Analysis

How will the government tackle the drop in children's immunisation rates?

Home secretary may consider compulsory vaccination, but NHS staff are unconvinced

Home secretary may consider compulsory vaccination, but there is little enthusiasm for this among NHS staff

  • Uptake of some childhood vaccinations is falling and the government is preparing a vaccination strategy 
  • Vaccination is important for ensuring herd immunity and can be an opportunity for nurses to pick up other issues
  • More flexible appointments for working families and catch-up clinics in schools and universities might help

Picture: Alamy

The UK government is preparing a vaccination strategy in response to falling child immunisation rates which could be out in weeks.

Health secretary Matt Hancock said he is also considering a move to compulsory vaccination and has sought legal advice.

5

years in a row uptake of the first dose of MMR has fallen

(Source: NHS Digital/World Health Organization)

The proposed strategy is a response to the UK's loss of its World Health Organization measles-free status in August three years after the virus had been eliminated, and the news that coverage for all the under fives vaccinations has fallen in 2018-19 compared with 2017-18.

How do NHS staff feel about compulsory vaccination?

Despite the health secretary’s interest in compulsory vaccination, there is little enthusiasm among NHS staff.

Representatives from the Royal College of Paediatrics and Child Health (RCPCH), RCN and School and Public Health Nurses Association (SAPHNA) have questioned the move.

RCPCH immunisation lead David Elliman says there is no evidence it would work and predicts it would start a row about civil liberties that could undermine the drive to increase vaccination rates.

‘We could make things worse. Instead we need to look at the reasons why vaccination rates have fallen and respond to that.’

Social and cultural factors that affect vaccination rates

Many blame the spread of the online anti-vaccination movement – something the government and certain social media sites have agreed to try to combat.

But University College London professor of child health Helen Bedford believes it should be easier for families to get children vaccinated. She says some groups are more likely to miss out, including children in care, Traveller families and some immigrant groups, and therefore outreach work is essential. 

9

routine child vaccines due before the age of five saw a fall in uptake in the UK in 2018-19

(Source: NHS Digital/World Health Organization)

She adds that access is a problem anyone can face. ‘People have busy lives, particularly if they have multiple children. Offering vaccination in places other than general practices – for example running pop-up clinics in supermarkets and children’s centres – could help.’

RCN professional lead for general practice nursing Marie Therese Massey says there are challenges to pop-up clinics, citing the need for an accurate vaccination history and gaining proper consent.

Cuts have affected care and more investment is needed

Ms Massey says it would be better to invest in the general practice nursing workforce to give nurses the time and training to improve communication and combat the falls in coverage.

‘You need to have challenging conversations with parents, guardians and children to combat misinformation and concerns.

‘If you don’t have enough time the issues are not dealt with and a vaccination opportunity is missed.’

RCN professional lead for public health Helen Donovan says investment could be used to provide more flexible appointment times including evening and weekend clinics for working parents.

She says a more consistent system to chase up children who remain unvaccinated would help, while more could be done to offer catch-up clinics in schools and universities for the pre-school vaccines.

991

measles cases in 2018 in England and Wales – up from 284 the year before

(Source: NHS Digital/World Health Organization)

But Ms Donovan says cuts following the reorganisation of the NHS under the 2012 Health and Social Care Act have hampered attempts to provide a more comprehensive service.

‘There used to be an immunisation lead in every primary care trust that could support vaccination teams, but now there are fewer as it is organised regionally by NHS England.’

Changes to school immunisation services

School vaccinations are carried out by school nurses or specially commissioned school vaccination teams. This winter all primary school pupils in England are being offered the flu vaccine for the first time, other parts of the UK are already doing this.

SAPHNA chief executive officer Sharon White says changes in the NHS have led to an overhaul of school immunisation services with delivery taken away from school nurses in some areas and given to external teams.  

‘Some teams are good, but some take a stab and jab approach with minimal time for anything else. They don’t always have time to do the soft stuff – talking to children and taking a holistic approach.

‘It’s not just about offering reassurances over vaccination, you can pick up other issues, safeguarding and mental health problems for example. Vaccination is an important window.’

What is happening to vaccination rates?

Winter flu vaccination coverage is generally increasing across the UK
There are flu vaccine delivery delays UK-wide this year. Picture: Alamy

Children in the UK are vaccinated against a range of diseases before the age of five.

There are ten vaccinations, including the two measles, mumps and rubella (MMR) doses and boosters for other diseases.

A booster for meningococcal group B was added to the list in 2019 and has no previous data to compare to, the remaining nine saw falls in uptake during 2018-19.

Coverage for the first dose of MMR fell for the fifth year in a row with 90.3% of children aged one recorded as having had it – below the 95% needed for herd immunity. London has the lowest rate, while Scotland and Northern Ireland have rates above the 95% threshold.

Overall performance is still better than it was at the turn of the century when rates plummeted because of the now discredited research by Andrew Wakefield. 

For other vaccinations the trend is different. The winter flu vaccination has been gradually introduced over the past six years and coverage is generally increasing, although this winter it is being restricted to children with underlying medical conditions first due to delivery delays with the Fluenz Tetra vaccine.

At secondary school, pupils are offered the three-in-one booster for tetanus, diphtheria and polio, MenACWY to protect against meningitis and septicaemia and the human papillomavirus (HPV) vaccine.

Coverage has been stable for the booster and MenACWY vaccinations and uptake for HPV in England is over 80%, ahead of many other countries.

Does compulsory vaccination work?

It is still an emerging picture. The rise in measles cases is a global phenomenon – outbreaks are not just contained to the UK. Italy and France have approved new regulations in 2017 and 2018 respectively, aimed at raising immunisation rates among children by introducing mandatory vaccination at school entry.

Parts of Australia are exploring compulsory vaccination by stopping parents from taking their children to nurseries and day centres if they are not vaccinated.

A study by BMC Medicine in May 2019 concluded the introduction of compulsory vaccination was producing positive effects.

But some have questioned whether this was a result of mandatory immunisations or the media publicity surrounding the policies.

 

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