delivered dropped during lockdown. Professor Helen Bedford believes this could partly be down to flawed messaging that “ provides little assurance for families that the NHS is open for routine care “.

Initially, the public was urged to “stay home”, which has since shifted to “stay alert”. Helen notes that this dominant message left little space for nuance and that important messages may not even reach families such as recent migrants and those with poor language literacy or access to technology.

In response to the drop, the NHS urged the public to get routine vaccines. Public Health England’s Head of Immunisations, Dr Mary Ramsay, said: “Routine vaccinations are available throughout the COVID-19 outbreak — it’s vital that parents continue to take their children to appointments.”

Beyond routine vaccinations, there are also concerns about the COVID-19 vaccines now in development. Imran’s recent YouGov poll suggested that a third of people were either “unsure” or “will not get vaccinated”, calling into question whether sufficient coverage is a realistic outcome.

“Developing a vaccine is just the first step — how we communicate the message is going to be so important,” says Andrew. “And this is going to be challenging when we deliver a new vaccine before having access to several years of safety data.

“For children, however, the biggest issue is not COVID-19, but the disruption to health systems and a subsequent rise in other infectious diseases that do affect them. Take measles, for example. After years of progress, epidemics have seeded in many countries, including the UK. This is a huge threat.”

“Routine vaccinations are available throughout the COVID-19 outbreak — it’s vital that parents continue to take their children to appointments.” — Dr Mary Ramsay, Public Health England

Over the last ten years, there has been a 73% reduction in global measles mortality. For several years, however, global coverage has stalled at 85%, and 2019 saw rising cases in a number of countries. This highlights the need to understand and improve vaccine acceptance.

In response to last year’s immunisation statistics, the British Society for Immunology restated a number of solutions. This included strengthening the role of immunisation coordinators, ensuring services are accessible, and engaging with families to provide information and answer their questions.

In our response to the Academy of Medical Sciences’ Preparing for a Challenging Winter, we highlighted the crucial role that vaccinations will play in the UK’s response to a potential new wave of coronavirus infections this winter.

While children and young people have, fortunately, been less affected by COVID-19, the same is not true of other viruses like influenza. Reaching coverage targets across routine childhood vaccinations, therefore, will help to protect them — and the wider population with who they interact.

Originally published at https://www.rcpch.ac.uk on August 24, 2020.