Childhood Immunisation

Childhood Immunisation
How can health professionals help parents get beyond MMR? Next 30 minutes or so, going to look at the publicity about MMR over the last 10 years and the effect this has had on parents of 0-2s with respect to both MMR and attitudes towards new immunisations. In particular, I will look at how Health Professionals can help parents continue to get beyond the MMR issues, to ensure that they are confident about the immunisation schedule going forwards. Welsh Immunisation Conference 23rd April 2009 Sally Malam

The annual research for WAG
PARENTS of 0-2s Surveys since 1997 Random location sampling Face to Face in-home interviews with 200 parents of 0-2s Fieldwork Oct-Nov HEALTH PROFESSIONALS who deal with immunisation Surveys since 2004 Random Probability Telephone interviews with 200 GPs, 175 Health Visitors, 250 Practice Nurses Fieldwork Jan-Mar Parents survey - Annual since 2005 – before that twice a year spring and autumn. GPs – Dendrite. All research carried out alongside similar research in England for DH. Response rates: GP: 27% HV: 61% PN: 55%

MMR the arc of publicity
There’s been a huge amount of publicity about MMR over the past ten years.

MMR - the changing focus of publicity
Wakefield claims MMR not properly tested. Ongoing negative publicity Murch disputes Wakefield’s claims. TV programmes critical of Wakefield Wakefield purports MMR/autism link Demichelli review - MMR link unlikely Increasingly positive publicity NB – Daily Mail since moved on – now printing scare stories about the HPV vaccine. February 1998 Wakefield purports links between MMR and autism/Crohn’s January 2001 Wakefield claims MMR was never properly tested February 2002 Period of unprecedented levels of (largely negative) publicity – Daily Mail, Melanie Phillips etc. October 2003 Simon Murch (Wakefield’s former colleague) claims that the association between MMR and autism has never been proved November 2004 – May 2005 TV programmes critical of Wakefield, which question his research and his motives in raising his concerns October 2005 Demichelli et al publish a systematic review to assess the evidence of effectiveness and unintended effects associated with MMR. Results suggest that MMR is unlikely to be associated with Crohn’s disease, ulcerative colitis, autism or aseptic meningitis

MMR warning as second outbreak of measles in Wales is investigated
Apr 9, 2009, Western Mail Shunning of MMR vaccine blamed for measles outbreak Jul , Birmingham Mail UK 'in grip of measles outbreak' news.bbc.co.uk, 14 June 2008 A lot of the more recent publicity – a lot about the impact of MMR refusals on measles outbreaks – usually mention that the work suggesting MMR is a risk has been discredited. All very positive coverage. Parents warned as measles outbreak hits Cheshire Dec , Chester Chronicle

BUT – press still covers the scare stories in a misleading way - Dec coverage of the case of a baby who died shortly after his MMR immunisation – Bad Science in the Guardian pointed out how misleading the coverage had been ..

“On Tuesday the Telegraph, the Independent, the Mirror, the Express, the Mail, and the Metro all reported that a coroner was hearing the case of a toddler who died after receiving the MMR vaccine, which the parents blamed for their loss. Toddler 'died after MMR jab' (Metro), 'Healthy' baby died after MMR jab (Independent), you know the headlines by now. On Thursday the coroner announced his verdict: the vaccine played no part in this child's death. So far, of the papers above, only the Telegraph has had the decency to cover the outcome. The Independent, the Mirror, the Express, the Mail, and the Metro have all decided that their readers are better off not knowing.” Most papers reported the original story – few bothered to follow up with the finding that the vaccine played no part in the child’s death – just the telegraph according to this article So even though coverage positive on balance, still get the misreporting. And the Daily Mail now seem to have moved onto scare stories about the HPV virus.

MMR the impact of publicity on parents
So we have seen a big arc of publicity tipping point – impact on parents?

Uptake of first dose MMR in Wales by age 2
Wakefield paper Turning point in publicity I am sure you are all familiar with problems the pattern of uptake of the MMR vaccination. In Wales uptake of the first dose of MMR by age 2 fell from a high of 92% in the mid 90s, to a low of 78% in 2003, Back up to 88% by 2006 – around that level still, but lower in some areas - Lots of info on the National Public Health Service for Wales website. This pattern of uptake seems to reflect the arc of publicity with 2003 as the turning point - Can we map the effect of the publicity onto parents attitudes to shed a bit more light on what was happening and implications? Source: COVER report Oct-Dec 2008

Awareness of MMR (spontaneous and prompted)
Increase with -ve publicity Delay, then decrease with +ve publicity Rebound in salience Turning point in publicity First of all - Awareness of MMR – all parents have heard of MMR – not the case for other immunisations – 7-8 in 10 for more established vaccinations, lower for newer ones e.g. half for pneumococcal. Spontaneous awareness – how top of mind or salient the vaccination is – shows more reaction to the publicity – saw increase to a peak of 87% of parents able to mention it spontaneously following the negative publicity – this went on until after the publicity became more positive in 2003, then dropped off again – however, 2008 back up again – so really quite reactive to any information that is out there – Likely to be positive publicity on balance, but MMR still pretty salient for parents even now. Other immunisations much lower awareness. E.g. men C 8 in 10 prompted. Polio half spontaneous So – spontaneous awareness of MMR clearly Reacts to publicity – increased salience when negative publicity and scare stories at peak in 01-02, but then delayed reaction as the stories became more positive – dropping off more slowly. Also – can rebound with any publicity – in 2008 back up again at a higher level so still top of parent’s minds. Base: All primary care givers of 0-2s (n = c.200)

MMR completely safe/only slight risk
c.8 in10 for other immunisations Turning point in publicity Clearer pattern for perceived safety – and this will be linked to uptake, but more extreme pattern. Clearly see drop in belief that completely safe or only slight risk down from 99 to 2003 (nb uptake only down to 78% at that point), but as the publicity turned around to become more positive on balance, so did this level of agreement – back up to three in four where it started and now stabilised here – still slightly below other immunisations which tend to be around 8-9 in 10 for this measure but no longer stands out as it used to. Can see it reacts fairly rapidly to changes in publicity. Base: All primary care givers of 0-2s (n = c.200)

Turning point in publicity
Whether parents have seen something that might persuade them not to immunise Turning point in publicity More direct question – clearly publicity has an impact on attitudes – how serious is this? At peak of publicity – 2001/2002, three in ten parents who had seen any publicity about immunisation said they had seen something that might persuade them not to immunise – this was almost exclusively MMR related, with mentions of autism and crohns. Started to drop off from 2003 and has continued to fall – 2003 at latest measure. 13% - only a few parents – but still most likely to mention autism and chrohns so still MMR linked. Clearly a direct link between publicity and parent’s attitudes Base: All primary care givers of 0-2s who have seen any publicity (n = c.150)

The process of deciding to have child immunised
How much do parents agonise over their decision? Pattern over time. Only have since the shift in publicity became more positive – so probably from about the peak of parent refusals and belief that MMR not safe. Clear pattern here from 42% of parents saying they weigh up the pros and cons, and 56% just saying they would automatically go ahead, through to Nov 08 when three in four parents say they just go ahead automatically. . Base: All primary care givers of 0-2s (n = c.200)

MMR implications for the future
So seen recovery in terms of attitudes towards MMR although still salient for parents. What implications does this have for future changes to the immunisation schedule.

Which immunisations would not allow a future child to have (prompted)
If we look at immunisations that parents said they would refuse in the future – can see at the top a decrease in planned refusals from a peak of 16% in Nov 04 – this was about as high as we recorded – similar level And can see that when this was at its peak back in 2004 MMR headed the field– when 16% of parents were planning to refuse something, 12% said MMR, 5% MMR second dose. And you can see that this has now dropped right back. But compare this with reactions to the three new immunisations – the 5 in 1 when first tracked in 2004 – 4% said they would refuse. A year later this was down to 1% and in 2008 no parents said they would refuse. At the bottom – children’s flu and pneumo – never really seen any resistance. SO – not the case that parents particularly suspicious of new immunisations – although initially some small amount of suspicion of 5 in 1 – another combined vaccine, but a year on, no bad publicity, and so no real worries about new vaccinations. Base: All primary care givers of 0-2s (n = c.200)

Agreement that “too many vaccines at once overloads the child’s immune system”
This issue of multiple or combined vaccinations is at the crux of parental worries – one in three parents agree that too many vaccines at once overloads the child’s immune system – and this has not really dropped off substantially since the publicity around MMR became more positive, and parents became generally less worried MMR as an issue. But can we get more insight into what feeds parental worries about new vaccines? Base: All primary care givers of 0-2s (n = c.200)

Willingness to give possible new vaccines
Given at separate visit 77% Given during non-MMR visit but as separate shot 66% Combined with another (non-MMR) vaccine 62% Given during MMR visit but as separate shot 54% From this question asked in 2008 we can see to what extent the concerns are MMR specific – looking at the bottom two bars, you can see that parents are least likely to be willing to give a new vaccine if combined with MMR or even if given alongside MMR – only half of parents Combined with MMR 50% Base: All primary care givers of 0-2s (2008, n = 204)

Given at separate visit 77% Given during non-MMR visit but as separate shot 66% Combined with another (non-MMR) vaccine 62% Given during MMR visit but as separate shot 54% Not just about combining vaccines either - More willing to give combined with another vaccine, than separately at same time as MMR – 62% compared with 54%. Although they would still be slightly happier if it was a separate shot. Combined with MMR 50% Base: All primary care givers of 0-2s (2008, n = 204)

Given at separate visit 77% Given during non-MMR visit but as separate shot 66% Combined with another (non-MMR) vaccine 62% Given during MMR visit but as separate shot 54% But can see at the top that most likely to find it acceptable if it was given at a separate visit from other immunisations – 77% would – 30% definitely would – well above the rest of the options. So a number of factors, but a clear order than preference: keep it totally separate if you can, and definitely DON’T do anything at the same time as MMR. Combined with MMR 50% Base: All primary care givers of 0-2s (2008, n = 204)

Whether type of new vaccine would affect likelihood of agreeing
MORE LIKELY 64% 36% 33% A further factor – how serious are the diseases. For MMR diseases – only a third to a half of parents saw each as serious. Can see here that parents much more likely to agree to a new vaccine for Meningitis – seen as serious, than for what see as minor childhood ailments – MMR always had a harder job to convince parents that it was worth the perceived risk on balance. 33% Base: All primary care givers of 0-2s (2008, n = 204)

Implications for attitudes to new vaccinations
Clear pattern of recovery in attitudes to MMR Resistance to MMR does not seem to be transferred to new immunisations Parents more open to new immunisation if disease seen as serious A key driver of parental concern remains the fear of “overloading the child” For a new immunisation, most open to a separate shot at a separate appointment Avoid any association with MMR appointment Parents do seem to have moved on.

How can HPs help parents overcome their fears?
3 in 10 parents say they need more information about immunisation This has been consistent for many years So – seems that parents are not automatically going to reject new immunisations, but there could be suspicion if immunisation is against something not seen as a serious childhood illness. How can HPs help? Information is key - 3 in 10 parents say they need more information about immunisation – this has been consistent for many years. This tends to be a general feeling that they need to know more, both about the immunisations and diseases, and some mentions of side effects. We know Information is key – seen how influenced parents are by media scares. HPs can play a role in helping inform parents.

Materials for parents ... Lots of information out their from official sources for parents – leaflets and websites. HPs could direct parents to these sources, but would need to be aware of what was out there.

Whether HPs seen or read WAG/NHS materials for parents
66% of parents 39% of parents 39% of parents Can see here the level of awareness for HPs on the charts, and for parents in the boxes. GPs least aware of any of the official materials. Not surprising – GPs different role, but parents will want to ask them questions. We know from past data that parents would like to get information from GPs in particular so if awareness of the leaflets was higher for GPs they could direct parents to them if asked for advice. For HVs and PNs – much more aware of two key leaflets, but even among these two groups this drops off for the website or the factsheets. Figures for parents in boxes – apart from the guide for babies, pretty low awareness for other sources – so there is a chance for HPs to point parents at these leaflets, and the website. Guide to Childhood Immunisations For Babies up to 13 months Pre-School Immunisations: Guide for 3-5 year olds Hib booster immunisation www. immunisation. nhs.uk NHS immunisation factsheets Base: All health professionals 2008, all parents of 0-2s 2008 (n=204)

Parents’ internet access and visits to Immunisation Information website
Heard of Imm Info website Website seems likely to be a key future resource – parents mention it as one source of info that could persuade them NOT to immunise, but could equally be a source of reassuring information – What we see is a vast increase in internet access for parents of 0-2s since 2004 BUT very little increase in reported visits to the immunisation information website, even though four in ten recognised it – a lot of room for growth here. Previous chart – 4 in 10 GPs, two in three PNs, three in four HVs know of it – If more HPs aware, then maybe they could direct parents towards this source rather than them finding other websites that may contain spurious stories. Can google and find all kinds of info out of your control. Visited Imm Info website Base: All primary care givers of 0-2s (n = c.200)

Had discussions about immunisation with health professionals
Any HP Health Visitor % Agree GP HPs are in a perfect position to do this. We know that Parents do TALK to HPs to get information about immunisation, so they play a role and have an oppportunity to allay parent’s fears. Most likely to be health visitor – related to when they have these conversations. Fewer conversations with GPs, midwives and PNs. PNs should be ideally placed to reassure parents during the imm visit. Midwife Practice Nurse Base: All primary care givers of 0-2s (n = c.200)

% of parents who strongly agree that they trust advice about immunisation given by ...
92% agree in total Health professionals NHS % Strongly agree Pharmacist Government And more evidence that HPs are in a great position to help = parents talk to them AND they trust them. Growing trust in many sources of information, but particularly in HPs. In total 92% of parents said they agreed strongly or tended to agree that they could trust advice from HPs. Much higher trust than for the NHS, or government – and well outstripping media stories. Media Base: All primary care givers of 0-2s (n = c.200)

Satisfaction with immunisation process
93% who have had a child immunised were satisfied with the immunisation process, 9% dissatisfied 68% were totally satisfied No change over time Main reasons not totally satisfied … Procedure: Too rushed Too rough with child Information: Not enough info Want info on alternatives Parents trust HPs, and Parental involvement with immunisation tends to be through HPs and this means Health Professionals have the opportunity to make this a good experience for parents. most parents happy overall, and few dissatisfied with the process, BUT only 68% totally satisfied meaning some room to improve the experience for parents. Three key areas of concern – first want more information – in general and – want to talk about the alternatives such as separate vaccinations. Second – need reassurance – worry about the pain, distress or side effects this could cause their child. Third – the way the procedures is carried out – perceived as too rushed, and rough on the child – Some examples ... Concerns: Worry about pain, distress or side effects Base: All primary care givers of 0-2s who have had a child immunised (2008 n=198)

Examples of concerns Not given info on the diseases. No sympathy for baby, just a process. Didn’t see the emotional side for the child and the mother The fact that it made the baby cry and it upset me a lot I would have liked a bit more information about the MMR jab The first immunisation I went for, the practice nurse was quite rough with my son and no empathy there The nurse’s approach to the procedure. I was just told to hold him and then she administered the injection and told me to come back in a month. I had no information about the procedure or the possible side effects. Illustrate these concerns. Over-arching themes – need more information, attention and reassurance – want to feel that not just another vaccination to the HP, but treated as concerned parent. Challenge here – how to fit all of this in within the busy schedule of appointments. The fact that nothing is explained properly and that you're not given much of a choice in your decision

Barriers for HPs So seen that parents talk to HPs, trust HPs, but want more information, attention and reassurance – HPs are ideally placed to help reassure parents and direct them to information, even if they don’t know the answers themselves. Any barriers to this? Already seen that GPs may be less aware of the immunisations materials out there than other hPs.

Health professionals’ awareness of local immunisation co-ordinator
Lack of support possible barrier? Local immunisation coordinator there to help HPs – high awareness for HVs, but lower for PNs and particularly lower for GPS and declining over time so this could be a barrier to getting the information they need to help parents. Seen a drop back for PNs this year as well. Not surprising – GPs different role, but parents will want to ask them questions. Base: All health professionals 2008

Health professionals’ awareness of and attendance of training (in past 2 yrs) (2008 only)
AWARE OF TRAINING NUMBER OF TRAINING SESSIONS 63% GPs Health Visitors 97% Lack of training second possible barrier. Training can also help HPs acquire the skills and information they need to reassure parents about immunisations. Most HVs and PNs aware of training – BUT only 2/3 of GPs HV and PN also more likely to attend training – around 1/3 have attended 3 or more sessions in the last 2 years (orange), with a high proportion attending 2 sessions (green). 1/3 of GPs had not attended any training (blue). (Changed question – no tracking data). Practice Nurses 98% Base: All health professionals 2008

Health professionals’ personal concerns
Around one in ten health professionals expressed some concern about immunisation Main concern: Feeling that too many immunisations are given in a short period of time Secondary concerns: About the confusion caused by changes in / complexity of the schedule Some Health Visitors were concerned about not having enough information Personal beliefs could also be a barrier to reassuring parents with doubts. Saw earlier that one in three parents were concerned about overloading the child with too many vaccines. HPs also have some concerns … Latest wave 11% GPs, 8% PN, 6% HV Base: All health professionals 2008

Examples of concerns GP: Because there are such a lot of immunisations, it’s difficult to make sure that patients all get what they should when they should HV: Too many of them which is hard to understand for parents GP: I do sometimes worry that there are too many immunisations and I wonder what that could do to the immune system HV: They’re constantly changing and it’s difficult sometimes to persuade parents to take them up PN: Having to give 3 injections on the infant’s 3rd appointment when they are 3/4 months old. It’s hard all in one day GP: The main concern I have is communication of changes to the schedule. We tend to find out through the press rather than through professional sources To illustrate this … HV: Need more knowledge on the flu vaccine

Conclusions

HPs obviously have a role to play …
Parents seem to have moved beyond MMR, BUT there is still concern about overloading the child, and always the potential for new scares to take hold Health professionals are perfectly placed as ‘trusted advisors’ to address the parental need for more communication, information and reassurance GP’s clearly take a different role in immunisation from Health Visitors and Practice Nurses, resulting in a lower level of awareness of support and information .. In helping allay parents fears, and making this a good experience Ideally placed as parents talk to HPs and trust them more than other sources, Even for HPs and PNs who are more aware of what is out there, concerns about the flow of information.

But this raises further questions …
How can the flow of information to HPs be improved, particularly about materials for parents and changes to schedule? How can HPs best help pass this on to parents? How can the limited time available at immunisation and other appointments with HPs be best used to provide the information and reassurance parents need? How can GPs, HVs and PNs make best use of their clearly different roles in relation to immunisation? How can they make sure parents understand what these different roles are? Raises questions – and I want to leave you with some ideas of things that could be discussed at this afternoon’s workshop on immunisation resources and how to improve uptake … So – as always, research raises as many questions as it answers, but hopefully that will give you some food for thought.

Childhood Immunisation
How can health professionals help parents get beyond MMR? Welsh Immunisation Conference 23rd April 2009 Sally Malam

Childhood Immunisation

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