Maintaining high immunisation coverage in the current COVID-19 disease circulating environment.
There has been much discussion about the fall in childhood immunisation coverage. It is clear that this has happened through COVID-19, but what many don’t realise is that a decline started in 2016.
Dr Anna Howe, Research Fellow, Paediatrics, Child and Youth Health at the University of Auckland, lays out the history and issues that may need to be addressed to change this.
COVID-19 has ensured that vaccination has been front and centre for all of us for well over 6 months now, but immunisation coverage at 6 months of age is a completely different story. It is currently the lowest it has been in 10 years at only 71% in September 2021. Meanwhile coverage at 8 months of age, which is an indicator of completeness of the infant schedule (allows for catch-up immunisations), during 2021 was the lowest it’s been since 2012 (when records began) at only 87%.
While the commentary has been that this decline is a reflection of the COVID-19 environment we had already started to see a decline in coverage from the highs seen in 2015-2016 (~93%) before the pandemic started.
Our COVID-19 mahi has been a distraction from our ‘business-as-usual’ healthcare and exacerbated already entrenched inequities, and this is reflected in our immunisation coverage.
Traditionally we have struggled to achieve equity for immunisation and the closest we achieved was in 2015-2016 when coverage for tamariki Māori was around 3%, behind NZ European.
However, this gap has now increased again with coverage for Māori children at 8 months of age (73%) which is significantly lower than children of other ethnicities (>89%) in December 2021. Similar patterns are seen with area-level socio-economic deprivation as well, with coverage in areas of high deprivation the lowest they have ever been since 2012.
The health sector is currently operating significant stress with a challenging environment and multiple completing needs. However, in the middle of these challenges we need to continue to find all possible avenues to maintain the National Immunisation Schedule, including the infant programme, this has always been considered an ‘Essential Service’ under the COVID-19 Community Response Framework.
Therefore, even under the ‘Severe Impact’ phase, it is important that general practices and outreach services across the country continue delivering essential health services, including on-time delivery of the childhood immunisation and other scheduled vaccines.
During previous lockdowns, there was a significant decrease in immunisation uptake. Some of this was that families did not feel confident to bring their infants and children into general practices with concerns about safety and spread of COVID-19.
Other issues included families feeling they were unwelcome with first line of services being contactless.
These challenges were highlighted by comments following the first lockdown:
“Our recall nurse says it is taking twice as long to recall under 2's as she is ringing the parent and having to allay their understandable fears before being able to make an appointment for them.
Also extra time explaining our infection risk procedures. Recalling by the usual text is not working - hence the phone calls are required.
Once at the practice, extra time is required due to infection control,cleaning afterwards, and keeping the patient and parent in the consult room for their wait time.” – comment from IMAC General Practice Survey April 2020.
Going forward we are also likely to have challenges with ensuring adequate staffing for primary care and outreach services. However, any further drop off in coverage will leave even more of our tamariki and whānau unprotected against serious diseases, and of particular concern are pertussis and measles.
Managing to maintain immunisation uptake over the next few months, may require changes in the way we manage patient access in our clinic, to ensure families feel welcome and while reducing the risk of cross infection, so it Is safe.
If a provider is unable to separate non- respiratory and respiratory appointments, then immunising at another venue or in the carpark may be appropriate, if the car parking area of the practice allows.
All practices need to provide a safe space where immunisations can occur, for example:
• scheduling separate appointment times for different services (e.g., vaccinations and other routine services performed in the morning and respiratory-related appointments in the afternoon).
• separate spacing of services (e.g., vaccinations and other routine services performed in one section of the practice or in the patient/caregiver’s vehicle and respiratory-related appointments in a separate area of the practice).
• general practice partners (e.g., one practice handling immunisations and other routine services for both practices and the other practice handling respiratory and other infectious conditions).
Please see the Ministry of Health guidance for Primary Care website for further details.
Examples of success from the IMAC General Practice Survey April 2020 – post first Lockdown
“We have been doing home visits for immunization if the parents did not have transport or they had elderly family members at home and didn’t want to come into the clinic.”
“Parents are continuing to follow the schedule, having both parents working from home has made it easier for parents to attend.”
“We designated a room (clean room with an external door to the car park we would offer especially 6wk vaccines in this room for early morning appointments. Especially during Level 4 when anxiety was so high.”
“We have changed the process completely - we have a 'Monday clean environment' clinic and phone all parents to get the child booked in to explain the steps we are taking to keep them and the children well - we wear PPE and don't allow anyone with any cold symptoms into our building. The area where we are vaccinating has its own separate waiting room and we are spacing the children out so there is no overlap.”
“Some were concerned about coming into practice. We have modified waiting times, and time spent in clinic by allowing parents to wait in vehicles prior to being seen by nurse, and also waiting in cars after immunisations with post check being done by nurses at vehicles.”
“We are doing these vaccinations at the practice on a Saturday when there is only a Nurse and GP onsite. This has given parents peace of mind.”
“Uptake of vaccines at practice is very good particularly after measles outbreak. Care is taken with leaving clients in car until ready to meet and greet. Clients then escorted through separate entrance into clean room for vaccinations. Clients leave through front entrance after 20 minutes post- vaccination wait.”
“In our clinic we have a room that is only for babies and children to be immunized in. No sick people are seen in this room. This has made mothers feel safer and happier.”
“As a practice we have set up in a separate building not currently being used and are providing immunisation only clinics there for well children for all immunisations, but not a flu clinic on the same day”
“Had a drive through garage to work in, which allowed children to be easily separated from others and not get as cold as vaccinating outside”
“We have a large garage that patients can drive their cars into. We then do the pre-consult at 2m, then get them out on to a chair with their child to vaccinate, they then wait 20mins within the car. Patients have felt quite safe vaccinating this way as it limits the contact time as well as how much cleaning of surfaces we have to do.”
“We have delivered childhood immunisation whilst patients have remained in their cars, with a practice nurse monitoring in the car park for 20 minutes post administration."
“Once we have a discussion with the parents and reassure them that our place is safe to present to, we tell them these are done via a Drive-Thru service with nurse in full PPE wear. This gives them added confidence and they usually present. We have had positive feedback from whanau and are also administering flu vaccines in patients' cars also, works well.”
“I think it has been easier for some families with both parents/caregivers at home during lockdown meaning one can stay home with the other children if applicable while other parent/caregiver can bring the one in for vaccination.”
“We now open on Saturdays with just one nurse and one in the building, just to do child immunisations. This way each family can have a private consult room to wait in post vaccination and do not cross paths with any other families. So far no parents have declined due to COVID concerns and find this method reassuring. We have also found this is the only time infants are being weighed as Plunket and midwives reduced contact so they appreciate being able to be seen.”