Improving MMR vaccination rates: herd immunity is a realistic goalBMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d5703 (Published 04 October 2011) Cite this as: BMJ 2011;343:d5703
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Improving MMR coverage in Birmingham
We agree with Cockman et al [ref 1 BMJ 2011 ;343;d5703] that
achieving herd immunity in an ethnically mixed deprived area is a
realistic goal. Between 2004 and 2006, the Heart of Birmingham PCT (which
is clustered demographically by ONS with the London Cosmopolitan PCTs,
including Tower Hamlets) increased MMR uptake from 82% to 94%. We have
consistently maintained that level of coverage for the past 7 years.
The core components of our intervention are very similar [2,3,4 ] -
namely creating a central register to identify children who have not been
vaccinated, list cleansing or "ghost busting ", contacting parents by
phone or letter , scheduling an appointment with the child's GP, and
finally home visits.
The main differences between the Tower Hamlets model and ours are
a) Our PCT does not incentivise practices to increase uptake - instead the
PCTs public health department is responsible for managing this system of
active patient management and works collaboratively with our 76 practices
to improve performance across a range of population based prevention and
b) To establish our central database of non-immunised children we use the
single, data held by the Birmingham Child Health System (CHS), not GP
practice based(e.g. EMIS) systems.
c) We have a small "on the road" team of ethnically diverse lay personnel,
not health visitors to make home visits and signpost families to GP
Unlike Cockman et al we are very clear which elements of our
intervention make the most difference. We illustrate their relative
effectiveness in relation to the birth cohort of August 2009. 107 children
in this cohort were classed as unvaccinated by the Child Health System,
giving an estimated MMR1 coverage of 81%.
Figure 1 shows the results of our various activities to improve
coverage - list verification [55 children], call and scheduling clinic
appointments ; and home visits . Figure 2 illustrates the final
vaccination status of our activity, the net impact of which was to
increase uptake by 11 % to 92%. Unfortunately 25 children still remain
Figure 1 - The results of our various activities to improve coverage
Figure 2 - Final vaccination status of 107 children
We firmly believe that most eligible patients who are entitled to
preventive health care wish to receive it and variations in the quality
and capacity of general practices to provide this care in a systematic way
should not impact on their ability to access this care.
Yet despite all our efforts over the past seven years we consistently
find that 3 practices responsible for 12% of all HOBtPCT babies
(133/1,009) fail to achieve satisfactory coverage and seem indifferent to
the need to improve their systems.
We therefore applaud the collaborative model adopted by the eight
practice networks in Tower Hamlets and view this primary care led
initiative as a new way of improving performance and delivering better
health outcomes for a deprived population.
Many thanks to: Karen Dawes, Failsafe project manager, Heart of
1. Cockman et al Improving MMR vaccination rates : herd immunity is a
realistic goal BMJ 2011 ;343;d5703
2. Nelson J , Chambers J , Rouse A Working Smarter , Improving Performance
. Manual produced by Heart of Birmingham PCT 2006
3. cited in London Assembly. Still Missing the point ? Infant
immunisation in London 2007 .http://legacy.london.gov.uk /assembly/reports
4 Nelson J Working smarter - improving performance
Competing interests: No competing interests
Cockman et al present their learning from their successful project to
increase childhood immunizations in Tower Hamlets.
We were able to achieve improvements in Hammersmith and Fulham
between 2009/10 and 2010/11 without additional incentive payments to
general practices by the following methods:
1.Organizing a PCT turnaround team to oversee improvements in
immunization with representation from public health, primary care
commissioning, children's commissioning, performance, CLCH and the Child
Health and IT team
2.Establishing a Failsafe team- a team of nurses and an administrator
to provide training, liaise with practices and health visitors and follow-
up persistent defaulters
3. Reintroducing scheduling by the Child Health System ensuring that
invitations and reminders were sent to children with immunizations due or
4. Instituting a Failsafe process- a month before each new quarter,
the Child Health System would produce a list of children reaching their
1st, 2nd and 5th birthdays in that quarter with outstanding immunizations.
This list would be passed to the Failsafe team for follow up with
practices to ensure that these children were called in. Where practices
had difficulties in contacting children, the Failsafe team would either
conduct a home visit or liaise with the health visiting team to confirm
the child's whereabouts. Where children had moved away, the Failsafe team
would liaise with the practice and health visitor to ensure removal from
the practice list.
5. A template with the appropriate Read Codes for the various
immunizations was installed in all practices and training provided on
6. A monthly update of immunization performance by practice was sent
to each practice with a Red Amber and Green rating
7. Regular basic and refresher training sessions were introduced for
practice nurses and other staff
8. Communication materials were produced and sent to all libraries,
children centres and practices in the borough
9. An immunization manual was produced for GP practices
These actions resulted in an increase in uptake for all childhood
immunizations, with the Pneumococcal vaccine at 2 years going from 69.9
per cent in 2009/10 to 83 per cent in the 3rd quarter of 2010/11 and the
MMR at 5 years from 58.5 to 72.6 per cent over the same period.
A key message in our communication and training with practices was to
emphasize that it was best practice to give the immunizations at the
scheduled time. So, although the DES payment for MMR allows practices to
give the 1st dose of vaccine by the 3rd birthday, this is 23 months later
than the recommended 13 months in the schedule and 11 months after the
time it needs to be given to reflect in the COVER statistics.
The programme was however affected by the organizational changes in
the NHS in 2011/12.
We would echo the call by Cockman et al for the DES payments for
immunizations to be aligned with the COVER data.
Competing interests: No competing interests