Appendix C: The evidence

This appendix lists evidence statements from the revised analysis of the review of effectiveness (see appendix A and B) and links them to the relevant recommendations. The evidence statements are presented here without references – these can be found in the full review (see appendix E for details). It also sets out a brief summary of findings from the economic analysis and the fieldwork

Evidence statement 7 indicates that the linked statement is numbered 7 in the revised review of effectiveness.

The review, economic analysis and fieldwork report are available online. Where a recommendation is not directly taken from the evidence statements, but is inferred from the evidence, this is indicated by IDE (inference derived from the evidence) below.

Recommendation 1: evidence statements 5, 6, 7, 8, 10, 11, 12, 13, 14, 15, 16, 38, 39, 40, 41, 47, 48, 49, 51, 52, 55, 61; IDE

Recommendation 2: IDE

Recommendation 3: evidence statements 25, 26, 27, 28; IDE

Recommendation 4: evidence statements 20, 41; IDE

Recommendation 5: evidence statements 16, 43, 48, 49, 51

Recommendation 6: 66; IDE

Evidence statements

Evidence Statement 5

There is mixed evidence from 3 RCT's, all from the USA, as to the effectiveness at increasing immunisation uptake of reminder/recall interventions targeting families of low socioeconomic status. One RCT ([++] n=601 [n is the number of participants]) found that reminder postcards in advance of appointments with follow-up postcards and phone calls if the appointment is missed significantly increased the number of infants up-to-date with immunisations compared with families that only received a single reminder postcard if they failed to keep the appointment. The second RCT ([+] n=1273) found that although postcard and telephone reminders in advance of an appointment significantly increased vaccination coverage in infants who were not up-to-date at baseline compared with families who didn't receive a reminder, there was no significant difference in overall vaccination coverage rates between reminder and control groups. Finally, 1 RCT ([−] n=222) found that although more children of families who received a computer-generated phone message in advance of an appointment were vaccinated within 1 month of being due compared with families who didn't receive a reminder, the difference was not significant.

Evidence Statement 6

There is mixed evidence from 3 studies from the USA: 2 RCTs (both −) and 1 non-randomised controlled trial (nRCT) (+) as to the effectiveness of universal reminder/recall interventions for children aged under 2 years. Two studies found that compared with children who received no contact, reminders comprising either mailed postcards or computer-generated telephone messages in advance of appointments increased uptake of DTP (RCT [−] n=1138) and DTP, OPV, Hib, and MMR (n-RCT[+] n=213). Conversely, 1 RCT found that letters comprising either a health message or a message reminding parents that vaccination is compulsory under state law had no significant impact on vaccine coverage at 7 months compared with a control group that received no reminder/recall letters ([−] n=1351).

Evidence statement 7

There is evidence from 1 RCT ([++] n=169) from Australia that a home vaccination service for children who were behind on the recommended immunisation schedule (DTP/OPV/Hib or MMR) significantly improved vaccination coverage compared with children who did not receive a home-based vaccination service.

Evidence statement 8

There is evidence from 1 BA study ([+] n=1075) from the USA that a community-based outreach programme comprising home visits to a large public housing development to identify children and pregnant women significantly improved children's vaccination coverage in this population.

There is evidence from 1 RCT ([+] n=220) from the USA that a community-based outreach programme comprising 7 home visits during the baby's first 15 months of life together with advice and support for mothers is as effective at ensuring age-appropriate immunisations regardless of whether it is delivered on a one-to-one basis or a group basis.(See also evidence statement 45.)

Evidence statement 10

There is evidence from 1 RCT from the USA reported in 2 articles ([+] and [−] n=102) to suggest that an intervention targeting pregnant adolescents which incorporated intensive home visits (approximately 17 antenatal and postnatal visits) extended from pregnancy to 1 year postpartum significantly improved vaccination uptake at age 12 months compared with a control group that received 1 or 2 visits. Evaluation of the programme at 24 months postpartum found that the intervention group was less likely than the control group to be up-to-date with immunisations, although more than 40% of participants had been lost to follow-up by 24 months, limiting the reliability of this finding.

Evidence statement 11

There is evidence from 1 RCT ([++] n=152) from Australia to suggest that regular home visits up to 6 months postpartum by midwives to new mothers who were illicit drug users did not significantly increase age-appropriate vaccination rates of newborns at 2, 4 or 6 months compared with a control group who received telephone contact at 2 months and a home visit at 6 months. Vaccination rates at 2 and 4 months were higher (although not significantly) in the intervention group compared with control.

Evidence statement 12

Conceptions of the severity of vaccine-preventable diseases: There is evidence from a focus group study with 66 parents (+) and an interview study with 22 parents (++) that many parents lacked knowledge about immunisations and vaccine-preventable diseases, their incidence in the UK and their severity.

There is evidence from 20 surveys of mothers of children aged under 3 years (n=15,000) carried out over a 10-year period from 1991 to 2001 (+) that the perceived severity of vaccine-preventable diseases has changed over time, with the perceived severity of some diseases having decreased (diphtheria, pertussis and polio), increased (meningitis C), remained stable (tetanus and mumps), or varied (Hib, measles and rubella).

There is conflicting evidence as to the relationship between how severe vaccine-preventable diseases are perceived to be by parents and the likelihood of their children having completed their immunisations. A postal survey of 44 parents (−) suggested that parents of children with incomplete immunisations were less likely to see childhood diseases as being severe. Conversely, an interview study with 759 parents (−) found that there were few differences between the beliefs of parents who had and had not had their children immunised regarding incidence and severity of vaccine-preventable diseases.

There was evidence from 2 qualitative studies with parents living in inner-city settings to suggest that vaccine-preventable childhood diseases were perceived to be severe or serious. One interview and focus group study with 21 Somali, Pakistani and African-Caribbean mothers (+) found that the severity and incidence of childhood diseases was perceived as high. Likewise, a survey of orthodox Jewish parents (n=67) in London found that most parents perceived vaccine-preventable diseases such as measles as being very serious or serious (+).

However, 3 studies found that there were mixed views on how serious different vaccine-preventable diseases were perceived to be. One recent interview study undertaken in October and November 2006 with mothers of children aged under 3 years (n=1016) found that meningitis was perceived as being the most severe disease, while measles, mumps and rubella were seen as being the least severe (++). One questionnaire study with 68 parents in an inner-city setting (+) found that meningitis was perceived to be the most serious disease, with pertussis, diphtheria and measles being perceived as serious or very serious and rubella being perceived as mild. One interview study with 13 parents in an inner-city setting (−) found that diphtheria, tetanus and polio were perceived as serious, whilst measles, mumps and rubella were perceived as mild.

There is evidence from 1 focus group study (++) with 25 orthodox Jewish mothers and 10 local healthcare workers from an orthodox Jewish community in North East London found that the separation of the community from outside influence led to feelings of safety and a lack of need for the BCG vaccination, a situation that local healthcare providers occasionally supported, although this was not done consistently.

Evidence statement 13

Misconceptions about the safety of vaccines: There is evidence from 1 study comprising 20 surveys of mothers of children aged under 3 years carried out over 10 years ([+] n=15,000) that most mothers (more than 90%) trust the safety of immunisations. However, there is evidence from 5 studies that some mothers and parents consider the risks of vaccines to be greater than the risks of acquiring vaccine-preventable diseases ([++] n=18,488; [−] n=87; [+] n=68; [−] n=29; [−] n=13).

There is evidence to suggest that a range of perceived risks of immunisation may influence some parental decisions to delay or avoid immunisations for their children, as suggested by a postal questionnaire with 87 parents (−), a nationally representative interview survey with 18,488 mothers (++), and a postal survey of 44 parents (−). A fear of vaccines being contraindicated for existing medical conditions such as eczema was indicated by some parents (proportion not stated) in an interview study with 759 parents (−). Concerns about combined antigens putting too much stress on a baby's immune system were identified by 3 studies ([+] n=72; [++] n=22; [−] n=44).

There is evidence from 1 survey (n=NR) that reported that 1 in 3 parents of children aged 0–2 years worry about the effect of multiple vaccines and too many vaccinations on the child. One in 3 parents had some concern over the immunisation process, with the principle concerns being around a lack of information and worries about the effect on the child, but also concern about the way health professionals carry out immunisation appointments (a perceived lack of empathy, concern and time, in particular [−]).

There is evidence from an interview study with 10 orthodox Jewish mothers (−) that mothers' fears of adverse reactions to vaccines were a reason for low uptake. A multi-method study with 21 Somali, Pakistani and African-Caribbean mothers (+) indicated that none of the mothers knew anyone who had suffered an adverse reaction to immunisation and all were positive about immunisation.

A study which included focus groups with health professionals (−) found that health professionals thought that parents' fears of side effects were a reason for low uptake and that in close-knit communities negative reports about immunisation were perpetuated.

Some studies indicated that parents making the decision to immunise their children weighed up the risks and benefits of immunisation as they perceived them, as illustrated in a postal questionnaire with 87 parents (−), an interview study with 13 parents in an inner-city setting (−), a questionnaire study with 68 parents in an inner-city setting (+) and an interview study with 19 mothers and 10 health professionals (−). However, the decision-making process is complicated and different parents in different studies raised differing perceptions of risks and benefits.

Evidence statement 14

Information sources: Evidence from 20 surveys carried out over 10 years involving 15,000 mothers (+) suggests that the majority of parents discuss immunisation with a health professional before uptake. However, the same study and an interview study with 759 parents (−) found that a substantial minority did not. There is also evidence from 2 studies to suggest that some health professionals would like more time to discuss immunisation with parents and that some health professionals worried about 'overloading' parents with information particularly if it might cause otherwise compliant parents not to immunise their children ([+] n=22 health visitors; [+] n=58 primary healthcare professionals).

There is evidence from 5 studies which suggest that parents find health professionals, NHS literature, friends and the media (including television and the Internet) to be important sources of information on immunisation ([+] n=859 parents; [+] n=278 parents and n=322 health professionals; [−] n=44 parents; [−] n=NR; [−] n=759).

Evidence statement 15

Satisfaction with information sources: There is evidence from 2 UK postal surveys that found that although the majority of parents (70%) were satisfied with information on immunisation, parents of fully immunised children were more likely to be satisfied with available information than parents whose children were unimmunised or only partially immunised ([+] n=859 parents of children aged 18–24 months; [−] n=20 parents). However, there is also evidence from 1 study from Scotland that found that an investigation of parents' beliefs indicated dissatisfaction with the information provided by NHS leaflets and professionals ([+] n=278 parents).

There is evidence from an interview study with 13 parents in an inner-city setting who had chosen not to immunise their children (−), and a questionnaire study with 68 parents in an inner-city setting with children with incomplete immunisation (+) to suggest that some parents mistrusted the information provided (proportion not reported in the first study, 28% in the second study), because they perceived that the information exaggerated the efficacy of vaccines and did not adequately acknowledge the potential side effects of vaccines.

A postal questionnaire including 278 parents in Scotland (+) found that parents of children with incomplete immunisations were more likely to rely on information from the media (including the Internet) and friends and were less likely to have discussed immunisation with a health professional, compared with parents with completely immunised children. Similar results were found by a postal survey of 44 parents (24 of whom had completely immunised children and 20 of whom had partially or unimmunised children [−]).

A postal questionnaire study of 859 parents reported that there were mixed views on the preferred timing of information (for example, either before the baby's birth, at the first health visitor's visit or at the 6–8 week postnatal check[+]).

Evidence statement 16

Tailoring information to population subgroups: Three studies (2 [+] and 1 [−]) indicated a need to tailor immunisation information to particular groups. There is evidence from a multi-method study with 21 Somali, Pakistani and African-Caribbean mothers (+) and an interview study with 22 health visitors (+) that there are concerns about the accessibility of immunisation literature (whether translated or not), particularly for migrants with low levels of literacy. Concerns were also raised by African-Caribbean mothers in 1 study (+) who were dissatisfied with the lack of ethnic minority representations in literature on immunisation. Two studies, 1 interview study with orthodox-Jewish mothers (n=10) in London (−) and another focus group study with 25 orthodox Jewish mothers and 10 local healthcare workers from an orthodox Jewish community in North East London (++) found that the research participants felt 'cut off' from the media as a source of information and instead relied on sources of information within their social networks.

Evidence statement 20

There is evidence from an interview study with head teachers (n=31), school nurses (n=12) and parents (of n=1411 children) in inner-city London (+) that the majority of head teachers would be in favour of asking about immunisation status on school entry, and would be prepared to recommend that parents had their children fully immunised before school entry.

Evidence statement 25

Poor knowledge of the benefits and risks of vaccines: There is evidence from 1 questionnaire study with 174 health professionals in Liverpool (−) and 1 postal questionnaire including 116 health visitors and practice nurses in Scotland (+) to suggest that there are mixed views from health professionals about what constitutes a contraindication to some vaccines.

There is evidence from 1 questionnaire study (−) of health professionals (n=120; midwives, nurses, allied professionals and doctors) from an acute hospital in England that found that less than 50% could accurately identify which babies should receive a neonatal BCG vaccine.

There is evidence from 1 recent survey (n=NR) of GPs (31% response rate), health visitors (63%) and practice nurses (63%) that found one-third of health professionals who stated concerns about immunisation reported their main concern as being that babies were given too many immunisations (−). Similar concerns were reported in a postal questionnaire of 116 health visitors and practice nurses in Scotland (+) that found that several health professionals (n=NR) were concerned about the ability of babies' immune systems to cope with vaccines. Other concerns raised by health professionals included difficulties with the practicalities of administering the number of vaccinations in the current schedule, the complexity of and changes to the schedule, and difficulties with keeping up-to-date (−).

There is evidence from 1 questionnaire study (−) that found that health professionals (health visitors, school nurses and clinical medical officers) judged that different vaccines offered different levels of protection with pertussis and measles vaccines being given lower scores than others. The study also found that more health professionals thought it very important to prevent diphtheria, tetanus, pertussis and polio, but fewer thought measles prevention to be very important.

Evidence statement 26

Health professionals views on immunisation education and training: There is evidence from 2 surveys from the UK that found that most health professionals (including health visitors and practice nurses) surveyed would like further education or training on immunisation ([−] n=174; [+] n=116). Recent evidence from 1 survey (n=NR) of GPs (31% response rate), health visitors (63%) and practice nurses (63%) found that compared with GPs, health visitors and practice nurses were more likely to be aware of immunisation training (89% of health visitors versus 94% of practice nurses versus 49% of GPs) and their local immunisation coordinator (89% of health visitors versus 94% of practice nurses versus 49% of GPs). The study also found that health visitors and practice nurses were more likely to have attended 1–2 sessions of immunisation training in the preceding 2 years than were GPs (69% of health visitors versus 72% of practice nurses versus 64% of GPs; p value not reported; [−]).

Evidence statement 27

Information sources for health professionals: There is evidence from 2 surveys that found that Department of Health publications (including the Green Book and Chief Medical Officer letters or updates) and NHS information and publications are important and frequently used sources of information for GPs, health visitors and practice nurses (1 [−] and 1 [+]). One study reported that in addition to being the most frequently used source of information, Department of Health/NHS information and publications were the most useful source of information. The Department of Health's website was mentioned most frequently (21% of GPs versus 46% of health visitors versus 36% of practice nurses). The NHS Immunisation Information website was the second most commonly mentioned Internet site (6% of GPs versus 23% of health visitors versus 18% of practice nurses). GPs continued to be least likely to use the Green Book often (39%) with greater use among health visitors (of whom 46% used it often) and practice nurses (with 71% using it often and 25% using it very often).

There is evidence from 1 recent survey that found that health professionals' (including GPs, health visitors and practice nurses) preferred format for the Green Book was hard copy (around 30% in each group), with very few preferring an Internet-only version (−).

There is evidence from 1 recent survey that found that other sources of information on immunisation used by health professionals included medical and nursing journals, the media (for example, television, radio and newspapers), trust and professional body guidelines and the Internet. Among health visitors and practice nurses there appeared to be widespread use of a large variety of information sources, with GPs generally using a more restricted range of materials (−).

Evidence statement 28

There is evidence from 4 UK studies (1 ITS [+] and 3 BA [−]) that education and training for health professionals (including midwives, health visitors, GPs and paediatricians) in the implementation of targeted neonatal BCG vaccination policies (comprising identification and referral of at-risk neonates; administration of the BCG vaccine, identification of contraindications etc) was effective at increasing the proportion of at-risk neonates that received timely vaccination (Gill and Scott, 1998; 1 ITS [+] and 3 BA [−]).

Evidence statement 38

There is evidence from a focus group study of 48 parents which found that some (not further quantified) parents felt that opportunistic immunisation of children in accident and emergency departments, or during a hospital admission, was both inappropriate and distressing (+).

Evidence statement 39

There is strong evidence from 7 studies from the UK (1 BA [−] and 1 BA [+]), USA (1 RCT [+]; 1 BA [++]; 1 BA [+]; 1 cohort [−]), and Australia (1 BA [+]), that hospital-based opportunistic immunisation strategies are effective for increasing uptake of recommended vaccinations in children admitted to hospital. One RCT ([+] n=1835) from the USA found that fewer children remained under-immunised after discharge if the hospital had either sent a letter to primary care providers notifying them of under-immunisation status or had vaccinated before discharge compared with no intervention, although the difference was not significant. Two BA studies from the USA found that hospital-based vaccination of children (aged 0–2 years) who were either under-immunised or from predominantly low-income families significantly increased the proportion of children who were age-appropriately immunised (BA [++] n=2006) and reduced the number of missed opportunities for vaccination (BA [−] n=1163).

One BA ([+] n=866) from Australia found that after introduction of an opportunistic vaccination strategy that comprised training of health professionals and vaccination of under-immunised children, the number of vaccinations provided significantly increased in paediatric wards, but not emergency departments. Two studies from the UK found that some children were successfully brought up-to-date with the recommended vaccination schedule after hospital-based immunisation (BA [+] n=56; and BA [−] n=1000). Although 1 study found that some carers refused, preferring to have vaccinations administered by their primary care provider. Finally, 1 cohort study ([–] n=1301) from the USA found that the proportion of pre-school children not up-to-date with the recommended immunisation schedule on admission to the emergency department significantly decreased on discharge after hospital-based vaccination. However, by 6 months, there was no significant difference in the proportion of children up-to-date on discharge compared with that on hospital admission.

Evidence statement 40

There is evidence from 2 studies from Australia and Switzerland (1 NRCT [−] and 1 NRCT [+]) that delivery of a verbal reminder to parents of children identified on admission to hospital as being not up-to-date with the recommended immunisation schedule with or without a follow-up letter sent to the child's primary care provider, was effective at encouraging vaccination within 30 days compared with children whose parents were not given a reminder (NRCT [+] n=430; NRCT [−] n=54).

Evidence statement 41

There is evidence from an interview study with head teachers (n=31), school nurses (n= 12) and parents (of 1411 children) in inner-city London (+) that although most parents (69%) whose children were not fully immunised were in favour of opportunistic school-based immunisations (for example, at the school health interview), there were mixed views among school nurses and head teachers. Findings from a postal survey of 24 school nurses in Oxfordshire found that where school-based immunisations had taken place they had greatly increased school nurses' workload (−).

There is evidence from a questionnaire that sought to identify lessons for future practice, training needs, operational planning and resource management of school nurses (throughout England; response rate 57.6%) after undertaking a nationwide rubella and measles immunisation programme for children aged 5–16 years ([−] n=288). The study found that: the timing of the campaign was not ideal for school nurses with the dates coinciding with the beginning of school holidays, a time when most school nurses do not work; 75% felt confident in undertaking immunisations but a few nurses who did not have access to training admitted to lacking confidence; the majority (95%) found the campaign tiring and many put in extra time that was not remunerated; 92% of nurses had found the campaign a challenge and stimulating and most (96%) enjoyed working in a team (those that worked within a team structure felt more confident and enjoyed the camaraderie).

There is evidence from a semi-structured focus group study involving parents (n= 39) and pupils (n=50) in Glasgow (++) that explored immunisation in general and universal hepatitis B vaccination. It found that most parents agreed with vaccinations being delivered at school, and felt that their children thought likewise. A minority of pupils and parents perceived a lack of privacy and embarrassment to be barriers to vaccination in school. Pupils liked receiving vaccine at school because they felt supported by their peers.

Evidence statement 43

There is evidence from 1 ITS (+) from the UK that offering hepatitis B vaccination to all injecting drug users (aged 16–20 years) who were inmates of youth offender institutions and prisons, significantly increased uptake.

Evidence statement 47

There is strong evidence from 10 studies to suggest that targeted multicomponent community-based interventions are effective at increasing uptake of childhood immunisations.

Four RCTs (3 [+] and 1 [−]) and 4 BA studies (1 [+] and 3 [−]) found that multicomponent community-based interventions targeting children at risk of low immunisation uptake (for example, already behind in their vaccinations or from low-income or black and minority ethnic group families) increased the number of children who were up-to-date with the recommended vaccination series or who received vaccinations, at least in the short term (6 months to 1 year) compared with children who did not receive community-based outreach. Although intervention components varied between studies they generally comprised: home visits; advice and support for parents;, local media campaigns and networking with local organisations; vaccination-specific components such as referral and reminders of upcoming vaccinations; working with parents to ensure they understood the immunisation schedule, reduced their misconceptions about vaccinations or encouraging them to be proactive and request immunisations from their providers; direct contact with the family's immunisation providers; immunising in other settings such as hospitals and immunisation-linked incentives.

One cluster RCT ([+] n=286) found that a multicomponent community-based intervention comprising home visits, parent-baby developmental play groups, parent support groups and monthly support calls, targeting children from black, low-income families, significantly improved uptake of immunisations to age 9 months compared with children receiving standard social services. Although there was no significant difference in completion of primary immunisation series at 12 months, drop out was greater than 50%, limiting reliability of this finding.

One NRCT ([+] n=1,508) compared a media-based education and outreach campaign to encourage Vietnamese American parents to have their children vaccinated with hepatitis B vaccine with a community mobilisation strategy undertaken by a Vietnamese American community-based organisation that developed an action plan of activities and timeline with the goal of improving vaccination rates. It found that both strategies significantly increased uptake of hepatitis B vaccine compared with a control group that did not receive any intervention.

However, there is mixed evidence on the long-term effectiveness of community-based outreach interventions at increasing immunisation uptake. One RCT ([+] n=232) followed up children for 7 years and found there was no significant difference between intervention and control groups in the proportion of children that had received MMR or the school booster, although subsequent children of mothers in the intervention group were significantly more likely to have completed polio and Hib immunisations compared with subsequent children of mothers in the control group.

Two RCTs (1 [+] and 1 [−]) found that universal multicomponent community-based interventions which comprised postnatal home visits in addition to parental advice and support (RCT [+] n=439) or postcard or telephone reminders for parents to attend for vaccinations and a number of provider-based interventions (RCT [−] n=3015) significantly improved up-to-date vaccination coverage rates compared with no intervention.

Evidence statement 48

Barriers to immunisation uptake: A nationally representative interview survey with 18,488 mothers found that parents of partially immunised children were likely to refer to practical or logistical problems with getting to immunisation clinics as reasons for incomplete immunisation (++).

An interview study with parents of 1411 children in inner-city London found that recent immigration was a practical barrier to immunisation, although the study did not elaborate on the types of barriers caused by immigration (+).

Evidence statement 49

Parental and health professional views on interventions to reduce barriers to immunisation uptake: There was evidence from 2 studies, 1 postal survey of health professionals (including school nurses, clinical medical officers and health visitors) and 1 focus group study (involving health visitors and parents), that identified a number of practical suggestions for improving immunisation uptake. These included: mobile or home-based immunisation; incentives for parents to bring their children for immunisation; special clinics solely for immunisation; general improvements to the immunisation service ([−] n=174 health professionals), and varying clinic timing ([−] n=15 health visitors and parents). Only 6–9% of professionals supported compulsory immunisation.

An interview study with 759 parents found that 25% of them would prefer immunisation in the home by a health visitor (−). Another interview study of 22 parents indicated that parents had a preference for a flexible system for immunisation appointments (++).

There is evidence from an interview study with 10 orthodox Jewish mothers (−) and a questionnaire study with 67 orthodox Jewish parents (+) that identified a number of interventions such as reducing clinic waiting times, improving play facilities in clinics and reducing overcrowding in waiting rooms that may help to improve immunisation uptake, many of which sought to address practical barriers such as having to care for large families and multiple competing demands on time.

Evidence statement 51

There is evidence from 2 studies (1 cluster RCT [+] and 1 ITS [−]) that targeted multicomponent programmes based on enhancing access to vaccination services in combination with reminder/recall interventions is effective at increasing uptake of immunisations. The first study (cluster RCT [−] n=2665) found that an intervention based on reminder/recall in addition to home visits and transportation to the clinic for children of low-income families in need of vaccinations was effective at increasing the proportion of babies up-to-date with immunisations compared with children receiving no contact ([+] n=2665). The second study (ITS [−] n=3184) found that a programme comprising a community-wide reminder/recall and outreach system in which children behind in their immunisations received reminder/recall (telephone, postcard, or letter) with increasing intensity for children who were further behind in immunisations, and home visits for those where all previous strategies had failed, significantly increased immunisation rates in city and suburban settings from baseline after 3 years. After 6 years the increase was no longer statistically significant.

Evidence statement 52

There is evidence from 1 BA study ([++] n=464) from Ireland that a targeted multicomponent provider-based intervention comprising: checking of practice immunisation records and implementation of opportunistic immunisations; sending postal reminders to non-vaccinated children and providing monthly written feedback of uptake figures to all practice staff, significantly increased uptake after the postal reminders were sent of DTP and Hib among children aged more than 6 months living in a deprived area.

Evidence statement 55

Differences in knowledge and beliefs across different ethnic groups: There is evidence from a study that used mixed methods (quantitative analysis and focus groups with 37 mothers) in Brent, North West London and found a significant relationship between uptake of the first dose of MMR vaccine and ethnicity. Uptake of the first dose of MMR vaccine was highest among children from Indian backgrounds followed by African-Caribbean children and lastly white children (++).

Among people of Asian origin, immunisation was seen as beneficial, possibly influencing their uptake; these people followed their cultural tradition of consulting their elders, especially their mothers-in-law, for advice about immunisation. Asian mothers were also more likely to consult their GPs for advice and were most trusting of such advice. Conversely, African-Caribbean and white mothers were more likely to question pro-MMR vaccination advice given by healthcare professionals (++).

Differences in knowledge and beliefs across different socio-economic groups: There is evidence from a recent interview study undertaken in October and November 2006 with mothers of children aged under 3 years (n=1016) that found that mothers from lower socioeconomic groups were significantly more likely to consider the MMR vaccine as being completely safe compared with mothers from higher socioeconomic groups. Furthermore, the study found that before 2002, a greater proportion of mothers from higher socioeconomic groups considered the MMR vaccine to pose a greater risk than diseases it protected against than did mothers from lower socioeconomic groups, although the gap had narrowed in subsequent years and by 2006 the proportion was 14% in both groups (++).

Evidence statement 61

There is evidence from 1 recent cluster RCT ([+] n=142) from the UK that found that children were significantly more likely to have been vaccinated with MMR if their parents had received the NHS Health Scotland information leaflet 'MMR – your questions answered' and were also invited to attend a parent-led intervention, a one-off, 2-hour parent meeting (consisting of information giving and a question and answer session), a support network and enablement, compared with parents that received only standard information.

Evidence statement 66

There is mixed evidence from 2 cohort studies (1 [+] and 1 [−]) and 2 ITS studies (both [−]) to suggest that neonatal hepatitis B immunisation strategies centred around early identification of hepatitis B positive mothers and initiation of the vaccination schedule in hospital can increase neonatal hepatitis B vaccination coverage. The first cohort study ([+] n=265) from the UK found that a hospital-based service in which an immunisation clinic was held in the hospital at the same time as the neonatal follow-up clinic led to higher levels of vaccination compared with a neighbouring area with no hospital intervention. The second cohort study ([−] n=832), in which HBsAg-positive mothers were contacted by phone, letter or home visit and counselled about the risks of transmission and importance of screening household contacts found that babies were significantly more likely to complete the hepatitis B vaccination series if the first dose was given in hospital. However, 1 poor-quality study (ITS [−] n=323) found that a comprehensive immunisation strategy where the first dose of hepatitis B vaccine was given in hospital and a GP was nominated to continue the vaccination schedule did not increase the proportion of eligible babies receiving the recommended 3 doses of the vaccine.

One study from Italy (ITS [−] n=NR) reported that over a 4-year period the proportion of eligible babies immunised against hepatitis B increased significantly following introduction of a policy to administer intramuscular hepatitis B immunoglobulin within 24 hours of birth and the first dose of hepatitis B vaccine within 7 days of birth.

Finally, 1 cohort study in Australia ([−] n=658) found that extension of an existing neonatal hepatitis B vaccination policy (covering neonates born to mothers who carried HBV) to include neonates born to mothers from high-risk countries (including Vietnam), irrespective of the mother's hepatitis B status significantly increased hepatitis B vaccine coverage rates, although the applicability of this study to the UK context may be limited.

Cost-effectiveness evidence

At current levels of coverage, immunisation against measles is estimated to save the NHS money (that is, the money saved as a result of not having to treat a case of measles more than pays for the immunisation). This is likely to be true even when taking into account the cost of home visits targeting children who have not been immunised. (It would only cost money if the refusal rates were very high.) The level of vaccine coverage required against measles is higher than for other universal vaccinations, such as mumps and rubella. It follows that immunisation against these infections would be cost saving in almost all circumstances, as it is given as a combined vaccine.

Currently, the targeted immunisation programme to reduce the incidence of infant hepatitis B is estimated to be cost saving, where it costs less than about £30 per injection. It would still be cost effective (but not cost saving) if the administration costs were up to several hundred pounds.

Fieldwork findings

Fieldwork aimed to test the relevance, usefulness and the feasibility of putting the recommendations into practice. PHIAC considered the findings when developing the final recommendations. For details, go to the fieldwork section in appendix B and Reducing differences in the uptake of immunisations (including targeted vaccines) in children and young people aged under 19 years.

Fieldwork participants who have a direct or indirect role in the delivery of immunisation programmes for children and young people were very positive about the recommendations. If implemented, they felt that they could help reduce differences in the uptake of immunisations.

Many participants felt that the recommendations would raise the profile of immunisation, particularly in primary care settings and, potentially, could be effective in areas where immunisation uptake is low. Information systems were thought to be integral to implementing the guidance successfully.

The recommendations were seen to reinforce government policy on immunisation, particularly in relation to:

  • completion of the appropriate immunisation schedule

  • timely vaccination

  • the lead role of health visitors, working with other frontline practitioners and with parents and families to improve the health and development of children under the age of 5 years

  • the role of children's centres and family nurse partnerships in promoting the health of children from the most disadvantaged families.

Although neither practitioners nor commissioners felt the recommendations offered a new approach, they agreed that the measures had not been implemented universally. They believed this could be achieved if there was:

  • a robust information system on immunisation, based on good quality data

  • collaborative working between professional groups and services that have a role in the immunisation of children and young people

  • greater access to good quality training for all those working to improve the uptake of immunisations, so that they can confidently communicate the benefits (and how safe the vaccines are) to parents and young people.

  • National Institute for Health and Care Excellence (NICE)