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1.  Immunisation state of young children admitted to hospital and effectiveness of a ward based opportunistic immunisation policy. 
BMJ : British Medical Journal  1991;302(6767):31-33.
OBJECTIVE--To study the need for and effectiveness of a ward based opportunistic immunisation policy. DESIGN--A six month prospective study. SETTING--An acute medical paediatric ward of an inner city teaching hospital. SUBJECTS--296 children admitted to the ward who lived within Central Manchester Health Authority boundaries and were aged from 5 months to 6 years. MAIN OUTCOME MEASURES--Completion of immunisation schedule appropriate for age. RESULTS--56 children were three or more months behind with immunisations. The parent's history was not reliable for 18 children. Accessing health authority immunisation records was not difficult. The main reasons for falling behind were the mobility of the families (15 children), lack of motivation (14), and frequent minor illnesses (9). 40 children were immunised before discharge, but three could not be because of valid contraindications. Of the 16 children requiring more immunisations after discharge, only four obtained them at the correct time and five children not at all. CONCLUSION--An opportunistic immunisation policy is an important means of immunising a vulnerable group of children who would often default on routine immunisations, and such policies should operate whenever possible. Our ward based policy can achieve immunisation of three quarters of possible children without change or inconvenience to the daily ward work, but efficacy relies on adequate levels of enthusiastic staff. The system can be improved by having accurate and updated immunisation records available in the hospital, and by encouraging nursing staff to participate.
PMCID: PMC1668766  PMID: 1991185
2.  Missed opportunities to vaccinate children admitted to a paediatric tertiary hospital 
Archives of Disease in Childhood  2007;92(7):620-622.
Inequalities in vaccine uptake exist. Studies suggest paediatric inpatients have lower rates of immunisation uptake than the general population. Various UK policies advocate opportunistic immunisation.
To evaluate practice within a paediatric tertiary hospital in identifying and facilitating vaccination of inpatients who were not fully immunised.
Case notes for 225 inpatients were examined. Thirty staff of various professions and grades were interviewed. Policies, forms and documents used in the hospital were reviewed.
Immunisation status was recorded for 71% of children admitted, but for 69% of these immunisations were documented as “up‐to‐date” without any further information recorded. At least 20% of inpatients were incompletely immunised, but very little was done to facilitate vaccination. There was no training for staff either in giving advice or in administering vaccines and staff views differed regarding the hospital's role in immunisations. While there were guidelines for specific groups of patients, there were no general immunisation policies. Incorrect and out‐of‐date immunisation schedules were found on documents.
Opportunities to immunise children continue to be missed by all levels of health care service provision. Tertiary centres have a role to play in supporting primary care services to ensure that these vulnerable children are appropriately immunised. Measures are being taken to address the problems identified in this study and we strongly suspect that other hospitals in the UK ought to be confronting these issues as well.
PMCID: PMC2083800  PMID: 17213260
children; hospitals; inequalities; opportunistic immunisation; vaccinations
3.  Using routinely collected data to improve immunisation histories 
BMJ Quality Improvement Reports  2013;2(2):u203292.w1492.
Immunisation is one of the most effective health interventions in existence yet outbreaks of vaccine-preventable diseases continue to occur in developed countries. High rates of cover are needed to provide adequate herd immunity and there is evidence that a significant proportion of paediatric inpatients are not up to date even in areas with high levels of community cover. A proportion of these children will have parents who consciously declined immunisation, however the remaining children represent a vulnerable cohort whose under-immunisation is not routinely identified.
Two-hundred consecutive admissions to rural paediatric assessment unit had their routinely documented vaccination histories checked against their records on the regional Child Health Information System (CHIS). 30 children (15%) were not up to date on the CHIS, yet routine clerking only identified 5 of these children (17%). After introduction of a simple system whereby ward clerks and doctors were taught how to access and print full immunisation histories from the CHIS, a further 200 consecutive admissions were audited. A similar number were not up to date (29/200) but the proportion of children with missing immunisations correctly identified in the clerking documentation increased to 52% (15 children). This is a 35% improvement (95% CI; 12–58%).
Access to routinely collected data can significantly improve identification of under-immunised children and contribute towards higher levels of individual and herd-immunity.
PMCID: PMC4663820  PMID: 26734213
4.  Reasons for non-uptake of measles, mumps, and rubella catch up immunisation in a measles epidemic and side effects of the vaccine. 
BMJ : British Medical Journal  1995;310(6995):1629-1632.
OBJECTIVE--To investigate the reasons for poor uptake of immunisation (non-immunisation) and the possible side effects of measles, mumps, and rubella vaccine in a catch up immunisation campaign during a community outbreak of measles. DESIGN--Descriptive study of reasons for non-immunisation and retrospective cohort study of side effects of the vaccine. SETTING--Secondary schools in South Glamorgan. SUBJECTS--Random cluster sample of the parents of 500 children targeted but not immunised and a randomised sample of 2866 of the children targeted. MAIN OUTCOME MEASURES--Reasons for non-immunisation; symptoms among immunised and non-immunised children. RESULTS--Immunisation coverage of the campaign was only 43.4% (7633/17,595). The practical problems experienced included non-return of consent forms (6698/17,595), refusal of immunisation (2061/10,897 forms returned), and absence from school on day of immunisation (1203/8836 children with consent for immunisation). The most common reasons cited for non-immunisation were previous measles infection (145/232), previous immunisation against measles (78/232), and concern about side effects (55/232). Symptoms were equally common among immunised and non-immunised subjects. However, significantly more immunised boys than non-immunised boys reported fever (relative risk 2.31 (95% confidence interval 1.36 to 3.93)), rash (2.00 (1.10 to 3.64), joint symptoms (1.58; 1.05 to 2.38), and headache (1.31 (1.04 to 1.65)). CONCLUSIONS--Many of the objections raised by parents could be overcome by emphasising that primary immunisation does not necessarily confer immunity and that diagnosis of measles is unreliable. Measles, mumps, and rubella vaccine is safe in children aged 11-15.
PMCID: PMC2550008  PMID: 7795447
5.  Invasive Haemophilus influenzae type b disease in the Oxford region (1985-91). 
Archives of Disease in Childhood  1993;69(2):225-228.
For a seven year period (1985-91) clinical and epidemiological data were prospectively collected on children aged < 10 years with microbiologically confirmed invasive Haemophilus influenzae type b infection in the Oxford region to study the epidemiology of the disease and determine the potential impact of early primary immunisation in infants. Computer records of primary immunisations given to these cases were retrospectively analysed and, where necessary, hospital and general practitioner records were searched to determine the immunisation history. Over the seven year period, 416 cases of invasive H influenzae type b disease were reported. Widescale immunisation against H influenzae type b began in 1991 as part of a regional trial. The estimated annual incidence for invasive disease between 1985 and 1990 was 35.5 cases per 100,000 children aged less than 5 years; for H influenzae type b meningitis it was 25.1 per 100,000 children aged less than 5 years. The cumulative risks for invasive disease and meningitis by the fifth birthday were one in 560 and one in 800 respectively. The majority of disease (71%) occurred in children less than 2 years of age with the peak monthly incidences at 6 and 7 months of age. The overall mortality was 4.3% and 50% of these deaths occurred suddenly. Most (91%) of the children had received at least one primary immunisation against diphtheria, tetanus, and pertussis before H influenzae type b infection and there was only one case of parental refusal of immunisation. None had received H influenzae type b immunisation. Given a vaccine uptake of 90% by 5 months of age it is estimated that at least 82% of the H influenzae type b infections could have been prevented. Extrapolated nationally, 1150 cases of infection and 50 deaths could be prevented each year by routine primary immunisation.
PMCID: PMC1029463  PMID: 8215526
6.  A comparison of populations vaccinated in a public service and in a private hospital setting in the same area 
BMC Public Health  2008;8:278.
Improving immunisation rates in risk groups is one of the main objectives in vaccination strategies. However, achieving high vaccination rates in children with chronic conditions is difficult. Different types of vaccine providers may differently attract high risk children.
To describe the characteristics of two populations of children who attended a private and a public immunisation provider in the same area. Secondarily, to determine if prevalence of patients with underlying diseases by type of provider differs and to study if the choice of different providers influences timeliness in immunisation.
We performed a cross-sectional study on parents of children 2 – 36 months of age who attended a private hospital immunisation service or a public immunisation office serving the same metropolitan area of Rome, Italy. Data on personal characteristics and immunisation history were collected through a face to face interview with parents of vaccinees, and compared by type of provider. Prevalence of underlying conditions was compared in the two populations. Timeliness in immunisation and its determinants were analysed through a logistic regression model.
A total of 202 parents of children 2–36 months of age were interviewed; 104 were in the public office, and 98 in the hospital practice. Children immunised in the hospital were more frequently firstborn female children, breast fed for a longer period, with a lower birthweight, and more frequently with a previous hospitalisation. The prevalence of high risk children immunised in the hospital was 9.2 vs 0% in the public service (P = 0.001). Immunisation delay for due vaccines was higher in the hospital practice than in the public service (DTP, polio, HBV, and Hib: 39.8% vs 22.1%; P = 0.005). Anyway multivariate analyses did not reveal differences in timeliness between the public and private hospital settings.
Children with underlying diseases or a low birthweight were more frequently immunised in the hospital. This finding suggests that offering immunisations in a hospital setting may facilitate vaccination uptake in high risk groups. An integration between public and hospital practices and an effort to improve communication on vaccines to parents, may significantly increase immunisation rates in high risk groups and in the general population, and prevent immunisation delays.
PMCID: PMC2531109  PMID: 18684316
7.  Evaluating the implementation of the 13-valent pneumococcal vaccine supplementary dose program in Australian primary health care settings 
The availability of new pneumococcal conjugate vaccines covering a broader range of serotypes, has seen many countries introduce these into their national immunisation program. When transitioning from 7-valent to 13-valent pneumococcal conjugate vaccines, Australia is one of a small number of countries that included a supplementary dose of the 13-valent pneumococcal conjugate vaccine to offer protection against additional serotypes to an expanded age group of children. An evaluation of the implementation and uptake of the 13-valent pneumococcal conjugate vaccine supplementary dose was undertaken in two local health districts (LHDs) in New South Wales, Australia.
A self-administered postal survey of immunisation providers in the Northern New South Wales and Mid North Coast LHDs. Trends in vaccine ordering were examined. Coverage was assessed using data from the Australian Childhood Immunisation Register (ACIR).
Of the 177 surveys sent, 125 were returned (70%). Almost all providers (96%) were aware of the 13vPCV supplementary dose program though took an opportunistic approach to program promotion and parental reminders. Supplementary doses of 13vPCV were ordered for 37% of the eligible cohort, mostly in the program’s first six months. Coverage as recorded on the ACIR was 27%, though was lower in older children and those not due for scheduled childhood vaccines. Of the children who received the 13vPCV supplementary dose, 3% received it at the same time as vaccines due at 12-months of age, and 44% at the time of those due at 18-months of age.
Despite the high awareness of the program, reported coverage was lower than that for other PCV supplementary dose programs in Australia and internationally. This may be influenced by providers’ largely opportunistic approach to implementation, under-reporting to the ACIR or vaccine uptake. Lessons learned from this evaluation are relevant for future time-limited childhood vaccination programs. Prior to commencement, providers should be informed about the importance of catch-up/supplementary vaccination for their patients and their active role in promoting this. They should also receive program information before parents. An understanding of parental reasons for non-receipt of time-limited childhood vaccines and evaluation of the effect of aligning supplementary (or catch up) vaccination programs with the NIP schedule would be useful to inform future programs.
PMCID: PMC4404082  PMID: 25889782
Immunization; Pneumococcal; Evaluation; Vaccine
8.  Improving immunisation timeliness in Aboriginal children through personalised calendars 
BMC Public Health  2013;13:598.
Delayed immunisation and vaccine preventable communicable disease remains a significant health issue in Aboriginal children. Strategies to increase immunisation coverage and timeliness can be resource intensive. In a low cost initiative at the Aboriginal Medical Service Western Sydney (AMSWS) in 2008–2009, a trial of personalised calendars to prompt timely childhood immunisation was undertaken.
Calendars were generated during attendances for early childhood immunisations. They were designed for display in the home and included the due date of the next immunisation, a photo of the child and Aboriginal artwork. In a retrospective cohort design, Australian Childhood Immunisation Register data from AMSWS and non-AMSWS providers were used to determine the delay in immunisation and percentage of immunisations on time in those who received a calendar compared to those who did not. Interviews were undertaken with carers and staff.
Data on 2142 immunisation doses given to 505 children were analysed, utilising pre-intervention (2005–2007) and intervention (2008–2009) periods and a 2 year post-intervention observation period. 113 calendars were distributed (30% of eligible immunisation attendances). Improvements in timeliness were seen at each schedule point for those children who received a calendar. The average delay in those who received a calendar at their previous visit was 0.6 months (95% CI -0.8 to 2.6) after the due date, compared to 3.3 months (95% CI −0.6 to 7.5) in those who did not. 80% of doses were on time in the group who received a calendar at the preceding immunisation, 66% were on time for those who received a calendar at an earlier point and 57% of doses were on time for those who did not receive a calendar (P<0.0001, Cochran-Armitage trend test). Interview data further supported the value and effectiveness of the calendars as both a prompt to timely immunisations and a community health education project without undue resource implications.
Personalised calendars can increase the timeliness of immunisations in Aboriginal children. This simple, low cost tool appears practicable and effective in an Aboriginal community setting in improving early childhood vaccination timeliness and has high potential for local adaptation to suit the needs of diverse communities.
PMCID: PMC3704958  PMID: 23786829
Immunisation; Indigenous; Aboriginal; Timeliness of immunisation; Delayed immunisation
9.  Duration of effectiveness of pertussis vaccine: evidence from a 10 year community study 
A 10 year study of whooping cough in a discrete general practice community was performed to assess longitudinally the efficacy of pertussis vaccine from one to seven years after immunisation. Of the 436 cases of whooping cough over 10 years, 326 occurred in children aged 1-7 years. The rate of immunisation was known for each cohort of children born during each year, and the attack rate of whooping cough was thus calculated for those immunised and unimmunised. The attack rates were highest in those cohorts exposed to the epidemics of 1977-9, 1981-3, and 1985-7. The efficacy of the vaccine was calculated as a percentage as (attack rate in unimmunised group—attack rate in immunised group) × 100/attack rate in unimmunised group. It fell from 100% in the first year to 46% in the seventh, being 84% in the fourth and only 52% in the fifth.
Thus the pertussis vaccine or its schedule of use does not seem to provide sufficient herd immunity to prevent outbreaks of whooping cough. Matters might be improved if vaccination against pertussis were included in the preschool immunisation programme.
PMCID: PMC2545243  PMID: 3126927
10.  Pattern and determinants of BCG immunisation delays in a sub-Saharan African community 
Childhood immunisation is recognised worldwide as an essential component of health systems and an indispensable indicator of quality of care for vaccine-preventable diseases. While performance of immunisation programmes is more commonly measured by coverage, ensuring that every child is immunised at the earliest/appropriate age is an important public health goal. This study therefore set out to determine the pattern and predictors of Bacille de Calmette-Guérin (BCG) immunisation delays in the first three months of life in a Sub-Saharan African community where BCG is scheduled at birth in order to facilitate necessary changes in current policy and practices for improved services.
A cross-sectional study in which immunisation delays among infants aged 0-3 months attending community-based BCG clinics in Lagos, Nigeria over a 2-year period from July 2005 to June 2007 were assessed by survival analysis and associated factors determined by multivariable logistic regression. Population attributable risk (PAR) was computed for the predictors of delays.
BCG was delayed beyond three months in 31.6% of all eligible infants. Of 5171 infants enrolled, 3380 (65.4%) were immunised within two weeks and a further 1265 (24.5%) by six weeks. A significantly higher proportion of infants born in hospitals were vaccinated in the first six weeks compared to those born outside hospitals. Undernourishment was predictive of delays beyond 2 and 6 weeks while treated hyperbilirubinaemia was associated with decreased odds for any delays. Lack of antenatal care and multiple gestations were also predictive of delays beyond 6 weeks. Undernourishment was associated with the highest PAR for delays beyond 2 weeks (18.7%) and 6 weeks (20.8%).
BCG immunisation is associated with significant delays in this setting and infants at increased risk of delays can be identified and supported early possibly through improved maternal uptake of antenatal care. Combining BCG with subsequent immunisation(s) at 6 weeks for infants who missed the BCG may be considered.
PMCID: PMC2821326  PMID: 20157426
11.  Integration of hepatitis B vaccination into rural African primary health care programmes. 
BMJ : British Medical Journal  1991;302(6772):313-316.
OBJECTIVE--To determine the efficacy of hepatitis B vaccine when added to the routine expanded programme on immunisation under field conditions in rural Africa. DESIGN--Infants were immunised according to two schedules--an early schedule at birth, 3 months, and 6 months and a later schedule to correspond with routine vaccination in the expanded programme on immunisation at 3 months, 4 1/2 months, and 6 months. SETTING--Venda, northern Transvaal, South Africa, a self governing region of 7460 square kilometers varying from rural villages to small towns. SUBJECTS--The 1989 birth cohort of Venda. MAIN OUTCOME MEASURES--Coverage for hepatitis B vaccine at first, second, and third doses; serological assessment of vaccine efficacy by prevalence of antibodies to hepatitis B surface antigen in infants who had completed the three dose course of immunisation; antibodies to hepatitis B core antigen to determine if natural infection occurred. RESULTS--Vaccine coverage for hepatitis B dropped sharply from 99% to 53% to 39% for the first, second, and third dose respectively. In contrast, vaccine coverage was maintained at 97-99% for the three doses of poliomyelitis vaccine. Serological evaluation of vaccine efficacy showed that only 3.5% of recipients of all three doses failed to develop antibodies to hepatitis B surface antigen. Only 6.6% of vaccine recipients were vaccinated according to either the early or later schedules whereas 93.4% received their doses of vaccine at intervals beyond the limits of either of the planned schedules. There was, however, no significant difference in seroconversion to the surface antigen between the "unscheduled" or scheduled groups of those who were vaccinated according to the early or late schedules. The pattern of prevalence of antibodies to hepatitis B core antigen, which showed a sharp fall in children aged over 7 months, suggested that the antibodies were acquired passively rather than by active infection. CONCLUSIONS--Supplementation of the present expanded programme on immunisation with hepatitis B vaccine in rural Africa is fraught with difficulties. However, the vaccine was effective within a fairly wide spacing of dosage. Adding hepatitis B vaccine to diphtheria, tetanus, and pertussis as a tetravalent vaccine is proposed as a means of effectively integrating it into the expanded programme on immunisation in Third World settings.
PMCID: PMC1668978  PMID: 1825799
12.  A qualitative study of lay beliefs about influenza immunisation in older people 
Although influenza immunisation is now recommended for all people aged 65 years and over in the UK, many people in that age group still remain unimmunised.
To investigate lay beliefs about influenza and influenza vaccine in older people to identify appropriate ways of promoting vaccine uptake.
Qualitative study using narrative interviews.
Urban and rural communities in South Wales.
Participants were 54 people aged 65 years and over who were interviewed in their own home. Of these, 11 were regularly immunised, 18 had consistently refused immunisation (refusers), 15 had defaulted (defaulters), five had never been offered immunisation, and five had recently been immunised for the first time.
There was an overwhelming consensus among immunised and unimmunised individuals that they were not at risk from influenza. Even if they did catch influenza, they would not suffer from any serious consequences. Refusers and defaulters were more likely to believe that the influenza vaccine had serious side-effects, while the regularly immunised group were more likely to perceive the vaccine as effective. Multiple prompts from family, friends, or primary care staff were important triggers for receiving immunisation.
Many older people did not feel vulnerable to influenza, regardless of their age, and this influenced their views on the need for immunisation. Both refusers and defaulters overstated adverse effects from influenza vaccine so this is a potential target for an intervention. Individual prompts, particularly from GPs, seemed to be the most significant motivators to attend for immunisation.
PMCID: PMC2047008  PMID: 17504584
aged; influenza vaccine; patient acceptance of health care; qualitative research
13.  Attitudinal and Demographic Predictors of Measles-Mumps-Rubella Vaccine (MMR) Uptake during the UK Catch-Up Campaign 2008–09: Cross-Sectional Survey 
PLoS ONE  2011;6(5):e19381.
Background and Objective
Continued suboptimal measles-mumps-rubella (MMR) vaccine uptake has re-established measles epidemic risk, prompting a UK catch-up campaign in 2008–09 for children who missed MMR doses at scheduled age. Predictors of vaccine uptake during catch-ups are poorly understood, however evidence from routine schedule uptake suggests demographics and attitudes may be central. This work explored this hypothesis using a robust evidence-based measure.
Cross-sectional self-administered questionnaire with objective behavioural outcome.
Setting and Participants
365 UK parents, whose children were aged 5–18 years and had received <2 MMR doses before the 2008–09 UK catch-up started.
Main Outcome Measures
Parents' attitudes and demographics, parent-reported receipt of invitation to receive catch-up MMR dose(s), and catch-up MMR uptake according to child's medical record (receipt of MMR doses during year 1 of the catch-up).
Perceived social desirability/benefit of MMR uptake (OR = 1.76, 95% CI = 1.09–2.87) and younger child age (OR = 0.78, 95% CI = 0.68–0.89) were the only independent predictors of catch-up MMR uptake in the sample overall. Uptake predictors differed by whether the child had received 0 MMR doses or 1 MMR dose before the catch-up. Receipt of catch-up invitation predicted uptake only in the 0 dose group (OR = 3.45, 95% CI = 1.18–10.05), whilst perceived social desirability/benefit of MMR uptake predicted uptake only in the 1 dose group (OR = 9.61, 95% CI = 2.57–35.97). Attitudes and demographics explained only 28% of MMR uptake in the 0 dose group compared with 61% in the 1 dose group.
Catch-up MMR invitations may effectively move children from 0 to 1 MMR doses (unimmunised to partially immunised), whilst attitudinal interventions highlighting social benefits of MMR may effectively move children from 1 to 2 MMR doses (partially to fully immunised). Older children may be best targeted through school-based programmes. A formal evaluation element should be incorporated into future catch-up campaigns to inform their continuing improvement.
PMCID: PMC3094347  PMID: 21602931
14.  Primary immunisations in Liverpool. II: Is there a gap between consent and completion? 
Archives of Disease in Childhood  1993;69(1):115-119.
The association between completion of primary dipht eria, tetanus and pertussis, measles, mumps, and rubella and polio immunisation courses in Liverpool and five sociodemographic factors, namely the child's sex, position in the family, family type, migration into Liverpool since birth, and local deprivation was examined. Only 68% of children were fully immunised by their second birthday. The immunisation rate for pertussis was 74%, compared with 85-89% for the other antigens. Children who had older siblings, were recorded as living with one parent, had moved into Liverpool or who lived in areas of high deprivation were less likely to complete the full set of antigens and individual courses. Boys were significantly less likely than girls to be fully immunised against pertussis. Differences in the completion of pertussis immunisation associated with the child's sex and with local deprivation were a direct reflection of differences in rates of parental consent. Parental consent did not wholly account for significantly lower rates among children with older siblings, those living with a lone parent, and those who had moved into Liverpool, however. This may reflect the practical difficulties of attending immunisation clinics. To achieve immunisation targets, a more flexible and targeted approach is required of health professionals. This may include the careful targeting of efforts to increase consent and the improvement of access to immunisations by providing domiciliary services or by opportunistic immunisation of infants when they are in contact with primary and community health care services.
PMCID: PMC1029423  PMID: 8024292
15.  Comprehensive control (or elimination) of hepatitis B virus transmission in the United States. 
Gut  1996;38(Suppl 2):S24-S30.
In the United States, the reported rate of hepatitis B has declined by over 50% since 1987, probably as a result of vaccination programmes, behavioural changes, refinements in blood screening procedures, and the availability of virus inactivated blood components. The majority of new hepatitis B infections occur in 20-39 year olds, and perinatal transmission is uncommon except in certain at risk groups. Initial efforts to control hepatitis B in the US were targeted at high risk groups, including health care personnel. Then, in 1988, the Centers for Disease Control and Prevention (CDC) recommended screening of all pregnant females for hepatitis B surface antigen and full immunisation of infants born to those testing positive. A recommendation for universal immunisation of infants was endorsed in 1991. Compliance has been slow but progressive. The CDC also has recommended 'catch up' immunisation of adolescents and high risk children and adults. Demonstration projects suggest that these can be successful, given the provision of free or low cost vaccine and appropriate support. Hepatitis B vaccination has been shown to be cost effective and should be integrated into the routine childhood immunisation schedule. Responses to hepatitis B vaccine have largely been shown to be durable, although at least one booster dose after five to 10 years seems prudent, especially if a low dose, yeast derived vaccine has been used.
PMCID: PMC1398039  PMID: 8786049
16.  Timeliness of childhood vaccine uptake among children attending a tertiary health service facility-based immunisation clinic in Ghana 
BMC Public Health  2014;14:90.
Childhood immunisation is a cost-effective activity in health. Immunisation of children has contributed to reducing child morbidity and mortality. In the last two decades, global deaths from vaccine-preventable illnesses have decreased significantly as a result of immunisation. Similar trends have been observed in Ghana following the introduction of the Expanded Programme on Immunisation. The administration of vaccines is based on the period of highest susceptibility among others. Ghana has long used the proportion of children receiving vaccines and the trends in vaccine preventable illness incidence as performance indicators for immunisation. The addition of timeliness of vaccine uptake as an additional performance indicator has been recommended. This study evaluated the timeliness of vaccine uptake among children immunised at the Komfo Anokye Teaching Hospital, Kumasi, Ghana.
The study was conducted at the Maternal and Child Health clinic of the hospital between February and March 2012. A representative sample of 259 respondents was selected by simple random sampling. Data collection was by a structured questionnaire and included the examination of Child Health records booklet. Data was entered into a Microsoft Office Access database and analysed using Epi Info Version 3.5.1 2008.
The majority of mothers attended antenatal clinics during pregnancy. An overwhelming majority of babies (98.8%) were delivered in a hospital. About 85% of babies were less than 12 months of age. Mean time taken to reach the clinic was 30 minutes. Vaccine uptake was generally timely for initial vaccines. The proportion of children receiving the vaccines later increased with latter vaccines. Overall, 87.3% of babies received vaccines on time with only 5.3% receiving vaccines beyond 28 days of the scheduled date. Children receiving immunisations services in the same facility as they were born were more likely to receive the BCG vaccine on time.
Vaccine uptake is mostly timely among respondents in the study. The BCG vaccine in particular was received on time among children born in the same facility as the immunisation clinic. There is the need to further examine the timeliness of vaccine uptake among children delivered outside health facilities in Ghana.
PMCID: PMC3912921  PMID: 24476339
17.  Compliance with diphtheria, tetanus, and pertussis immunisation in Bangladesh: factors identifying high risk groups. 
BMJ : British Medical Journal  1992;304(6827):606-609.
OBJECTIVE--To evaluate factors associated with non-compliance with having second vaccination against diphtheria, tetanus, and pertussis in a treatment centre in Dhaka to determine which children were most at risk of not completing immunisation. DESIGN--Cohort study of infants given first dose of the vaccine and followed up six weeks later to ascertain compliance with having second dose. Factors associated with non-compliance were evaluated. SETTING--Dhaka treatment centre of the International Centre for Diarrhoeal Disease Research, Bangladesh. SUBJECTS--136 unimmunised children aged 6 weeks to 23 months who lived within reach of the treatment centre. At time of the six week follow up 16 of the children could not be traced and seven had died. INTERVENTIONS--All children received their first dose of the vaccine. In each case health education workers had informed the mother about the value of immunisation, and she was given clear instructions to bring the child back after four weeks for the second dose. MAIN OUTCOME MEASURE--Rate of non-compliance with advice to return child for second vaccination. RESULTS--46 of 113 children (41%) received the second dose of the vaccine. Factors most closely associated with mothers' failure to comply with the second dose were lack of education and low income. Children whose mothers knew most about immunisation at first interview were more likely to have their second dose. CONCLUSIONS--Preventive health care services such as immunisation are appropriately offered in treatment centres, but compliance among children varies with socioeconomic status and mother's education. Further research should be aimed at ways to make health education more effective among uneducated parents.
PMCID: PMC1881328  PMID: 1559089
18.  Teenagers’ understandings of and attitudes towards vaccines and vaccine-preventable diseases: A qualitative study☆ 
Vaccine  2013;31(22):2543-2550.
•Explored understandings of diseases and knowledge and experiences of vaccination.•Teenagers had limited knowledge and little direct experience of the diseases.•Participants attitudes towards receiving vaccines’ varied.•The success of mass immunisation programmes is associated with disease perceptions.•Need to engage with teenagers to address misconceptions about vaccines and diseases.
To examine immunisation information needs of teenagers we explored understandings of vaccination and vaccine-preventable diseases, attitudes towards immunisation and experiences of immunisation. Diseases discussed included nine for which vaccines are currently offered in the UK (human papillomavirus, meningitis, tetanus, diphtheria, polio, whooping cough, measles, mumps and rubella), and two not currently included in the routine UK schedule (hepatitis B and chickenpox).
Twelve focus groups conducted between November 2010 and March 2011 with 59 teenagers (29 girls and 30 boys) living in various parts of Scotland.
Teenagers exhibited limited knowledge and experience of the diseases, excluding chickenpox. Measles, mumps and rubella were perceived as severe forms of chickenpox-like illness, and rubella was not associated with foetal damage. Boys commonly believed that human papillomavirus only affects girls, and both genders exhibited confusion about its relationship with cancer. Participants considered two key factors when assessing the threat of diseases: their prevalence in the UK, and their potential to cause fatal or long-term harm. Meningitis was seen as a threat, but primarily to babies. Participants explained their limited knowledge as a result of mass immunisation making once-common diseases rare in the UK, and acknowledged immunisation's role in reducing disease prevalence.
While it is welcome that fewer teenagers have experienced vaccine-preventable diseases, this presents public health advocates with the challenge of communicating benefits of immunisation when advantages are less visible. The findings are timely in view of the Joint Committee on Vaccination and Immunisation's recommendation that a booster of meningitis C vaccine should be offered to teenagers; that teenagers did not perceive meningitis C as a significant threat should be a key concern of promotional information. While teenagers’ experiences of immunisation in school were not always positive, they seemed enthusiastic at the prospect of introducing more vaccines for their age group.
PMCID: PMC3679446  PMID: 23602536
Teenagers; Adolescents; Disease; Risk; Vaccines; Immunisation; Understanding
19.  Is childhood immunisation associated with atopic disease from age 7 to 32 years? 
Thorax  2006;62(3):270-275.
There is ongoing conjecture over whether childhood immunisation leads to an increased risk of developing atopic diseases.
To examine associations between childhood immunisation and the risk of atopic disease.
Immunisation histories of 8443 Tasmanian children born in 1961 obtained from school medical records were linked to the Tasmanian Asthma Study. Associations between immunisation status and atopic diseases were examined while adjusting for possible confounders using multiple logistic regression.
Diphtheria immunisation was weakly associated with an increased risk of asthma by age 7 years (odds ratio (OR) 1.3, 95% confidence interval (CI) 1.1 to 1.7), but there was no evidence of any association for four other vaccinations studied. An increased risk of eczema by age 7 years was associated with immunisation against diphtheria (OR 1.5, 95% CI 1.1 to 2.1), tetanus (OR 1.5, 95% CI, 1.1 to 2.0), pertussis (OR 1.5, 95% CI 1.1 to 1.9) and polio (OR 1.4, 95% CI 1.0 to 1.9) but not small pox. Similar but slightly weaker patterns of association were observed between the risk of food allergies and immunisation against diphtheria (OR 1.5, 95% CI 1.0 to 2.1), pertussis (OR 1.4, 95% CI 1.1 to 1.9), polio (OR 1.4, 95% CI 1.00 to 2.1) and tetanus (OR 1.30 95% CI 0.99 to 1.70), but not with small pox. There was no evidence of associations between immunisation history and hay fever, or incidence of later‐onset atopic outcomes.
The few effects seen in this study are small and age‐dependent, and nearly all our findings support numerous previous studies of no effect of vaccines on asthma. Based on these findings, the fear of their child developing atopic disease should not deter parents from immunising their children, especially when weighed against the benefits.
PMCID: PMC2117158  PMID: 17090571
20.  Symptoms after accelerated immunisation. 
BMJ : British Medical Journal  1992;304(6841):1534-1536.
OBJECTIVE--To document the incidence of symptoms after accelerated immunisation with diphtheria-tetanus-pertussis vaccine. DESIGN--Controlled study of children immunised with adsorbed diphtheria-tetanus-pertussis vaccine at accelerated and standard schedules. SETTING--Colchester and north Hertfordshire. SUBJECTS--107 children scheduled to receive immunisation at 2, 3, and 4 months of age and 115 children scheduled to receive immunisation at 3, 4 1/2 to 5, and 8 1/2 to 11 months of age. MAIN OUTCOME MEASURES--Parentally recorded symptoms, axillary temperatures, and size of local redness and swelling at the injection site during the seven days after immunisation. RESULTS--In general symptoms occurred less frequently with the accelerated schedule. Proportions of parents reporting axillary temperatures greater than 37.2 degrees C or local redness or swelling greater than 2.5 cm after the third dose of vaccine were significantly reduced in the accelerated schedule group. CONCLUSION--Immunisation at 2, 3, and 4 months of age is likely to cause fewer reactions than immunisation at 3, 4 1/2 to 5, and 8 1/2 to 11 months of age.
PMCID: PMC1882405  PMID: 1628051
21.  Persistence of antibody after accelerated immunisation with diphtheria/tetanus/pertussis vaccine. 
BMJ : British Medical Journal  1991;302(6791):1489-1491.
OBJECTIVE--To determine the persistence of antibody to diphtheria, tetanus, and pertussis in children receiving an accelerated schedule of primary immunisation. DESIGN--Controlled study of antibody testing of blood samples from children immunised according to various schedules: three doses of triple vaccine completed at 8-13 calendar months, 6-7 calendar months, before 6 calendar months, or three doses followed by diphtheria/tetanus before age 2. SETTING--Plymouth Health Authority. SUBJECTS--129 children aged 4 years who had received three doses of diphtheria/tetanus/pertussis vaccine with or without a diphtheria/tetanus booster. MAIN OUTCOME MEASURES--Diphtheria and tetanus antitoxin concentrations and antibody titres to pertussis toxin, filamentous haemagglutinin, and agglutinogens 2 and 3. RESULTS--All children had protective concentrations of antitoxin to diphtheria and tetanus (greater than or equal to 0.01 IU/ml). There was no evidence of a significant difference in diphtheria or tetanus antitoxin concentrations and pertussis antibody titres in children immunised with an accelerated course (third dose of triple vaccine before 6 months) compared with those who received a longer course (third dose at 8-13 months) with no booster (geometric mean antitoxin concentration 0.411 (95% confidence interval 0.273 to 0.618) v 0.426 (0.294 to 0.616) for diphtheria and 0.358 (0.231 to 0.556) v 0.299 (0.197 to 0.453) for tetanus; geometric mean antibody titres 903 (500 to 1631) v 1386 (848 to 2266) for pertussis filamentous haemagglutinin, 179 (130 to 248) v 232 (167 to 322) for pertussis toxin, and 2002 (1276 to 3142) v 3591 (2220 to 5809) for agglutinogens 2 and 3). CONCLUSION--Immunisation with three doses of triple vaccine at monthly intervals completed before 6 months of age probably provides adequate protection against diphtheria, tetanus, and whooping cough which will persist until the age of the preschool booster.
PMCID: PMC1670210  PMID: 1855015
22.  Protection against pertussis by immunisation. 
British Medical Journal  1980;281(6252):1390-1391.
Review of all 126 children admitted to the communicable diseases unit with whooping cough during the epidemic in 1978 showed that two had received two doses of triple vaccine and only one had had full primary immunisation against the disease. None of these three children suffered complications of the disease. Of the 123 children who had not been immunised against pertussis, however, 66 had had one or more complications. In Birmingham the dramatic decline in immunisation against pertussis has been accompanied by a fall in acceptance rates for diphtheria and tetanus immunization. Nevertheless, of the 62 children aged over 1 year in this series, 41 had been so immunised. These findings suggest that the apparently positive decision by parents to omit pertussis immunisation was misplaced, since immunisation does protect against the more serious complications of the disease. Furthermore, there is no firm evidence that pertussis immunisation of children without specific contraindications is associated with serious adverse reactions.
PMCID: PMC1715025  PMID: 7437805
23.  Primary care strategies to improve childhood immunisation uptake in developed countries: systematic review 
JRSM Short Reports  2011;2(10):81.
To conduct a systematic review of strategies to optimize immunisation uptake within preschool children in developed countries.
Systematic review.
Developed countries
Preschool children who were due, or overdue, one or more of their routine primary immunisations.
Main outcome measures
Increase in the proportion of the target population up to date with standard recommended universal vaccinations.
Forty-six studies were included for analysis, published between 1980 and 2009. Twenty-six studies were randomized controlled trials, 11 were before and after trials, and nine were controlled intervention trials. Parental reminders showed a statistically significant increase in immunisation rates in 34% of included intervention arms. These effects were reported with both generic and specific reminders and with all methods of reminders and recall. Strategies aimed at immunisation providers were also shown to improve immunisation rates with a median change in immunisation rates of 7% when reminders were used, 8% when educational programmes were used and 19% when feedback programmes were used.
General practitioners are uniquely positioned to influence parental decisions on childhood immunisation. A variety of strategies studied in primary care settings have been shown to improve immunisation rates, including parental and healthcare provider reminders.
PMCID: PMC3205560  PMID: 22046500
24.  Immunisation state and its documentation in hospital patients. 
Archives of Disease in Childhood  1990;65(7):763-767.
Two prospective surveys of the immunisation state and its documentation were conducted among children under 2 years old attending a children's hospital. A survey of 111 children attending the casualty or outpatient departments showed that, according to reliable records, 106 (95%) were fully immunised for age with oral polio vaccine, 93 (84%) with triple antigen, and 26 of 33 children greater than or equal to 16 months of age (79%) with measles-mumps vaccine. A survey of 204 inpatients showed that, according to verified records, significantly fewer inpatients than outpatients were fully immunised for age with oral polio vaccine (176, 86%) and with triple antigen (144, 71%). The proportion of inpatients vaccinated with measles-mumps vaccine was 81% (48 of 59). The inpatient figures are all lower than the 95% goal of current child immunisation programmes. Although parents of 98% of inpatients had a personal health record for the child, it was available at the time of admission for less than half the children. Lack of use of the personal health record by admitting medical staff was reflected in incorrect or absent documentation of the immunisation state in 17 of 49 (35%) of the records of children verified to have inadequate immunisations. Parents and health care staff need to be educated in the optimal use of the personal health record. Hospital paediatric staff need to be encouraged to verify the immunisation state of all young children, on admission, and arrange to rectify any deficiency found.
PMCID: PMC1792440  PMID: 2386382
25.  Comparison of immunisation rates in general practice and child health clinics. 
BMJ : British Medical Journal  1991;303(6809):1035-1038.
OBJECTIVE--To compare immunisation uptake rates in general practice surgeries and community child health clinics. DESIGN--Cohort study using data from a computerised child health system. SETTING--Four health districts of North East Thames Regional Health Authority. SUBJECTS--3616 children born January to March 1990 and resident in the four districts at the end of January 1991. MAIN OUTCOME MEASURES--Immunisation uptake rates at 10-12 months of age, age at immunisation, scheduling performance at the two locations, and odds ratios of outstanding immunisations. RESULTS--80% of children registered at general practices had completed their third dose of pertussis immunisation compared with 68% of those at health clinics. Median ages at the third dose were 24 weeks and 29 weeks at the two locations respectively. Scheduling was more effective at general practice surgeries. Unscheduled immunisations were more likely to be given after the recommended age. Overall, children resident in rural and suburban areas had greater uptakes than those in inner cities. Odds ratios for not being fully immunised among children registered at health clinics were 1.4 times those among children immunised in general practice and 3.0 times greater among children resident in inner cities than among those in rural and suburban districts. Children who moved into a district, however, were no less likely to be fully immunised than children who were born there. CONCLUSIONS--The immunisation uptake rate was better in general practices than in child health clinics in both inner city and rural and suburban areas. Uptake may be increased with additional support to enable general practitioners to undertake immunisations, especially in inner cities.
PMCID: PMC1671732  PMID: 1954458

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