Opportunistic vaccination in a children’s hospital outpatients department

Abstract

Correspondence to Dr Jonathan Cohen; [email protected] Vaccination coverage for all routine childhood immunisations is lower in London than in other English regions and below WHO targets.1 This is driven by factors that include sustained pressures in primary care and structural barriers to accessing vaccination, compounded by deprivation, other social inequities and population mobility,2 exacerbated by the COVID-19 pandemic.3 Opportunistic vaccination in secondary care settings, combined with existing efforts in primary care, may be an approach to increase coverage and reduce inequalities for underserved communities. Key challenges included the resource-intensive nature of the delivery model, integrating vaccination into routine patient care, ensuring outpatient staff access to patient immunisation records and triangulating conflicting patient immunisation records. [...]research should explore the feasibility of delivery models in which immunisation is integrated into routine patient care, particularly if supporting uptake across the childhood immunisation schedule.

Correspondence to Dr Jonathan Cohen; [email protected]

Vaccination coverage for all routine childhood immunisations is lower in London than in other English regions and below WHO targets.¹ This is driven by factors that include sustained pressures in primary care and structural barriers to accessing vaccination, compounded by deprivation, other social inequities and population mobility,² exacerbated by the COVID-19 pandemic.³ Opportunistic vaccination in secondary care settings, combined with existing efforts in primary care, may be an approach to increase coverage and reduce inequalities for underserved communities.

Our study evaluated the feasibility of opportunistic immunisation delivered in an outpatient department at Evelina Children’s Hospital, London, between October and December 2022. The service was an in-reach delivery model, with the ‘external’ Guy’s and St Thomas’ NHS Foundation Trust (GSTT) vaccination outreach service establishing vaccination clinics in the outpatient department. Inactivated polio vaccine-containing vaccinations were administered in support of the London-wide campaign for children aged 1–9 years following the detection of vaccine-derived poliovirus (VDPV2) isolates in London sewage treatment works.⁴ Children aged 1–9 years who were resident in London were eligible for vaccination in the campaign, regardless of prior vaccination history.

Nurses promoted vaccines in the waiting area on clinic days, assessing eligibility with a dedicated doctor who prescribed them in the absence of a patient group directive. A trained vaccinator administered the vaccine. Evelina outpatient staff had responsibility for booking clinic rooms and promoting the scheme.

High-level outcome data and information relating to programme design/delivery were collated for the evaluation. In addition, semistructured interviews (table 1) were held with Evelina (n=3) and GSTT vaccination service staff (n=5). The interviewer recorded a narrative summary. Data from two interviews—both GSTT vaccination service staff—were subsequently excluded due to interviewees having limited involvement in the intervention. Interview data were analysed through a three-step inductive thematic analysis approach.

Table 1

Questions asked to interviewees during evaluation of opportunistic immunisation delivered in outpatients

Question number	Question
1	Please can you describe the delivery model used to offer and deliver IPV vaccinations in this pilot?
2	What was your role in the delivery of this programme?
3	What were the successes in delivering vaccines through this delivery model?
4	Were there any challenges in delivering vaccines through this delivery model and/or in this setting more generally?
5	Do you feel offer of vaccination was beneficial for patients and how (eg, because they were unlikely/weren’t able to get vaccinated in another setting)?
6	Are there any key learnings from this pilot that you feel should be considered as part of this evaluation?
7	Do you feel that this delivery model, or an adapted version of it, could be adopted to support delivery of wider routine childhood immunisations in secondary care settings? Are there any key barriers that would need to be addressed?

11 vaccination clinics were delivered (October–December 2022). 258 potentially eligible children visited outpatients on dates vaccination clinics were held; 95 (37%) were vaccinated. Vaccination service staff cited three commonly reported reasons for non-uptake: patients had already received the vaccine elsewhere, patients were not eligible for IPV vaccination or patients/guardians wanted to focus on their primary reason for attending.

Key successes of the pilot included the ability to mobilise a rapid response to a national public health incident, increased access to vaccinations valued by families and having opportunities to discuss immunisations with vaccination specialists. Key challenges included the resource-intensive nature of the delivery model, integrating vaccination into routine patient care, ensuring outpatient staff access to patient immunisation records and triangulating conflicting patient immunisation records.

Vaccination in the outpatient setting was largely acceptable to patients and staff. This approach supports efforts to increase vaccination coverage by reaching a potentially vulnerable patient cohort. Uptake was encouraging, although the resource-intensive nature of the outreach delivery model means this specific approach is unlikely to be a sustainable way of delivering opportunistic immunisations in secondary care settings. Further research should explore the feasibility of delivery models in which immunisation is integrated into routine patient care, particularly if supporting uptake across the childhood immunisation schedule.

Many thanks to colleagues in the GSTT Vaccination Service and Evelina paediatric outpatients, the NHS England London Immunisation team and the NHS England London Legacy and Health Equity Partnership team and oversight group for their contributions to the delivery of this project.

Ethics statements

Patient consent for publication

Not applicable.

Ethics approval

Not applicable.

Footnote

JC and LW contributed equally.

Contributors The paper was conceived by all authors. All report authors were involved in the design of the intervention. JC was involved in the implementation of the intervention. LF led the thematic analysis, wrote the paper which was reviewed and edited by overseen by LW and JC. JC is the guarantor.

Funding Funding for the time of LF and LW for this pilot was through the Legacy and Health Equity Partnership, which in itself is an NHS England London Region embedded and funded programme to reduce inequalities in screening, immunisation and access to health. Guys & St Thomas’ NHS Foundation Trust was commissioned by the South-East London Integrated Care Board to provide vaccination services as part of the polio booster campaign.

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

References

¹ England N. Childhood vaccination coverage statistics. Available: https://digital.nhs.uk/data-and-information/publications/statistical/nhs-immunisation-statistics [Accessed 1 Dec 2024 ].

² Bedford H, Skirrow H. Action to maximise childhood vaccination is urgently needed. BMJ 2023; 383: 2426. doi:10.1136/bmj.p2426

³ Hoang U, de Lusignan S, Joy M, et al. National rates and disparities in childhood vaccination and vaccine-preventable disease during the COVID-19 pandemic: English sentinel network retrospective database study. Arch Dis Child 2022; 107: 733–9. doi:10.1136/archdischild-2021-323630

⁴ Department of Health and Social Care. Joint committee on vaccination and immunisation statement on vaccination strategy for the ongoing polio incident 2022. Available: https://www.gov.uk/government/publications/vaccination-strategy-for-ongoing-polio-incident-jcvi-statement/joint-committee-on-vaccination-and-immunisation-statement-on-vaccination-strategy-for-the-ongoing-polio-incident [Accessed 1 Dec 2024 ].