The post-pandemic era of vaccine delivery

Following Covid-19, the rise in measles cases in Ireland and elsewhere has brought renewed attention on the obstacles facing the vaccination system. David Lynch reports

Measles is back on the public health agenda and, with it, the issue of vaccination.

The widespread outbreak occurring across Europe is impacting this island. According to a Health Protection Surveillance Centre report issued towards the end of April, there had been 18 confirmed cases in Ireland with a further 22 cases under investigation.

The month coincided with the visit to Ireland of former Director of the US National Institute of Allergy and Infectious Diseases, Dr Anthony Fauci (see panel). Dr Fauci told journalists the rise in measles cases in the US, and across the globe, was a result of vaccination uptake figures going “below a critical level”.

“With measles, it [vaccine uptake levels] needs to be well above 90 per cent,” according to Dr Fauci. “Once you get below that, into the 80s, and, God forbid, even lower than that, when an outside case comes in… that’s when you have an outbreak.”

He said that uptake levels have been impacted by growing vaccination hesitancy.

“The problem is that the ‘anti-vaxxers’ have gained a lot of strength during Covid,” Dr Fauci said. “It’s spilling over now to people questioning whether you should vaccinate your children for measles or the mumps or rubella, or hepatitis.”

He warned “once the childhood immunisation level gets to a low level, we are all going to be in a lot of trouble”.

Hesitancy

In Ireland, addressing vaccine hesitancy will be a central focus for the new IMO President Dr Denis McCauley. During the IMO AGM in Killarney last month, the Donegal GP briefly attended the national public health and community health doctors meeting to address members. 

Praising the role the group played during the pandemic, and the recent “success” of public health doctors achieving full consultant status, Dr McCauley said vaccination is a priority issue for his presidency.

He referred to the measles, mumps, and rubella (MMR) vaccine as “another area where we have to fight against disinformation”.

“I think we have to… demand that parents have a conscious discussion about vaccines.”

The IMO President is concerned that awareness of the importance of vaccines is “drifting”. He noted that towards the end of the Covid pandemic, a feeling that vaccines were more “optional” began to take hold within some sections of the public.

“I think that has impacted further, so that some people are thinking the childhood vaccine is optional… as well.”

Dr McCauley said doctors needed to have a “conscious conversation” with parents around vaccines.

He added that after this discussion, “whatever they [parents] decide, that is their right.”

Reduction

Dr Paddy Kelly, ICGP Clinical Lead for Immunisations, also spoke at the IMO conference during a session on tackling falling vaccination rates. Speaking to Medical Independent (MI) after his talk, Dr Kelly said many European countries “are reporting a reduction in vaccine uptake”.

“There is an element of vaccine fatigue. For three years of the pandemic, we were all ‘vaccinate, vaccinate, vaccinate’. People are naturally tired from it,” the Kildare-based GP said.

Dr Kelly argued the public does not always “understand the nuances” behind public health decisions regarding vaccination. Such decisions require “multiple factors” to be considered.

Regarding direct patient engagement, Dr Kelly said he would never describe a person as ‘anti-vax’. “I think that label is reductive; I always refer to people who are ‘concerned about vaccines’.”  

He said social media “obviously” plays a role regarding a person’s stance on the issue.

“If someone reads an article in a newspaper, not to disparage the media or anything, or they see something online, they consider that research,” he said. “But research that doctors, or nurses or healthcare professionals deem to be appropriate are randomised control trials, or they are meta-analysis; they are very rigorously critiqued studies.

“But the public think, ‘I did my research because I saw an article online or in a Facebook post’. And that is the source of their information, because they might not have access to a doctor or nurse to ask about their worry or concern.”

MMR

The HSE is currently running an MMR catch-up vaccination programme. It “is progressing as expected and in line with other catch-up vaccination programmes”, a HSE spokesperson told this newspaper.

The campaign is due to continue until June and will focus on delivering the vaccine to key groups, including those who may have missed their vaccines in the past, children, young adults, and health and care workers.

Additionally, the HSE is providing targeted clinics for specific groups including students and young people in education settings, underserved groups including refugees, applicants seeking protection, and other minority groups.  

The programme has received praise from public health doctors. On X (formerly Twitter), public health consultant Dr Niall Conroy wrote last month: “I think a really under-celebrated and under-utilised part of our measles response is the fact that there now are free walk-in measles vaccination clinics happening all over the country each week, which were stood up urgently in response to the threat of measles.”

The catch-up programme has “been stood up quickly in a challenging time, when we have recruitment bans and competing vaccination programmes”, a spokesperson for the Irish Society of Specialists in Public Health Medicine (ISSPHM) told MI.

“Supporting GPs to do this, as well as making sure clinics target disadvantaged communities, is crucial. In addition, if we had a national immunisation information system, [it] would allow us to do this more effectively.”

Biggest challenge

In the aftermath of the Covid pandemic, the Irish vaccination system faces some significant lingering difficulties.

The absence of a national immunisation information system is the single biggest problem facing the vaccination system, according to many Irish public
health specialists.

The ISSPHM insists such a system would allow doctors “to determine where the gaps really are in terms of our population and where we need to focus our efforts”.

“We also have challenges for families in accessing GPs – if someone has to ring five GPs to try and get an appointment for their baby’s vaccines it is going to affect uptake,” the Society spokesperson said.

“Some people – for example, some families seeking international protection – cannot access a GP at all.”

The spokesperson added that Covid has left a negative legacy. During the pandemic some services were closed, staff re-deployed, “and emphasis was not on routine immunisation programmes and services.”

“We also have more immunisation programmes than we used to have and that has an impact on our workforce and capacity, but probably also on vaccine fatigue.”

Data

Dr Kelly also told MI that the “main challenge” facing the vaccine system in Ireland is that “we lack the data system that will give us comprehensive information”.

“Unless we know how many people need to be vaccinated, or the medical conditions that require vaccination, then we are not going to capture everyone that needs to be vaccinated.”

He gave the example of people moving into Ireland.

“From a public health perspective, we need to understand that they are here so that we know to check their vaccine status, and offer them vaccines.”

Dr Kelly said that this is a similar challenge within the general population.

“If you have people who are on chemotherapy or are smokers… they are at risk of certain vaccine-preventable illnesses that we would need to vaccinate,” said the Kildare-based GP. “So the lack of an electronic healthcare record is the main challenge. Without knowledge you can’t go to Government and say, ‘we need funding because x per cent [pregnant] females are not getting vaccinated for whooping cough’.

“We actually don’t even know what the percentage uptake of vaccine among pregnant people is. Because there is [no] reliable system to capture the data.”

The HSE “is working on” a national electronic healthcare record, Dr Kelly noted. “The impetus is being driven by the EU,” he added.

GPs

On what can be done to improve the system, the ISSPHM informed MI that in addition to a national immunisation information system, “primary care and GPs must be resourced to be able to deliver, monitor, and follow up” on vaccination.

“Some areas of the HSE have HSE staff employed as immunisation coordinators, who are on the ground and assist GPs in following up children who are late and/or unimmunised. They are very effective and make a significant difference to uptake. This model works and should be replicated.”

The Society spokesperson said making vaccination services more readily accessible, and easy to navigate, is “really important”.

“It’s no good promoting vaccination if a person then cannot get an appointment, or if the only appointment available is in a clinic miles from where they live.”

The spokesperson added “every opportunity” should be taken to “remind parents and the public about vaccination”. 

“Reminding people about vaccination works. For example, texting parents to remind them about their baby’s vaccine.

“It’s also been shown in several studies that interpersonal communication about vaccines really makes a difference in increasing vaccine uptake in people who are hesitant.”

Dr Fauci’s ‘observations’ for Irish doctors

Last month Dr Anthony Fauci visited Dublin where he received the Stearne Medal from the RCPI for “outstanding contribution to public health”.

Dr Fauci was Director of the US National Institute of Allergy and Infectious Diseases from 1984 to 2022. He became a familiar global face during the early years of the Covid-19 pandemic with his high-profile press conferences from the White House.

“Dr Fauci’s guidance informed the decisions of seven US Presidents during his career,” noted the RCPI
when announcing the award. “His pioneering work in combating the HIV/AIDS epidemic and, more recently, in navigating the challenges posed by the Covid-19 pandemic saved millions
of lives.”

Communication

In an interview at the RCPI in Dublin, the Medical Independent (MI) asked Dr Fauci what advice he would give to Irish doctors dealing with ‘anti-vaccination’ sentiment online and in-person with their patients.

“You bring up a very good point,” said Dr Fauci. “In the era that I grew up, in medicine, there was no social media; social media has changed everything.”

“Anybody, regardless of how strange and weird and incorrect their idea is, can have access to millions of people.”

Dr Fauci said that on social media “there is no editorialising, there is no quality control there”.

Addressing Irish doctors, he said: “I’m very hesitant to give advice, because sometimes it is a little presumptuous, so I use the word ‘observation’.”

“So I have an observation – I think the younger doctors and physicians as they get involved in their field, they should feel more comfortable in the dissemination of correct information.

“Because there is so much energy out there spreading incorrect information that the general public…who have a lot of other things on their mind… when they hear [this] they assume it’s true. And if you have enough people sending out false information, then you have what I refer to, and what I’m very concerned about, which is the ‘normalisation of untruth’.”

“So my observation for younger [doctors] is don’t hesitate to openly communicate about facts, data, and evidence,” Dr Fauci told MI. “That is
what our discipline is based on; science is a mechanism to gather information, data, and facts.”

The American physician said that young doctors “really need to be energetic in spreading that correct information”.

Consultants

MI mentioned to Dr Fauci the recent awarding of full consultant status to public health specialists in Ireland. We asked whether the pandemic could result in greater interest in the specialty from young doctors across the world?

“In the beginning of the outbreak, when it became so clear how public health was important and how [public health physicians] were important, there was a major influx of people
who wanted to get involved in public health,” Dr Fauci said.

“There was a major influx of people who wanted to become [public health] physicians. Because the public health physicians and the nurses were very influential in sacrificing themselves for the general public.”

However, over four years since the outbreak of Covid-19, Dr Fauci said he perceives more challenging trends emerging for the specialty.

“Right now, there’s an interesting negative issue happening in the US. Public health officials are being attacked by the anti-science people, online attacks, sometimes even
threats to them….

“The energy of the anti-science people, that spills over sometimes into threats. I don’t know how it is in Ireland, but a significant number of public health officials who are public figures [in the US], including myself, [are] extensively threatened because we are saying things that should be done for the public health.”

Dr Fauci concluded that while the specialty of public health has witnessed “an influx of interest, and more people want to get involved in it… it’s a specialty now that is getting threatened by hostile forces”.

However, despite these concerns, Dr Fauci struck a positive note for public health.

“I think at the end of the day, the net effect [of the pandemic] will be that more people will want to come into public health, so the net effect is going to be positive.”