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Childhood immunisation in general practice

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10th Sep 2010
Liz McCullagh   all articles by this author
Jane Smart   all articles by this author

This Clinical Update looks at effective management of childhood vaccinations and strategies to maximise immunisation rates in your practice.

Introduction

IMMUNISATION is one of the most effective public health interventions in preventing childhood morbidity and mortality. According to the World Health Organization, “immunisation currently averts an estimated 2.5 million deaths every year in all age groups from diphtheria, tetanus, pertussis (whooping cough) and measles”.

One of the most important decisions that parents must make is whether to have their children immunised, yet many fail to do so often because of their lack of understanding or misinformation about the risks involved (McMurray, 2003). 

General practice is integral to delivering immunisation to the community as it has significant contact with the target group: children younger than seven years.

Protocols, equipment and drugs necessary for the management of anaphylaxis should be checked for availability before any vaccination session. 

An anaphylaxis response kit should be on hand at all times and should contain:

• Adrenaline 1:1000 (minimum of three ampoules – check expiry dates)

• Minimum of three 1 mL syringes and 25 mm length needles (for IM injection)

• Cotton wool 

• Pen and paper to record time of administration of adrenaline

• Laminated copy of recognition and treatment of anaphylaxis (found on the back cover of the NHMRC’s Australian Immunisation Handbook, 9th ed, 2008).

Know your target group

It is useful to recognise the idiosyncrasies of your region and/or community to enable you to target your efforts for the most benefit. 

In our local community, for example, we see roughly four different groups of parents in terms of childhood vaccination. 

There is a large group who will immunise their children, more or less on time without the need for reminder or follow-up. 

There is a smaller but significant group who will not immunise their children under any circumstances. There are the parents who, for a variety of reasons (e.g. travel, illness), may have fallen behind the schedule and need to catch up. 

And finally there are the new parents who are simply unsure. 

It is these last two groups who will benefit most from communication, recall and reminder systems.

Contraindications

Children between the ages of six months and five years may contract up to 60 viral illnesses, so they are often “unwell” during these years (Perrott, 1997). 

Many parents and some immunisation providers wrongly believe that immunisation should not be given when a child is “unwell”. Vaccination should be deferred only when a child is febrile – that is, with a temperature higher than 38.5° C (Australian Immunisation Handbook).

There are only two absolute contraindications to vaccination:

• anaphylaxis following a previous dose of the relevant vaccine

• anaphylaxis following any component of the relevant vaccine.

There are two further contraindications applicable to live vaccines:

• Live vaccines should not be administered to individuals with impaired immunity, regardless of whether the impairment is caused by disease or treatment. The exception is that, with specialist advice, MMR can be administered to HIV-infected individuals in whom impaired immunity is mild.

• In general, live vaccines should not be administered during pregnancy, and women should be advised not to become pregnant within four weeks of receiving a live vaccine.


Reminders and recalls

Immunisation coverage needs to exceed 90% to achieve and maintain the level of community immunity required to interrupt the ongoing transmission of vaccine preventable diseases in the population (Australian Institute of Health and Welfare, 2009). 

To be eligible for PIPs (Practice Incentive Payments), a practice needs to achieve a target of 90% or greater immunisation coverage for those children younger than seven years attending their practice. So how do we hit the magic 90% and keep them coming back for more?

Many strategies to increase vaccinations have been used. One way is to remind people to receive their vaccinations. A review by Jacobson Vann and Szilagyi (2002) found that reminding people to have vaccinations increased the number of people vaccinated, whether people were due or overdue for vaccinations. 

The increases were observed in both children and adults. Reminding people over the telephone, sending a letter, or postcard, or speaking to them in person increased vaccinations. Providing numerous reminders is more effective than single reminders. 

They also found reminding people over the telephone was more effective than postcard or letter reminders, but reminders over the telephone may be more expensive compared with alternative approaches. 

The reminders were effective in all locations: a private doctor’s office, a medical centre, and a public health department clinic.

Technique tips and tricks

A secure hold while injecting is vital. This “holding tight” is the traumatic part for most kids, so it is good to discuss exactly how you want the parent to hold the child and when, but don’t get them to hold tight until you need to. We prefer the parents to hold the arms if we are injecting into the legs, and ensure the parent’s hands are well clear of the injecting area.

Diversionary tactics that involve colour, noise and/or movement will distract most crying kids (e.g. blowing bubbles, shaking the jelly bean jar).

NeisVac-C should not be given in the same limb as any other vaccine.

Prevenar stings on administration and should be given second for this reason (once you have done a few, you will realise that this is the vaccine that gets the emotional reaction). 

It is good practice to always give the ‘tetanus’-containing vaccine on the left so that in the event of a local reaction, we can be sure of which vaccine is responsible even before we check the patient’s vaccination record.

If using a 25-gauge needle for an IM vaccination, ensure the vaccine is injected slowly over a count of five seconds to avoid injection pain, muscle trauma and vaccine leakage (Australian Immunisation Handbook).

Use the four-year-old Healthy Kids Check to assess immunisation status.

Screen all children who attend the practice opportunistically for immunisation status. This can be a team effort by reception, nursing and medical staff, all of whom can flag a child patient to ask if the child’s vaccinations are up to date, to document the parent’s response and to record vaccination history in patient notes. Then be sure to add the child to the recall system.

Resources and tools

With a rapidly evolving immunisation schedule, new vaccinations, and interstate and international variations in schedules, there are some valuable tools to assist in making the right vaccination decision. The definitive guide to immunisation is the current Australian Immunisation Handbook, 9th edition, 2008. 

As an authorised user, you can access ACIR to clarify a child’s immunisation status and identify due or overdue immunisations. 

Ensure all childhood vaccinations administered in your practice are recorded on ACIR. You need to have at least one doctor per site to have previously signed a 46E form to receive a quarterly GPII 20A report. 

This useful tool will identify children who are overdue for vaccination in the previous quarter. Information regarding this resource can be found at www.gpns.org.au

Following up these children with a phone call and offering to make an appointment can quickly bring them up to date.

The South Australian Govern-ment supports a website (www.health.sa.gov.au/immunisationcalculator) that parents, carers and immunisation providers can use to assist in ‘catch-up’ scheduling for vaccinations.

The calculator is a computer-based system that uses the National Immunisation Program Schedule and is specific to each state. It recommends doses of vaccine be given at specific ages. 

If doses of vaccine are delayed or missed, the calculator will assist in providing a ‘catch-up’ schedule for future vaccine doses. 

The World Health Organization offers a website where you can view the antigens administered and the schedule for a specific country.

This is particularly useful for people who do not have any written records.

Conclusion

Everyone working in a general practice can contribute to improving immunisation rates by making sure all team members understand their role. 

The promotion of immunisation is a repetitive and ongoing activity that requires tracking, personalised reminders and positive feedback to parents.

We hope the tips and tricks listed will assist you in keeping your immunisation rates above 90% and making the whole immunisation experience for nurse, parent and child as effective as possible.

Setting up an immunisation clinic

When setting up for immunisation in your practice, several key elements must exist:

• Competent, certified, confident nursing staff

• Dedicated vaccine fridge and cold chain management

• Pre-vaccination checklist

• Reception staff educated on times of availability 

• Anaphylaxis response kit.

A snapshot of the Australian Childhood Immunisation Register (ACIR)

THE Australian Childhood Immunisation Register was developed in 1996 in response to a declining immunisation rate and an increase in vaccine-preventable childhood diseases in Australia. 

The register records the immunisation status of children younger than seven years who are enrolled in Medicare (by the age of 12 months, this is estimated to be more than 99% of children). At 30 June 2010 more than 2.06 million children younger than seven years were on the register.

Children who are not eligible for Medicare can still be added to the register (Medicare Australia 2009; NCIRS 2007).  The program offers financial incentives to parents and GPs and has raised immunisation coverage to record levels. 

This Update is by Liz McCullagh and Jane Smart.

Liz and Jane are both registered nurses with a combined experience of 30 years in nursing; 14 years in immunisation and 15 years in general practice. They work at Margaret River Surgery and Cowaramup Surgery in WA.

The authors have no disclosures. Any reference to products throughout this review does not constitute endorsement.

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