A meeting took place on Monday 8th May 2017 to discuss the topic “Immunisation – a Jewish question? Problems and Solutions?”
This meeting arose following considerable recent publicity about the decline in uptake of the Measles – Mumps – Rubella (MMR) vaccine – and of other immunisations – in the strictly observant London Jewish community.
Prof David Katz opened the meeting, reporting that several Association members have been involved in this debate. In late 2016 representations were made to both local and national public health authorities about the best way to tackle the problem.Six months later we have been told that progress has been made, and the aim was that this discussion meeting will provide an opportunity to hear about it, ask questions, and draw lessons for the future.
Dr Tammy Rothenberg (Paediatrician at the Homerton Hospital) introduced the subject with an overview of the current UK vaccination schedule, explaining that the routine infant vaccinations are “5 in 1” (which covers Diphtheria, Tetanus, Pertussis, Polio and Haemophilus) as well as others (Pneumococcus, Meningococcus and Rotavirus) were also included. MMR is given at 12 months. She showed the historical dramatic effect of vaccination, highlighting that the introduction of measles vaccination (1967) had led to a drop in number of cases reported annually from >400,000 to 130.
With regard to Hackney and the Charedi community, she explained that London has one of the biggest Charedi city populations in the world. ~25 babies are born / week and the average number of children / woman is 7.
She showed data from the 4th quarter of 2014:
5 in 1 vaccination uptake at one year:
City and Hackney: 82%
Stamford Hill: 60%
Measles vaccination uptake at two years:
WHO target (to achieve herd immunity): 95%
UK: 92.5%
City and Hackney: 87.9%
Stamford Hill: 78.3%
During the recent measles outbreak (2013) there had been 1843 laboratory confirmedmeasles cases, of which 474 were 4 years old, 192 were in London and 73 were in Hackney.
The data / 100,000 during the 2006-13 period were alarming. In epidemic year 2007 there 276 cases in Hackney, and the population rate was 503 / 100,000 in the Charedim and 90 / 100,000 in the non-Charedi – i.e. a five fold difference. In 2013 there was a ten fold difference between the two groups.
From Dr Rothenberg’s perspective, based on research into this topic by the local Public Health department, the factors associated with poor vaccine uptake included vaccine hesitancy, lack of access to vaccines, place in birth order, health beliefs, maternal education and perception of risk. Disease outbreaks promoted uptake. Furthermore, cultural differences, and the lesser impact of internet communication made vaccination campaigns more difficult in this community.
Possible recommendations to resolve the problem in the Charedi community included community clinics, appointment of outreach nurses and health visiting teams, and using school based clinics. A balance between the community, commissioners, providers and health protection services needed to be struck.
Laura Sharpe (Chief Executive of the City and Hackney GP Confederation) introduced her presentation with background about City and Hackney, and then spoke about the vaccination problem and the role of the Confederation In attempting to address this.
There are 307,000 registered patients in the area; in the 0-5 age group in Hackney there were 20,400 children in 2014; in the City there were 370. Hackney has a 55% “white” population, of which more than a third are not British; the City has 79% “white”. Over 40% are born out of the UK; the area has the 5th highest number of residents who cannot speak English. The Charedi population is ~25,000 (<10%) but in the 0-19 age group they represent ~20%.
She provided update figures on all immunisations (using standard schedules) for children turning 5 during 2016/7 as at March 2017. There were wide differences between General Practice: in the north east (highest Charedi) area 63% to 85% were fully immunised; in other parts of Hackney 89%, and in the City 92%.
The City and Hackney GP Confederation is a Social Enterprise set up by the local GPs, aiming to improve practice performance and long term viability. Maximising practice income is also central.
The GP Confederation, and the Care Commissioning Group (CCG) both recognise the importance of the immunisation programme, and the CCG has provided £242,000 for the Confederation in order to develop a practical approach which will raise the profile of the problem, and do something about it.
An ex practice manager is now in post to co-ordinate this, and a nursing team is being recruited
Recruitment and training of staff needs to be a priority
Unfortunately the CHIMS system is not as robust as it should be ….all / recall systems need to be improved and clinical effectiveness group data generated
Catch-up clinics need to be provided in the community
Critical to success are the strong links and dialogue with the community; the trust of the general practices, a supportive no blame co-operative approach, and raising the profile of the programme and its evidence base.
Dr Joseph Spitzer (a local City and Hackney General Practitioner) welcomed these initiatives and described the problems he confronts on a day-to-day basis in the community in his role as immunisation promoter and advocate. Media reporting often does not help – vaccination is a victim of its own success, in that families will never have seen poliomyelitis, or hospitalisation for respiratory complications of measles.
Dr Spitzer described some of the arguments that are used against him. The media coverage of complications – as in the MMR / autism story – does have some impact. However, there are many other “excuses”.Parents are “waiting for the immune system to get more mature”, and should not have too much pressure on it. “The Rabbi says we should not do it” – although support for immunisation is almost universal amongst Rabbinic authorities. “We do not do it in our family” – coupled with “if others do it then the disease will not be in the community and we will not get it”. “I cannot remember exactly whether or not (this child) has had immunisations”. Perhaps the most damaging is the comment “you would say so wouldn’t you – you are paid to persuade us to have immunisations”.
Dr Jonathan Cohen (UCLH Paediatrician, involved particularly in handling infectious diseases) noted his experience handling complications of failure to vaccinate, which he said was a very disturbing problem. He felt that much more work is needed in this field, and that it was sad that little co-ordinated support had been available for this previously.
Dr Rilwan Raji (who trained at the Hebrew University School of Public Health, sponsored by the Pears Foundation) introduced his remarks by saying that he was struck by the fact that although from Nigeria the perception was that in the “developed Western world” problems about immunisation uptake did not occur, nonetheless many of the problems that he faces are very similar. He was struck by the similarity as he often heard the comment in Northern Nigeria “what the West is trying to do to you”. He highlighted that how he handles health promotion questions mall in a different context also involves faith communities and beliefs, and also involves small villages and communities where strong traditional approaches are dominant. His main framework was the elimination of poliomyelitis, but he also aims to promote other vaccines. Cultural leadership is important, and he uses a card system to encourage return visits. He has to be careful about accuracy of coverage rates and about adverse event reporting; and he also faces media reporting that may contain “fake news”.
Dr Fiona Sim (Past Association President, and past Chair, Royal Society for Public Health) said she believed the failure to achieve adequate uptake of immunisation in the Charedi community was a health inequalities issue. She suggested that what we had heard this evening could be considered through the four ethical principles: of justice, beneficence [and mentioned that, by the way, doctors’ remuneration does not detract from beneficence], nonmaleficence [“do no harm” – badly breached by Andrew Wakefield] and autonomy [which requires us to work with communities to gain their trust and lay no blame]. Fiona referred to a recent publication from Israel that described ‘social solidarity’ as central to gaining trust and confidence in boosting immunisation uptake.
Dr Sim summed up the evening by thanking all the speakers, who had presented a range of valid perspectives on this important topic. In particular, she congratulated the local CCG for recognising the importance of this issue and supporting the evidence-based project that had been so eloquently described by Laura Sharpe, which offered ground for optimism for the future.