With school closures earlier in the year amid a national lockdown and NHS resources stretched to breaking point there must have been some trepidation heading into the autumn immunisation season. At the time of writing, the Prime Minister announced an additional four-week lockdown as a reaction to rising COVID-19 infection rates and associated deaths. Schools are set to remain open and it must be hoped that the school-based immunisation programme can be completed successfully.
The autumn/winter months correspond with the typical ‘flu’ season which makes it even more important that the programme maintains good uptake rates. This year, in addition to school children aged 2–10-years-old, all children in year7 (the first year of secondary education) will be offered the flu vaccine. Other vaccines in the childhood immunisation schedule include: the HPV vaccine for 12–13-year-olds, the 3-in-1 teenage booster and MenACWY for 14-year-olds.
New challenges and barriers to uptake and immunisation
Clearly, there are many challenges ahead, but this year's programme has already faced setbacks. According to Kelly Riddles, immunisation staff nurse, Wakefield 0–19 Service at the Bradford District Care NHS Foundation Trust, the biggest challenge her team faced was in gaining parental consents to vaccinate. ‘The immunisation timetable in Wakefield usually starts with the first HPV vaccine for year8 in September and we then begin the flu campaign from October to December. We are not on e-consents yet and the paper consent forms usually go out to schools in June/July for the HPV and beginning of September for flu. Due to school closures during lockdown, we were unable to get the HPV consents out.’
This year, in addition to school children aged 2–10-years-old, all children in year7 will be offered the flu vaccine.
Archaic systems were also highlighted as a barrier to successful uptake by Sharon White, CEO School and Public Health Nurses Association (SAPHNA): ‘Many areas still have archaic systems, including paper-based, which bring huge issues and barriers. E-consent (electronic) systems are a must to ensure maximum efficiencies, safety and uptake.’
When schools began to re-open, there was little consistency in how they operated, many had reduced class sizes, reduced hours or days per year group, etc. Although many schools fully opened for the autumn term, some have remained closed, and for those that did fully open, health and safety continues to dominate the school day. With increased testing for COVID-19, it has not been uncommon for individual children, whole classes or entire year groups to be sent home for periods of self-isolation, causing further disruption. This has had a knock-on effect on the uptake levels for the immunisation programme.
‘Schools were a little cautious about us going back in to start with,’ explains Kelly Riddles, ‘however, we have had mostly positive encounters with schools and they want to work with us.’
The problem of access to schools was also raised by Sharon White: ‘Infection control mean less space for schools to operate within and naturally some are reluctant to allow external visitors, including immunisation teams.’
‘Infection control mean less space for schools to operate within and naturally some are reluctant to allow external visitors, including immunisation teams.’
Access to vaccines has not been an issue, although the challenges involved in delivering the programmes to different groups has put pressure on staff. Sharon White suggests that staff members are having to work more hours and late evenings to ensure the programmes are delivered on time.
The flu immunisation programme is the largest of the school-based immunisation programmes, which puts pressure on resources. Kelly Riddles: ‘Our flu cohort is approximately 34 000 (including year7 children) and we have 177 schools which include private schools, special educational schools and pupil referral units. We are a team of seven nurses with two bank staff (during flu only).’
In Norfolk, Nancy Campen's, Norfolk School Immunisation Team, faced similar challenges: ‘We were asked to compress the flu programme into a 10-week period which, when you are providing a service in a county as big as Norfolk, is extremely challenging. Our nasal flu cohort is 74 831. Each day [of the flu programme] we have around six teams travelling around the county from one base, so for each flu season, we use a large number of bank staff to supplement the permanent team. This has proved challenging this year because we have been trying to recruit during a pandemic and, traditionally, our bank staff have been “older” and some have chosen not to work due to the risk posed by COVID-19, which has reduced the pool of staff we can call on.’
Given the number of children involved in the programme, the pandemic has meant making other changes to the normal vaccination routine: ‘Previously, schools have tended to put us in small rooms. However, we have found that more schools have now reserved the hall for us to immunise in to allow us to spread out and ensure social distancing. This has been much better,’ says Kelly Riddles. ‘Staff so far have been very good with maintaining social distance from the team when in with most wearing masks and/or visors during the session. With regards to social distancing from the children, they come to the nurse and stand back while we check their details with them, then they will sit down to have the vaccine done. There has not been any problems with this so far.’
It is important to always be respectful of the schools and the protocols they have in place, as Nancy Campen explains: ‘We never lose sight of the fact that we are guests in a school, so we have to be respectful of each school's individual views and processes. We worked hard to reassure schools of how we could work safely with our COVID-19 risk assessment and using an online booking system enabled us to have minimal cross over between students. When we re-started in June we used the online consent portal, which we have for each vaccination in each school, to contact parents who had previously consented. Capacity was much reduced to enable us to maintain social distancing. When the need for full PPE was reduced we were able to speed up the appointments, and in September we went back into schools again based on those schools that had a lower uptake for MenACWY and DTP.’
HPV and drive-through clinics
Despite the excellent work to gain consents, the Wakefield 0–19 Service has made the decision to delay the HPV vaccine programme until the start of next year. However, in other areas, the use of drive-through clinics have proved successful, moving the delivery away from school buildings themselves.
Back in March, the School Age Immunisation Service, Derbyshire Community Health Services (DCHS), was faced with the challenge of vaccinating 13 000 children against HPV at a time when schools and health centres were shut. It was decided that the safest option for both service users and staff would be to pilot drive-through clinics, familiar to those who have been tested for COVID-19. Sites included school car park areas and DCHS properties, such as Walton Hospital. The next challenge was how to avoid thousands of phone calls from those seeking to book appointments. An online booking system proved essential, as did promotion on social media platforms, especially Twitter.
By the end of June, 19 clinics had been completed, with as many as 200 appointments per session facilitated. For those unable to attend or shielding, home visits were arranged. By the end of August, 67 clinics had taken place across 17 different locations in the county, with 9 700 children vaccinated against HPV. Such was the success that Public Health England featured the drive-through clinics on the cover of Vaccine Update (Public Health England, 2020). The prospect of attending a drive-through clinic in the winter months may well affect uptake, however, something that will need assessing alongside any further COVID-19 restrictions.
Looked-after children
For those delivering immunisation programmes to looked after children (LAC) there are a different set of challenges. Local authorities are required to report annually to the Department for Education (DfE) the percentage of LAC who have been in care 12 months or longer and who are up-to-date with their immunisation schedule.
LAC will often enter the care system with either missing or outstanding immunisations, so it was vital that this cohort was prioritised in the delivery of immunisations once the school-based programmes restarted.
According to Jennifer Donnelly, the Named Nurse for LAC in the Virgin LAC team, Lancashire, the impact of the pandemic will lead to poor performance indicators nationally. ‘Looked after children's immunisation status has been monitored and reviewed at each review health assessment. These have continued throughout the COVID-19 pandemic. We have continued to have LAC move into the local area who have outstanding school-based immunisations on arrival.’ The problem was exacerbated by a number of school-based immunisation staff being furloughed. Some of these were ‘emergency moves’ which meant that those children were not enrolled in school upon arrival to the area, which ensured school-based immunisation catch-ups proved even more problematic.
What has this year's uptake been like?
Sharon White believes that consent and uptake rates might be adversely affected by the increased number of absences caused by children self-isolating and absent from school.
But such challenges can lead to innovation. With 5 000 children to gain consent for the HPV vaccine, the Wakefield team tried both traditional and modern methods: ‘As a team, we contacted the parents of children due HPV to gain verbal consent by telephone or letter. We also used social media as a way of spreading the message and this worked very well for us – we managed to get 10% of the cohort consented just by parents seeing our social media post and contacting us to give consent. Schools were very kind during lockdown, sending out texts to parents of children due to HPV to ask them to contact us to consent and many of our schools will also chase up any outstanding consent forms on our behalf.
‘…consent and uptake rates might be adversely affected by the increased number of absences caused by children self-isolating and absent from school.’
‘Overall, we got 65–70% consent using this method during lockdown. For all the children that we didn't manage to contact, once schools opened in September we sent consent forms to try and increase our uptake to 95%.’
While consent is on the increase overall, Wakefield made a decision to delay the HPV vaccines until the start of next year. However, uptake for the flu vaccination has increased, with the team hopeful that this will rise from an average of 70% in previous years to 75% this year.
The LAC team in Lancashire has seen a significant increase in requests for information in relation to eligibility for the seasonal flu vaccine, as well as a significant increase in enquiries regarding the expected COVID-19 vaccine and how this may be prioritised and/or allocated.
In Norfolk, the uptake trend seems positive: ‘The impression is that parents are more interested in vaccinations generally and the uptake for flu is looking better. The flu programme started on the 12th of October, so it is a bit too early to see what the overall trend is. We have been surprised by how well the year7 nasal flu is being taken up in schools because, traditionally, the take-up has tended to tail off as the children get older in primary school.’
Practical advice
Despite uptake looking positive, it is important not to ignore the potential disruption that might be caused by the ongoing COVID-19 pandemic. Here are some practical tips that may help the delivery of your immunisation programme and help maintain good uptake rates:
- ‘We have found establishing a single contact in schools ensures that the process and sessions run smoothly and also develops those relationships,’ says Kelly Riddles
- Work with schools to conduct risk assessments
- Replace outdated paper-based systems with electronic systems, if possible
- Make use of social media to get messages out to parents and to ask for consent
- Sharon White: ‘Use examples of best practice/case studies to build upon, such as the video provided by the Derbyshire Community Health Services NHS Foundation Trust (2020) on YouTube about their use of drive-through clinics for delivering HPV vaccines.’
- Work with looked after children nursing teams. ‘We would be able to assist in the prioritisation of LAC who may not be enrolled in a local school, may have missed school-based immunisations due to frequent placement moves or missed education provision previously’, says Jennifer Donnelly.
- Work with local authorities and children social care to ensure that consent for immunisations for LAC is not a barrier and that it is available in preparation for school-based immunisation programmes. This will help ensure that children are not disadvantaged by not having the correct consent provided.
- Drive-through clinics proved a great success, but as Sharon White points out, they could be sited to make them even more accessible: ‘Drive-throughs should also be on bus routes, so that we don't create further inequalities for non-drivers/car owners.’
- Finally, as Nancy Campen points out: ‘Supporting your team is really important during this time because stress levels are so much higher for everyone.’