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Thursday 29 September 2016
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Vaccines: Needle in a haystack?

Vaccinations: Needle in a haystack?

There have been many changes to the vaccination schedules this year, but where does this leave practices? Health journalist Alison Moore explains...

Ensuring that patients are offered the vaccinations recommended for them and that staff are available to deliver these services when needed is already a major challenge for general practices.

But that task is about to become even more demanding as a number of vaccinations are offered to additional groups of patients. Practices will need to offer hundreds of new appointments – many of them in the next couple of months. 

Sandy Gower, a manager partner in Hertfordshire and co-chair of the Royal College of General Practitioners’ General Practice Foundation, says the workload for practices is ‘enormous.’ As well as arranging extra hours of nursing cover, the GPs in her practice are working Saturdays. 

But her main concern is that the extra workload is dealt with in a safe manner that does not put too much stress on staff members. “The overriding leadership role for me is making sure that the team are safe,” she says.  The pressure has been increased by introducing two major changes – affecting shingles and flu – which both involve large numbers of people within weeks of each other.

The most difficult challenge is likely to be flu vaccinations for two and three-year-olds which will need to be done this autumn. For some three-year-olds this could be added onto a pre-school booster appointment, but the majority of children will need a separate appointment. These extra appointments will be on top of the annual flu jab sessions practices already run for older adults and at-risk adults and children, putting a considerable strain on practices both in terms of delivery of the vaccinations and the associated administration.

The level of uptake is unknown, making it difficult for practices to be certain how much vaccine to order. The vaccine also has a short shelf-life so practices which over-order could be left with relatively expensive vaccines that have to be thrown away, unless they have a same or return agreement with their supplier. Dr Bill Beeby, chair of the British Medical Association’s GP prescribing sub-committee, warns that this could wipe out profits from the rest of the immunisation campaign and mean some practices are extremely cautious about the number of doses they order. 

Practices will already be starting to vaccinate 70 and 79-year-olds in England against shingles with a catch-up programme for other ages in years to come. Some practices will try to combine this with an invitation to be vaccinated against flu or may offer appointments opportunistically when patients in the right age group visit for other conditions.

The other changes – rotavirus for infants and whooping cough for pregnant women – may be easier to deliver. Rotavirus can coincide with other childhood vaccines, while pregnant women will be seeing their midwife, maternity unit or GP routinely, offering opportunities for vaccination without additional appointments. In addition, publicity about a number of infant deaths from whooping cough may make women more likely to accept the vaccination. Models of delivery differ around the country and practices need to be aware of what their role in the local one is. 

Helen Donovan, public health adviser at the Royal College of Nursing, says that practices may also want to ensure that reception staff are aware of the new vaccination schedules and who is included, so they can direct people to the most appropriate information, and potentially have leaflets available for patients and parents. 

But Gower points out that some of the information put out through different channels has been conflicting or incomplete – making it harder for staff to give consistent advice and understand the details of the vaccination programmes. Caroline Kerby, from the NHS Alliance’s practice managers’ network, says that the organisational changes in the NHS have meant it is harder for practices to know where to go for advice on issues such as patient group directives.  

Ms Gower regrets the lack of a national advertising campaign to inform the public about vaccination, which would have helped practices deal with patients who perceive themselves to be at risk. “When we applied for some of the national leaflets, they were already out of stock,” she says.  

All practices will have to identify patients in the affected age ranges and call them in for vaccination – either by letter, phone or text – as well as the existing cohort of patients called for vaccinations in the autumn. To ensure high uptake they are likely to have to chase many patients. Then they will need to offer appointments at suitable times, bearing in mind many children’s parents will work. Kerby’s practice is offering the flu nasal spray in extended child immunisation clinics rather than alongside older patients in flu clinics.

Looking further ahead, annual flu vaccinations will be introduced for all two to 16-year-olds – although it is likely many will be vaccinated at school or in other settings, such as children’s centres. A number of models of delivery are being tested this year. However, even if the majority of vaccinations can be delivered in schools, practices may be involved when children miss their appointment. In the short term, they may also have to field questions from parents about why older children can’t be vaccinated as well. 

The shingles programme will also need to catch up on those currently aged 70 and 79 who have not been vaccinated. 

The meningitis catch-up scheme – expected to be introduced next year for students going off to university – may also be problematic as vaccinations will need to be done in the summer. This is likely to coincide with staff annual leave. 

The epidemiological evidence for the additional vaccinations seems to be widely accepted by health professionals – and some of the vaccinations have been given routinely in other countries for many years, although Dr Beeby points out shingles uptake in the US is low. As well as preventing cases in the individual to some extent, wider vaccination against diseases such as flu will contribute to ‘herd immunity’ and make it harder for these diseases to spread. He argues that practices will cope with the changes but questions whether, with so many other priorities, they will be able to achieve high levels of take up. And Kerby says at a time of such change in the NHS it would have been preferable to stagger the introduction of the shingles and child flu programmes. 

 

What’s new

Flu vaccination for young children.

This is being introduced this autumn for two and three-year-olds, although some areas have pilot schemes for primary school age children. In time all children between two and 16 will be offered the annual nasal spray. Up to now only those with long-term conditions have been routinely vaccinated - many of these will now swap from the injectable vaccine to the nasal spray.

Shingles

In England, adults aged 70 and 79 on 1 September 2013 are being offered shingles vaccinations. This is a one-off vaccination and does not need annual boosters. Those currently between 71 and 78 will be offered the vaccination over the next few years.  

Rotavirus vaccination for babies

This was introduced recently for very young babies, with oral doses given at two and three months, alongside other vaccinations. Guidance says the first dose needs to be given before the baby is 15 weeks old and no vaccination should be given after 24 weeks because of the risk of intestinal blockages. 

Whooping cough vaccination for pregnant women

Babies are most at risk from whooping cough before they can be vaccinated at two months old, but vaccinating the mother between weeks 28 and 38 of pregnancy can protect the child as well. Pregnant women have been offered this vaccination since summer 2013 after a rise in the number of cases of whooping cough and the deaths of a number of babies.