Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Education and age are not risk factors but benefit the health of a woman's children
- Susan K Claridge (2 June 2006)
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My experience
- Ashok Beckaya (9 June 2006)
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Working smarter - improving performance
- Janice Nelson (16 June 2006)
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Need for routine collection and reporting of ethnicity in immunisation statistics
- Peter J Aspinall (20 June 2006)
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Letter to the Editor: Risk factors for not being fully vaccinated in Flanders versus UK
- Heidi M Theeten, Corinne Vandermeulen (27 June 2006)
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Affluent parents refusing routine immunisations.
- Anne McGowan (10 July 2006)
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Susan K Claridge, Researcher/writer Archetype Ltd, Auckland, NZ, 1309
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Samad et al. regard better education and greater age as risk factors for mothers who do not vaccinate their children. Perhaps we just aren't as gullible, trusting or foolish as younger mothers with a poorer education; not as likely to succumb to outrageous scare tactics, and are entirely capable of doing our own research, asking questions and making our own decisions in the best interests of our children. As a woman with a Master of Science, and as a first time mother at the age of 35, I made clear, researched and rational decisions about my children's health from before conception. That the majority of pro-vaccine medical papers were funded in some way by the pharmaceutical industry did not escape me. Such conflict of interest has been widely discussed in the pages of this journal, albeit regarding drugs in general, rather than vaccines specifically. This paper is not the first to characterise non-consenting mothers - those that make an informed and conscious decision not to vaccinate (as opposed to those who only partially vaccinate their children) - as more highly educated and older. Among several others, an Israeli study (Maayan-Metzgera, A., Kedem- Friedrichc, P. and Kuinta, J., 2005: To vaccinate or not to vaccinate- that is the question: why are some mothers opposed to giving their infants hepatitis B vaccine? Vaccine, Vol. 23, Is. 16, 14 March 2005, pp 1941- 1948) is worth mentioning. The authors found that in addition to the above characteristics, mothers who decided not to vaccinate expressed more knowledge about the vaccine, and held more naturalistic and less conventional medical attitudes than did the women who complied and had their babies vaccinated. The non-consenters also planned to breastfeed for a longer period than the control group, and one of the most telling characteristics of the non-consenting mothers was that approximately 20 percent of them had careers in health/medical professions, while only 2% of the consenting group had such a background. Perhaps it was altogether too scary for the authors of this most recent BMJ paper to ask their UK cohort about their occupation. After all, it is bad enough to find educated women rejecting the one-size-fits all vaccination model of child health, how much worse would it be to discover that women with medical training were over-represented in this group? Mothers, such as myself and many other women I know, are blessed with a brain that works, and the intestinal fortitude to not only use it but to question a medical dogma that is increasingly driven by drug industry profits. We have the strength and the independence to make decisions in the best interests of our families. Among other things, these decisions usually involve long term breastfeeding and excellent post-weaning nutrition. In an age in which it is slowly being recognised that the industry is over-medicalising life, and pharmacuetical companies are pushing "cradle to the grave" medication (e.g. the new adult adolescent pertussis boosters which the manufacturers are pushing for adults to get at least every ten years) achieving a constant market in the "worried well", an age in which ever more people are turning to so-called alternative medicine (in reality holistic medicine which treats the body as a whole) does it really surprise anyone that increasing numbers of us reject such a model for the health of our children? Until both the medical community and the pharmaceutical industry recognise that child health does not come through a needle, but from good diet/nutrition and a reduction in exposure to toxins such as tobacco smoke and environmental contaminants no amount of "different interventions" is going to make a blind bit of difference. Regards Sue Claridge Competing interests: None declared |
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Ashok Beckaya, Paediatrician - Associate Specialist Epsom & St. Helier University Hospitals NHS Trust
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Working in the east end of London a number of years ago, frequently came across families who were either unsure or were completely against the idea of immunisation. I always made a point to spend time sympathetically talking to these parents and was delighted that almost all of these families agreed to immunise their children minus, ofcourse, the pertusis. As you would recall during the 80's the pertusis immunisation rates had dropped significantly due to the scare of brain damage that was passionately debated in the media I believe in the 70's. My discussions wih the parents revealed that there main concern was around pertusis vaccine and therefore agreed to go ahead with other jabs once proper explanation was given. A few parents, even agreed for pertussis. This extra time spent talking to these parents proved rather rewarding both for me and the children. Interestingly, one of the common explanation given by caucasian young mothers including single parents was - they saw no reason for immunising their children as they themselves were not immunised and their own parents and grand parents were also not immunised. As nobody was harmed, they found it difficult to understand why their child should be subjected to immunisations. Happily, most of these mothers did agree for some form of immunisation after a chat. In those days the majority of immunisations were done in community clinics rather than in GP surgeries and the health visiting service was excellent which helped enormously with opportunistic immunisations process. I also remember coming across a few mothers who were intelligent and articulate - with strong views about the dangers of immunisation. It was almost impossible and rather challenging, to get through to these individuals as their minds were already made up. Competing interests: None declared |
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Janice Nelson, Immunisation Coordinator Heart of Birmingham Teaching Primary Care Trust, 142 Hagley Road, Birmingham B16 9PA
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You state partial or no immunisation status can be attributed to deprived, ethnically diverse or education of populations. I suggest that this is a popular myth that is often quoted (Baker, MR, Bandaranayake, R,Schweiger, MS,1984) and one that I wish to dispel. Heart of Birmingham Teaching Primary Care Trust (HOB) has extremely high levels of ethnic diversity with 7 out of 10 being Asian or Black. We also have the highest levels of deprivation with populations living in the lowest 10% nationally. Until recently, HOB had the worst coverage for MMR (2004 = 80% aged 24 months) and influenza (2004 = 49%). We now have the best coverage that ranks in the top ten nationally (MMR = 95%) and (Influenza = 78%). Hitherto, our attempts to improving immunisations coverage, we assumed myths that inequalities in immunisation uptake are persistent and result in lower coverage in poorer families. Recently, our focus has been providing support for underperforming General practices by implementing a variety of failsafe activities. To resolve the issue of partial or non immunisation, an active patient management system should be implemented. This should include: • professional leadership and commitment to good performance • an accurate, up to date list of registered patients • a personalised system of call up e.g. letter signed by GP • a schedule of dedicated clinics • active follow up and direct contact with defaulters • a system of “opportunistic visits” In summary, gross poor performance should not be attributed to culture, education or deprivation. Three things matter; Organisation, organisation & organisation. The good news is that 2/3 of poor performance is artefactual (ghost patients or non reporting; and easy and cheaply addressed) We would like to invite you and your team to Birmingham to discuss the detail of our innovations and see the systems that we utilise. Competing interests: None declared |
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Peter J Aspinall, Senior Research Fellow Centre for Health Services Studies, University of Kent, George Allen Wing, CANTERBURY, Kent CT2 7NF
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Dear Editor, Samed et al.’s(1) important findings on the relationship between ethnicity and immunisation status in infants under one year – notably, that infants of black Caribbean mothers were more likely to be unimmunised than were those of white mothers - indicate the need for the routine collection and reporting of ethnicity in immunisation statistics. Their analysis of the millennium cohort study data has provided for the first time evidence of ethnic disparities in a large national sample. The fact that the papers cited on the role of ethnicity in uptake of immunisation in the UK date from the 1980s belies the sparsity of ethnically coded data. Indeed, in the last two or three decades only a handful of studies have appeared, most on ethnic differences in the rates of selective neonatal BCG immunisation. These new findings - together with obligations in the Race Relations (Amendment) Act 2000 - present a case for the ethnic coding of the COVER (Cover of Vaccination Evaluated Rapidly) data collected as a central return(2), a step which might also catalyse wider ethnicity data collection in primary care trusts. The NHS has indicated that, as a general rule, all central return submissions relating to patients and the services provided to patients should include consideration of the case for collecting ethnic origin information (and that this should be the norm in cases where personal profile information such as age and gender is collected)(3). With reference to the national contexts referred to by Crampton and Carr(4), the National Immunization Survey in the USA includes data on race(5) and the data requirements for the National Immunisation Register, set up in New Zealand in 2004, incorporate ethnic group. 1.Samad L, Tate AR, Dezateux C, Peckham C, Butler N, Bedford H. Differences in risk factors for partial and no immunisation in the first year of life: prospective cohort study. BMJ 2006; 332: 1312-3. 2. Health & Social Care Information Centre. NHS Immunisation Statistics, England: 2004-05. Bulletin 2005/05/HSCIC. Leeds: HSCIC, 2005. 3. Health & Social Care Information Centre. Dealing with race information in the ROCR approval process. Leeds: HSCIC, 2005. http://www.ic.nhs.uk/rocr/approval/dealingwithrace 4. Crampton P & Carr J. Socially or materially marginal children are less likely to be fully immunised – a systems response. BMJ 2006; 332: 1314. 5. Smith PJ, Hoaglin DC, Battaglia MP, Khare M, Barker LE. Statistical methodology of the National Immunization Survey, 1994-2002. Vital Health Stat 2 2005; Mar (138): 1-55. Yours sincerely, Peter J Aspinall
Competing interests: None declared |
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Heidi M Theeten, assistant researcher, CEV, University of Antwerp B-2610 Belgium, Corinne Vandermeulen
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Dear Sir, As pointed out by Samad et al(1), there are several factors that may play a role in partial or no immunization in the first year of life. Factors for not being fully immunised have been looked for in Flanders, Belgium, in the recent 2005 vaccination coverage study funded by the Flemish government. According to the two cluster sampling technique recommended by the World Health Organization (2), a sample of 1354 infants aged 18-24 months was identified, of whom the parents were interviewed at home. In this study, particular attention was paid to the validity of coverage data: only vaccine doses that were documented in a vaccination leaflet at home or in the medical file of the vaccinating doctor have been considered for analysis. The coverage rate of recommended vaccines (polio, tetanus, diphtheria, pertussis, H influenzae type b, hepatitis B, measles, mumps, rubella and meningococcal C) reached 93%, including booster dose at around 15 months of age. The coverage for the primary doses was comparable to what was found in UK children in the Millenium Cohort Study(1). However, a logistic regression analysis for risk factors associated with partial or no immunisation identified differences with the UK situation: maternal age or education and ethnicity of the parents were not found to be significantly associated, neither was family size, but being the youngest child in rank was associated. Similarly to the UK findings, working mothers were associated with more fully immunised children. A particular finding was that the risk of being not fully immunised was associated with whom the parents chose to immunise the child: GP, paediatrician or youth doctor at well baby clinic. Full results will be published in the near future. (1) Samad L; Tate AR, Dezateux C, Peckham C, Butler N, Bedford H. Differences in risk factors for partial and no immunisation in the first year of life: prospective cohort study. (2) Salmaso S, Rota MC, Ciogi ML et al. Infant immunization coverage in Italy: estimates by simultaneous EPI cluster surveys of regions. Bulletin of the World Health Organisation, 1999, 77(10): 843-85 Heidi Theeten, Center for the Evaluation of Vaccination, University of Antwerp, Universiteitsplein 1, 2610 Antwerp, Belgium heidi.theeten@ua.ac.be Corinne Vandermeulen, dienst Jeugdgezondheidszorg, Katholieke Universiteit Leuven, Kapucijnenvoer 35/1, 3000 Leuven, Belgium corinne.vandermeulen@med.kuleuven.be Competing interests: None declared |
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Anne McGowan, Nurse Immunisation Co-ordinator Gwent Healthcare NHS Trust, NP44 8YN
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Samad et al in their study suggest that factors influencing childhood immunisation uptake may have changed over time. In Gwent, South Wales the highest immunisation uptakes for both primary and MMR vaccines in recent years have been in the most deprived areas with lower rates in the more affluent areas. These findings are supported by an ecological study of ' no consents to vaccines ' entered onto the Child Health computer (CH2000) in Gwent between 2000 and 2004(1). (A 'no consent' is a disclaimer form completed by a parent and health care professional after full consultation. The CH2000 system changes the consent of the specific antigen as requested on the disclaimer to 'no consent' and no further immunisation appointments are sent. The 'no consent' can be revisited anytime by the parent attending surgery or contacting the HV/PN/GP.) In this study using the CH2000 system all postcodes with a recorded no consent to routine childhood immunisations were identified n = 4778. Non consenting postcodes were then compared to postcodes with recorded consents to the same immunisations n = 168537. When the proportion of no consents to immunisations were calculated by quintile of social deprivation using Townsend scores, the highest rates of 'no consents' figures were significantly associated with the most affluent quintile and lowest rates with the most deprived quintile. This was confirmed geographically using Arc View maps. The maps highlighted that the more affluent areas had higher rates of 'no consents' and sometimes bordered one another in Gwent. Chi-Squared test for the proportion of parents refusing consent for both MMR and Polio vaccines and social economic status as measured by the Townsend index were statistically significant at p < 0.001. This study looked at intentions to consent to immunise and not actual uptake. Nevertheless it supports the view that different approaches may be needed to maximise immunisation rates especially with regard to training, support and access to timely information enabling staff to meet the needs of the 'no consenting' parents. Factors associated with low immunisation uptake have been well described with a body of evidence reporting that deprivation is associated with reduced immunisation uptakes. It is hypothesised that in recent years there has been a reverse of this finding that the uptakes in the more deprived areas are higher than the uptakes in the more affluent areas. Samad's et al study and this ecological study in Gwent suggest that different interventions are needed to promote uptakes in the more affluent areas where primary immunisations are declined by a concerned minority of parents. Anne McGowan Nurse Immunisation Co-ordinator Oakfield House Torfaen Wales NP44 8YN anne.mcgowan@gwent.wales.nhs.uk (1) Are there socio- economic factors which determine consent to immunisations in Gwent? M.P.H. dissertation Cardiff University 2005 Competing interests: None declared |
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