Uptake of infant and preschool 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

Reviewed by

Read the full article

Listed in

Log in to save this article

Abstract

In 2020, the SARS-CoV-2 (COVID-19) pandemic and lockdown control measures threatened to disrupt routine childhood immunisation programmes with early reports suggesting uptake would fall. In response, public health bodies in Scotland and England collected national data for childhood immunisations on a weekly or monthly basis to allow for rapid analysis of trends. The aim of this study was to use these data to assess the impact of different phases of the pandemic on infant and preschool immunisation uptake rates.

Methods and findings

We conducted an observational study using routinely collected data for the year prior to the pandemic (2019) and immediately before (22 January to March 2020), during (23 March to 26 July), and after (27 July to 4 October) the first UK “lockdown”. Data were obtained for Scotland from the Public Health Scotland “COVID19 wider impacts on the health care system” dashboard and for England from ImmForm.

Five vaccinations delivered at different ages were evaluated; 3 doses of “6-in-1” diphtheria, tetanus, pertussis, polio, Haemophilus influenzae type b, and hepatitis B vaccine (DTaP/IPV/Hib/HepB) and 2 doses of measles, mumps, and rubella (MMR) vaccine. This represented 439,754 invitations to be vaccinated in Scotland and 4.1 million for England. Uptake during the 2020 periods was compared to the previous year (2019) using binary logistic regression analysis. For Scotland, uptake within 4 weeks of a child becoming eligible by age was analysed along with geographical region and indices of deprivation. For Scotland and England, we assessed whether immunisations were up-to-date at approximately 6 months (all doses 6-in-1) and 16 to 18 months (first MMR) of age.

We found that uptake within 4 weeks of eligibility in Scotland for all the 5 vaccines was higher during lockdown than in 2019. Differences ranged from 1.3% for first dose 6-in-1 vaccine (95.3 versus 94%, odds ratio [OR] compared to 2019 1.28, 95% confidence intervals [CIs] 1.18 to 1.39) to 14.3% for second MMR dose (66.1 versus 51.8%, OR compared to 2019 1.8, 95% CI 1.74 to 1.87). Significant increases in uptake were seen across all deprivation levels.

In England, fewer children 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-in-1 (95.8 versus 96.3%, OR compared to 2019 0.89, 95% CI 0.86– to 0.91) to 2.1% for third 6-in-1 (86.6 versus 88.7%, OR compared to 2019 0.82, 95% CI 0.81 to 0.83).

The use of routinely collected data used in this study was a limiting factor as detailed information on potential confounding factors were not available and we were unable to eliminate the possibility of seasonal trends in immunisation uptake.

Conclusions

In this study, we observed that the national lockdown in Scotland was associated with an increase in timely childhood immunisation uptake; however, in England, uptake fell slightly. Reasons for the improved uptake in Scotland may include active measures taken to promote immunisation at local and national levels during this period and should be explored further. Promoting immunisation uptake and addressing potential vaccine hesitancy is particularly important given the ongoing pandemic and COVID-19 vaccination campaigns.

Article activity feed

  1. Version published to 10.1371/journal.pmed.1003916
  2. ScreenIT

    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
    SentencesResources
    Results have been reported using the STROBE (20) and RECORD (21) guidelines.
    RECORD
    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.

    About SciScore

    SciScore is an automated tool that is designed to assist expert reviewers by finding and presenting formulaic information scattered throughout a paper in a standard, easy to digest format. SciScore checks for the presence and correctness of RRIDs (research resource identifiers), and for rigor criteria such as sex and investigator blinding. For details on the theoretical underpinning of rigor criteria and the tools shown here, including references cited, please follow this link.

  3. Version published to 10.1101/2021.07.19.21260770v1 on medRxiv