Letters

Health professionals' attitudes to MMR vaccine

"Green book" should be updated every six months

Format of "green book" should be changed

More interactive training and updates on immunisation should be provided

Advice in primary care affects parents' decision to take up MMR vaccination

Doctors must understand reasons behind vaccination

"Green book" should be updated every six months

EDITORPetrovic et al describe some of the uncertainties of health professionals involved in giving vaccinations.¹ A degree of vulnerability is evident in the decreased rates of vaccination against measles, mumps, and rubella (MMR) and the negative publicity in the media. We suggest a way of increasing confidence clinically by improving the supply of information.

We have been concerned for some time about the lack of an up to date version of the Department of Health's "green book," Immunisation against Infectious Disease. These concerns are reinforced by the controversy surrounding vaccine programmes such as against measles, mumps, and rubella. The green book is a convenient form of evidence and advice covering the main vaccinations delivered through the NHS and is regarded as the Bible by many health professionals. A wide range of NHS staff is given responsibility for implementing these major public health programmes and other protective immunisations. These staff become accountable for the standard of the service provided but are currently impeded by a lack of updated, timely, and accessible information.

The green book was published in 1990, 1992, and 1996; the 1996 edition states on page 13 that its recommendations "reflect present national immunisation policy," although clearly it is five years out of date.² Updated information either has been sent out in loose-leaf form or is available on the internet, but these sources may not be readily available to community nurses as they carry out their immunisation clinics. Access to a copy of the book is more likely.

If the British National Formulary were published only every four years or so and prescribers had to rely on companies sending out individual updates on their products they might feel vulnerable when prescribing. Would it not be possible to publish the green book every six months with the latest advice and evidence then available to all health professionals? A similar initiative has just been funded so that professionals can have access to the BMJ's Clinical Evidence, also published every six months.

We suspect that the cost would be offset by the ability of health professionals to provide consistent and current advice. This would increase the public's confidence in the effectiveness of the immunisation programmes and probably increase compliance to achieve higher rates of vaccination. The least that can be done is to offer an improved supply of the best information available for the sake of health professionals, parents, and patients.

Jonathan Howell, consultant in public health medicine. 
jonathan.howell{at}lycos.com

Harsh Duggal, consultant in communicable disease control. 
South Staffordshire Health Authority, Stafford ST16 3SR

Karen Howell, director. 
Travel Health, Stafford ST17 0TL

Format of "green book" should be changed

EDITORPetrovic et al report their survey of health professionals' knowledge, attitudes, and practices regarding the measles, mumps, and rubella (MMR) vaccine.¹ This is one of the main factors that influence uptake rates of the vaccine.² As the authors point out, health professionals' knowledge and practice regarding the second dose of the vaccine vary widely; many health professionals are not aware of or do not use the written sources that exist, although local educational initiatives could remedy this.

We conducted a similar questionnaire survey among health professionals in the Halton area (north Cheshire) in 1998.³ The survey was of 62 general practitioners, 29 practice nurses, and 25 health visitors, and response rates were 87% (54/62), 66% (19/29), and 80% (20/25) respectively. With regard to confidence in the safety of MMR vaccine, six of the 116 health professionals stated that their level of confidence was 1 on a five point scale (1=not confident; 5=very confident). Worryingly, over half (66) considered severe egg allergy to be an absolute contraindication to MMR vaccination, which it is not.⁴

The survey also found that 65 of the health professionals had not attended any educational session(s) on vaccination or immunisation during the three years prior to 1998. There was no significant difference, however, in professionals' confidence in the safety of the vaccine between those who had and had not attended educational session(s) (20/41 (49%) v 28/52 (54%); P=0.75). Similarly, there was no significant difference between the two groups in the proportion who considered a serious egg allergy to be an absolute contraindication for the vaccination (25/41 (61%) v 29/52 (56%); P=0.59). Although we do not have information on the quality and appropriateness of the educational sessions, this raises important questions about the effectiveness of local and national educational initiatives in raising health professionals' awareness.

A large proportion of health professionals involved in the vaccination programme (>90% in our survey) consider the "green book"⁵ to be the most important source of information. Local educational initiatives, as suggested by Petrovic et al, might improve health professionals' awareness, but in the light of our findings we believe that success is more likely if the format of the green book is changed to enable it to be updated more frequently.

The green book could be modified into a more practical format whereby new information and supplements (including electronic circulars) could be easily added. This would not only improve professionals' awareness but also boost their confidence and promote consistency in the advice given to parents.

Samuel Ghebrehewet, specialist registrar in public health medicine. 
Communicable Disease Surveillance Centre (CDSC) North West, Chester CH1 4EF sg1samg1{at}hotmail.com

Catherine Quigley, consultant in communicable disease control. 
Cheshire and Wirral Communicable Disease Unit, Public Health Laboratory, Chester CH2 1UL

More interactive training and updates on immunisation should be provided

EDITORPetrovic et al surveyed health professionals' knowledge and attitudes about measles, mumps, and rubella (MMR) immunisation.¹ Their results confirm what is already known about one of the most important influences in the uptake of child immunisationthe knowledge of the health professionals.²

In 1998 we surveyed the primary immunisation givers at all the practices in our district. We had a 93% response rate (95/102) and found a considerable contrast in the availability of updating and training about immunisation between areas of high and low immunisation uptake rates.

In the western part of the district, where an enthusiastic paediatrician provided regular training sessions for primary care staff, there was a high uptake of all immunisations, including the second dose of MMR vaccine. In contrast, in the eastern sector, where immunisation training had not been as easily available, there was a consistently lower uptake of immunisations, especially with the MMR vaccine. This was despite the fact that the eastern area was comparatively wealthier than the western area, which included a high proportion of practices in deprived inner city areas.

Petrovic et al say that local education initiatives could remedy the apparent variation in knowledge of practice among health professionals. Rather than yet more written material being added to the information overload in the health service, more interactive training and updates on immunisation should be provided as part of continuous professional development.³ This would not only provide information but also give people an opportunity to discuss with their peers any problems encountered when advising parents about immunisation.

We are starting a rolling educational programme this year, targeting those areas with low coverage, and we will be monitoring the effect on immunisation uptake over the coming years.

Gill Lewendon, immunisation coordinator. 
Gill.Lewendon{at}sw-devon-ha.swest.nhs.uk

Moira Maconachie, senior research fellow. 
Kevin Elliston, health promotion specialist. 
Public Health Department, South and West Devon Health Authority, Dartington, Devon TQ9 6JE

Advice in primary care affects parents' decision to take up MMR vaccination

EDITORPetrovic et al's paper¹ complements our study of factors affecting maternal intentions to take up the measles, mumps, and rubella (MMR) vaccination.² We found that failure to take up the second dose in particular is not simply a function of fear of the vaccine. The two-dose schedule is problematic for parents, as it is for the health professionals whose views are reported here. The reasons, however, are different.

Parents have not been educated in the rationale behind the schedule; many seem to believe that the second dose is a booster. Therefore, if their child has received the first dose they see the second dose as being less important for the child's health. In addition, comments show that mothers are unconvinced by arguments concerning herd immunity when it comes to decisions about their child. Petrovic et al have shown that a sizeable proportion of professionals who do understand the rationale are uncomfortable about the schedule, and explaining it to parents.

Children receive the second dose at a time when parents have less contact with primary care professionals regarding the health of their child than they do during babyhood. Mothers reported obtaining most general information about vaccination from their health visitor. The source that they trusted most was their general practitioner. The actual source of most of their information about the MMR vaccine and side effects, however, was television.

Informal comments from general practitioners when we were setting up the study suggest that some are reluctant to raise the issue of the MMR vaccination with parents; they fear that parents who were previously unaware of the controversy will be alerted to it. In a world where people are inundated with information from the media this seems naive. Petrovic et al's data raise the further problem of the reluctance of health professionals to recommend the second dose because they themselves are not convinced of its safety or efficacy.

Our conclusion was that health education and advice from primary care professionals, and particularly general practitioners, could have a considerable impact on the decision to take up the MMR vaccination. Unfortunately, the data collected by Petrovic et al suggest that we need to go some way to educating and training professionals before we can expect them to give reliable help to parents in this difficult decision.

Helen Pattison, senior lecturer. 
h.m.pattison{at}bham.ac.uk

Manish Pareek, medical student. 
Department of Primary Care and General Practice, Medical School, University of Birmingham, Birmingham B15 2TT

Doctors must understand reasons behind vaccination

EDITORPetrovic et al's paper highlights the misunderstandings that arise through misinformation.¹ The health professionals surveyed had misgivings about the need for a second dose of measles, mumps, and rubella (MMR) vaccine in children of preschool age. The paper highlighted the fact that most practitioners did not refer to the standard guidance on vaccination from either the Department of Health or the Health Education Authority.

Education of doctors about virus based disease is minimal. Medical school curriculums rarely give more than a few hours to a subject that occupies about 30% of a general practitioner's working day (research undertaken by Primary Care Virology Group). So much information on every subject is presented to doctors that it is impossible for most general practitioners to read and assimilate the mass of literature that pours through their letterbox every day. It is perhaps not surprising that misinformation results in ill informed opinion.

Measles vaccine is roughly 80% efficient in leading to immunity after a single vaccination. Thus if 80% of a population is vaccinated only 64% (80% of 80%) will actually develop effective antibodies and 36% will still be at risk of measles. If a second attempt at raising immunity is made then a further 80% of that 36% will develop immunity. This will result in a total immune population of 92%, which is approaching the level needed to prevent epidemics.

The second dose is not a booster dose. It would not be needed if we could see which child had developed immunity and which hadn't merely by looking at the child; this is not the case, and blood tests are required to ascertain immune response. Routine administration of a second dose at an appropriate time interval is therefore the most sensible way forward.

Failure to understand the importance of a second dose of vaccine means that inaccurate conclusions may be reached by journalists wishing to sensationalise Petrovic et al's survey as a lack of support for MMR vaccine by health professionals. Journals such as the BMJ do not abuse their position of power by publishing articles that might mislead selective journalists; sometimes more explanation is required for those working in medicine, nursing, or journalism to interpret the importance of some research.

Nigel Higson, chairman, Primary Care Virology Group. 
Goodwood Court Medical Centre, Hove, Brighton BN3 3DX surgery{at}goodwoodcourt.org