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Too few school nurses to administer proposed flu vaccination programme, experts say

BMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e5108 (Published 26 July 2012) Cite this as: BMJ 2012;345:e5108
  1. Nigel Hawkes
  1. 1London

Flu vaccination is to be extended to all children aged between 2 and 17, at a cost of £100m (€127m; $155m) a year. But how the vaccine will be administered, and by whom, remains uncertain, and the evidence underpinning the decision is unpublished.

The Joint Committee on Vaccination and Immunisation (JCVI), whose recommendation has been endorsed by health secretary Andrew Lansley, admits that severe logistical difficulties need to be overcome first.

They include the supply of the vaccine, the attitude of parents, the shortage of school nurses who would otherwise provide the best mode of delivery for children between 5 and 17 years, and the possibility that extending the programme could disrupt existing flu vaccination for over 65s and those in high risk groups.

Despite these issues, the committee believes that the evidence shows the proposal to be cost effective. In a statement published on 25 July on its website, it says that the study from the Health Protection Agency and the London School of Hygiene and Tropical Medicine provided “a suitable and robust basis for informing immunisation policy.”1

But David Elliman, consultant in community child health at Great Ormond Street Hospital, said that it was hard to judge if that conclusion was justified while the study behind it remained unpublished. “I have not seen the evidence for this programme so cannot say whether or not I support it,” he said. “I have no concerns about the safety of the vaccine but would like to be convinced of the benefits.”

In a statement announcing the new programme, the Department of Health claims that vaccinating nine million children with a live attenuated intranasal vaccine (Fluenz, marketed by AstraZeneca) would see a 40% drop in the number of people getting flu, with at least 11 000 fewer hospital admissions and 2000 fewer deaths.

The committee’s statement, however, is less specific in its claims. It says that the unpublished study concludes that the extended programme “might appreciably lower the public health impact of influenza by averting a large number of cases of influenza disease in children as well as many cases of severe influenza disease and influenza-related deaths, which mostly occur in older adults and those of any age with clinical risk factors.”

It acknowledges that there is uncertainty about the level of expected population impact arising from the vaccination of children.

The JCVI concluded that the age range from 2 to 17 was appropriate, because the vaccine is not licensed for those under 2 and there is no suitable alternative. The evidence of benefit is greater for the 5 to 17 age group, all of whom are at school. Experience shows, it says, that offering vaccination through schools is the best route, but at present there are far too few school nurses to make it practicable.

Even to achieve moderate levels of uptake—the JCVI calculations are based on a range between 15% and 50%—the number of school nurses would need to be expanded several fold. In the minutes of its June meeting, the JCVI raises the possibility of lay people administering the vaccine, and says it will seek the advice of the Medicines and Healthcare products Regulatory Agency. It assumes that preschool children would be vaccinated in general practice.

There are uncertainties about how willing parents would be for their children to be given a live vaccine. It is an advantage that the vaccine is given intranasally, but there may still be “mixed reactions,” the JCVI admits.

A campaign to inform and educate parents, children, healthcare professionals and others would be needed in advance of, and alongside, the extended vaccination programme. Given this and the need to ensure long term supply, the JCVI says that implementation cannot begin until autumn 2014 at the earliest, a timetable accepted by the department.

Elliman said that he had immense concerns about the practicality of the scheme. “School nurses are already very hard stretched and come nowhere near delivering the basics from the Healthy Child Programme,” he said. “If this is just added in to their workload, it will devastate their morale.

“If it is carried out by ‘lay personnel,’ is this appropriate? Giving immunisations involves much more than just administering the vaccine, but counselling parents and, where appropriate, the young people. Lay people would not have the knowledge to do this. I am not aware of large pools of professionals able to step in. In the past, school nurses have risen to the occasion, but that has been for a blitz in a single year or for a limited cohort. This is a very different kettle of fish.”

Adam Finn, professor of paediatrics at the University of Bristol, said he thought the plan a good one. “Flu can be a serious illness in childhood, not just in old age,” he said. “There should be time to do some more research before we introduce the vaccine to help us predict how well such a programme would be accepted and would work.”

The chief medical officer, Sally Davies, said: “We accept the advice of our expert committee that rolling out a wider programme could further protect children, with even a modest take-up helping to protect our most vulnerable.

“There are significant challenges to delivering a programme that requires up to nine million children to be vaccinated during a six week period, and we will look at the recommendations in detail to decide how best to develop and deliver the programme.”

Notes

Cite this as: BMJ 2012;345:e5108

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