Child vaccination schedule: new risks and tackling hesitancy
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Child vaccination schedule: new risks and tackling hesitancy

Erin Dean Health journalist

Uptake of childhood vaccines shows a worrying fall due to several factors, but nurses can answer parents’ questions and allay vaccination fears

New data show vaccination coverage for young children fell in 2021-22 for virtually all programmes. Uptake was falling before the pandemic, and COVID-19 is likely to have had a further effect on parents having their children vaccinated.

Nursing Children and Young People. 35, 2, 6-8. doi: 10.7748/ncyp.35.2.6.s2

Published: 02 March 2023

The UK Health Security Agency has issued a warning to parents about ensuring their children’s vaccines are up to date.

Figures for 2021-22 show that none of the childhood vaccines given up to the age of five met the recommended 95% uptake target in England. Vaccine coverage decreased compared with the previous year in 13 out of 14 routine disease vaccination programmes.

The number of children receiving the first mumps, measles and rubella (MMR) injection fell to 89%. Rates for receiving all three doses of the six-in-one baby vaccine have been falling since 2012-13, when it peaked at 94.7%. In 2021-22, it was 91.8%.

The NHS vaccination schedule starts at eight weeks old, when babies receive their 6-in-1 vaccine, which protects against diphtheria, hepatitis B, Hib (Haemophilus influenza type b), polio, tetanus and pertussis. They are also given the rotavirus stomach infection vaccine and the MenB vaccine for meningococcal group B bacteria.

How can nurses support parents to get children vaccinated?

While a minority of parents will remain firmly against vaccinations for their children, many just want an opportunity to discuss their concerns or questions with a nurse.

Advanced clinical practitioner Elia Monteiro, who is practice educator at the South East London Training Hub, says that giving parents the opportunity and time for these conversations, and explaining the positive benefits backed up by scientific evidence, often reassures people sufficiently for them to decide to go ahead.

‘When a parent has not vaccinated their child at all, or for a long time, I will often call them to invite them to a vaccination clinic and then, while on the phone, we can have a chat about any concerns they have,’ she says.

‘I can send them links to information leaflets through a phone message, and I stress that by coming to the clinic they are not automatically consenting to the vaccinations. But this is a good way of talking about any concerns, and explaining the science. While it takes longer, I’ve found it very successful.

‘Often parents will have other children who can then also be vaccinated over a number of appointments. It is so important, as we are protecting against such serious diseases with these vaccines.’

Pneumococcal infection

At 12 weeks, babies receive the second dose of the 6-in-1 and rotavirus vaccines, and the pneumococcal vaccine, to protect against serious pneumococcal infections.

At 16 weeks there is a third dose of 6-in-1 vaccine and a second of the MenB vaccine.

At the age of one, children receive the first dose of a combined vaccine against Hib and meningitis C, and the first dose of the MMR vaccine. They also receive the second dose of the pneumococcal vaccine and a third of the MenB.

‘When a parent has not vaccinated their child at all or for a long time, I will often call them to invite them to a vaccination clinic’

Elia Monteiro, advanced clinical practitioner, South East London Training Hub

Between the ages of two and ten years, children are entitled to an annual flu vaccination.

At three years and four months there is a second dose of the MMR and the 4-in-1 pre-school booster against diphtheria, tetanus, pertussis and polio.

At the age of 12 to 13 years there is a vaccine against the human papillomavirus, which causes cervical cancer and some other cancers.

At the age of 14 years children should receive the 3-in-1 teenage booster against tetanus, diphtheria and polio, and the MenACWY vaccine. This protects against four strains of meningococcal bacteria, A, C, W and Y, to prevent meningitis and septicaemia. Two doses of the COVID-19 vaccine are being offered to all children aged 12-15 and some aged 5 to 11.

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Picture credit: Asadour Guzelian

Hepatitis and tuberculosis

Some children at high risk of hepatitis B or tuberculosis will be offered extra vaccinations against these conditions, and some children with underlying health conditions will be offered additional vaccines to reduce their risks.

Everyone, including children, arriving to claim asylum in the UK is currently being offered a diphtheria vaccination and a course of antibiotics. This is after a number of cases were detected in centres for asylum seekers in Kent as well as other parts of the UK.

All children aged between one and nine in London are currently being offered a dose of polio vaccine, after concerns were raised about the disease in the capital.

This extra dose was launched after the polio virus was found in sewage last year. This suggests that the virus, which attacks the nervous symptom and can paralyse muscles, is now spreading between people, according to government scientists. It has probably happened because vaccine uptake for infant and toddler vaccinations in London is lower than it should be.

The combined vaccine protecting against Hib and MenC given to babies at one year of age has been discontinued by the manufacturer, GSK.

The Joint Committee on Vaccination and Immunisation (JCVI), which advises the government on such matters, says there is no available alternative to this vaccine, so it will have to be stopped when current supplies run out.

In its place, an additional dose of a Hib-containing vaccine should be given at 18 months.

The MenC element is not being replaced, as the MenACWY vaccine for teenagers is succeeding in controlling rates of meningococcal C across the whole population through herd immunity, according to the JCVI.

Measles outbreak

The committee has also advised that the second dose of MMR should be brought forward to the new 18-month vaccination appointment to reduce the likelihood of measles outbreaks. Research suggests this can boost uptake of the vaccine.

Advanced clinical practitioner Elia Monteiro, who is practice educator at the South East London Training Hub, says that in south east London the MMR booster is already given at 18 months in line with local guidance.

She says: ‘In south east London there have historically been high rates of measles outbreaks, so the MMR booster is given at 18 months to protect against this.

‘For practice nurses in other areas, the main impact will be the extra resources needed to provide an additional vaccination appointment to all children at 18 months old.’

The government says the current stock of the Hib/MenC vaccine will run out in 2025 and by then an updated immunisations schedule will be used.

Meningitis charities have raised concerns that the Men C element of the vaccine is not going to be replaced.

The Meningitis Research Foundation strongly urged the JCVI not to drop the vaccine before current stocks run out. It said the decision is a missed opportunity to provide the broadest protection to infants through a new early dose of the MenACWY or Men ABCWY vaccine.

Global review

There are several reasons for parents not vaccinating their children. A global overview of 30 reviews published in the BMJ found that the reasons fell into six main areas of access (which can include not having enough time to attend appointments), clinic or health system barriers, concerns and beliefs, health perceptions and experiences, knowledge and information, and social or family influence.

Ms Monteiro says the majority of parents are happy to have their children vaccinated, some are completely against it and often remain so, and there are some who are uncertain or hesitant. Some parents will accept some childhood vaccines but reject others.

She says a 1998 paper in the Lancet that implied a link between the MMR vaccine and autism continues to have a profound effect on some parents even though it has been completely discredited. It was retracted by the journal in 2010.

‘Parents will sometimes agree to others but refuse the MMR. For those who are reluctant there is also often a feeling that they don’t want their child to have too many vaccines at the same time, despite there being absolutely no evidence to say this can be a problem,’ says Ms Monteiro.

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