The latest national report on vaccination rates was released today by the Australian Institute of Health and Welfare (AIHW). It give Australia a snapshot of rates for children in 2015-2016 and compares them with previous reports. It also shows rates down to postcode level. The report is here with some nice visuals. For the very latest figures you should go here.
What does the report tell us?
Australia is travelling reasonably well with vaccination rates for children now reaching 93%. But we still have no national snapshot of adult vaccination rates.
While some regions have persistently low childhood vaccination rates, national figures are climbing slightly, as they have done for some years. The media have occasionally reported a decline, even plummeting vaccination rates but generally this is incorrect.
Aboriginal and Torres Strait Islander pre-schoolers lead the way with vaccination rates reaching the 95% target.
The good news story is that Aboriginal and Torres Strait Islander 5-year-olds are now the first population group at a national level to reach the target of 95%. This article and this thesis tells a bit of that story in NSW and the Aboriginal people and services behind it. There is still some work to do in the 1 and 2 year olds with coverage at only 90% – 3% lower than the national average.1
What this report does not tell us.
- What our adult vaccination rates are like – they are much lower, judging by smaller or older studies. Now that we have a whole of life register, the AIHW should ideally report on these in future. Here’s a useful blog about adult vaccination by Gid M-K.
- Why these regions have lower coverage. Beware the pejorative stereotypes. For every one child who isn’t vaccinated, there is a unique reason. Research by the Collaboration on Social Science and Immunisation network and others looks into these questions in detail. For example, our recently funded NHMRC study is looking at why parents choose not to vaccinate.
- The relevance of other risk factors for under-vaccination (like poverty, larger families, home-boundedness) shown in studies to be associated with not vaccinating. The maps are compelling but they only show one dimension.
- How successful No Jab No Pay has been. First, it’s a bit early because it reflects data from only the first 6 months of implementation (Jan-June 2016). Also lots of other efforts were put into improving vaccination rates around this time.
- Beware inferring policy causation with aggregate data. We can’t know whether ‘Sam’ got up to date because his state health department called his parents when he became overdue; or whether they were prompted by a letter from Centrelink advising of non-payment of FTB-A supplement; whether their doctor asked them about overdue vaccines during another visit; or whether his mum saw a video on facebook of a baby with whooping cough. It was probably all or some of these.
- Beware postcode level data such as that on page 5 of the report. While the postcodes attract interest from local media, they are such small numbers that the rates can jump around a lot with just a few more children being caught-up. Also, the lowest two postcodes are suburbs of Sydney with more transience and/or overseas born children so their vaccination records might just need updating, as suggested in this study.
Who is in the gap nationally?
Two main groups fill the gap between actual and ideal rates, based on the most reasonable estimate from historical data on vaccine objection and many studies of factors associated with under-vaccination.
Which large regions have the lowest vaccination rates for 2 year olds? (Based on data from the AIHW for Primary Health Network)
- North Coast of NSW where 87.2% (724 children are not fully vaccinated)
- Western Sydney where 88.8% (1650 children are not fully vaccinated)
- Perth South where 88.8% (1490 children are not fully vaccinated).
Which large regions have the largest number of children not fully vaccinated?
- North West Melbourne where 2,228 two-year-olds are not fully vaccinated (90.4%)
- Central and Eastern Sydney where 1,901 two-year-olds are not fully vaccinated (89.8%)
- South Eastern Melbourne where 1,809 two-year-olds are not fully vaccinated (90.5%).
What about the smaller areas?
There are two dimensions to observe – the percentages and the raw numbers. In the table you can see which SA3 areas have the lowest ranking. The last column is my addition, showing how many of these two-year-olds would need to be fully vaccinated for that region to reach 95%.
Table: The bottom 10 ranked SA3 areas* for rates and numbers.#
* SA3 areas generally have a population of between 30,000 and 130,000 people, “often closely aligned to large urban Local Government Areas (e.g. Gladstone, Geelong). In outer regional and remote areas, SA3s represent areas which are widely recognised as having a distinct identity and similar social and economic characteristics.” Reference
# This reports the two-year olds. It looks slightly different for other age groups. See note below.
Why should we worry about the number of kids in a region who are not fully vaccinated?
Numbers of under-vaccinated children in a region is important in terms of disease control. As we note in our recent publication in the Medical Journal of Australia,
Measles outbreaks in recent years have not been concentrated in areas with the lowest levels of coverage and highest levels of vaccine refusal, but rather in highly populated urban areas with overall vaccination rates of over 90% (Najjar et al) This is probably due to both greater population density and likelihood of travel-related importation in such areas.
Beard F, Leask J, McIntyre P. Medical Journal of Australia 2017; 206 (9): 381-383
Which age group should we focus on?
All are important. Above I used the 2-year-old milestone because … measles. Measles vaccination coverage is the basis for Australia’s 95% target. The 2 years figure tells you what percentage of children got timely protection from measles, mumps and rubella, meningococcal C disease and Hib and those due by 12 months. Australia gets ongoing outbreaks of measles, often starting with young adults without immunity returning from overseas where it’s endemic. It’s extremely infectious so spreads locally in little spot fires that public health authorities work hard to put out, but these cost a lot and people get sick.
The 1-year-old coverage figure is also very important because it reflects the first baby vaccinations against whooping cough, tetanus, diphtheria, polio, hepatitis B, haemophilus influenzae type b (Hib), and pneumococcal disease given at 2, 4 and 6 months of age. Whooping cough protection in infants is best started nowadays starting with vaccination of pregnant women.
The 5-year-old figure tells you how many children are up to date with their booster shots of polio and DTP and at this time, MMR for some kids. The AIHW focused on this figure in their report.
What is being done now to improve coverage?
Recent policy and program initiatives include:
- Making available free vaccines for all 10-19 year olds and newly arrived refugees and humanitarian entrants from 1 July 2017.
- Incentivising GPs to give catch-up vaccinations for overdue kids.
- State-based efforts to remind families whose kids are behind on vaccination.
- Childcare entry requirements that have hard to reach exemptions for objectors (the firm but fair version like NSW currently has).
- Various national and state campaigns.
Who still needs attention?
That remaining 7% of children still not fully vaccinated for age need tailored attention. No one measure will do this and the current penchant for sticks over carrots has significant downsides when balanced against any modest disease control gains, as noted in our recent paper.
Support professionals to work with the hesitant. This article highlights some work we are doing with health professionals in the Sharing Knowledge About Immunisation approach.
Home visiting vaccination services or more flexible services for the willing but homebound families or those whose lives are disrupted or chaotic.
Health professional support. Audits, assessment and feedback, reminders and individual support all enable health professionals to readily access reports of children not up-to-date within their practices to enable catch-up, feedback and recognition for high practice coverage. Strategies may also involve visiting individual practices with lower vaccination rates to provide guidance and support. Primary Health Networks are well placed to do this but recent years saw their roles in this reduce.
National approach to Aboriginal Health Workers/Practitioners at Certificate 4 level to vaccinate independently. Aboriginal and Torres Strait Islander children are less likely to be vaccinate on time for the baby vaccines. Coverage can be improved when Aboriginal and Torres Strait Islander health workers are able to vaccinate. A national approach to accreditation was a recommendation at the 2016 NHMRC CRE Immunisation Round Table, Yarning Together.
Mandatory record checks at childcare in every state and territory. Introduce a fair and more consistent approach to requiring childcare facilities to see documentation of age appropriate vaccination or a recognized catch-up schedule, medical, or vaccine objector exemption that has been signed by a doctor or immunisation provider. This is a fairer version of No Jab No Play that means that the children of entrenched non-vaccinators can still access childcare through exemptions that sort the entrenched from the merely hesitant or forgetful.
No fault vaccine injury compensation scheme. This is needed to sustain trust in our program that government will fulfil its reciprocal obligation to look after the very few who are affected by the extremely rare injury from a vaccine. Such schemes are in place in 19 other countries, including New Zealand, but our government has not responded to over a decade of the vaccination community calling for such a scheme.
Improve adult coverage. Adult vaccination is more challenging – different types of professionals will be involved – from antenatal care to aged care. The doctor or nurse must ask themselves if the person has a medical risk factor making them eligible for a recommended vaccine. There are many missed opportunities. The new Australian Immunisation Register will enable better monitoring of coverage but government should provide support, resourcing and ongoing consultation with relevant sectors. Our article provides further detail.