French modification of the infants DT-IPV primary vaccination seems possible and acceptable. The preliminary evaluation of the acceptability of this modification by primary care physicians has highlighted some main points that will facilitate the implementation of the new vaccination schedule:
~Scientific justification and health authorities’ support
~Simplicity and stability of vaccine recommendations
~Tools to help management of vaccinations
Physicians needed strong scientific evidences to justify the new vaccination recommendations. These justifications involve health authorities’ support. At the international level, the objectives are based on transparency and clarity on vaccination strategies [22
]. Reviews and reports of the Public Health High Council, in charge of vaccination strategies development in France, are available on their website [http://www.hcsp.fr
]. Their availability and reading can respect this principle. Even if scientific justification is a determining factor, it is not sufficient in itself, as shown by the example of hepatitis B vaccination. Despite Public Health High Council in 2004 showed no evidence of a link between hepatitis B vaccination and demyelinating diseases, the infants’ vaccination coverage at the age of 24 months reached only 41.9% in 2007 [7
In 1996, Pathman et al.
developed a four-step model necessary for the use of clinical guideline recommendations, particularly on paediatric vaccine usage [23
]. These four steps are awareness, agreement, adoption and adherence. Adherence was defined for a physician as 90% or greater of their patients received the vaccine as recommended. Mickan et al.
realised in 2011 a meta-analysis on the implementation of the recommendations in the United States on various medical fields [24
]. The authors showed progressive drop off with the proportion dropping off at each step at about 15%. Awareness of the recommendation is only one of these four steps to improve professional’s practice [23
]. When changing the DT-IPV infant primary vaccination, health authorities would have to work on each step to obtain high coverage.
The acceptance of this modification was balanced by physician’s needs to have a stable and simple vaccination schedule. Even if regular changes are required to follow the evolution of advanced vaccinology and epidemiological characteristics, their impact on the health professional’s practices should be taken into account. In Great Britain, two years after the cessation of routine BCG vaccination in 2005 and the implementation of targeted vaccination, two-thirds of parents and professionals interviewed were not aware of the new recommendation [25
]. About multiplying specific indications, a French study of 2009 on the determinants of BCG vaccination showed that the probability of an eligible child being properly vaccinated increased with the number of instructions known by the physician [26
From a practical point of view, demand for developing specific tools to help track the vaccination status of their patients was high among the physicians interviewed. A study in the US showed that the use of a computerised medical record increased opportunities for updating children’s vaccinations and vaccinated them earlier [27
]. However, the role of computerised vaccination alerts would be uncertain. Two studies in the US have shown a significant increase in vaccination coverage through the use of computerised vaccination alerts in obstetrics and gynaecology, and rheumatology departments [28
]. In primary care, this effect has not been demonstrated in a study [30
]. It would be interesting to evaluate the effectiveness of computer tools in the modification of the DT-IPV infant’s primary vaccination. With the development of innovative tool like mesvaccins.net, vaccination coverage may be better. This application can be used in France both by physicians and patients to know when and which vaccine are recommended. It is update regularly. For nowadays it is not available for medicine software. This could be something to work.
Asking upstream the local providers about vaccination schedule changes is innovative. Another strength of the study was to obtain heterogeneous focus groups, supplemented by four semi-structured interviews. This permitted to raise most important barriers to implementation of the new calendar. Otherwise the study has several limitations. First, the sampling method might have caused selection bias, including physicians belonging to a network (the French GPs Sentinelles network, or the French Association of Ambulatory Paediatrics (AFPA)). Second, physician has indirectly described parents’ demands, in addition of their own perception. Other study should be done to confirm these results. Third, the qualitative data might have been influenced by interpretation bias, despite efforts to reduce such bias. These included double data analysis and discussion of the data with the research team. Fourth, the results of the collection of observational data (non-verbal behaviour of the participants) have not been fully exploited.