Creating immunity through vaccination is second only to clean water in the fight against infectious disease-related deaths worldwide (Andre et al, 2008). Thankfully, vaccination means that individuals, families and communities in the UK no longer experience the devastating effects of more than 20 diseases (Jakab, 2020). Although primarily used to prevent disease, as in the case of smallpox, vaccines also reduce transmission and severity of disease.
The national vaccination campaign response to the COVID-19 pandemic is testament to the impact that vaccination has on the transmission and severity of disease. More than 25 million people in the UK have now had the vaccine and its impact on reducing symptomatic disease and hospitalisation is already evident (Lopez-Bernal et al, 2021). For many of us, this will be the first time we have witnessed the real-time impact of vaccination.
Taking a life-course approach to vaccinations in the UK
Vaccination is a routine element of NHS universal health care, which starts before birth and has proven success in improving key health outcomes. For example, rubella vaccination prior to conception, with its associated 95% immunity (Plotkin and Orenstein 2004), has eliminated rubella infection and reduced the risk of congenital rubella syndrome (Public Health England (PHE), 2019). Furthermore, the introduction in 2014 of pertussis (whooping cough) vaccination for all women during pregnancy has reduced the number of babies dying in the first 3 months of life (Amirthalingam et al, 2014). The offer of free vaccination continues from 8 weeks of life for all people across the UK, extending further to include travel vaccines for those visiting countries where diseases such as polio, hepatitis A and typhoid, remain prevalent.
Advancing age causes degenerative changes to the immune system, called immunosenescence, which leads to increased susceptibility to infections such as influenza, pneumococcal disease and shingles (Crooke et al, 2019). Consequently, vaccination remains an important part of ageing healthily.
Advised by the Joint Committee for Vaccination and Immunisation (JCVI), the UK's vaccination programme is both evidence based and dynamic, responding to emerging research and disease threats. The JCVI ensures that all the UK health departments are appraised of the evidence for vaccination, the burden of disease, vaccine safety, efficacy and the impact and cost-effectiveness of vaccination strategies.
Since its inception as the advisory board for polio immunisation in 1963, the JCVI has been instrumental in the vaccination schedule we use today. Indeed, it is playing a vital role in the national coronavirus vaccination strategy, and helping the UK to set its focus and direction in terms of the order that people are invited for vaccination. Sustained uptake of vaccination will mean that individuals, communities and families in the UK can effectively move out of the public health restrictions accompanying the pandemic. This should remind us how the UK's vaccination programme safely and effectively improves people's health and wellbeing, and that failure to vaccinate will result in unnecessary morbidity and mortality (Jakab, 2020). Box 1 provides a summary of the key terms used in this article.
Box 1.Immunisation: the basics
| Vaccine | A medicine that stimulates a person's immune system, protecting the person from that disease |
| Vaccination | The act of introducing a vaccine into the body to produce immunity to a specific disease |
| Immunisation | A process by which a person becomes protected against a disease through vaccination. This term is often used interchangeably with vaccination or inoculation |
Adapted from: Centers for Disease Control, 2018
Confidence in vaccination is high in the UK, with only 2% of parents reportedly refusing vaccination for their children, with health professionals and the NHS seen as the most trusted sources of advice on vaccination (Campbell et al, 2017).
Most people in the UK are happy to engage with vaccination programmes, with uptake in the first 5 years of life close to 95% (NHS Digital, 2020). Consequently, fewer than 130 people contracted measles in 2014 compared with more than 460 000 a year in 1967 (PHE, 2016). However, the success of the vaccination programme may also risk reducing uptake as those with no experience of the disease fail to perceive their risk of infection and fail to consider their need for protection (Bedford, 2021). When vaccine uptake is insufficient to create population immunity, the resulting fall in herd immunity makes it possible for the disease to return.
As health and care professionals, we may attribute people's inquiry about vaccination or a refusal to be vaccinated to hesitancy. This could be due to several reasons, including complacency (no need for the vaccine), convenience (lack of access to the vaccine) and confidence (a lack of trust in vaccine provider) (World Health Organization, 2014). Consequently, if we are to enable all people to benefit from vaccination, we must ensure that our response to each inquiry is comprehensive.
Vaccination uptake and coverage may be lower in vulnerable and underserved groups, such as migrants, looked after children, people with disabilities, and traveller and Roma communities. Individuals with increased risk of disease, or more severe disease, such as the immunocompromised or chronically ill, derive more benefit from vaccination than otherwise healthy people. Ensuring high vaccine uptake in these group can lessen inequality in disease outcomes (PHE, 2021a). Nurses can contribute to this by, for example, monitoring vaccination status as part of a wider assessment of children and young people's health; they could also consider home visits to discuss immunisation or adopting a strategy of offering vaccination to groups that may not use primary care services, for example, travellers or asylum seekers (National Institute for Health and Care Excellence, 2017).
To support all health and care professionals to comprehend the importance but, more importantly, take action on supporting the UK's vaccination programmes, PHE has published online e-learning resources on the topic. The All Our Health (PHE, 2021b) framework is a call to action for all health and care professionals to embed prevention, early intervention and health improvement in their day-to-day practice. Through educational materials, tools and resources (see Case study).
Building back better and fairer
As we start to focus on the recovery phase of the COVID-19 pandemic, it will be essential for our nursing and midwifery workforce to appraise the lessons learnt and consider what changes need to be made to ensure that we build back better and fairer. The 2020s need to be used as a decade that sees transformation across our nursing and midwifery workforce, placing equal focus on both preventing disease and treating it. In addition, to truly address the unacceptable outcome differences that have been amplified by the pandemic, we will need to urgently consider our important role in addressing the existing health inequalities, such as those affecting people living in deprived communities or certain ethnic groups.
Case Study
Registered nurse Abdul works in the emergency department of his local hospital. The December to March winter months are extremely busy and sometimes upsetting when older people are admitted with the flu. He is surprised because he thought that flu was no longer something that made people so unwell that they needed to come to hospital. One night shift in mid-December an elderly man, Ron, is admitted feeling very unwell and short of breath. Abdul recognises him as having been previously admitted in September and November. Looking at Ron's health records, Abdul can see an entry stating that he had refused the influenza and pneumococcal vaccine on both occasions.
Abdul finds out from Ron's daughter that he had not refused the vaccinations, but chose not to arrange to have them because he was scared they would interfere with his medication. She tells Abdul that her father is a proud man and he hadn't wanted to waste anyone's time asking silly questions, so he decided not to pursue his inquiry.
Abdul has limited knowledge of the influenza and pneumococcal vaccines. He is aware that the Nursing and Midwifery Council (NMC) Code of practice states he should avoid making assumptions and should act on best evidence when advising people about treatment to protect their health. Abdul decides to do some research using the All Our Health resources (NMC, 2018; Public Health Education (PHE), 2021b).
Abdul consults chapters 19 and 25 of the ‘Green Book’ (PHE, 2020) and learns that Ron will only need to have the pneumococcal vaccine as a one-off and that he should have the influenza vaccine once every year. Because Ron finds it difficult to leave his home without help, Abdul contacts his GP, asking that he is put on the list for domiciliary visits, so he can be offered the vaccine following discharge from hospital. This also means that Ron can be offered the vaccine the following year. After spending time talking with Ron and his daughter, Abdul realises that Ron would be happy to have the vaccinations, once his questions about them and his current medication have been answered.
On reflection, Abdul could see that his work with Ron began when he asked him why he hadn't had the vaccinations, rather than merely assuming that non-vaccination was the consequence of refusal. The All Our Health framework provided an accessible set of resources for Abdul to consult, as well as written information that he could share with Ron and his daughter. Increasing his own understanding of how the vaccination service is offered to people in the community meant that Abdul could contact the GP on Ron's behalf and put a plan in place for him to have an annual influenza vaccination in future.
Until this point Abdul would not have described himself as a public health practitioner, because he had assumed public health nurses worked only in the community. Following this brief intervention, working with Ron and his daughter, Abdul could see that his practice had made a big difference and would hopefully prevent future hospital admissions. Abdul realised that he was playing a critical public health role within his current practice and recognised that all nurses played an important role in preventing illness, protecting health and promoting wellbeing.