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Brakes put on booster scheme

04 Sep 2013

Dara Gantly

Dara Gantly looks at the rationale behind the HSE’s decision to pull the vaccination of the pre-school booster out of GP surgeries.

It hasn’t gone away, you know. Since the beginning of the year, there have been large outbreaks of measles right across Europe. In Wales alone there have been more than 1,300 cases (thankfully, the measles outbreak in the Swansea area was declared over on  July 3), and more than 900 cases have been reported in Germany, with other outbreaks in the Netherlands, France and Italy. Between January and the beginning of July, Ireland saw more than 30 cases of measles — 10 confirmed — with 17 cases in the HSE East.

Since 2010, Ireland has been committed to the World Health Organization’s European strategy to eliminate measles by 2015. The recommendation is for at least 95 per cent of children to receive a first vaccination with the measles, mumps, and rubella (MMR) vaccine before age 2 and a booster before 5 years of age to achieve herd immunity and prevent outbreaks. But Ireland — like many countries — is failing to reach that goal.

The HSE provides the vast bulk of vaccines for 4- to 5-year-olds through the schools immunisation programme. It was only in January of this year that the Health Protection Surveillance Centre (HPSC) first made available comprehensive school immunisation programme data at national level. It revealed that the national uptake of the MMR vaccine was 84 per cent, but this ranged from 79 per cent in the West to 89 per cent in Dublin Mid-Leinster. Another apparent (more anon) black spot was in Dublin North East, where the uptake for MMR2 vaccinations in many areas hovered, according to the Executive, between 72 and 76 per cent.

In Dublin North Central, Meath, Louth and Cavan/Monaghan, the booster programme is not delivered in schools by the HSE but by local GPs in their own surgeries. However, this programme — and its associated payments to GPs — has been pulled, with the HSE deciding from October that the best way to achieve uptake rates greater than 95 per cent is through a school-based approach.

Is this the right move? In a recent letter to GPs in the region, the HSE’s Regional Director of Operations Leo Kinsella stated that much of the evidence from international literature backed a school-based programme, referencing a study from the Journal of Public Health (J Public Health (2012) 34 (4): 498-504. doi: 10.1093/pubmed/fds047). This paper from Wales found that higher uptake rates of the ‘teenage’ booster were achieved with greater consistency in schools (76–81 per cent) compared with general practice (5–74 per cent). But should we be satisfied with 81 per cent? Is it not time for the Executive to inject some new thinking into the scheme?

On first examination, the figures in the North East appear to raise concerns. However, uptake rates in Louth, Cavan/Monaghan and Meath are actually not available, according to the HPSC, so the HSE’s low figure mentioned above is disputed by some.  And the GP-led scheme in Dublin North Central actually recorded a higher uptake rate (79.3 per cent) than the parallel HSE school immunisation programme in place in Dublin North West (74.5 per cent). So should we be ditching one for the other?

What is not disputed is that the current system needs improving. Yet instead of taking the vaccinations away from general practice, should the State not be utilising GPs to their full potential? As Cavan GP Dr Garrett Igoe points out in a letter in this week’s publication (see page 18), GPs achieve very high rates for primary immunisation — 95 to 100 per cent in many areas. He points out that when GPs took over the primary vaccination of infants, key to the scheme’s success was providing them with an accurate target population list, generated by the public health nurse (PHN). Could the PHNs not do the same with all 4-year-olds and provide GPs with a pre-school target list to vaccinate? Given such administrative assistance, does anyone doubt that the GPs in the North East would step up to the mark — especially if properly incentivised?

GPs in parts of the HSE West also administer the boosters and IMT has heard reports (unconfirmed by the HSE at time of going to press) that GPs in the region were no longer being reimbursed for the vaccinations, and were having to charge patients Ä20. Doctors were also concerned that no arrangements, apparently, had been put in place for entering those children’s vaccination details onto the national database, now that GPs were no longer being paid. Clarification is awaited from the HSE.

As someone about to take parental leave to care for their 1-year-old infant — and who will be arranging a first MMR vaccination within weeks — I would prefer the GP surgery as a setting for her booster vaccine.  But from a public health perspective, reaching the magic 95 per cent uptake rate should be our main goal. Yet we also need to protect against scoring a possible OG in the process.

4 September 2013

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