Routine vaccination during covid-19 pandemic responseBMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m2392 (Published 16 June 2020) Cite this as: BMJ 2020;369:m2392
- Sonia Saxena, professor of primary care1,
- Helen Skirrow, public health medicine specialist registrar1,
- Helen Bedford, professor of children’s health2
- 1Department of Primary Care and Public Health, Imperial College London, London, UK
- 2UCL Great Ormond Street Institute of Child Health, London, UK
- Correspondence to: S Saxena
Routine vaccination of pregnant women and children must remain a priority during the covid-19 pandemic response. The UK and other countries could experience outbreaks of measles and other vaccine preventable diseases if uptake of routine vaccinations falls, undoing decades of progress. Vaccination has been one of the most effective interventions in driving down infant mortality to historically low levels worldwide. Complete, timely vaccination protects and confers benefits across the whole of childhood. However, this protection is greatly reduced if vaccine schedules are delayed or incomplete.1
In the UK, almost 95% of infants have completed their primary vaccinations by their first birthday,2 but uptake of later childhood vaccines and seasonal flu and whooping cough vaccines recommended in pregnancy, varies from year to year.34 Uptake is lower in inner cities, in deprived postcodes, and among some minority ethnic groups.3 Disease epidemics can disrupt healthcare and cause resurgence of vaccine preventable infections.5 In 2019, the UK lost its measles “elimination status” because of outbreaks resulting from historical low vaccine uptake.6 Children risk becoming unseen victims of the covid-19 pandemic.
Health professionals are concerned about the effect on children’s health of the upheaval of NHS routine care.7 The number of MMR (measles, mumps, and rubella) vaccines delivered in England dropped by 20% during the first three weeks of the lockdown,8 and smaller falls were reported in infant vaccines in Scotland.9 Although vaccination services are on the priority list for primary care, this message has been lost among the dominant message that everyone should stay at home and avoid burdening the NHS throughout April 2020.
Children’s visits to emergency departments fell by over 90% during April 2020.10 Parents have expressed concerns about overburdening the NHS and fear of exposure to covid-19 when attending for vaccination. Of 752 health visitors surveyed by the Institute of Health Visiting in May 2020, over 60% reported contact with families who had considered cancelling or postponing their child’s vaccinations (Institute of Health Visiting, personal communication).
The public is now being urged to “Stay alert, protect the NHS, save lives,” which provides little assurance for families that the NHS is open for routine care. Messages are tailored to those with an excellent command of English and may not reach families such as recent migrants and those with poor health or language literacy or little access to digital technology. Over 75% of pregnant women admitted to hospital in the UK with covid-19 were black or Asian,12 and the risk of dying from covid-19 during hospital admission is twofold to fourfold higher among black, Asian, and minority ethnic groups than among white people.12 Hence, pre-existing inequalities in uptake may widen if parents from minority ethnic groups feel more vulnerable and avoid healthcare settings. Families concerned about vaccine safety will be susceptible to strongly voiced opinion and misinformation in the media.13 Many new parents will also lack support and information usually available from antenatal and postnatal support groups.
Time for action
General practitioners, practice nurses, midwives, and health visitors are well positioned to counsel prospective and new parents about vaccination. In areas of low uptake, contacting parents and pregnant women directly may be valuable, as conversations with a trusted healthcare professional can influence vaccination decisions.14 Vaccine uptake in primary care is highest when parents feel safe and are given timely information that vaccines are due, and when healthcare staff have systems to ensure robust call and recall.15 Primary care has risen to the challenges posed by covid-19 by enforcing triage to ensure safe distancing and by introducing hygiene measures and protective equipment to reduce infection risk. Some general practices have adopted drive-in vaccine clinics to reduce face-to-face contact with parents.16
Urgent action is required to maintain vaccination rates and limit preventable infections. We need clearer government messaging that reaches all groups and more support in the community to inform and reassure pregnant women and new parents about the importance and safety of attending primary care for vaccines during the pandemic. This needs to be accompanied by investment to support primary care teams to protect themselves and patients and to access, store, and deliver vaccines during disruptions to services and supplies. Primary care teams also need to follow up missed vaccinations quickly by strengthening reminder systems and providing opportunistic vaccination. Finally, the government must acknowledge that its policies have been blind to the serious health disparities uncovered by covid-19.17 It must invest in stronger public health surveillance to monitor areas and populations in real time to enable rapid local public health response to any drop in vaccine uptake, particularly among vulnerable groups.
The current pandemic is a reminder of the ever present threat of infectious disease. We should not miss this opportunity to strengthen public trust in primary care and public health. We hope that a covid-19 vaccine will enable us to end containment measures safely, if such a vaccine can be developed. In the meantime, the health of our children and the whole population depends on high uptake of routine vaccinations.
We thank two new parents for their helpful advice.
Competing interests: The BMJ has judged that there are no disqualifying financial ties to commercial companies. The authors declare the following other interests: SS is supported by the NIHR School for Public Health Research Programme and NW London Applied Research Collaboration. SS holds funding from the Daily Mile Foundation. HS is supported by the IMPRINT network funded by UK’s Global Challenges Research Fund (GCRF). HB is a member of the health improvement committee of Royal College of Paediatrics and Child Health.
Provenance and peer review: Commissioned; externally peer reviewed.
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