Vaccination as per a doctor’s recommendation and on schedule, both in children and adults, can be an effective public health intervention to drastically reduce the burden of infectious diseases in our country. The current situation however remains that, despite efforts to improve vaccine coverage for all, adult vaccinations somehow fail to complete their entire journey from recommendation to patient uptake in India.

Our recent M3 India survey sought to identify where the possible drop-out occurs for adult vaccination - is it at the physician or the patient level? We investigated adult vaccination practices among doctors- General Physicians and Respiratory Disease Specialists from both, larger and smaller Indian cities.

60 doctors were surveyed, 31 General Physicians (General and Family Medicine practitioners) and 29 Specialists in Respiratory Medicine. All the doctors had a patient load of ~600 per month on an average.

Here we present the interesting findings we gathered from this survey.

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Pneumococcal vaccine had the highest recall value: 77% of GPs and all Respiratory Disease Specialists mentioned it when asked to list the 3 most important vaccines

1. 24 of 31 GPs and all Specialists who participated in the survey, mentioned Pneumococcal vaccine in one of the three spots for order of recall when requested for names of adult vaccines they were aware of.
2. Influenza ranked a close second with 61% of GPs and 93% of Specialists placing it in one of the 3 spots for recall value.
3. Hepatitis B vaccine featured third- 45% of the GPs and 17% of the Specialists could recall the vaccine. In this case, the higher figure for GPs seems to be obvious as they are the first point of contact for such patients.

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Overall doctor awareness on recommendations for adult immunisation was high

All Specialists of Respiratory Diseases were aware of recommendations being available for Adult Pneumococcal and Influenza vaccines; 93% of them recollected recommendations existing for Hepatitis B vaccine, as well.

Among General and Family Medicine doctors too, close to 90% mentioned being familiar with specific recommendations for adults, available for Pneumococcal, Influenza, and Hepatitis B vaccines. However, awareness was lower for adult vaccines such as Tetanus, Diphtheria, Pertussis (Tdap), Measles, Mumps, Rubella (MMR), Varicella and Zoster despite being the doctors being the first patient touch points for such conditions.

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Doctors had a clear opinion on the undeniable benefits of adult vaccination

1. Of the surveyed GPs, 100% considered Hepatitis B vaccine as beneficial; 87% of them attached high benefit to Pneumococcal vaccine, but not so much to Influenza shots for adults.
2. More than 90% of all Specialists agreed to there being benefits with Influenza, Pneumococcal, and Hepatitis vaccines, which they ranked high on their scales of measure.
3. Interestingly, both groups of surveyed doctors did not feel the same for the HPV vaccine and voted lower benefit for it.

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Common guidelines doctors follow for various vaccines

Doctors seemed to follow global guidelines by Centres for Disease Control and Prevention (CDC) and the World Health Organisation (WHO), despite there being prominent guidelines from Indian societies like API for Pneumococcal, Influenza, Hepatitis and HPV vaccines.

CDC is the most followed guideline, followed by WHO’s. Only an average of 10% doctors mentioned following the Association of Physicians of India (API) guidelines.

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Factors affecting vaccine uptake

Vaccine recommendation to older healthy adults was below average and only 62% for at-risk adults

On an average, only 24% of all General/Family Medicine doctors and 21% of all Specialists reported recommending adult vaccines- Influenza, Pneumococcal, HPV, and Hepatitis to more that 80% of all eligible healthy adults who consult them. For at risk individuals, the average percentage was higher, but still not significant enough. Only 58% of GPs and 62% Specialists recommended the vaccines to over 80% of eligible, at-risk patients.

35% of GPs recommended vaccine for Hepatitis A and B to eligible healthy individuals; 61% recommended vaccination to eligible at-risk patients of HPV and Hepatitis (A and B).

Recommendations by Specialists for Pneumococcal and Influenza vaccines to at-risk patients were about as high as 69% and 76% respectively. However, the percentage of vaccination recommendations for either of the diseases to healthy individuals were hardly mention-worthy, which as a preventive measure should have been higher.

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Why are doctors NOT recommending vaccines to 100% of eligible patients?

The findings here also include those observed for metros and non-metros.

Affordability: This stood out as the primary reason for 38% of all surveyed doctors, not recommending vaccines to eligible patients. The figures for affordability as a reason were the same for metros and non-metros - 38%.

A Specialist from Mumbai with 23 years of experience mentioned:

Cost is one reason; it is difficult to convince patients. Also, there is shortage of OPD time, so we cannot effectively counsel patients on the advantages of vaccines, especially the healthy adults.

Lack of counselling: 15% doctors in non-metros reported lack of time for patient counselling as their reason for not trying to change the patient’s bias toward vaccination.

Patient belief: 26% of all doctors in non-metros faced lack of patient conviction as a reason. The percentage of doctors in metros who faced the same obstacle was 19%.

An MD from Ludhiana with 28 years of experience in treating TB and respiratory diseases said:

Recommendation (of vaccines) to healthy patients sometimes leads to losing patients, as they think (their) doctor is putting a cost burden on them.

Poor patient awareness: 23% doctors in metros reported awareness as a hindrance in making relevant recommendations. This issue can be and should be resolved with appropriate communication of benefits of vaccines to at-risk individuals and education for healthy individuals, as a preventive measure.

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Affordability and patient conviction- two major factors challenging vaccine uptake

Though doctors saw clear benefit with certain vaccines, they faced challenges in recommending the vaccines to their patients. The reasons were related to affordability and a general lack of belief in the efficacy of the vaccine at the patient level.

Affordability was reported as a factor by more than half of surveyed Specialists and this, according to them, seemed to be a crucial determinant in vaccine adoption and uptake (by patients).

A Specialist (MD in Tuberculosis and Respiratory Diseases) from Ahmedabad with 25 years of experience said,

In my practice of Pulmonary Medicine, cost of these vaccines is the biggest challenge.

Some physicians also claimed that patient belief played an important role. For example:

An MD in Tuberculosis and Respiratory Diseases from Ludhiana, 28 years in practice, said,

It has to do with the mental block of patients. They think vaccination is only for children. Cost of vaccination is also a concern.

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Disclaimer: Data presented in the article should be read as indicative of rather than exact figures.