Reducing differences in the uptake of immunisations

NICE guidelines [PH21] Published date:

1 Recommendations

This is NICE's formal guidance on reducing differences in the uptake of immunisations, including targeted vaccinations, among children and young people aged under 19 years. When writing the recommendations, the Public Health Interventions Advisory Committee (PHIAC) (see appendix A) considered the evidence of effectiveness (including cost effectiveness, fieldwork data and comments from stakeholders). Full details are available online.

The evidence statements underpinning the recommendations are listed in appendix C.

The evidence review, supporting evidence statements and economic analysis are available online.

PHIAC considers that all the recommended measures are cost effective. For the research recommendations and gaps in research, see section 5 and appendix D respectively.

The guidance supports implementation of the vaccination courses as recommended by the Joint Committee on Vaccination and Immunisation and indicated in the 'Green book[1]'. It also supports timely vaccination according to the recommended schedule.

Focus of the recommendations

The guidance focuses on increasing immunisation uptake among groups and settings where coverage is low.

Recommendations 1 to 5 apply to all vaccinations for children from birth to 19 years.

Recommendation 6 focuses on the hepatitis B vaccination programme for infants, as an example of a programme targeted at particular groups. Specifically, it focuses on immunisation to prevent hepatitis B among babies and young children born to mothers who are chronically infected with the virus, or who have had acute hepatitis B infection during pregnancy. The hepatitis B programme for infants was chosen because some babies born to infected mothers (and their siblings) are not receiving the complete course at the right time. (For more details see sections 2 and 3)

Parental responsibility

A person with parental responsibility may be a parent, step-parent or the parent's civil partner. In the case of looked after children, this responsibility may have been acquired by another adult or the local authority under the Children Act.

Those with parental responsibility do not necessarily need to be present when a vaccination is given, provided they have received information about it and then arranged for another person (for example, a grandparent or childminder) to attend with the child. For further information see chapter two of the 'Green book'[1].

The term 'parent' is used throughout the recommendations to describe anyone with parental responsibility.

Recommendation 1: immunisation programmes

Who is the target population?

  • Children and young people aged under 19 years, particularly those who may not have been immunised or may have only been partially immunised.

  • Parents of children and young people aged under 19 years.

Who should take action?

  • Commissioners, managers and coordinators in primary care trusts (PCTs), children's services, children's trusts, Sure Start children's centres and services for vulnerable groups (including those run by family nurse partnerships[2]).

  • Health professionals responsible for children and young people's immunisation services including paediatricians, health visiting and school nursing teams, GPs and practice nurses.

  • Directors of public health, immunisation coordinators and others who provide or commission immunisation services in PCTs and GP practices.

  • Health protection specialists and immunisation leads in health protection units (HPUs).

  • Children's service managers and nursing staff in hospital trusts, children's social care organisations and child and adolescent mental health services.

What action should they take?

  • Ensure Department of Health (DH) guidance and updates on immunisations (including official letters from the Chief Medical Officer, Chief Nursing Officer and Chief Pharmaceutical Officer) are disseminated to relevant professionals and implemented.

  • Adopt a multifaceted, coordinated programme across different settings to increase timely immunisation among groups with low or partial uptake. The programme should form part of the local child health strategy and should include the following actions:

    • Monitor vaccination status as part of a wider assessment of children and young people's health.

    • Ensure there is an identified healthcare professional in the PCT and every GP practice who is responsible – and provides leadership – for the local childhood immunisation programme.

    • Ensure all staff involved in immunisation services have access to the 'Green book'[1]. Also ensure updates to the childhood immunisation programme and schedule are monitored and services adapted appropriately.

    • Improve access to immunisation services. This could be achieved by extending clinic times, ensuring children and young people are seen promptly and by making sure clinics are child- and family-friendly.

    • Ensure enough immunisation appointments are available so that all local children and young people can receive the recommended vaccinations on time.

    • Send tailored invitations for immunisation. When a child or young person does not attend appointments, send tailored reminders and recall invitations and follow them up by telephone or text message.

    • Provide parents and young people with tailored information, advice and support to ensure they know about the recommended routine childhood vaccinations and the benefits and risks. This should include details on the infections they prevent. Information should be provided in different formats, for example, for those whose first language is not English.

    • Ensure parents and young people have an opportunity to discuss any concerns they might have about immunisation. This could either be in person or by telephone and could involve a GP, community paediatrician, health visitor, school nurse or practice nurse.

    • Ensure young people fully understand what is involved in immunisation so that those who are aged under 16, but considered sufficiently capable, can give their consent to vaccinations, as advised in the 'Green book'.

    • Ensure young people and their parents know how to access immunisation services.

    • Consider home visits to discuss immunisation with parents who have not responded to reminders, recall invitations or appointments. Offer to give their children vaccinations there and then (or arrange a convenient time in the future). Such visits could include groups that may not use primary care services, for example, travellers or asylum seekers.

    • Check the immunisation status of children and young people at every appropriate opportunity. Checks should take place during appointments in primary care (for example, as part of a child health review), hospital in- or outpatient and accident and emergency departments, walk-in centres or minor injuries units. Use the personal child health record (PCHR, also known as the 'Red book') as appropriate. If any vaccinations are outstanding:

      • discuss them with the parent and, where appropriate, the young person. Where they have expressed concerns about immunisation and this is documented, these appointments should be used as an opportunity to have a further discussion

      • offer vaccinations by trained staff before they leave the premises, if appropriate. In such cases, notify the child or young person's GP, health visitor or local child health information department so that records can be updated

      • and, if immediate vaccination is not possible, refer them to services where they can receive any outstanding immunisations.

Recommendation 2: information systems

Who is the target population?

  • Children and young people aged under 19 years, particularly those who may not have been immunised or may have only been partially immunised.

  • Parents of children and young people aged under 19 years.

Who should take action?

  • Those responsible for information services within PCTs, acute trusts and GP practices.

  • Strategic health authority immunisation leads, PCT immunisation coordinators, directors of public health and community paediatricians.

  • Health protection specialists and immunisation leads in health protection units.

  • GPs, practice nurses, health visiting teams and those who commission or provide immunisation services.

  • Independent and private sector providers of immunisation services.

What action should they take?

  • Ensure PCTs and GP practices have a structured, systematic method for recording, maintaining and transferring accurate information on the vaccination status of all children and young people. Vaccination information should be recorded in patient records, the personal child health record and the child health information system. The same data should be used when reporting vaccinations to the child health department and when submitting returns to the PCT for GP and practice payments. This will ensure records in both systems are reconciled and consistent.

  • Encourage and enable private providers to give the relevant GP practice or PCT details of all vaccinations administered to children and young people, so they can be recorded in the appropriate information system.

  • Record any factors which may make it less likely that a child or young person will be up-to-date with vaccinations in their patient records and the personal child health record. For example, note if children and young people are looked after, have special needs or have any contraindications to vaccination. Also note if the parents or young person have expressed concerns about vaccination.

  • Regularly update and maintain the databases for recording children and young people's immunisation status. For example, ensure records are transferred when a child or young person moves out of the area, ensure information is not duplicated and follow up on any missing data.

  • Ensure up-to-date information on vaccination coverage is available and disseminated to all those responsible for the immunisation of children and young people. This includes those who are delivering the vaccinations.

  • Use recorded information on immunisation, together with surveillance data on the incidence of infection, to inform local and joint strategic needs assessments and health equity audits. These data should also be used to support delivery of an immunisation programme for children and young people.

  • Monitor the age composition of the practice population so that there is enough capacity to provide timely immunisations. Waiting lists are unacceptable.

Recommendation 3: training

Who is the target population?

Those who advise on and provide immunisation services including:

  • GPs, health visitors, practice nurses, community nurses (including school nurses), midwives and nurses working in neonatal care, nurseries, child and adolescent mental health services, young offender institutions and secure units.

  • PCT immunisation coordinators and public health professionals.

  • Hospital and community paediatricians, nursing staff in hospital trusts and walk-in centres and pharmacists.

  • NHS health trainers.

  • NHS support staff, including clinic clerks and receptionists.

  • Managers of children's services and children's centres, social care workers (working with children) and those with parental responsibility for looked after children.

Who should take action?

  • Professional bodies, skills councils and other organisations responsible for setting competencies and developing continuing professional development programmes for health professionals.

  • Health protection units.

  • Employers and managers in PCTs and strategic health authorities, including GPs whose staff are involved in immunisation services.

  • Private and independent sector providers of immunisation services for children and young people aged under 19 years.

What action should they take?

  • Ensure all staff involved in immunisation services are appropriately trained. Training should be regularly updated. It should be tailored to individual needs to ensure staff have the necessary skills and knowledge, for example, communications skills and the ability to answer questions about different vaccinations.

  • Ensure health professionals who deliver vaccinations have received training that complies with the 'National minimum standard for immunisation training[3]'.

  • Professional bodies should ensure health professionals working with children and young people have the appropriate knowledge and skills to give advice on the benefits and risks of immunisation. Specifically, they should be well-versed in the core topics defined in the Health Protection Agency's 'Core curriculum for immunisation training[4]'.

  • Ensure staff are appropriately trained to document vaccinations accurately in the correct records.

Recommendation 4: contribution of nurseries, schools, colleges of further education

Who is the target population?

  • Children and young people aged under 19 years attending nurseries, schools and colleges of further education, particularly those who may not have been immunised or may have only been partially immunised.

  • Parents of children and young people aged under 19 years.

Who should take action?

  • PCT directors of public health, immunisation coordinators and community paediatricians.

  • Health visiting and school nursing teams, GPs and those involved in family nurse partnerships.[2]

  • Head teachers, school governors and heads of further education colleges and pupil referral units.

  • Nursery, pre-school and early years providers.

  • Managers, nurses and early years support staff in Sure Start children's centres and children's services.

What action should they take?

  • The Healthy Child team, led by a health visitor working with other practitioners, should check the immunisation record (including the personal child health record) of each child aged up to 5 years. They should carry out this check when the child joins a day nursery, nursery school, playgroup, Sure Start children's centre or when they start primary school. The check should be carried out in conjunction with childcare or education staff and the parents.

  • School nursing teams, working with GP practices and schools, should check the vaccination status of children and young people when they transfer to a new school or college. Working with the PCT, they should also advise young people and their parents about the vaccinations recommended at secondary school age.

  • If children and young people are not up-to-date with their vaccinations, school nursing teams, in conjunction with nurseries and schools, should explain to parents why immunisation is important. Information should be provided in an appropriate format (for example, as part of a question and answer session). School nursing teams should offer vaccinations to help them catch up, or refer them to other immunisation services.

  • Head teachers, school governors, managers of children's services and PCT immunisation coordinators should work with parents to encourage schools to become venues for vaccinating local children. This would form part of the extended school role.

Recommendation 5: targeting groups at risk of not being fully immunised

Who is the target population?

  • Children and young people aged under 19 years at risk of not being immunised or only being partially immunised.

  • Parents of these children and young people.

Who should take action?

  • Commissioners, managers and coordinators of children's services in PCTs, children's trusts, Sure Start children's centres and immigration services.

  • Health professionals responsible for children's immunisation services including directors of public health, paediatricians, GPs, practice nurses, school nursing teams, health visiting teams and those involved in family nurse partnerships.[2]

  • Nurses working in child and adolescent mental health services, young offender institutions and secure units.

  • Other health professionals who have contact with children and young people aged under 19 years.

  • Immunisation coordinators and others who work in immunisation services within PCTs and GP practices.

  • Managers of children's services and children's centres.

  • Social care workers responsible for children and those with parental responsibility for looked after children.

What action should they take?

  • Improve access to immunisation services for those with transport, language or communication difficulties, and those with physical or learning disabilities. For example, provide longer appointment times, walk-in vaccination clinics, services offering extended hours and mobile or outreach services. The latter might include home visits or vaccinations at children's centres.

  • Provide accurate, up-to-date information in a variety of formats on the benefits of immunisation against vaccine-preventable infections. This should be tailored for different communities and groups, according to local circumstances. For example, offer translation services and provide information in multiple languages.

  • Consider using pharmacies, retail outlets, libraries and local community venues to promote and disseminate accurate, up-to-date information on childhood immunisation.

  • Health professionals should check the immunisation history of new migrants, including asylum seekers, when they arrive in the country. They should discuss outstanding vaccinations with them and, if appropriate, their parents, and offer the necessary vaccinations administered by trained staff.

  • Prison health services should check the immunisation history of young offenders. They should discuss any outstanding vaccinations with the young person and, if appropriate, their parents, and offer appropriate vaccines administered by trained staff.

  • Check the immunisation status of looked after children during their initial health assessment, the annual review health assessment and statutory reviews. Ensure outstanding immunisations are addressed as part of the child's health plan. Offer opportunities to have any missed vaccinations, as appropriate, in discussion with the child or young person and those with parental responsibility for them.

Recommendation 6: hepatitis B immunisation for infants

Who is the target population?

  • Children born to mothers who are hepatitis B-positive.

  • Parents of children who are hepatitis B-positive.

Who should take action?

  • GPs, health visitors, midwives, neonatal and community paediatricians, nursery and neonatal nurses, support workers and those involved in family nurse partnerships.[2]

  • PCT directors of public health and immunisation coordinators.

  • Managers and family health and support teams in children's services.

  • Managers, health professionals and early years support staff in Sure Start children's centres.

  • Commissioners and providers of immunisation services.

What action should they take?

  • PCTs should have an identified person responsible for coordinating the local hepatitis B vaccination programme for babies at risk of hepatitis B infection. The person should also be responsible for scheduling and follow-up to ensure babies at risk are vaccinated at the right time. This may involve working within and across several PCT areas.

  • A clear process for the local infant hepatitis B vaccination programme should be developed and implemented. Antenatal, postnatal, neonatal, paediatric, primary care and community support teams should communicate effectively and share information so that the children and families affected can be contacted and followed up.

  • Babies born to hepatitis B-positive mothers should be given the first dose of the vaccine promptly, whether they are delivered in hospital or at home. They should then receive all other recommended doses, a blood test to check for infection and, where appropriate, hepatitis B immunoglobulin, in line with the 'Green book'[1].

  • Health professionals should record the mother's hepatitis B status in the personal child health record as soon as possible after birth, before the midwife hands over care of the baby to the health visitor. The mother's hepatitis B status should also be entered on the child's record in the local Child Health Information System.

  • Health professionals should provide parents with information, advice and support on how to prevent the transmission of hepatitis B. They should emphasise the importance of ensuring babies complete the recommended vaccination course at the right time. In addition, they should assess whether or not the baby's siblings need to be immunised against hepatitis B or tested for infection and should offer them vaccinations and blood tests if necessary.

  • Health professionals should ensure administered doses of hepatitis B vaccination are recorded in the patient records and the personal child health record.

  • All the above actions should be integrated into the local care pathway for infant hepatitis B. (See also NICE clinical guideline 62 on antenatal care).



[1] Department of Health (2006) Immunisation against infectious disease. London: Department of Health.

[2] Under the family nurse partnership programme, specially trained nurses visit some of the most vulnerable young mothers and their families at home, working with them from early pregnancy until the child is aged 2 years.

[3] Health Protection Agency et al. (2005a) National minimum standard for immunisation training.

[4] Health Protection Agency et al. (2005b) Core curriculum for immunisation training.

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