Childhood vaccination rates in 2015: what, why and what next?

A new immunisation coverage report has been released by the National Health Performance Authority. Here it is with key statistics and excellent visual aids. The report doesn’t attempt to explain the changes in immunisation rates, nor why they are low in some regions, so I’ll attempt that in this blog. At the end is an update on the ‘No Jab No Pay’ policy.

What did the NHPA report find?

90.9% of children were fully vaccinated in 2014-2015;

9.1% were not fully vaccinated. That was 84,571 children aged 1, 2 and 5 years;

Only 2 of 31 regions reached the target coverage of 95%;

Compared with the previous period there were promising increases in 1 and 5 year old immunisation rates but still room for improvement;

There was a reduction for 2 year olds most likely because two new vaccines were added to the requirements. (Like adding a harder set of questions to the NAPLAN test for stage 3 in 2015 so their national grades appear to decline slightly);

7 regions increased coverage for 1 year olds with biggest leaps in outback South Australia and the Gold Coast, parts of the central highlands of QLD, parts of the North Coast and parts of inner Sydney;

At a postcode level the lowest rates are in Katoomba, Leura and Medlow Bath; Parramatta and Brunswick Heads, Ocean Shores, South Golden Beach, Burringbar and 10 nearby towns. These are different communities with different reasons for low vaccination rates and one size won’t fit all but clearly, more should be done.

What does this report tell us about No Jab No Pay?

Nothing – the No Jab No Pay amendment bill was only introduced this year and we shall have to wait until next year’s report to see any impacts. Journalists should not report any causal connection between a January 2016 policy and 2014-2015 vaccination rates. Reporting the announcement of the policy in April 2015 as affecting these rates is highly speculative without having more granular evidence.

 

Why don’t some children get fully vaccinated?

Among the 84,571 children noted as not fully vaccinated there are 84,571 different reasons. A significant percentage are actually up-to-date but there was a recording error. And the rest? We don’t know for sure and understanding this group better should be a priority now that vaccine objection is not recorded.

Research suggestions that parents or caregivers either don’t accept vaccines or just face practical and logistical difficulties. See here and here for more information.

A recent paper outlined a simple and memorable group of reasons for under-vaccination – the Five A’s, developed by Angus Thomson and colleagues (below). This schema would group vaccine objectors under the lack of Acceptance banner. The detective work is in finding the degree to which each factor contributes to that 9% who aren’t up to date and of course it varies by age group and region.

 

 

Screenshot 2016-02-17 22.37.20
Source: Thomson A et al / Vaccine 34 (2016) 1018-1024

Why was there a general increase in rates for 12 month olds and 5 year olds?

  1. Some regions made a concerted effort to clean up register data and update records for children who were actually vaccinated. Western Australia has done lots of work in this regard.
  2. Much more attention was paid to vaccination rates – this was the year following the first NHPA report’s release. Communities got to see their own rates for the first time and there was more public and political pressure and hence resourcing and action.
  3. Some communities and individuals galvanised more local positive action and national awareness. See for example the Northern Rivers Vaccination Supporters, the WA Immunisation Alliance, and the Light for Riley campaign
  4. National Immunisation Strategy 2013-2018 which includes improving coverage as a priority.
  5. Incentives motivate people but they also motivate governments. From 2011-12 states and territories were given a reward payment for meeting certain vaccination coverage targets. Check out the informative review of the Review of the National Partnership Agreement on Essential Vaccines with loads of useful general information about our national program and how it’s going.
  1. Other? Readers are welcome to share their thoughts via comments.

When will we know more about the impact of No Jab No Pay?

Next year’s NHPA report will reflect the impact but see here for more recent vaccination rates.  For more detail on No Jab No Pay and the other reforms surrounding it, read my previous blog.

What has been the impact so far of No Jab No Pay and its ad-ons?

A refresher:

No Jab No Pay is a change the national rules for receiving family assistance payments and No Jab No Play relates to three states (Vic, QLD and NSW) with variations on a theme of childcare exclusion for the unvaccinated.

No Jab No Pay is from the Department of Human Services and involves tightening to existing requirements for receipt of FTB-A supplement, Childcare Benefit, Childcare Rebate: (1) no more exemptions for vaccine objectors; (2) it’s audited every year now; (3) and audited up to age 19 years instead of just 5 years.

The national ad-ons from the Department of Health include: (1) free catch-up vaccines for children over 7 years; (2) incentives to catch-up children; (3) expansion of the ACIR from age 7 to age 19 and eventually to whole-of-life.

Policy impacts so far:

There are encouraging accounts of parents who were previously vaccine objectors getting their kids up to date, e.g., a nurse who is “doing almost nothing but vaccination at the moment”. Some parents are very anxious but report the next day that their child is ok. However, others remain angry and resentful, feeling coerced into making the decision because they cannot afford to miss the payments. Occasionally such parents front up to providers in an aggressive manner, demanding they immunise the children. Some providers in this situation refuse to vaccinate as they believe valid consent has not been obtained.

Yesterday, I received an email from Angela Newbound, an experienced immunisation coordinator in a major metropolitan region. She noted major implementation issues mostly from problems recording or updating the Australian Childhood Immunisaiton Register (ACIR) and was keen to share them. She mentions problems faced by providers (GPs, nurses and Aboriginal Health Workers who give vaccines) and parents:

  • Primary Health Networks not being given access/full access to the ACIR secure site until March, rendering them helpless to provide much practical assistance, despite the considerable expertise some of their staff have as the ‘ACIR Whisperers’.
  • ACIR data being inaccurate because of provider recording error (ACIR is quite particular in how data must be entered).
  • Providers being unable to update address details of client/patient on the ACIR site meaning they direct the parents to contact Medicare which becomes problematic for people with low levels of computer literacy, language literacy (both English and their language of origin) and physical, psychological, social and geographical disadvantage. Changing these details is important for reminder letters.
  • Clinics who are overwhelmed with catch up and ACIR arrangements being almost unable to cope and having no extra resources to address this.
  • Families who are facing financial hardship because they won’t shift even with the new requirement
  • Families who don’t have the resources/knowledge/access to arrange their GP or clinic to document catch up and therefore also facing financial hardship despite their desire to vaccinate.
  • 2 adolescent children were re-vaccinated because even though they were up-to-date, parents could not find the paper record of vaccines because they were given after the children turned 7 when the register only recorded up to 7 years.

An extension to the grace period for catch-up until at least 1st July may be one option. A delay in implementation was something we both advocated for to the Senate hearing and supported by the Greens but it was not heeded.

There is no doubt that the implementation is very challenging for all involved, including the public servants working in the health department, with the ACIR and in Centrelink who have been given about 6 weeks from the final passage of the legislation to implementation of an extremely complex system.

Conclusion

There are two goals here: one is to ensure children are vaccinated and another to ensure that vaccination programs are implemented so that the wellbeing of children who fall through the gaps is not compromised through financial hardship or lost educational opportunities. Our generally high vaccination rates show what can happen with comprehensive and well-oiled systems, good record keeping, incentives, free vaccines, supported providers and motivated parents. To address the persistent gap in coverage, government has, or has come close to, making vaccination compulsory. To keep their part of the bargain, government has a responsibility to ensure that the services and the register work well.

Public servants, program managers, local coordinators, health professionals and parents are working very hard in the circumstances to implement a complex policy in a very short timeframe. An extended grace period would provide more time to iron out some of these major issues.

Finally, government has a responsibility to evaluate this large national experiment. It’s promising news that there are accounts of children getting vaccinated. However, all the impacts of No Jab No Pay/Play will need to be evaluated. Right now there are no apparent plans from government to evaluate this policy and the opportunity to do so in real-time is dwindling.

 

 

 

 

 

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