The all-of-life vaccination register is brimming with promise, so why is it dogged by so much dissatisfaction?
Mention the words “Australian Immunisation Register” in a room full of vaccination experts and see how quickly the mood slides into one of disquiet and defensiveness.
Frustration with the register was plainly evident at last month’s Adult Immunisation Forum held in Melbourne.
Advocates for adult vaccination have been hankering for a lifetime immunisation record for more than a decade. In September last year, the federal government finally granted their wish by transforming the longstanding Australian Childhood Immunisation Register (ACIR) into the Australian Immunisation Register (AIR).
The change was timed to coincide with the addition of shingles vaccine Zostavax to the National Immunisation Program, presumably so the government could track how many adults aged over 70 actually got the vaccine. It has been almost a year since that vaccine became free for older adults. But the government has remained silent on the coverage rates and there is no timeline for the release of data.
“We are hamstrung,” one forum attendee complained. “The Commonwealth ought to be providing, in a timely manner, a reasonable level of coverage [data].”
And the last national survey of adult vaccination was conducted in 2009. “That’s eight years ago. It is another example of the inequity. It would never happen with a children’s vaccine,” the attendee said.
The Medical Republic asked the Federal Department of Health if it could provide a schedule for release of adult immunisation data, only to be told: “At this stage, the Department is not publishing adult vaccination coverage rates.”
Childhood immunisation coverage rates are available on the Immunise Australia website, dating from 1997, when the register was first established. A Health Department spokeswoman said the AIR’s database on adult vaccination would grow over time. To fill the information void, a representative from Zostavax supplier, Seqirus, volunteered a proxy statistic at the Melbourne conference. “We have distributed over 50% of the catch-up cohort numbers,” a spokeswoman for the supplier said. “They [the vaccines] are not all in arms yet.”
TIME LAG OR INADEQUACY?
There are a few possible explanations for why the AIR isn’t living up to everyone’s expectations. Perhaps the system is running smoothly, as the government claims, but there is simply a time lag while information is collected. When the ACIR was rolled out in 1997, it was a good four years before the records reflected real vaccination rates, said Dr Rob Menzies, a UNSW researcher who specialises in vaccine preventable disease epidemiology. But, he added: “We shouldn’t have to wait that long for the AIR, because technology is much better now.”
For its part, Department of Health says there have been no major technical issues with AIR since its roll out in September last year.
And some vaccine providers concur. Angela Newbound, the immunisation project coordinator at Adelaide PHN, said the AIR was implemented with minimal disruption for providers.
“The AIR is already a very useful and beneficial tool,” Ms Newbound said. “The development of the AIR will continue for some time yet, and will have further enhanced features and functions. AIR data for adults will be available in due course and will be very useful in understanding adult vaccination coverage.” AMA vice president, Dr Tony Bartone, tells a similar story. “I am not aware of anything in terms of specific complaints or concerns,” he told TMR. “We are able to upload everything [following] our practice management software update.”
A different explanation for the slow progress of the AIR is that the system is not working properly yet. Ms Newbound acknowledged that some site disruptions had been experienced. “While these disruptions have caused some inconvenience, the AIR staff have been most helpful … and have worked tirelessly to ensure disruptions are minimal,” she said. “Teething issues” were also noted by epidemiologist Professor Paul Van Buynder, chairman of the Immunisation Coalition. But these glitches had mostly been resolved, he said.
However, some GPs were not yet entering vaccination data into the AIR, which could limit utility of the database, Professor Van Buynder said, adding: “The AIR is not yet fully functional.”.
The Department of Health’s own figures appeared to confirm this, with as many as 27% of all vaccinations not being recorded on the AIR by Medicare GPs. TMR spoke to one GP who said it took her over 40 minutes to attempt to gain access to the AIR and that she was struggling to use the system. And an immunisation nurse told TMR that some information sent to the AIR for adults bounced, but that it was very difficult to determine whether an error had occurred. This shook her confidence in the system. For GPs who have not yet transitioned to the new system, Ms Newbound recommended two the “How to use the AIR” resources provided by the Western Australian and Queensland governments. (1,2)
NO JAB, NO PAY FIASCO
The sometimes exasperating slowness with which systems such as the AIR develop is nothing new, according to Dr Margie Danchin, a paediatrician at the Royal Children’s Hospital and a senior research fellow at Murdoch Children’s Research Institute.
“The ACIR, which preceded the AIR for kids up to age seven, was exactly the same,” she said. The ACIR was achingly slow to update vaccination records. This caused havoc when, on 1 January last year, the government’s “no jab, no pay” policy swung into action.
“Parents tried to flock to their GPs to get their kids caught up on vaccines so that they didn’t lose payments,” Dr Danchin said. There were delays of up to six weeks in processing vaccination records. Parents who had fully vaccinated their children received letters from Centrelink threatening to cut off benefits and some families unfairly lost payments. Despite evidence to the contrary, the Federal Human Services Department Manager, Hank Jongen, told The Courier-Mail newspaper last year that there had been no backlog. “All the notifications are being processed within 14 days of when they are received from medical providers or State Government authorities,” he said in September. Dr Danchin disagrees.
‘“I think it would be very dishonest to say there are not issues with keeping the register up-to-date,” she said. Recording a full vaccination history and complex catch-up record for people with no previous record created a huge amount of work for primary-care providers. And there were no resources for providers to help them deal with the increased workload.
Difficulties in record-keeping put migrant and refugee families at particular risk of losing payments under the “no jab, no pay” policy, even though vaccine objection was very low or absent in these communities, she said.
Children born overseas often were not vaccinated or had no record of vaccinations. To prevent loss of payments, GPs had to spend up to 20 minutes per patient to enter a full vaccination history into the ACIR and implement complex catch-up schedules, researchers wrote in the MJA. (3) Providers reported unacceptable delays in updating the ACIR. Many services started faxing records to the ACIR due to inadequate capacity to enter information directly, the researchers said.
REGISTERING OBJECTIONS
From the start of the “no jab, no pay” policy, the ACIR no longer recorded registered objection to vaccination based on personal, philosophical or religious beliefs. This has continued under the AIR, much to the dismay of researchers.
The loss of this information was a blow to Dr James Fielding, an epidemiologist of vaccine preventable diseases at ANU, who had been using historical data to analyse the potential effectiveness of the policy.
His research, co-authored by Dr Danchin, found that Victorians living in postcodes with fewer economic resources were less likely to be immunised than those living in wealthier areas. (4) Financial barriers, such as not getting time off work or transport costs, might be preventing lower income families from accessing vaccinations, whereas conscientious objection might be lowering vaccination rates in higher socioeconomic areas, Dr Fielding said.
“This has raised red flags for us in terms of the ‘no jab, no pay’ policy,” he said. “It is actually kind of a double whammy for [lower income families],” Dr Fielding said. These families had difficulty accessing vaccinations without financial strain but, instead of receiving assistance, they were being further penalised.
Without recording conscientious objection on the AIR, it would be difficult to devise strategies for targeting that population in the future, Dr Danchin said.
The last available data showa 1.8% of Australians had registered a vaccine objection in 2014.(5) “But it’s actually higher than that,” said Dr Danchin. A recent study put the figure closer to 3.3% if an estimate of unregistered objections was included. (6)
All the evidence suggested that “no jab, no pay” might be a blunt instrument when it came to convincing anti-vaxxers to change their minds, Dr Danchin said.
A better policy would compel families to reevaluate their decision not to vaccinate their children on a yearly basis. Parents would need to have a conversation with their GP each year to register as a conscientious objector. This would also mean that families with inflexible attitudes, such as those who had one child with autism and mistakenly feared the effect a vaccine might have on a sibling, would not have payments stripped away, she said. Additionally, only around half of the 7 to 8% of children who are not fully immunised in Australia are not immunised because of conscientious objection. To actually improve vaccination rates, the government must target other groups, including migrants and children with access issues, Dr Danchin said.
FUTURE OF AIR
Outbreaks of vaccine-preventable diseases in Australia are rarely caused by conscientious objection. The 2012-2013 measles epidemic in Sydney, for instance, was driven more by under-vaccination in migrant communities.
And while vaccination levels in older adults fall well below what is required for herd immunity, that also cannot be explained by anti-vaccination sentiment.
The largest barrier to vaccination in Australia is identifying which individuals need vaccinations at what time. This is particularly pronounced in adult populations, which are mobile and often have multiple vaccination providers. When records are incomplete, GPs may hesitate to give certain vaccines due to the possibility that a patient might have received them previously.
A fully functional and smart AIR could solve that problem, said Raina MacIntyre, Head of School, School of Public Health and Community Medicine, at University of NSW.
Ideally, the AIR would automatically alert GPs about which patients were overdue for vaccination or at high risk of under-vaccination, regardless of age.
A state-of-the-art AIR could include additional information relevant to vaccination status, such as whether the patient is a healthcare worker, working in aged care, a migrant, an indigenous Australian or born overseas.
“These are often the people who are most at risk for infections,” Professor MacIntyre said. “That’s the kind of functionality that will really make a difference in terms of improving immunisation rates.”
It could also reduce vaccine wastage and potential adverse events from over-vaccination, she said.
The ultimate goal was to maximise the utility of the AIR, by recording information about adverse events, comorbidities, as well as closely tracking influenza vaccinations over the course of the flu season, she said.
Recording travel vaccines was particularly important for preventing the importing of infectious diseases.
A register that indicated whether a patient was a second-generation migrant could also give GPs a hint about their risk of contracting certain infections overseas.
“It’s about using the register as a way to promote vaccination as well as recording vaccination,” Professor MacIntyre said.
The current version of the AIR is very useful in identifying what vaccines a child is overdue for, but it lacks this functionality for adults. As the database for adult vaccinations grows, this capability will increase.
But how long it will take before providers feel confident relying on the AIR for adult vaccinations? That’s anyone’s guess. References: 1 Guide to Australian Immunisation Register, WA Department of Health (bit.ly/2uwbO4T)
2 Immunisation records and data explained: A guide for immunisation providers, 2nd edition, April 2017, Queensland Government (bit.ly/2tsRHjb)
3 MJA 2016, 3 October 4 Australian and New Zealand Journal of Public Health 2017, online 30 June
5 Immunisation coverage annual report, 2014
