Reported general practitioner vaccination procedures, 1994 and 1996

Abstract

MJA 1997; 167: 299-302  

Introduction

More than 60% of childhood vaccinations in Australia are given by general practitioners (GPs),² and vaccination guidelines are published by the National Health and Medical Research Council (NHMRC) in The Australian immunisation handbook, which is updated regularly.^3-5

Studies in the United States have shown that health care systems and immunisation provider services contain major barriers to childhood vaccination, including inaccessibility, insufficient staff, insufficient clinic hours, missed opportunities to vaccinate (i.e., not vaccinating children who present for another reason and are due or overdue for vaccination), and misconceptions about true and false contraindications to vaccination.⁶ The existence or otherwise of these barriers to childhood vaccination in Australian health care has not been well researched, but one study showed that many immunisation providers in Victoria were unaware of the NHMRC recommendations for diphtheria-tetanus-pertussis (DTP) vaccine and combined diphtheria-tetanus (CDT) vaccine.⁷ Other studies found that GPs frequently do not follow the NHMRC recommendations for site of injection of vaccines and vaccine storage.^8,9

The National Childhood Immunisation Program was devised to address the problem of low vaccination cover - age through a coordinated national approach. The Program, which commenced in July 1994, involved Commonwealth, State and Territory health authorities, as well as professional and consumer bodies. Aspects of the Program included improving surveillance and reporting for vaccine-preventable diseases and vaccination coverage; improving vaccine purchasing, distribution and delivery; and educating parents, the general public and vaccination providers about vaccination.

We conducted two national surveys of GPs to estimate changes in vaccination procedures during the first two years of the National Childhood Immunisation Program.  

Methods

Sample selection and survey method

Both surveys were anonymous self-completion mail surveys. For each survey, an initial questionnaire and covering letter was sent to each GP, followed a week later by a reminder letter and a duplicate questionnaire. Practitioners were asked to ignore the reminder if they had already completed the questionnaire, and to return only one blank questionnaire if they did not wish to participate in the survey. The two surveys contained identical questions about GPs and their practices, vaccine storage methods and vaccination procedures. Questions on vaccination procedures and vaccine refrigeration were based on the NHMRC recommendations in the fifth edition of The Australian immunisation procedures handbook (1994). No identifying information was collected.  

Interventions

Survey 2 was conducted in April/May 1996, after the National Childhood Immunisation Program had been in place for almost two years. Activities of the Program during that time included distribution of the publications mentioned above (November 1994), a community education campaign (April to November 1995), and the introduction of the Australian Childhood Immunisation Register (January 1996).

During the period between the two surveys, other activities which may have affected GP immunisation practices included State and Territory initiatives to inform immunisation providers about vaccination procedures, changes in vaccine distribution and funding systems, the development of school-entry vaccination record requirements in some jurisdictions, media coverage, and local promotion of vaccination issues through Divisions of General Practice and other agencies.  

Statistical analysis

Results

Response rates

Vaccine administration procedures

There were statistically significant rises from 1994 to 1996 in reported willingness of GPs to vaccinate children with mild upper respiratory tract infections or who were taking antibiotics (Box 3), and there was a fall from 94% to 90% in the proportion of GPs who would not vaccinate a febrile child. There was no change between the two surveys regarding when CDT should be used to replace DTP, or vaccination for a child taking inhaled or topical steroids.

Reported storage of vaccines according to NHMRC recommendations improved between the two surveys, including use of a maximum/minimum thermometer, storing vaccines only on the top and middle shelves of the refrigerator and not storing food or specimens in the same refrigerator (Box 4). Although reported daily checking of the vaccine refrigerator temperature increased, in 1996 only 27% of GPs reported that this was done. A further 30% reported that the refrigerator temperature was checked weekly.

In November 1994, 15% of respondents reported their practices had immunisation recall/reminder systems functioning. In April 1996, 78% of GPs reported always contributing to the Australian Childhood Immunisation Register.

Discussion

Our study showed a significant improvement in several reported GP vaccination procedures between 1994 and 1996. The reasons for these changes are probably multiple, and include the information provided through the National Childhood Immunisation Program, State and Territory immunisation provider information and other professional education sources, as well as community and media interest in the topic. The degree to which each of these sources may have influenced the change cannot be assessed from our study. However, the coordination and information dissemination role of the National Childhood Immunisation Program meant that the information conveyed from health authorities and professional organisations to GPs between the two surveys was consistently based on NHMRC recommendations. Our results indicate, however, that more progress needs to be made in some areas.

Opportunistic vaccination, including in hospital emergency departments, has frequently been identified as a way of improving immunisation coverage.¹² In 1996, many GPs potentially missed opportunities to vaccinate by infrequently or never checking children's immunisation status when they presented for another reason.

The high use of the parent-held Personal Health Record identified in our survey was also found by Bailey et al.¹³ Recording of batch number on the Record and/or in practice records improved between the two surveys; this is recommended by the NHMRC to ensure that children potentially at risk of illness can be found if a faulty batch of vaccine is identified.

Misconceptions about true and false contraindications to vaccination have previously been recognised as barriers to full vaccination; this especially applies to when it is appropriate to replace DTP with CDT.^6,7 The NHMRC guidelines have previously not been clear about pertussis vaccination, and this is likely to have contributed to the confusion. Most GPs in our study would replace DTP with CDT if a child had a febrile convulsion or persistent screaming after the last dose of DTP. These are situations which were previously classed by the NHMRC as contraindications to DTP and which, in the 1994 recommendations, "may preclude" another dose of DTP. The 1997 sixth edition of The Australian immunisation handbook provides new, clear guidelines on pertussis vaccination.⁵ GPs need to be aware of these changes; following the new recommendations should increase pertussis vaccination rates and prevent more disease.

Vaccine storage procedures have been previously shown in New South Wales to be inadequate in many immunisation provider practices.^9,14 Although there were improvements between our two surveys, in 1996 only 27% of practices checked and recorded the refrigerator temperature daily. Correct vaccine storage is essential to maintain vaccine potency.

Our study looked only at private vaccination providers. We currently have no information about immunisation procedures of public providers, who administer around 40% of vaccines, and further studies are needed to assess procedures in this sector.

While many GPs have kept abreast of changing recommendations, further improvements are possible. In addition, because of the impending availability of new vaccines and combinations of vaccines, further changes to the vaccination schedule and recommendations are likely in the coming years. Our study has not identified the best way to inform GPs of changes in recommendations, and this must be determined. The 78% participation rate of GPs in the Australian Childhood Immunisation Register five months after its commencement shows that good communication channels with GPs are available. Further improvements in vaccination provider practices will result in more children receiving the correct, efficacious vaccines safely and on time.  

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