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School immunisation certificates — a review over time in a disadvantaged community

School immunisation certificates — a review over time in a disadvantaged community Abstract Objectives: To compare proportions of kindergarten children in Auburn presenting School Immunisation Certificates (SIC) or other school-entry immunisation documentation over time, and to examine the immunisation status of these children. Smita Shah Primary Health Evaluation and Research Unit, Department of Public Health and Community Medicine, University of Sydney at Westmead, New South Wales Shanti Raman Western Sydney Area Health Service, Westmead, New South Wales and Children’s Hospital at Westmead, New South Wales Methods: Immunisation records of kindergarten children enrolled in all primary schools in the Auburn local government area were reviewed in 1994 and 1998. Conrad Moreira Western Sydney Public Health Unit, Western Sydney Area Health Service, New South Wales Results: Eight hundred and thirty-three and 737 school entry records of children enrolled in kindergarten were reviewed in 1998 and 1994 respectively. There was no change in the overall proportion of children with immunisation documentation and SICs. Sixty-nine per cent (571/833) of children had SICs in 1998, compared with 72% (531/737) in 1994. Thirteen per cent of children had other immunisation documentation in 1998, compared with 11% in 1994. The proportion of invalid certificates fell from 39.2% in 1994 to 12.6% in 1998 (p<0.001). The 1998 survey indicated that 80.2% of children provided a certificate indicating they were completely immunised compared with 56.7% in 1994 (p<0.001). C. Raina MacIntyre National Centre for Immunisation Research and Surveillance of Vaccine Preventable Diseases, Children’s Hospital at Westmead, New South Wales Implications: Although SICs play an important role in promoting the importance of immunisation among parents and in the school community, there continues to be a substantial number of children whose immunisation status is unknown. In the event of an outbreak, an effective public health response may need to incorporate the use of additional objective measures, such as the Australian Childhood Immunisation Register or personal health records. (Aust N Z J Public Health 2001; 25: 534-8) mmunisation is a simple, safe and effective way of protecting children from many infectious diseases. Vaccination against childhood diseases has had a major impact on mortality and remains one of the most cost-effective child health interventions.1 Reducing the incidence of vaccinepreventable diseases is one of the five health goals and targets for Australian children and youth.2 Concerns about poor immunisation coverage in Australian children have prompted many national initiatives to improve vaccination rates and recording of immunisation status. These have included linking childcare and maternity benef its to immunisation, and the establishment of a national immunisation register. The National Health and Medical Research Council advocated legislation requiring immunisation certif icates at school entry in 1982. Victoria was the first State to implement this recommen- dation, introducing school entry immunisation legislation in 1991. 3 New South Wales followed in 1994, with a change to its Public Health Act.4 The legislation requires schools to request parents and guardians of all children starting school to provide a SIC. The legislation was introduced to encourage parents to complete their child’s vaccination before entering school. An equally important purpose of the legislation was to allow rapid identification of children who might require urgent immunisation or exclusion during outbreaks of vaccine preventable diseases in schools. The certificates, which are held at schools, contain details of each child’s immunisation status. They may be obtained from general practitioners, local councils, community health centres and public health units on presentation of appropriate documentary evidence of prior immunisation. Submitted: April 2001 Revision requested: August 2001 Accepted: October 2001 Correspondence to: Dr Smita Shah, Primary Health Care Education and Research Unit, Department of Public Health and Community Medicine, University of Sydney at Westmead, Westmead, NSW 2145. Fax: (02) 9689 1049; e-mail: Smita_Shah@wsahs.nsw.gov.au AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 2001 VOL. 25 NO. 6 Controlling Infection A review of school immunisation certificates Auburn, a local government area (LGA) in Western Sydney, with a population of 57,000, is among the most socio-economically disadvantaged in NSW.5 Forty-eight per cent of Auburn residents were born overseas and 63% speak a language other than English at home. Many of the risk factors that contribute to low immunisation levels in a population6,7 are present in Auburn. Coverage rates for children in Auburn have been consistently lower than the rates for Western Sydney and NSW.8 An earlier review of SICs held by Auburn primary schools in 1994 found that although 72% of kindergarten children presented SICs, 9 a signif icant number of these certificates were incorrectly completed in 1994. The aims of the present study were to: • Compare the proportions of kindergarten children in Auburn presenting SICs and other documentary evidence of immunisation in 1994 and 1998; • Assess any differences between government and non-government schools; and, • Document the immunisation status of children with SICs at school. written evidence of immunisation held by schools in lieu of SICs, including copies of personal health records and letters from doctors. Analysis Data from each school were entered into a Microsoft Excel 97 database. Proportions were compared using Epi Info 2000. 10 A chi-squared statistic (1 df) and p-value were calculated for each comparison. Statistical signif icance was set at the 5% level. Results Eight hundred and thirty-three immunisation records presented at school entry were reviewed from six government schools (559 children) and f ive non-government schools (274 children) in 1998. These were compared with 737 records reviewed from five government schools (501 children) and five non-government schools (236 children) in 1994. Schools held immunisation certificates for 72% of children in 1994 (531/737) and 69% of children in 1998 (571/833) (see Table 1). Eleven per cent of children in 1994 and 13% of children in 1998 presented documentary evidence of immunisation other than certificates. Seventeen per cent of children in 1994 (126/737) Methods We surveyed all primary schools (six government and five nongovernment) in Auburn LGA in term 4, December 1998. Prior to the study, we wrote to school principals informing them about the process and requesting their co-operation. One additional government school was added to the 1998 survey due to adjustment of LGA boundaries. A medical officer (SS) and a project officer reviewed all available immunisation documents of kindergarten children enrolled in 1998. The procedures used in this survey were identical to those in 1994.9 As this survey focused only on comparing proportions of children with immunisation documentation, no uniquely identifying data were collected. Figure 1: New South Wales School-Entry Immunisation Certificate. Classification of certificates We used a short checklist, with the same list of definitions used in 1994 to ensure uniformity of data collection.9 We classified the SIC (see Figure 1) as follows: • A child was considered to have complete immunisation if all the vaccination boxes in Section A of the certificate were ticked and the appropriate box (Section A) in the Issuer’s Declaration was also ticked. • A child was considered to have incomplete immunisation if appropriate boxes were ticked in Section B and also (Section B) in the Issuer’s Declaration. • The certificate was considered invalid if the information in the certificate was inconsistent, for example, if all the vaccination boxes in Section A were ticked and the incomplete box (Section B) in the Issuer’s Declaration. The term ‘other immunisation documentation’ refers to any other 2001 VOL. 25 NO. 6 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 535 Shah et al. Article Table 1: Immunisation documentation held by Auburn schools, 1994 and 1998. 1994 % students (n=737) Evidence of immunisation SICs Other documentation No evidence of immunisation 82.9 (611) 72.0 (531) 10.9 (80) 17.1 (126) 1998 % students (n=833) 81.6 (680) 68.5 (571) 13.1 (109) 18.4 (153) and 18% of children in 1998 (153/833) had no documentary evidence of immunisation. These differences were not significant. Table 2 shows the breakdown of SICs held by schools. Between 1994 and 1998, the proportion of invalid certif icates decreased signif icantly from 39.2% to 12.6% (p<0.001). Of the children with SICs in 1998, 80% (458/571) were certified as having complete immunisation compared with 57% in 1994 (323/ 531) (p<0.001). There was no change in the overall proportion of children presenting immunisation documentation in either government or nongovernment schools between 1994 and 1998 (see Table 3). Children attending non-government schools were more likely to present some form of documentary evidence of immunisation in both 1994 and 1998 (p<0.01). In both years, the use of SICs was more evident in government schools (p<0.001). calendar year were surveyed. Second, identical procedures were used in both surveys. Third, the same researcher (SS) was responsible for conducting and reviewing both surveys. Finally, all SICs were individually inspected, rather than relying on reports from schools, questionnaires or telephone interviews. A major disadvantage of relying on schools to assess and report the immunisation status of students is the variability in the amount and quality of information recorded on SICs by immunisation providers,11 leading to difficulties in interpreting this information correctly by school staff.12 Numerous studies have been undertaken to evaluate compliance with school entry legislation and the status of SICs in schools.11-17 The results in Auburn schools are consistent with other surveys in New South Wales in which SICs were directly inspected.11,17 Studies that did not involve direct inspection of certificates may have overestimated the use of SICs.14 In Victoria, early reports indicated that almost 90% of parents complied with the legislation.3 However, validation revealed an overestimation of certificates by teachers.18 This study has a number of limitations. The immunisation status of children with invalid SICs or other documentation was not ascertained. Limited resources prevented the collection of data on the characteristics of children who did not present immunisation documentation or were incompletely immunised. Finally, there was no follow-up of children who did not present immunisation documentation. However, lists of children without immunisation documentation were given to each school at the completion of the visit for school staff to contact their families. Children from non-government schools were more likely to present alternative immunisation documentation at school entry. This could be due to the practice in non-government schools of enrolling students early in the calendar year. Changes to the Australian Standard Vaccination Schedule in 2000,19 which brought forward the timing of pre-school booster immunisations, Discussion This is the first study in NSW reviewing the impact of school entry legislation four years after its implementation. Overall, the level of documentary evidence of immunisation held by schools did not change significantly between 1994 and 1998. We found that almost one in five children had no immunisation documentation at school entry in both years. Of children with some documentary evidence of immunisation, more than one in 10 did not present a SIC. However, it was encouraging to see an improvement in the completion of certificates by immunisation providers. As a result of a significant decrease in the proportion of invalid certificates, a higher proportion of children were noted to have complete immunisation in 1998. Of interest is that children in non-government schools were significantly more likely to present documentary evidence of immunisation at school entry, yet were less likely to present SICs, than children from government schools. Several measures were used to minimise bias in this study. First, all kindergarten children enrolled in Auburn schools in each Table 2: Immunisation status of children with SICs, 1994 and 1998. 1994 % students (n=531) Complete immunisation Incomplete immunisation Invalid cer tificates 56.7 (301) 4.1 (22) 39.2 (208) 1998 % students (n=571) 80.2 (458) 7.2 (41) 12.6 (72) <0.001 0.03 <0.001 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 2001 VOL. 25 NO. 6 Controlling Infection A review of school immunisation certificates Table 3: Immunisation documentation held by government and non-government schools in Auburn, 1994 and 1998. Schools Government % students (n=501) 1994 Non-government % students (n=236) 88.1 (208) 66.1 (156) 22.0 (52) 11.9 (28) Government % students (n=559) 78.7 (440) 76.6 (428) 2.1 (12) 21.3 (119) 1998 Non-government % students (n=274) 87.6 (240) 52.2 (143) 35.4 (97) 12.4 (34) Evidence of immunisation 80.5 (403) SICs Other documentation No evidence of immunisation 74.9 (375) 5.6 (28) 19.6 (98) 0.01 <0.001 <0.001 0.01 0.002 <0.001 <0.001 0.002 may increase providers’ use of SICs to document the immunisation status of children enrolling in non-government schools. The f inding that there has been no change in the proportion of children in Auburn presenting SICs, during the first four years following school entry legislation, is cause for concern. A possible explanation rests with the population characteristics of Auburn with its high number of non-English speaking, mobile, and economically disadvantaged residents. In Victoria, Thompson et al. noted that mobile and immigrant families found it particularly difficult to achieve certification. They reported that issuing of certificates by councils was inconsistent and follow-up and feedback to parents and schools was essential to improve compliance.3 Similarly, Miksevicius et al. found that targeting parents of children without SICs, using personalised letters, can be an effective way to improve compliance with SICs.11 In New South Wales, the debate about the use of SICs in its present form continues. Earlier studies have suggested that reliance on SICs as a surveillance tool during an outbreak management can be problematic.9,11,17 Current legislation states that any child not presenting a complete SIC will be regarded as unimmunised in an outbreak and would have to be excluded from school for the incubation period of the disease. 4 Our results indicate that approximately 18% of children in both surveys had no documentary evidence of immunisation. If schools were to use only SICs, then based on our classification, only 55% (458/833) in 1998 would have had evidence of complete immunisation. Therefore it is possible that almost half the student population would have to be excluded from school should the legislation be rigorously complied with during a mass outbreak of a vaccinepreventable disease, such as measles. Implementing such measures would undoubtedly generate considerable and understandable opposition from parents. In the event of an outbreak, it is also unclear how school principals would, in practical terms, deal with children whose immunisation status is not adequately defined and to what extent they would implement the policy of exclusion. Where children have not presented definite evidence of immunisation, a public health response may need to be guided by further validation of a child’s immunisation status using other objective measures such as the 2001 VOL. 25 NO. 6 Australian Childhood Immunisation Register (ACIR) and in NSW, personal health records. To optimise the use of SICs, the following strategies are recommended based on available evidence: 1. Increase parental awareness of the need for immunisation certificates during enrolment and orientation. 2. Mail reminder letters to parents of children who either do not present SICs or are certified as having incomplete immunisation at school entry. 3. Conduct periodic random audits of compliance with legislation. 4. Consult with immunisation providers and schools about difficulties they may experience in complying with the legislation. 5. Improve the design of the SIC to make it more user-friendly. Conclusion Our study found no change in the overall proportion of children presenting SICs between 1994 and 1998 in Aub urn schools. Although SICs play an important role in promoting immunisation among parents and in the school community, there continues to be a substantial number of children whose immunisation status is unknown. Further studies are needed to determine how schools implement the legislation in the event of an outbreak. Acknowledgements The authors thank the Auburn schools for their participation. Comments from Professor Margaret Burgess are gratefully acknowledged. Thanks also to Samantha Hutchins. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Australian and New Zealand Journal of Public Health Wiley

School immunisation certificates — a review over time in a disadvantaged community

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Publisher
Wiley
Copyright
Copyright © 2001 Wiley Subscription Services, Inc., A Wiley Company
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1326-0200
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1753-6405
DOI
10.1111/j.1467-842X.2001.tb00319.x
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Abstract

Abstract Objectives: To compare proportions of kindergarten children in Auburn presenting School Immunisation Certificates (SIC) or other school-entry immunisation documentation over time, and to examine the immunisation status of these children. Smita Shah Primary Health Evaluation and Research Unit, Department of Public Health and Community Medicine, University of Sydney at Westmead, New South Wales Shanti Raman Western Sydney Area Health Service, Westmead, New South Wales and Children’s Hospital at Westmead, New South Wales Methods: Immunisation records of kindergarten children enrolled in all primary schools in the Auburn local government area were reviewed in 1994 and 1998. Conrad Moreira Western Sydney Public Health Unit, Western Sydney Area Health Service, New South Wales Results: Eight hundred and thirty-three and 737 school entry records of children enrolled in kindergarten were reviewed in 1998 and 1994 respectively. There was no change in the overall proportion of children with immunisation documentation and SICs. Sixty-nine per cent (571/833) of children had SICs in 1998, compared with 72% (531/737) in 1994. Thirteen per cent of children had other immunisation documentation in 1998, compared with 11% in 1994. The proportion of invalid certificates fell from 39.2% in 1994 to 12.6% in 1998 (p<0.001). The 1998 survey indicated that 80.2% of children provided a certificate indicating they were completely immunised compared with 56.7% in 1994 (p<0.001). C. Raina MacIntyre National Centre for Immunisation Research and Surveillance of Vaccine Preventable Diseases, Children’s Hospital at Westmead, New South Wales Implications: Although SICs play an important role in promoting the importance of immunisation among parents and in the school community, there continues to be a substantial number of children whose immunisation status is unknown. In the event of an outbreak, an effective public health response may need to incorporate the use of additional objective measures, such as the Australian Childhood Immunisation Register or personal health records. (Aust N Z J Public Health 2001; 25: 534-8) mmunisation is a simple, safe and effective way of protecting children from many infectious diseases. Vaccination against childhood diseases has had a major impact on mortality and remains one of the most cost-effective child health interventions.1 Reducing the incidence of vaccinepreventable diseases is one of the five health goals and targets for Australian children and youth.2 Concerns about poor immunisation coverage in Australian children have prompted many national initiatives to improve vaccination rates and recording of immunisation status. These have included linking childcare and maternity benef its to immunisation, and the establishment of a national immunisation register. The National Health and Medical Research Council advocated legislation requiring immunisation certif icates at school entry in 1982. Victoria was the first State to implement this recommen- dation, introducing school entry immunisation legislation in 1991. 3 New South Wales followed in 1994, with a change to its Public Health Act.4 The legislation requires schools to request parents and guardians of all children starting school to provide a SIC. The legislation was introduced to encourage parents to complete their child’s vaccination before entering school. An equally important purpose of the legislation was to allow rapid identification of children who might require urgent immunisation or exclusion during outbreaks of vaccine preventable diseases in schools. The certificates, which are held at schools, contain details of each child’s immunisation status. They may be obtained from general practitioners, local councils, community health centres and public health units on presentation of appropriate documentary evidence of prior immunisation. Submitted: April 2001 Revision requested: August 2001 Accepted: October 2001 Correspondence to: Dr Smita Shah, Primary Health Care Education and Research Unit, Department of Public Health and Community Medicine, University of Sydney at Westmead, Westmead, NSW 2145. Fax: (02) 9689 1049; e-mail: Smita_Shah@wsahs.nsw.gov.au AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 2001 VOL. 25 NO. 6 Controlling Infection A review of school immunisation certificates Auburn, a local government area (LGA) in Western Sydney, with a population of 57,000, is among the most socio-economically disadvantaged in NSW.5 Forty-eight per cent of Auburn residents were born overseas and 63% speak a language other than English at home. Many of the risk factors that contribute to low immunisation levels in a population6,7 are present in Auburn. Coverage rates for children in Auburn have been consistently lower than the rates for Western Sydney and NSW.8 An earlier review of SICs held by Auburn primary schools in 1994 found that although 72% of kindergarten children presented SICs, 9 a signif icant number of these certificates were incorrectly completed in 1994. The aims of the present study were to: • Compare the proportions of kindergarten children in Auburn presenting SICs and other documentary evidence of immunisation in 1994 and 1998; • Assess any differences between government and non-government schools; and, • Document the immunisation status of children with SICs at school. written evidence of immunisation held by schools in lieu of SICs, including copies of personal health records and letters from doctors. Analysis Data from each school were entered into a Microsoft Excel 97 database. Proportions were compared using Epi Info 2000. 10 A chi-squared statistic (1 df) and p-value were calculated for each comparison. Statistical signif icance was set at the 5% level. Results Eight hundred and thirty-three immunisation records presented at school entry were reviewed from six government schools (559 children) and f ive non-government schools (274 children) in 1998. These were compared with 737 records reviewed from five government schools (501 children) and five non-government schools (236 children) in 1994. Schools held immunisation certificates for 72% of children in 1994 (531/737) and 69% of children in 1998 (571/833) (see Table 1). Eleven per cent of children in 1994 and 13% of children in 1998 presented documentary evidence of immunisation other than certificates. Seventeen per cent of children in 1994 (126/737) Methods We surveyed all primary schools (six government and five nongovernment) in Auburn LGA in term 4, December 1998. Prior to the study, we wrote to school principals informing them about the process and requesting their co-operation. One additional government school was added to the 1998 survey due to adjustment of LGA boundaries. A medical officer (SS) and a project officer reviewed all available immunisation documents of kindergarten children enrolled in 1998. The procedures used in this survey were identical to those in 1994.9 As this survey focused only on comparing proportions of children with immunisation documentation, no uniquely identifying data were collected. Figure 1: New South Wales School-Entry Immunisation Certificate. Classification of certificates We used a short checklist, with the same list of definitions used in 1994 to ensure uniformity of data collection.9 We classified the SIC (see Figure 1) as follows: • A child was considered to have complete immunisation if all the vaccination boxes in Section A of the certificate were ticked and the appropriate box (Section A) in the Issuer’s Declaration was also ticked. • A child was considered to have incomplete immunisation if appropriate boxes were ticked in Section B and also (Section B) in the Issuer’s Declaration. • The certificate was considered invalid if the information in the certificate was inconsistent, for example, if all the vaccination boxes in Section A were ticked and the incomplete box (Section B) in the Issuer’s Declaration. The term ‘other immunisation documentation’ refers to any other 2001 VOL. 25 NO. 6 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 535 Shah et al. Article Table 1: Immunisation documentation held by Auburn schools, 1994 and 1998. 1994 % students (n=737) Evidence of immunisation SICs Other documentation No evidence of immunisation 82.9 (611) 72.0 (531) 10.9 (80) 17.1 (126) 1998 % students (n=833) 81.6 (680) 68.5 (571) 13.1 (109) 18.4 (153) and 18% of children in 1998 (153/833) had no documentary evidence of immunisation. These differences were not significant. Table 2 shows the breakdown of SICs held by schools. Between 1994 and 1998, the proportion of invalid certif icates decreased signif icantly from 39.2% to 12.6% (p<0.001). Of the children with SICs in 1998, 80% (458/571) were certified as having complete immunisation compared with 57% in 1994 (323/ 531) (p<0.001). There was no change in the overall proportion of children presenting immunisation documentation in either government or nongovernment schools between 1994 and 1998 (see Table 3). Children attending non-government schools were more likely to present some form of documentary evidence of immunisation in both 1994 and 1998 (p<0.01). In both years, the use of SICs was more evident in government schools (p<0.001). calendar year were surveyed. Second, identical procedures were used in both surveys. Third, the same researcher (SS) was responsible for conducting and reviewing both surveys. Finally, all SICs were individually inspected, rather than relying on reports from schools, questionnaires or telephone interviews. A major disadvantage of relying on schools to assess and report the immunisation status of students is the variability in the amount and quality of information recorded on SICs by immunisation providers,11 leading to difficulties in interpreting this information correctly by school staff.12 Numerous studies have been undertaken to evaluate compliance with school entry legislation and the status of SICs in schools.11-17 The results in Auburn schools are consistent with other surveys in New South Wales in which SICs were directly inspected.11,17 Studies that did not involve direct inspection of certificates may have overestimated the use of SICs.14 In Victoria, early reports indicated that almost 90% of parents complied with the legislation.3 However, validation revealed an overestimation of certificates by teachers.18 This study has a number of limitations. The immunisation status of children with invalid SICs or other documentation was not ascertained. Limited resources prevented the collection of data on the characteristics of children who did not present immunisation documentation or were incompletely immunised. Finally, there was no follow-up of children who did not present immunisation documentation. However, lists of children without immunisation documentation were given to each school at the completion of the visit for school staff to contact their families. Children from non-government schools were more likely to present alternative immunisation documentation at school entry. This could be due to the practice in non-government schools of enrolling students early in the calendar year. Changes to the Australian Standard Vaccination Schedule in 2000,19 which brought forward the timing of pre-school booster immunisations, Discussion This is the first study in NSW reviewing the impact of school entry legislation four years after its implementation. Overall, the level of documentary evidence of immunisation held by schools did not change significantly between 1994 and 1998. We found that almost one in five children had no immunisation documentation at school entry in both years. Of children with some documentary evidence of immunisation, more than one in 10 did not present a SIC. However, it was encouraging to see an improvement in the completion of certificates by immunisation providers. As a result of a significant decrease in the proportion of invalid certificates, a higher proportion of children were noted to have complete immunisation in 1998. Of interest is that children in non-government schools were significantly more likely to present documentary evidence of immunisation at school entry, yet were less likely to present SICs, than children from government schools. Several measures were used to minimise bias in this study. First, all kindergarten children enrolled in Auburn schools in each Table 2: Immunisation status of children with SICs, 1994 and 1998. 1994 % students (n=531) Complete immunisation Incomplete immunisation Invalid cer tificates 56.7 (301) 4.1 (22) 39.2 (208) 1998 % students (n=571) 80.2 (458) 7.2 (41) 12.6 (72) <0.001 0.03 <0.001 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 2001 VOL. 25 NO. 6 Controlling Infection A review of school immunisation certificates Table 3: Immunisation documentation held by government and non-government schools in Auburn, 1994 and 1998. Schools Government % students (n=501) 1994 Non-government % students (n=236) 88.1 (208) 66.1 (156) 22.0 (52) 11.9 (28) Government % students (n=559) 78.7 (440) 76.6 (428) 2.1 (12) 21.3 (119) 1998 Non-government % students (n=274) 87.6 (240) 52.2 (143) 35.4 (97) 12.4 (34) Evidence of immunisation 80.5 (403) SICs Other documentation No evidence of immunisation 74.9 (375) 5.6 (28) 19.6 (98) 0.01 <0.001 <0.001 0.01 0.002 <0.001 <0.001 0.002 may increase providers’ use of SICs to document the immunisation status of children enrolling in non-government schools. The f inding that there has been no change in the proportion of children in Auburn presenting SICs, during the first four years following school entry legislation, is cause for concern. A possible explanation rests with the population characteristics of Auburn with its high number of non-English speaking, mobile, and economically disadvantaged residents. In Victoria, Thompson et al. noted that mobile and immigrant families found it particularly difficult to achieve certification. They reported that issuing of certificates by councils was inconsistent and follow-up and feedback to parents and schools was essential to improve compliance.3 Similarly, Miksevicius et al. found that targeting parents of children without SICs, using personalised letters, can be an effective way to improve compliance with SICs.11 In New South Wales, the debate about the use of SICs in its present form continues. Earlier studies have suggested that reliance on SICs as a surveillance tool during an outbreak management can be problematic.9,11,17 Current legislation states that any child not presenting a complete SIC will be regarded as unimmunised in an outbreak and would have to be excluded from school for the incubation period of the disease. 4 Our results indicate that approximately 18% of children in both surveys had no documentary evidence of immunisation. If schools were to use only SICs, then based on our classification, only 55% (458/833) in 1998 would have had evidence of complete immunisation. Therefore it is possible that almost half the student population would have to be excluded from school should the legislation be rigorously complied with during a mass outbreak of a vaccinepreventable disease, such as measles. Implementing such measures would undoubtedly generate considerable and understandable opposition from parents. In the event of an outbreak, it is also unclear how school principals would, in practical terms, deal with children whose immunisation status is not adequately defined and to what extent they would implement the policy of exclusion. Where children have not presented definite evidence of immunisation, a public health response may need to be guided by further validation of a child’s immunisation status using other objective measures such as the 2001 VOL. 25 NO. 6 Australian Childhood Immunisation Register (ACIR) and in NSW, personal health records. To optimise the use of SICs, the following strategies are recommended based on available evidence: 1. Increase parental awareness of the need for immunisation certificates during enrolment and orientation. 2. Mail reminder letters to parents of children who either do not present SICs or are certified as having incomplete immunisation at school entry. 3. Conduct periodic random audits of compliance with legislation. 4. Consult with immunisation providers and schools about difficulties they may experience in complying with the legislation. 5. Improve the design of the SIC to make it more user-friendly. Conclusion Our study found no change in the overall proportion of children presenting SICs between 1994 and 1998 in Aub urn schools. Although SICs play an important role in promoting immunisation among parents and in the school community, there continues to be a substantial number of children whose immunisation status is unknown. Further studies are needed to determine how schools implement the legislation in the event of an outbreak. Acknowledgements The authors thank the Auburn schools for their participation. Comments from Professor Margaret Burgess are gratefully acknowledged. Thanks also to Samantha Hutchins.

Journal

Australian and New Zealand Journal of Public Health – Wiley

Published: Dec 1, 2001

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