An outbreak of measles in the Hunter area of New South Wales

Abstract: An outbreak of measles occurred in 1990 in the Port Stephens Shire of New South Wales. The incidence of confirmed cases of measles and associated histories of immunisation are detailed by age for the period 24 June 1990 to 31 December 1990. Data were obtained from health and education professionals and from interviews with parents. Among the 158 cases were 116 school pupils, 82 of whom attended two large primary schools which had attack rates of 9.4 per cent and 4.1 per cent. The cases also included 29 persons who had been appropriately immunised. Inadequate immunisation coverage was seen as the principal cause of the outbreak in the Port Stephens Shire. Observance of institutional protocol was regarded as a principal impediment to disease counter-measures in a neighbouring measles-affected area. Regulated immunisation of young children and cooperative interaction among service providers could ultimately lead to the control of this serious disease in New South Wales.     

Improved childhood immunization coverage using the World Health Organization’s Tailoring Immunization Programmes guide (TIP) in a regional centre in Australia

In 2017 the World Health Organization’s Tailoring Immunization Programmes guide (TIP) was used to identify pockets of low immunization coverage in Australia. The regional centre of Maitland had high numbers and rates of children who were overdue for scheduled vaccinations (2016, n = 344, 37.7%). Families were not opposed to immunization but had conflicting priorities or experienced service access barriers. A tailored strategy was developed including friendly, personalised reminders, outreach appointments and home visiting for those families most in need. Research translation was not quick and easy. A process evaluation identified areas where more support was needed to advance the strategy. Coverage rates have increased from 62.3% (2016) to 86.2% (2020). The number of overdue children has decreased even during COVID-19 restrictions when health services expected families would avoid primary care services. The TIP approach is valuable for improving childhood immunization coverage and is being utilised in other communities with low coverage.     

The Australian Childhood Immunisation Register: validation of the immunisation status of children who are very overdue

OBJECTIVES: To determine the true immunisation status of children identified by the Australian Childhood Immunisation Register (ACIR) as 90 days overdue, and determine why appropriately immunised children were flagged as overdue. METHODS: A telephone survey of immunisation providers and/or parents of a stratified random sample of 850 NSW children born on or after 1 January 1996 and identified by the ACIR as 90 days overdue for at least one scheduled immunisation at 17 June 1997. The survey was conducted in June to September 1997. RESULTS: Children in the sample ranged in age from 5 to 17 months. Only 526 (61.9%) could be traced. Of these, 452 (86.6%) were fully immunised, and 75% of immunisations were given on time (within 30 days of falling due). The overall proportion of NSW children identified by ACIR as 90 days overdue who were fully immunised was an estimated 85% (95% CI 82.6%-87.4%). For the 452 fully immunised children, a reason for the child's immunisation not appearing on the register could be attributed for only 248/452 (54.8%). There was evidence that the provider had failed to submit an encounter form for 141 of these children. CONCLUSIONS: In mid-1997, more than half the children identified by ACIR as 'overdue' were fully immunised. A significant reason for fully immunised continuing to be flagged as overdue was failure to return encounter forms. IMPLICATIONS: At the time of survey the ACIR could not accurately identify unimmunised children and was of limited use as a tool for public health services to follow up very overdue children.     

Tailoring immunisation programmes: Using behavioural insights to identify barriers and enablers to childhood immunisations in a Jewish community in London,UK

IntroductionDue to regular vaccine preventable disease outbreaks and sub-optimal immunisation uptake in the London borough of Hackney, home to the largest Charedi Orthodox Jewish community in Europe, it was decided, in consultation with the community, to implement the WHO Tailoring Immunization Programmes approach (TIP).DesignThe WHO Tailoring Immunization Programmes (TIP) approach was used. TIP provides a framework based on behavioural insights methodology to identify populations susceptible to vaccine preventable diseases, diagnose supply and demand side barriers and enablers to vaccination and recommend evidence-informed responses to improve vaccination coverage.ResultsThe results of the formative research and behavioural analysis challenged the assumption that a cultural or religious anti-vaccination sentiment existed within the community. Critical issues related to access to and convenience of immunisation services. Service providers in the area have challenges due to having to deliver immunisation services to the large numbers of children without additional resource. Where mothers were choosing to delay or refuse vaccinations their reasons were broadly similar to the wider population. The behavioural analysis identified potential categorisation of subgroups within the community enabling a more tailored approach to addressing concerns and meeting parents’ needs.ConclusionThe TIP approach was an effective way of investigating factors linked to sub-optimal immunisation within the Charedi community. The use of behavioural insights enabled the categorisation of subgroups so that more targeted interventions could be developed. The comprehensive stakeholder engagement which is a key pillar of the TIP approach ensured a deeper understanding of the barriers and enablers to vaccination as well as increasing the level of ownership in the community. TIP should be considered as a useful approach to identify main facilitators and barriers to vaccination in communities with suboptimal immunisation uptake.     

Measuring disparities in immunisation coverage among children in New Zealand

For the past 20 years, New Zealand has experienced low immunisation coverage levels. Following the introduction of the National Immunisation Register (NIR) in 2005 many practitioners envisaged improved overall immunisation uptake through enhanced surveillance and monitoring capacities. This study aimed to investigate the geographical distribution and variables associated with disparities in immunisation uptake in New Zealand using a large NIR data set of children aged 12 months old in 2007–2009. DHB immunisation uptake was adjusted for individual ethnicity and deprivation status, year of birth and geographic location. Substantial variations in uptake by ethnicity and District Health Board (DHB) level were evident. Māori (NZ indigenous) and ‘Other’ ethnicity remain a substantial risk factor for low immunisation uptake after controlling for socio-economic deprivation. In addition, a general north–south gradient was confirmed across New Zealand. Current immunisation programme strategies for planners and providers in New Zealand need to recognise varying DHB compositions in order to provide efficient service provision and to focus on those groups at higher risk of not being immunised.     

Barriers to childhood immunisation: Findings from the Longitudinal Study of Australian Children

ObjectivesTo examine barriers to childhood immunisation experienced by parents in Australia.DesignCross-sectional analysis of secondary data.SettingNationally representative Longitudinal Study of Australian Children (LSAC).ParticipantsFive thousand one hundred seven infants aged 3–19 months in 2004.Main outcome measureMaternal report of immunisation status: incompletely or fully immunised.ResultsOverall, 9.3% (473) of infants were incompletely immunised; of these just 16% had mothers who disagreed with immunisation. Remaining analyses focussed on infants whose mother did not disagree with immunisation (N = 4994) (of whom 8% [398] were incompletely immunised).Fifteen variables representing potential immunisation barriers and facilitators were available in LSAC; these were entered into a latent class model to identify distinct clusters (or ‘classes’) of barriers experienced by families. Five classes were identified: (1) ‘minimal barriers’, (2) ‘lone parent, mobile families with good support’, (3) ‘low social contact and service information; psychological distress’, (4) ‘larger families, not using formal childcare’, (5) ‘child health issues/concerns’. Compared to infants from families experiencing minimal barriers, all other barrier classes had a higher risk of incomplete immunisation. For example, the adjusted risk ratio (RR) for incomplete immunisation was 1.51 (95% confidence interval: 1.08–2.10) among those characterised by ‘low social contact and service information; psychological distress’, and 2.47 (1.87–3.25) among ‘larger families, not using formal childcare’.ConclusionsUsing the most recent data available for examining these issues in Australia, we found that the majority of incompletely immunised infants (in 2004) did not have a mother who disagreed with immunisation. Barriers to immunisation are heterogeneous, suggesting a need for tailored interventions.     

Barriers and facilitators of immunisation in refugees and migrants in Australia: an east-African case study

BackgroundImmunisation programs available in low and middle-income countries include fewer vaccines in comparison to Australia’s National Immunisation Program. As a result, refugees and migrants may have a heightened risk of being inadequately immunised upon arrival to Australia. Several studies have suggested that East African immigrants have low vaccination coverage. As such, the aim of this study was to explore the underlying attitudes, barriers and facilitators to immunisation in east African communities in two states of Australia: New South Wales and Victoria.MethodsA qualitative study involving 17 semi-structured, in-depth interviews were undertaken with East African refugees and migrants living in two states of Australia: New South Wales and Victoria. These refugees and migrants were from four key East African countries: Kenya, Somalia, Ethiopia and South Sudan. Thematic analysis was undertaken to analyse and interpret the results.ResultsLanguage barriers, low risk perception and a lack of education were the key barriers identified by participants. Facilitators mentioned included the development of resources in participants’ languages and the implementation of reminder systems consistently across all GP practices. There was also a unanimous agreement amongst participants that community organisations need to play a greater role in the dissemination of information about immunisation.ConclusionsFurther research needs to be undertaken with regards to how education about immunisation is delivered and disseminated to refugee and migrant communities. Current findings also support the need to improve the health literacy of refugees and migrants by providing culturally and linguistically appropriate resources in participants’ respective languages.     

Impact of a promotion program for hepatitis B immunisation

Abstract: This study compared levels of hepatitis B immunisation in a group of 524 infants in Northland, New Zealand, with levels in the remainder of the country. The Northland sample had specific encouragement from an immunisation coordinator and had been followed from birth. Levels throughout the rest of the country were estimated from four samples totalling 317 infants whose parents were interviewed when the child was at least two years old. The cross-sectional nationwide sample had fewer children ‘fully immunised’ by two years of age (minimum estimate 61.8 per cent, maximum estimate 69.7 per cent) than the cohort of children (not lost to follow-up) who were encouraged to have the immunisations in Northland (77.5 per cent) (Z = 4.73, P < 0.001 for comparison with the minimum nationwide estimate; Z = 2.45, P = 0.014 for comparison with the maximum estimate). Of the Northland cohort, 13.5 per cent were lost to follow-up before the scheduled completion of the hepatitis B vaccinations. Assuming that every child lost to follow-up was not fully immunised, the efforts of the immunisation promotion program operated by a nurse coordinator increased the percentage of children fully immunised by between about 7.8 per cent and 15.7 per cent. A promotion program for hepatitis B immunisation, operated by an immunisation coordinator, is an effective tool for increasing immunisation coverage.     

Catch-up immunisation for migrant children in Melbourne: A qualitative study with providers to determine key challenges

BackgroundCurrent models of immunisation service delivery in Australia are not meeting the needs of migrant children, who experience a higher burden of vaccine preventable disease and lower immunisation rates compared to non-migrant children. Understanding the experiences of immunisation providers is critical for designing effective and tailored interventions to improve this service. This study aimed to identify the facilitators and barriers to providers delivering a comprehensive catch-up immunisation service to migrant children in Melbourne, Australia.MethodsSemi-structured interviews with council and general practice immunisation providers were conducted. Recorded interviews were transcribed and coded inductively using thematic analysis. Identified themes were then deductively categorised according to the Capability, Opportunity and Motivation of Behaviour (COM-B) model.ResultsTwenty-four providers (five practice nurses, six general practitioners, six council nurses and seven council administration officers) were interviewed between March and June 2021. Fourteen themes were identified that contributed to the delivery of an effective catch-up immunisation service. Capability themes included training, experience and skills to perform the service and communicate with families. Opportunity themes incorporated time, workplace norms, traits of migrant families, costs, systems and resources. Themes related to motivation were provider responsibility, beliefs about migrant health, and immunisation prioritisation.ConclusionsKey barriers for providers to deliver a comprehensive catch-up immunisation service were related to opportunity. Developing an online tool to support catch-up schedule development and reporting, and funding provider time to calculate the schedule are primary actions that could overcome opportunity barriers. Capability and motivation barriers for general practitioners included limited time, skills, and motivation compared to nurses. These barriers may be overcome with improvements to training that focus on upskilling nurses to deliver the catch-up service. Service delivery challenges are multifactorial, requiring a range of strategies to optimise this service and increase immunisation coverage in migrant children.     

Geospatial analysis of childhood pertussis in Victoria, 1993-97

OBJECTIVE: To demonstrate the feasibility of using Geographical Information Systems (GIS) in public health research. METHODS: Area-based relationships between the incidence of pertussis and immunisation coverage using data on Victorian children aged 0-4 years who contracted pertussis in 1993-97, were analysed at the Local Govemment Area (LGA) level. DTP3 immunisation uptake by LGA was first stratified into two groups: > or = 90% or < 90% (national target). Those under 90% were then divided into two equal bands. The incidence rates for LGAs were classified into quartiles. Immunisation records of children in the 1996-97 birth cohort were reviewed. RESULTS: When the DTP3 immunisation uptake was > or = 90%, seven LGAs were in the upper quartile and eight LGAs in the lower quartile of childhood pertussis notifications incidence. An equal amount of LGAs were in the upper (n = 6) and lower quartiles (n = 6) of notified childhood pertussis incidence rates with an associated DTP3 coverage rate in the lowest band. Of children bom between 1996-97 who contracted pertussis under the age of two, 29% were not immunised and 78.6% were partially immunised at the time of pertussis onset. CONCLUSIONS: GIS enabled the integration of disparate immunisation-related datasets and identified geographic LGAs where immunisation rates were low and pertussis rates were high. IMPLICATIONS: Future research needs to explore the social and environmental factors associated with those not fully immunised at onset of pertussis disease, particularly those in geographic areas highlighted by this research. GIS has the potential to add value in the monitoring and surveillance of geographical patterns of child health, but investments in data quality are urgently required.     

Immunisation coverage reporting through the Australian Childhood Immunisation Register--an evaluation of the third-dose assumption

OBJECTIVE: The Australian Childhood Immunisation Register (ACIR) currently classifies those children who have the third dose recorded as fully immunised at 12 months of age, even if records of earlier doses are missing. This analysis assesses the impact this "third-dose assumption" has on immunisation coverage estimates for children aged 12 months. METHODS: ACIR records from three equally spaced cohorts of children at 12 months of age, which relied on the third-dose assumption, were examined for variation in doses and vaccine types recorded by jurisdiction and Medicare registration status. RESULTS: Although the percentage reduction in coverage without application of the third-dose assumption decreased through the three cohorts examined, the proportion classified as fully immunised still decreased by 11-12% (to < 75%) if the third-dose assumption was not used in the most recent cohort. "Fully immunised" status among children with delayed Medicare registration or in jurisdictions with a high proportion of paper reporting to the ACIR was disproportionately reduced without use of the assumption. CONCLUSIONS AND IMPLICATIONS: While independent sources of data continue to show that the ACIR incorrectly classifies some children as not fully immunised even with the third-dose assumption, its use seems appropriate for reporting population trends in immunisation coverage. Earlier Medicare registration and increased electronic reporting to the ACIR, together with incentives for parents and providers to ensure complete ACIR records, should eventually eliminate the need for the third-dose assumption.     

Identifying barriers and drivers to vaccination: A qualitative interview study with health workers in the Federation of Bosnia and Herzegovina

BackgroundVaccination coverage in Bosnia and Herzegovina has been declining over recent years. A World Health Organization Tailoring Immunization Programmes (TIP) project is underway to gain insights into the underlying reasons for this, to develop tailored interventions. As part of TIP, this study aimed to investigate the views of health workers on their barriers and drivers to positive childhood vaccination practices.MethodsFace-to-face qualitative interviews explored 38 health workers’ views on vaccination coverage, their vaccination attitudes, and system, programme and institutional influences on their vaccination practices. The data were analysed using content analysis and organised by the COM (Capability, Opportunity and Motivation) factors.FindingsVery few differences in barriers and drivers were evident between high and low coverage primary care centres or across different professional roles.Capability: Drivers included awareness of the risks of low vaccination coverage, regular use of the Rulebook and Order, knowledge of how to advise parents on mild side effects and recognition of the importance of good communication with parents. Key barriers were the use of false contraindications to postpone vacination and poor skills in tailoring communication with parents.Opportunity: Drivers were sufficient time for adminstering vaccination and good availability of vaccines. Several barriers were evident: lack of implementation of mandatory vaccination, no uniform recall and reminder system or system for detecting under-vaccinated children, staff shortages and lack of time to discuss vaccination with parents.Motivation: Drivers were a belief in the value, safety and effectiveness of vaccination and seeing that they have an important role to play. Barriers were a tendency to blame external factors e.g. anti-vax movement and a fear of being blamed for adverse events.ConclusionsThe study identified complex and inter-related barriers and drivers to health worker positive vaccination practices. These insights will now inform a process to identify and prioritize interventions.     

Children overdue for immunisation: a question of coverage or reporting? An audit of the Australian Immunisation Register

Objective : Vaccinations in Australia are reportable to the Australian Immunisation Register (AIR). Following major immunisation policy initiatives, the New South Wales (NSW) Public Health Network undertook an audit to estimate true immunisation coverage of NSW children at one year of age, and explore reasons associated with under‐reporting. Methods : Cross‐sectional survey examining AIR immunisation records of a stratified random sample of 491 NSW children aged 12≤15 months at 30 September 2017 who were >30 days overdue for immunisation. Survey data were analysed using population weights. Results : Estimated true coverage of fully vaccinated one‐year‐old children in NSW is 96.2% (CI:95.9‐96.4), 2.1% higher than AIR reported coverage of 94.1%. Of the children reported as overdue on AIR, 34.9% (CI:30.9‐38.9) were actually fully vaccinated. No significant association was found between under‐reporting and socioeconomic status, rurality or reported local coverage level. Data errors in AIR uploading (at provider level) and duplicate records contributed to incorrect AIR coverage recording. Conclusions : Despite incentives to record childhood vaccinations on AIR, under‐reporting continues to be an important contributor to underestimation of true coverage in NSW. Implications for public health : More reliable transmission of encounters to AIR at provider level and removal of duplicates would improve accuracy of reported coverage.     

Childhood immunisation: factors associated with failure to complete the recommended schedule by two years of age

Abstract: This study aimed to determine the immunisation status of preschool-aged children attending formal child-care facilities in north Queensland, and to examine factors associated with failure to be completely immunised by two years of age. Child-care centres and kindergartens within the Cairns City and Mulgrave Shire local government boundaries were selected randomly with probability proportional to size, and 613 children (median age of 47.0 months) were selected randomly from the facilities. Only 60.3 per cent (95 per cent confidence interval (CI) 56.3 to 64.3) of the children were fully immunised by two years of age. Children who had not received any vaccines by three months of age (that is, ‘late starters’) were less likely to be fully up-to-date at two years of age than children who started on time (odds ratio (OR) 10.3; CI 5.2 to 20.9). Children without a parent-held immunisation record were less likely to be up-to-date at two years of age than those children with a parent-held immunisation record (OR 2.8; CI 1.9 to 4.0). With follow-up of late-starters, and with the simultaneous administration of overdue vaccines with vaccines given in the second year of life, the percentage of children up-to-date at 24 months of age could have increased from 60.3 per cent to 82.3 per cent (CI 79.1 to 85.5). The immunisation coverage rates were inadequate to prevent outbreaks of vaccine-preventable diseases. Innovative strategies will be required if the vaccine coverage rates are to be improved. The parent-held immunisation record is of fundamental importance to all these strategies.     

Family practice nurse views on barriers to immunising children

New Zealand (NZ) has low immunisation coverage for infants and children compared to many other westernised countries. Barriers to improving uptake are multifactorial, with health professional knowledge and attitudes identified as important modifiable factors. In NZ practice nurses give most childhood vaccinations in the primary health care setting. This study explored aspects of 150 family practice nurse views, knowledge and experience about immunisation. Qualitative and quantitative text data were obtained through randomised computer assisted telephone surveys and converged using a triangulated multi-method approach. Response rate was 89.3% nurses identified parents' fear as the greatest barrier to achieving better immunisation uptake and disagreed that health professional knowledge was a barrier. However, findings showed lack of knowledge among many participants, despite many feeling confident about their knowledge base. Factors associated with lower practice coverage of infants under 2 years were poorer knowledge of contraindications to vaccination and lack of completion of vaccinator training, especially an update course. A high level of confidence, more years in practice, dedicated time to follow-ups were not associated with better coverage rates. Practice nurses may be unaware that their knowledge in some areas needs improving. A trained practice nurse appears to play a significant role in overcoming fears and maintaining high coverage rates in their practice. We conclude that strategies that focus on primary health care provider support and education are more likely to gain high coverage than those that are purely directed at overcoming access barriers.     

An outbreak of measles in a highly immunised population: immunisation status and vaccine efficacy

Abstract: An outbreak of 18 cases of measles in a primary school in the Australian Capital Territory in August and September 1993 provided the opportunity to study measles immunisation status and measles vaccine efficacy. Parents of 384 (78 per cent) of 491 children answered a questionnaire on recent illness consistent with measles and measles immunisation. Parents transcribed details of measles immunisation from the personal health record of the child to the questionnaire. Thirty-three per cent of cases and 3.4 per cent of the other children had not been immunised. Overall, 95 per cent of children had been immunised. The efficacy for all measles vaccines was estimated to be 90 per cent (95 per cent confidence interval (CI) 75 to 96) and for measles-mumps vaccine 87 per cent (CI 70 to 95). All of the immunised cases had received measles-mumps vaccine. There was no increased risk of measles infection in those who had been immunised at under 15 months of age compared with those immunised at 15 months or older, or in those who could not provide a date of immunisation compared with those who could. None of the children who had received two doses of vaccine caught measles. The date of immunisation was provided by 65 per cent of the respondents who said their children had been immunised. Asking parents to provide this date instead of viewing the health record is a less expensive way of assessing immunisation status but this method needs to be evaluated. Measles outbreaks still occur in highly immunised populations when vaccine efficacy appears to be acceptable.     

Equity in disease prevention: Vaccines for the older adults – a national workshop,Australia 2014

On the 20th June, 2014 the National Health and Medical Research Council’s Centre for Research Excellence in Population Health “Immunisation in under Studied and Special Risk Populations”, in collaboration with the Public Health Association of Australia, hosted a workshop “Equity in disease prevention: vaccines for the older adults”. The workshop featured international and national speakers on ageing and vaccinology. The workshop was attended by health service providers, stakeholders in immunisation, ageing, primary care, researchers, government and non-government organisations, community representatives, and advocacy groups. The aims of the workshop were to: provide an update on the latest evidence around immunisation for the older adults; address barriers for prevention of infection in the older adults; and identify immunisation needs of these groups and provide recommendations to inform policy.There is a gap in immunisation coverage of funded vaccines between adults and infants. The workshop reviewed provider misconceptions, lack of Randomised Control Trials (RCT) and cost-effectiveness data in the frail elderly, loss of autonomy, value judgements and ageism in health care and the need for an adult vaccination register. Workshop recommendations included recognising the right of elderly people to prevention, the need for promotion in the community and amongst healthcare workers of the high burden of vaccine preventable diseases and the need to achieve high levels of vaccination coverage, in older adults and in health workers involved in their care. Research into new vaccine strategies for older adults which address poor coverage, provider attitudes and immunosenescence is a priority. A well designed national register for tracking vaccinations in older adults is a vital and basic requirement for a successful adult immunisation program. Eliminating financial barriers, by addressing inequities in the mechanisms for funding and subsidising vaccines for the older adults compared to those for children, is important to improve equity of access and vaccination coverage. Vaccination coverage rates should be included in quality indicators of care in residential aged care for older adults. Vaccination is key to healthy ageing, and there is a need to focus on reducing the immunisation gap between adults and children.