This past week there has been impressive news about the impact of routine HPV vaccination of girls aged 12-13 in Scotland. This program has clearly reduced preinvasive cervical disease, with the promise of dramatic decrease in cervical cancer in years to come. A systematic review and meta-analysis of the impact of HPV published in the Lancet also provided compelling evidence of the indispensable role of this type of immunisation worldwide.
We know that, however much we may see this as compelling evidence, getting the message across, winning all hearts and minds to the cause of immunisation, remains a great challenge in the face of virulent sources of misinformation that work against public health efforts.
In my last blog on childhood immunisation, I argued that anti-vaxxers speak and behave in a context. We can huff and puff as much as we want about the nonsense peddled on the internet but we won’t be blowing any houses down if we ignore the many strands that make up this context. In their own rights, each strand may have some validity. I identified 6 such strands for action. One action area focuses on the esteem of practitioners – to “re-establish the position of clinical and other expertise and to think more self-critically why this has fallen from grace”.
One helpful approach might be if practitioners were to be seen as practisers of what is preached. Whether clinicians like it or not, they will inevitably be seen as models of the things and behaviours they are trying to promote. Given that health professionals are at the forefront of promotion for childhood vaccinations, is it not reasonable to ask to what extent they, themselves, are compliant when it comes to immunisation? And if there are issues, rather than to condemn outright, try and understand why?
Let’s take the example of the annual NHS staff influenza campaign. Influenza is important. Complications from it kill hundreds each year. It recurs on a seasonal basis and periodically as pandemics with potentially catastrophic consequences. The flu vaccine potentially protects staff from becoming ill, therefore reducing sickness absence at times of greatest service pressure. And it protects the vulnerable patients that health care workers care for. So why should compliance ever be a problem?
Each year Public Health England publishes an account of the seasonal influenza vaccine uptake in healthcare workers (HCWs) in England. The 2018-2019 season report can be viewed here. The report looks at the cumulative cover over the months October to February of frontline NHS HCWs involved in direct contact with patients.
There has been a Commissioning for Quality and Innovation (CQUIN) payment incentive for flu imms in contracts since 2016/17 which may have had an effect on raising overall average cover from 63.2% in 2016/17 to 68.7% in 2017/18 and 70.3% in 2018/19. All much higher than the 20% that was typical of the first decade of this century, although still some way short of the WHO’s 75% target. And, these are cumulative figures achieved over a 5-month period. In October 2018 (at the beginning of the “flu season”) the cover was only 46.3% rising to 65.8% only by the end of December.
Averages are almost meaningless when the spread around the mean is wide. It is good that over half of Trusts in 2018/19 recorded rates of 75% and above (you can see the Inter Quartile ranges in the PHE report) but many Trusts recorded way below that level.
Whilst some Trusts are able to record % cover in the 90s (the highest being 95.4%), one Trust was only able to cover 38.4% of its frontline HCWs.
The picture for primary care is also mixed. One NHS area was actually unable to submit any data at all for primary care and the London Region recorded a shockingly low 50%. If there is any truth in this figure (and it is so bad, one might question the accuracy), we have an extraordinary situation where those at the forefront of persuading the public are themselves manifestly non-compliant.
It would appear that organisational factors, Trust priorities and commitment, the variable distribution of imagination and initiative, could all play a part in the differences in cover rates. Incompetence or indifference may mean staff “not getting round to it”. However, the data returns also record staff who actually decline the immunisation when offered. In 2018/19, a staggering 80,000 NHS frontline HCWs were recorded as declining the immunisation. What message does that give? One can understand the frustration of Professor Dame Sally Davies, England Chief Medical Officer, who argued that the duty of care that clinicians themselves have to patients means they should be vaccinated. She suggested that NHS employers should make it a contractual obligation in the same way that staff working in certain services are required to have the BCG.
So why this resistance of NHS HCWs? A King’s Fund blog citing research from 2015 sets out common staff objections – a belief that the vaccination might make you unwell, that it was just too much trouble getting vaccinated, a belief that the risk of contracting flu is very low and that the vaccine is perceived to be pretty ineffective anyhow. You could argue that these are all in the “myth” category, although perhaps not of the mega nonsense proportions of some anti-vaxxers. Nevertheless, these are views that are held and held by people who should have access to the facts.
You may well argue that flu is different to childhood immunisation. For one thing, flu is always a moving target and we are not talking about one single disease. At best, in recent years, flu jabs will give protection against 40% of the viruses out there. No-one is talking about eliminating influenza. No-one is talking of “herd immunity”, to use that dubious term. However, since 2013, flu has been part of the childhood immunisation package – currently with annual vaccination for 2 to 8 year olds and from October 2019 will be extend to all primary school pupils. It would be odd if attitudes towards flu immunisations don’t inevitably become associated with those towards the other childhood immunisation programmes.
My Twitter timeline regularly throws up clinicians making forthright comment about parents who don’t have their children immunised. There has also been quite a bit of complaining recently about people who value what their phones tell them rather than “what I learnt through years of graft at medical school”. This may be highly therapeutic but doesn’t do much to address the problem. The NHS staff influenza experience shows, things aren’t necessarily that straight forward. As I have argued before, a greater understanding of the context may be required. And that may start with some practitioners first looking at themselves.