No 20 - 2014

Reminder concerning lacking childhood vaccinations

As from 15 May 2014, Statens Serum Institut (SSI) will send out written reminders concerning childhood vaccination to parents of children who turn 2 years, 6½ years and 14 years old, provided that the children lack a minimum of one of the vaccinations recommended under the Danish childhood vaccination programme. Parents of 2- and 6½-year-old children will also be reminded of childhood examinations.

The purpose of this scheme is to increase the vaccination coverage to ensure that as few children as possible are affected by serious diseases that may be prevented through vaccination.

Vaccination coverage is lower in Denmark than in the countries we are normally compared with, and this is reflected in repeated measles outbreaks observed in recent years.

Studies among parents have demonstrated that oversight is a frequent cause of lacking vaccination, EPI-NEWS 20/12, and it is hoped that the reminder scheme will reach this group of parents.

The Danish Parliament (Folketinget) has provided the statutory basis for the SSI's reminders in an amendment to the Danish Health Act and an Executive Order.

For more information about the reminder scheme, including examples of the reminder letters sent to parents, please see www.ssi.dk/vac.

How are the reminders made?

The reminders are made on the basis of information from the Danish Vaccination Register (DDV).

Children who turn 2, 6½ and 14 years old will be identified continuously.

Information about the children's vaccinations is collected from the DDV; and if a child is lacking one or more of the vaccinations recommended under the childhood vaccination programme, a reminder is sent out. Reminders are not sent for pneumococcal vaccination, as this is not normally relevant in children older than two years of age. Furthermore, reminders are not sent out for HiB vaccination, which is typically given concurrently with the DTAP-IPV vaccination and is no longer relevant once the child turns 6 years old. The reminder is sent to the parent holding the custody of the child. If the parents have joint custody, but do not share the same address, the reminder is sent to both parents.

The DDV does not hold information on custody for children born before 28 May 2004, unless a State Administration adjudication was made. Reminders concerning the 14-year-old children are therefore sent to the parent(s) who share an address with the child.

Preliminary calculations indicate that, for the moment reminders will be sent out to 25% of the children who turn 2 years old and approx. 40% of those turning 6½ and 14 years old.

Parents who do not want to receive reminders concerning vaccination can opt out of the scheme by sending an encrypted mail to the SSI via the borger.dk portal or by filling in and sending a form to the SSI by mail. For more information, please see www.ssi.dk/fravalg.

The Danish Vaccination Register

The DDV holds information about childhood vaccinations administered from 1996 onwards that were settled with the National Danish Health Insurance, and information about vaccinations given by prescription as from 2006 onwards.

Furthermore, in some cases the DDV holds information about vaccinations entered by citizens or GPs themselves after the DDV became operational on 1 February 2013. Using FMK-online.dk, healthcare staff may access the vaccination information of the patients they are currently treating. Citizens can access their children's vaccinations there as well, provided custody is known i.e. that the children were born after 28 May 2004 or that the State Administration made adjudication on custody prior to that date.

Delayed registration of vaccinations in the DDV

Up to three months can pass from a vaccination is settled with the National Danish Health Insurance until it appears in the DDV. Approx. 10% of the children who lack one or more vaccinations when they are 21 months old receive the lacking vaccinations before they turn 24 months old. This means that the parents of approx. 10% of the 2-year-olds will receive a reminder concerning lacking vaccination, which they may disregard because the lacking vaccination was administered within the past three months. This share is smaller in the 6½- and 14-year-olds, as the period from the last recommended vaccination to the processing of the reminder is longer.

Lacking registration of vaccinations in the DDV

Lacking registration of vaccinations in the DDV may also be due to lacking settlement of the vaccinations with the regional authorities, even though the children have, in fact, received the vaccinations. This applies e.g. to childhood vaccinations administered abroad (approx. 5-6% of the unregistered vaccinations, EPI-NEWS 20/12) and to childhood vaccinations given at paediatric departments/outpatient clinics. GPs may also forget to settle vaccinations, thereby causing the vaccination to appear as lacking in the reminders.

To establish to which degree vaccinations are not registered in the DDV, the SSI in 2011 contacted the parents of 580 randomly selected children born in the 2000-2003 period who had not received the 5-year vaccination according to the DDV, EPI-NEWS 20/12. The DTaP-IPV booster-vaccination has the lowest recorded coverage of any vaccination, i.e. approx. 82-84%, EPI-NEWS 21/13. The parents of 70% of the children participated in the study, and 70% of the participating parents stated that their child had been vaccinated. However, vaccination could only be confirmed for 30% of the children by provision of an exact vaccination date from a vaccination card.

On the basis of this study, it is difficult to assess just how many of the reminders sent under the reminder scheme are due to lacking registration of vaccinations in the DDV. Reminders sent due to lacking registration in the DDV may range anywhere from 20% to 70% depending on which of the study's definitions are used and depending on whether the children who did not participate are included in the denominator. These estimates also presuppose that the lacking registrations associated with the remaining vaccinations under the childhood vaccination programme are equal to those observed for the 5-year vaccination.

This is not likely to be the case, particularly not for the three initial basic vaccinations as these are more frequently given at the childhood examination, which presumably increases the focus on settlement.

Entering vaccinations into the FMK/DDV

The parents can check the child's yellow vaccination card themselves to see if the child has received the vaccinations listed as lacking in the letter. If this is the case, parents of the 2- and 6½-year-old children are encouraged to enter the lacking vaccinations into the DDV themselves. If they are in doubt as to whether the child has received the lacking vaccinations, they should contact their general practitioner for further advice.

If a physician can see that the lacking vaccination is recorded as such because an invoice covering the vaccination has not been sent to the regional authorities, settlement remains possible up to 3 years after the vaccination was administered. When settling within this period, the physician will receive payment for the vaccination, and the vaccination will be registered in the DDV; however, with a 3-month delay. Alternatively, the physician may also enter the lacking vaccinations directly into the DDV.

Questions concerning delayed or lacking vaccination and adaptation to the childhood vaccination programme

In some cases, the reminders may induce parents to contact their general practitioner for further guidance and advice. This may occur in the following situations, for example:

Counting of vaccinations: The counting of vaccinations leading to the generation of reminders is based solely on the number of vaccinations recorded in the DDV. The service code (ydelseskoden) indicating the age at vaccination is not taken into account.

For example; if a child has only received one DTaP-IPV/HIB vaccination with service code 8343 (DTaP-IPV/HIB vaccination at 12 months of age), this vaccination will count as the first DTaP-IPV/HIB vaccination and the reminder will show that the child has not received the second and third DTaP-IPV/HIB vaccinations that are normally given at 5 and 12 months of age - even though the child did receive a vaccination at 12 months of age.

Delayed vaccination under the childhood vaccination programme: If a child is receiving its vaccinations with considerable delay, there is a risk that the parents will receive notification of a vaccination that cannot yet be given due to delayed administration of the previous vaccinations. For example, if a child has only received its third primary DTaP-IPV at 4 years of age and not at 12 months as recommended, the reminder sent to the 6½-year-old child will state that the child has not received the 5-year DTaP-IPV booster-vaccination.

This is correct, but the vaccination should not be given until 4 years after the primary vaccination, i.e. when the child is 8 years old.

Lacking basic DTaP-IPV vaccination: In some cases, children have received the 5-year-vaccination (DTaP-IPV booster-vaccination) even though they have not received the three primary DTaP-IPV vaccinations recommended at 3, 5 and 12 months of age. In such cases, the reminder will state that the child lacks BOTH the primary DTaP-IPV AND the DTaP-IPV booster-vaccination, even though the 5-year DTaP-IPV booster-vaccination was administered. This is so because the DTaP-IPV booster-vaccination only has effect if the three primary DTaP-IPV vaccinations were given previously.

Atypical combinations of DTaP-IPV vaccinations: In some cases, a child has received more primary DTaP-IPV vaccinations than recommended, or it may have received one or more DTaP-IPV booster-vaccinations without first receiving the vaccinations, or e.g. an extra DT booster vaccination may have been given at an emergency room in children who have concurrently followed the childhood vaccination programme. In these cases, a tailored solution based on single-component vaccines may be a better option than the one proposed in the reminder. In such cases, health professionals may always contact the Department of Infectious Disease Epidemiology for further advice on how to proceed with the child's vaccination.

Reminder concerning hepatitis B vaccination

As part of a statutory amendment, the SSI will also send out reminders to general practitioners concerning children of chronic hepatitis B carrier mothers as from 15 May 2014. The reminder will be sent out as soon as possible after the child was born to inform the general practitioner that it is important to ensure that the child receives the recommended hepatitis B vaccinations at 5 weeks and at 3, 5 and 12 months of age, and that the child's HBV antibodies should be measured at 15 months of age. In a letter handed out to parents on the maternity ward, the mothers are also reminded of this. If, according to the DDV, the child has not been fully vaccinated against hepatitis B before it turns 2 years old, the SSI sends out a reminder to the general practitioner and to the holder of the custody of the child. The holder of custody may choose not to receive this reminder, as described above.

Conclusion

As from 15 May, the SSI sends reminders to parents whose children lack a minimum of one recommended vaccination at 2, 6½ or 14 years of age.

The purpose is to increase vaccination coverage to ensure that as few children as possible are affected by serious diseases that may be prevented through vaccination. Some of the parents receiving reminders will have children who have been vaccinated correctly. In these cases, the reminder was generated due to delayed or lacking registration of the administered vaccinations in the DDV.

The occurrence of delayed as well as lacking registration will diminish concurrently with the implementation of the DDV within the healthcare sector in the years to come.

It is important that physicians remember to settle any vaccinations with the regional authorities and that they use the correct service codes as this of great importance for the registering of vaccinations in the DDV.

The reminder scheme may cause general practitioners to receive more enquiries from parents concerning the vaccinations of their children.

At www.ssi.dk/vac, information material related to the reminder scheme is available. The material targets citizens as well as healthcare professionals.

At the above site, you will find information allowing you to access vaccination information via FMK-online.dk as well as information explaining how to register vaccinations in the FMK/DDV and how to opt out of the reminder scheme.

Healthcare personnel who have questions concerning how the vaccination scheme for children who lack vaccinations may again be adapted to the childhood vaccination programme may contact the Department of Infectious Disease Epidemiology for further advice.

(T.G. Krause, P. Valentiner-Branth, S. Cowan, K. Mølbak, Department of Infectious Disease Epidemiology, Statens Serum Institut)

Link to previous issues of EPI-NEWS

14 May 2014