Uptake of infant and pre-school immunisations in Scotland and England during the COVID-19 pandemic: an observational study of routinely collected data

  1. Fiona McQuaid
  2. Rachel Mulholland
  3. Yuma Sangpang Rai
  4. Utkarsh Agrawal
  5. Helen Bedford
  6. J. Claire Cameron
  7. Cheryl Gibbons
  8. Partho Roy
  9. Aziz Sheikh
  10. Ting Shi
  11. Colin R Simpson
  12. Judith Tait
  13. Elise Tessier
  14. Steve Turner
  15. Jaime Villacampa Ortega
  16. Joanne White
  17. Rachael Wood

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Abstract

Background

In 2020, the COVID-19 pandemic and control measures such as national lockdowns threatened to disrupt routine childhood immunisation programmes. Initial reports from the early weeks of lockdown in the UK and worldwide suggested that uptake could fall putting children at risk from multiple other infectious diseases. In Scotland and England, enhanced surveillance of national data for childhood immunisations was established to inform and rapidly assess the impact of the pandemic on infant and preschool immunisation uptake rates.

Methods and findings

We undertook an observational study using routinely collected data for the year prior to the pandemic (2019), and immediately before, during and after the first period of the UK ‘lockdown’ in 2020. Data were obtained for Scotland from the Public Health Scotland “COVID19 wider impacts on the health care system” dashboard ( https://scotland.shinyapps.io/phs-covid-wider-impact/ ) and for England from ImmForm.

Five vaccinations delivered at different ages were evaluated; three doses of the ‘6-in-1’ DTaP/IPV/Hib/HepB vaccine and two doses of MMR. Uptake in the periods in 2020 compared to that in the baseline year of 2019 using binary logistic regression analysis. For Scotland, we analysed timely uptake of immunisations, defined as uptake within four weeks of the child becoming eligible by age for each immunisation and data were also analysed by geographical region and indices of deprivation. For both Scotland and England, we assessed whether immunisations were up to date at approximately 6 months (all doses 6-in-1) and 16-18 months (first MMR) of age.

We found that uptake rates within four weeks of eligibility in Scotland for all the five vaccine visits were higher during the 2020 lockdown period than in 2019. The difference ranged from 1.3% for the first dose of the 6-in-1 vaccine (95.3 vs 94%, OR 1.28, CI 1.18-1.39) to 14.3% for the second MMR dose (66.1 vs 51.8 %, OR 1.8, CI 1.74-1.87). Significant increases in uptake were seen across all deprivation levels, though, for MMR, there was evidence of greater improvement for children living in the least deprived areas.

In England, fewer children who had been due to receive their immunisations during the lockdown period were up to date at 6 months (6-in-1) or 18 months (first dose MMR). The fall in percentage uptake ranged from 0.5% for first 6-in1 (95.8 vs 96.3%, OR 0.89, CI 0.86-0.91) to 2.1% for third 6-in-1 (86.6 vs 88.7%, OR 0.82, CI 0.81-0.83).

Conclusions

This study suggests that the national lockdown in Scotland was associated with a positive effect on timely childhood immunisation uptake, however in England a lower percentage of children were up to date at 6 and 18 months. Reason for the improve uptake in Scotland may include active measures taken to promote immunisation at local and national level during this period. Promoting immunisation uptake and addressing potential vaccine hesitancy is particularly important given the ongoing pandemic and COVID-19 vaccination campaigns.

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    SciScore for 10.1101/2021.07.19.21260770: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    Ethicsnot detected.
    Sex as a biological variablenot detected.
    Randomizationnot detected.
    Blindingnot detected.
    Power Analysisnot detected.
    Cell Line AuthenticationAuthentication: These data are validated and analysed by Public Health England to check completeness, query any anomalous results, and are used to describe epidemiological trends, as well as being used directly locally by the NHS for performance management.

    Table 2: Resources

    Software and Algorithms
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    Results have been reported using the STROBE (20) and RECORD (21) guidelines.
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    suggested: (RECORD, RRID:SCR_009097)

    Results from OddPub: Thank you for sharing your code and data.

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    Strengths and limitations: It is important to acknowledge the limitations of the data presented, many of which arise from opportunistically using routinely collected data rather than that obtained from a specific study design. The SIRS electronic system is well-established and captures data on the entire child population in Scotland. However, the aggregate surveillance data derived from the system that we could access lacked detailed information on several potentially important factors, not least of which was ethnicity, which is known to affect both immunisation uptake and attitudes towards immunisation. (23) In the 2011 Scottish Census, 92% of the population of Scotland identified themselves as White Scottish/British, and only 4% as non-white, whereas in England, 81% described themselves as White British and 14% non-white. (24) It may not be appropriate to extrapolate these data to countries with a significantly different ethnic make-up and it is plausible that some of the difference seen between the Scottish and English data could be due to these factors. In using the mean percentage of the entire year 2019 as our baseline comparator, we potentially run the risk of confusing normal seasonal variation in immunisation uptake with the impact of lockdown measures. Ideally, direct weekly or monthly comparisons would be made between 2019 and 2020, however quarterly trends published for previous years including 2019 do not show major difference in uptake throughout the year and in...

    Results from TrialIdentifier: No clinical trial numbers were referenced.

    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

    Results from JetFighter: We did not find any issues relating to colormaps.

    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
    • No protocol registration statement was detected.

    Results from scite Reference Check: We found no unreliable references.

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  2. Version published to 10.1101/2021.07.19.21260770v1 on medRxiv