§ Motion made, and Question proposed, That this House do now adjourn.— [Mr. Goodlad.]11.10 pm
§ Mr. John Hannam (Exeter)
This Adjournment debate gives me the opportunity to draw attention to a matter of extreme importance in the context of the health of our nation. Vaccinations against serious diseases have been part of our lives for many years, and the worldwide campaign against smallpox, polio and diphtheria has resulted in the near eradication of those awful illnesses.
However, when it comes to other diseases such as whooping cough, measles and rubella, the picture is not as rosy, and I shall explain why the Department of Health should go further in promoting greater take-up of immunisation.
In 1940, before the vaccination programme got under way in England and Wales, 857 children died of measles and 678 of whooping cough. Many more were left disabled and ill. In the 1970s, when the whooping cough vaccine scare peaked as a consequence of the widespread publicity given to the vaccine damage compensation campaign, vaccination rates dropped to 30 per cent. at one point. and the old cycle of whooping cough epidemics began to return.
As recently as 1986, there were 36,500 notifications of whooping cough, which probably represented some 40 per cent. of the actual number of cases. That year, there were more cases of whooping cough in the United Kingdom than in the United States of America. Since then, matters have improved and immunisation rates have increased—although it is difficult to measure the effectiveness of national immunisation policy year after year without relevant records of the number of deaths or cases of disablement caused through non-vaccination. I ask my hon. Friend the Under-Secretary of State for Health to provide those figures, so that a benchmark can be established for years to come.
I confirm from my own discussions with constituents in recent days that families whose children were not given the whooping cough vaccine in the 1970s because of the scare campaign report without exception that there is among their children a high incidence of asthma following earlier attacks of whooping cough. I hope that my hon. Friend is aware of the longer-term effects of such diseases, even if they are not fatal. I certainly want to avoid a long-drawn-out public battle for compensation for those very few who suffered possible reaction to the earlier vaccines, but it must make sense to provide adequate compensation and to ensure the efficacy of the whole immunisation programme.
I am pleased to note that figures published recently by my hon. Friend the Under-Secretary show a further improvement in uptake rates in England and Wales, to 80 per cent. for measles vaccination, although that still means that one child in five remains unprotected, and to 75 per cent. for whooping cough, though with one child in four left unprotected.
The World Health Organisation's target for Europe in 1990 is 90 per cent., so Britain still falls well short. Worse still, the averages conceal substantial variations from district to district, with take-up in inner-city areas such as Hackney and Newham in London as low as 51 per cent., and in the low 60s in Liverpool, Birmingham, Manchester 1008 and Blackburn. For some groups, particularly ethnic ones and those in inner cities, this means that one in two children in such areas are not being vaccinated. Is my hon. Friend aware that the reason given for non-vaccination is usually apathy rather than resistance to it? The result in human terms is tragic if children die or suffer disability from preventable diseases.
It was because of a growing concern among many people working in medical research that Action Research for the Crippled child, on whose council I sit, last year commissioned an in-depth study by Professor Catherine Peckham into the factors influencing immunisation uptake in childhood. Her excellent report was published in April 1989. My purpose in seeking this debate tonight is to re-acquaint the Department of Health with the key recommendations in the Peckham report and to seek my hon. Friend's assurance that they are being given the most urgent consideration with a view to achieving and, more importantly, sustaining total protection from the preventable, infectious diseases of childhood. It is ironic that we spend millions of pounds researching new vaccines when we are not utilising the ones that we already have to full effect.
The Peckham study was based in 16 different district health authorities and random samples from general practitioners, consultant paediatricians, health visitors and clinical medical officers working in child health were taken. Some 2,071 health professionals were contacted and 86 per cent. responded. In addition, from each district, a sample of two-year-old children was drawn from six randomly selected general practices. That age group was chosen because the children should have completed their primary course of immunisation and the parents would have recent memory of it. Of 3,871 parents approached. 87 per cent. responded.
The Peckham report has effectively pointed the way for us to go if we really intend to translate a 99 per cent. parental consent for their child to be included in the immunisation system into achieving the World Health Organisation target of 90 per cent. actual uptake by next year.
The principal findings of the study were clear. First, health professionals demonstrated uncertainty about the contra-indications to measles and whooping cough immunisation. Their responses indicated inconsistency in the interpretation of contra-indications within and between professional groups. That has two important consequences—an unacceptable proportion of children are being denied immunisation for invalid reasons, and parents are being given conflicting advice.
Secondly, parents' attitudes had a marked effect on measles and pertussis vaccine uptake. A parent who thought measles was a serious disease and that the vaccine was safe and effective was much more likely to have his child immunised than the one who thought otherwise. Perceptions of the safety of pertussis vaccine was shown to be particularly important in determining uptake of it.
Family factors found to be associated with lower uptake included a large family, the presence of a chronically ill child and lower social class. The individual perception of a disease is important and, as immunisation rates increase and the disease becomes less common, the public forget the seriousness of it and may regard it as rare and trivial. 1009 Measles is frequently viewed as a trivial childhood illness, yet it is associated with significant morbidity and even death. It is the most common cause of death in children in remission from leukaemia.
As the study was carried out on a large randomly selected population with a very high response rate from parents and health professionals, the results can be generalised to apply to the entire country. Overall, health professionals had a positive attitude to immunisation and said that they encouraged it. One of the main obstacles to a child being immunised was the general practitioners' misconceptions about contra-indications to immunisation. It is estimated that only 1 per cent. of children have valid contra-indications to the measles vaccine and 3.5 pet cent. to the pertussis vaccine. It is clear that many children are being deprived of immunisation because health professionals inappropriately consider certain conditions or circumstances to be contra-indications.
Unless there are genuine contra-indications to vaccination—and there are few—it is irresponsible to fail to protect a child from a potentially damaging infection. The decision to withhold vaccination should be taken only after serious consideration of the consequences for the child and the community. It is partly the responsibility of practitioners to ensure that their knowledge of vaccination is up to date, but they cannot be held totally responsible for their uncertainty. Official guidelines have tended to be complicated and to leave excessive margins of doubt. I believe that the Department is intent on improving those guidelines, and I hope that my hon. Friend the Minister will confirm that tonight.
My hon. Friend will be aware that there is a wealth of additional detail provided by the Peckham report, which I have neglected in the interests of brevity. I conclude my references to the report by drawing attention to the summary of recommendations in the letter of the director general of Action Research for the Crippled Child on 11 July 1989, which pointed specifically to two or three fundamental requirements confirmed when the report was first subjected to professional scrutiny during a workshop convened by the Prince of Wales advisory group on disability last June.
It received unequivocal support from the Prince of Wales, when he said of the workshop's conclusions:What seems to emerge clearly (from the Peckham Report and the discussion of it) is that our performance will only improve sufficiently—and be maintained—by introducing certain basic changes to the current system.
Earlier, I mentioned the high take-up rate in the United States. There, laws require proof of immunity as a condition of school entry. The result is that, whereas the United Kingdom has 80,000 to 100,000 notifications of measles each year, the United States averaged about 1,500 to 6,000 cases each year between 1981 and 1987. In the south-west of England, in my area, in 1986 we had more cases than in the whole of the United States. It is on the basis of a proven system, linked to school entry, that this country must proceed if it is to achieve the 90 or 95 per cent. measles immunisation rate.
The policy being advocated is not compulsion but one which, at the very least, puts parents in the position of having to make a definite decision about immunising their child. That would ensure that only those children who should not be vaccinated for sound medical reasons, or 1010 those whose parents objected strongly for other reasons, were excluded from the protection which should be their right. It is evident from the strength of parent input to the report that responsibility for immunisation shared with the parent would be welcomed.
Standard parent-held records would be necessary to achieve that and would provide the mechanism for reviewing immunisation status at regular intervals during early childhood. Children should certainly be immunised at the earliest possible age, but for those who might otherwise fall through the net, a requirement to present the immunisation record before enrolment to day care, nursery school or secondary school, would ensure review of their immunisation status. Those children found not to be immunised should be vaccinated, provided that there are no valid contra-objections or parental objections.
It is my contention, and the strongly held view of the all-party disablement group, that the linchpin in a future immunisation system will be the introduction of a health record for every child, issued on registration of birth and related only to immunisation status, perhaps not dissimilar to the international certificate of vaccination issued as a requirement for entry to many countries when smallpox was still a threat. I still have my old certificate of vaccination in my passport in case I have to produce it on a visit to some part of the world.
Once high levels of immunisation uptake have been achieved, it is essential to maintain them. One cannot rely on repeated campaigns to effect that, and we should act responsibly to ensure a mechanism for the certain protection of future generations.
I congratulate my hon. Friend the Minister on the pilot study carried out by a number of health authorities and also on the accelerated schedule of primary immunisations at two, three and four months. However, I hope that he does not reply tonight that the Department is about to launch another publicity campaign. If we are to protect future generations from unnecessary death and disability, we need a straightforward policy of guidance for the practitioners and health record cards for the parents. Action Research for the Crippled Child and Catherine Peckham have shown the way, and I hope that my hon. Friend will follow their path.
§ The Parliamentary Under-Secretary of State for Health (Mr. Roger Freeman)
The House owes a debt of gratitude to my hon. Friend the Member for Exeter (Mr. Hannam) for his clear presentation of this subject. The House knows of his work with the all-party disablement group, which gives him a special expertise in this matter. I know that he is concerned not only for his constituents in Exeter, but for the children of the whole population. I agree with the basic thrust of his remarks, that parents should have their children immunised. The risks that he identified, especially in relation to pertussis, are modest indeed compared with the great benefits that flow from immunisation.
I should like to give my hon. Friend the most up-to-date statistics, for which he asked. Over recent years, immunisation uptake rates have been rising and the most recently available figures—for England for the year 1988–89—show that the uptake for polio, diphtheria and tetanus vaccines is now 87 per cent., measles vaccine uptake is 80 per cent. and that for pertussis vaccine, for whooping cough, 75 per cent. 1011 Given the rate of rise of these figures, and the fact that the measles uptake figure precedes the introduction of measles, mumps and rubella vaccine, which my hon. Friend will recall is now being offered to children just about to enter school, as well as to youngsters, we now have real prospects of reaching the 90 per cent. 1990 uptake targets set by the European region of the World Health Organisation—targets that are important milestones on the road to the elimination of these diseases, which is targeted for the year 2000. We have already achieved the elimination of poliomyelitis from this country and I am pleased to report that this success is recognised by the World Health Organisation, which lists us among the category A countries in which this disease no longer exists. Some other European countries have some way to go before they achieve that recognition.
In October 1988, we launched a new combined measles, mumps and rubella vaccine with the objective of improving measles uptake, eliminating mumps and the congenital rubella syndrome, a serious consequence of maternal rubella infection, which leaves babies who may be born blind or deaf with congenital heart disease or mentally handicapped. Although it is too early to measure the impact of this initiative on immunisation uptake, there are other measures available to us that give us reason to consider this initiative a considerable success.
The new vaccine has been recommended for the priority groups of children—those aged 12 to 15 months—in place of the previous measles vaccine, and for those aged four to five years coming for their pre-school booster immunisations. If every such child was to be immunised, we would have needed 1.5 million doses for the period October 1988 to January 1990. I am pleased to be able to tell the House that, over that same period, we distributed in excess of 3 million doses—more than twice the required amount. This enthusiastic use of vaccine suggests that it has been given not only to the priority children but to many others, and this will interrupt transmission of measles, mumps and rubella even sooner than we predicted.
Immunisation uptake provides a sensitive indicator for performance of the provision of immunisation services, but it measures the route through which our goals will be reached. Notification of diseases, and indeed their absence, provide the outcome measures that we seek to achieve. It gives me pleasure, therefore, to be able to report how our efforts to promote immunisation are producing very encouraging results for outcomes. Since the introduction of MMR vaccine, notifications of measles have been at the lowest levels ever. When 1990 is compared with 1988 and 1986—these are the appropriate years for comparison because of the cycle of the affliction—we find that notifications for the appropriate months are about 90 per cent. fewer than four years ago—a remarkable achievement. Every week there are significantly fewer children suffering the frequently underestimated and potentially very serious complications of measles.
We can see similar successes in the notifications for whooping cough. On the basis of previous epidemics, it could have been thought likely that there would be a whooping cough upsurge over the winter of 1989–90. Although notifications did rise last year, they reached their peak in the same months as the 1985 epidemic, but there were 70 per cent. fewer notifications, again suggesting that the successful promotion of immunisation has led to so many more children being protected from serious diseases.
1012 My hon. Friend may be interested to know that the new contract for doctors came into force today. This is the first working day of that new contract and he will be aware that incentive payments for immunisation are built into it. I know that he supports that principle.
The incentive payments in the contract cover only three immunisations: whooping cough, diphtheria-tetanus and polio; these vaccinations tend to run together, in that they are given at the same time. DT and polio is the second and measles is the third. We use measles as a proxy for the MMR vaccination. We take whooping cough, DT, polio and measles and for children aged two on a doctor's list, we make a calculation every quarter day by averaging the doctor's success with those three lines, using the completing dose.
My hon. Friend will know that there are three doses for DT, polio and whooping cough, and we make a payment on each quarter day. If the doctor achieves a 70 per cent. target figure, a quarterly payment, which over the year adds up to £579, is made. If a 90 per cent. target figure is reached for the averages of all three, a quarterly payment, which in the coming financial year will be £1,737 for the year, will be made.
There is a second target for five-year-olds, where we measure success in relation to the second diphtheria vaccination—the booster—and also tetanus and polio. A 70 per cent. success rate brings a payment of £193 over a year, and a 90 per cent. uptake results in a payment of £579. That information may be helpful, because I do not think that we have put it on the record as clearly as I hope I have outlined.
My hon. Friend spoke about the Peckham report. Although, as I have said, uptake figures are rising, in some areas they remain too low. I think that my hon. Friend cited some inner-city areas in Liverpool and London. The Department of Health undertook careful investigation last year into the reasons for poor performance and, along with other measures, commissioned a study of the management of the immunisation programme in every health authority.
The Joint Committee on Vaccination and Immunisation consists of clinical professionals and is a multi-disciplinary group advising the four territorial departments of England, Wales, Scotland and Northern Ireland. That committee carefully considered the reasons that lay behind the difficulties preventing higher uptake and has recommended that the schedule of primary immunisations be changed to an accelerated schedule used in all health authorities. This new schedule will start from May. The benefits that it will offer will be the likelihood of higher acceptance rates, earlier protection against whooping cough, fewer opportunities for immunisation to be postponed because of minor illnesses and greater convenience for parents as the immunisations will be given over the period when infants are brought regularly to clinics and before mothers return to work.
From memory, I am referring now to immunisations at two, three and four months after birth, as opposed to the longer period which currently exists and which can range up to 11 months or more. Professor Peckham has welcomed that change. After Easter, the Department of Health will issue a new edition of the memorandum "Immunisation against Infectious Disease". That is a green document which I am sure my hon. Friend has read. It provides details of the new schedule along with authoritative guidance on contra-indications, both 1013 genuine and false, and adverse events associated with immunisation. I shall send a copy of this document to my hon. Friend and also place a copy in the Library. I hope that, when he sees it, he will feel that I have answered his questions about greater guidance being given on contra-indications, which simply means medical reasons for children not being able to receive appropriate vaccinations.
In the autumn, there will be a national advertising campaign, promoted by the Department of Health and the Health Education Authority, to promote immunisation as the safest way to protect one's child. The campaign, which is being piloted in the Granada Television region, will use television advertising, along with material in newspapers and magazines.
Last year, Action Research for the Crippled Child published a valuable report on immunisation. Professor Catherine Peckham carried out the inquiry on its behalf. The report confirmed previous research that identified poor knowledge of immunisation contra-indications, undue fears over adverse effects, especially associated with pertussis vaccine for whooping cough, and lack of consistency of immunisation advice.
The Peckham report made recommendations, some of which relate to matters at health authority level that the Department of Health would support. The forthcoming change of the immunisation schedule will result in all children being given their immunisations according to an agreed national timetable—one of the report's main recommendations.
The report also recommends the availability of parent-held records of child health that would document the immunisation that a child has received. My hon. Friend's arguments were very persuasive. I am grateful to him for underlining the value that he believes a parent-held record card would provide. I am persuaded by his arguments. Such cards are on trial. My Department will be most interested in the outcome of the trials. I shall follow the results of those trials with a close personal interest. Furthermore, the Department of Health will shortly be issuing new immunisation record cards for all family practitioners to ensure that they are able to keep accurate immunisation records on all their patients.
Although the Peckham report does not recommend legal compulsion or school exclusion of unimmunised children—it recommends that, before school entry, the 1014 immunisation records of all children should be checked and that unimmunised children should be offered immunisation, a process facilitated by parent-held records —there are countries such as the United States where immunisation is, in effect, compulsory. Yet there are, equally, countries such as Holland and the Scandinavian countries where the uptake rates are exceptionally high without any form of compulsion. Moreover, those high rates are achieved before the age of two—that is, before the transmission of the appropriate diseases.
Although the United States policy initially led to dramatic reductions in measles, mumps and rubella notification, the United States is presently experiencing the worst outbreak of measles for many years. Many of these cases are occurring in children below the age of school entry, whose parents have delayed immunisation until it is compulsory. The lesson, perhaps, of the problem is that school entry measures may be too late to interrupt measles transmission and that the greatest successes will come from the attainment of the highest levels of uptake as early in life as possible—preferably without compulsion, but with the full support of doctors and parents alike.
My hon. Friend referred to the problem in the inner cities, where the uptake rate is undeniably low. The new contract which runs from today provides for much higher allowances—the so-called deprivation allowances—to be paid to the general practitioner for having a patient list in such areas. They amount to £8.50 a head, which can provide up to £17,000 a year for a doctor with an average patient list. That is a real additional resource to enable doctors to fight hard to increase the uptake of immunisation and cervical screening.
I understand my hon. Friend's views on publicity and campaigning. However, I believe that they have a part to play, in addition to the national campaign in the autumn, to which I referred. I assure my hon. Friend that I shall reflect carefully on whether we need to take specific measures in relation to the ethnic minority community, particularly Asian mothers who, in some parts of the country, may need to be persuaded about the value of immunising their children. Some success has been achieved, but more needs to be done.
I join my hon. Friend in underlining the central message that, for a safe childhood, parents must, for heaven's sake, immunise their children.
§ Question put and agreed to.
§ Adjourned accordingly at twenty-one minutes to Twelve o'clock.