Immunisation--lifting our game

The study by Herceg et al. in this issue of the Journal shows some encouraging trends in GPs' vaccination performance after the first two years of this Program.⁴ More GPs are now giving multiple vaccines at the same visit, injecting in the most appropriate site, and not inappropriately postponing vaccination if a child has a mild upper respiratory tract infection, or is taking antibiotics or using inhaled cortico steroids. However, few GPs reported consistently providing opportunistic vaccination. This is partly due to barriers inherent in the present system. GPs need better record systems to alert them to which children are due for vaccination, a greater commitment to providing opportunistic vaccination, as well as more flexible schedules so that they have the time to offer vaccination during family consultations.

To help overcome some of these barriers to vaccination, the Australian Childhood Immunisation Register was established by Federal and State governments in January 1996, as part of the National Childhood Immunisation Program. The Register sends vaccination reminders to parents and collects data on the vaccination status of individuals and the community. GPs, through their local Divisions of General Practice, have begun working in partnership with public health services to follow-up children who are overdue for vaccination. Unfortunately, some underreporting by vaccination providers has resulted in inappropriate reminders to parents and wasted effort in follow-up, but these problems could be overcome by streamlining the somewhat cumbersome reporting method (involving forms sent in batches to the Health Insurance Commission) and encouraging more GPs to install computer systems which report automatically to the Register. In addition, all providers need to be made more aware of the implications of not reporting.

GPs' uncertainty about pertussis vaccination, as reported by Herceg et al., is likely to diminish with the introduction of acellular pertussis vaccine to the Australian schedule over the next few months, and the clarification about contra indications to pertussis vaccination which is included in the 1996 immunisation handbook. Herceg et al. emphasise the importance of providing GPs with unequivocal information, as well as practical skills in educating and informing parents.

The Federal Government has also announced several initiatives to improve vaccination coverage which involve GPs, including vaccination days, public education programs, education for GPs, and support for projects initiated by Divisions of General Practice to improve immunisation coverage in local areas. An incentive payment through the Better Practice Program for GPs who achieve 90% immunisation coverage rates in their practices⁵ is another laudable initiative, but in the absence of some system of patient linkage it will be difficult to determine the appropriate denominator for such a calculation. One way to overcome this problem would be for parents to nominate their preferred vaccination provider when they register their child with Medicare (but this would not restrict their subsequent choice of GP for individual consultations). Thus, parents would be free to attend any GP, but one GP would be responsible for follow-up of their children for vaccination. This would also give GPs a clearer picture of which children they were responsible for. There is evidence that, with the aid of this information, GPs can improve vaccination levels even in lower socioeconomic and mobile population groups.⁶

Herceg et al. have shown that GPs' vaccination performance can improve with appropriate information and education. Education about vaccination should be a regular inclusion in GPs' continuing medical education and quality assurance programs organised by the Royal Australian College of General Practitioners and Divisions of General Practice. However, to achieve 95% coverage, educational interventions must be complemented by changes to the systems within which GPs operate, and concerted efforts at the local level, such as establishment of local immunisation coordinating groups involving Area Health Services, local government, Divisions of General Practice and consumer and community groups. The necessary commitment and collaboration between GPs and public health services can be achieved by financial and professional incentives, education and quality assurance.

R S Brian Kable
Chair, Preventive and Community Medicine Committee
Royal Australian College of General Practitioners, Sydney, NSW

Mark F Harris
Professor of General Practice, University of New South Wales, Sydney, NSW

1. Traynor V, Britt H, Bridges-Webb C, et al. Immunisation in general practice. Results from the Australian Morbidity and Treatment Survey 1990-1991. Aust Family Physician 1996; 25: 355-359.
2. Australian Childhood Immunisation Register. Preliminary data on proportion of immunisations reported by providers. Immunization Quarterly. Canberra: Commonwealth Department of Health and Family Services, April 1997.
3. Australian Bureau of Statistics. National Health Survey 1990. Canberra: ABS, 1990.
4. Herceg A, Johns M, Longbottom H. Changes in general practitioner vaccination procedures. Med J Aust 1997; 167: 299-302.
5. Wooldridge M. Immunise Australia. The Seven Point Plan. Commonwealth Minister for Health 1996. Canberra: Department of Health and Family Services, 1996.
6. Cullen R. Improving childhood immunisation rates in general practice: problems that affect comparison. N Z Med J 1995; 108: 171-172.