The influence of maternal mental illness on vaccination uptake in children: a UK population-based cohort study

Abstract

Reduced vaccination uptake is a growing and global public health concern. There is limited knowledge about the effect of maternal mental illness (MMI) on rates of childhood vaccination. This retrospective cohort study examined 479,949 motherbaby pairs born between 1993 and 2015 in the Clinical Practice Research Datalink (CPRD GOLD), a UK-based, primary health-care database. The influence of MMI on children's vaccination status at two and five years of age was investigated using logistic regression adjusting for sex of the child, child ethnicity, delivery year, maternal age, practice level deprivation quintile and region. The vaccinations were: 5-in-1 (DTaP/IPV/Hib) and first dose MMR by the age of two; and all three doses of 5-in-1, first and second dose of MMR vaccines by the age of five. Exposure to MMI was defined using recorded clinical events for: depression, anxiety, psychosis, eating disorder, personality disorder and alcohol and substance misuse disorders. The likelihood that a child completed their recommended vaccinations by the age of two and five was significantly lower among children with MMI compared to children with mothers without mental illness [adjusted odds ratio (aOR) 0.86, 95% CI 0.84-0.88, p < 0.001]. The strongest effect was observed for children exposed to maternal alcohol or substance misuse (at two years aOR 0.50, 95% CI 0.44-0.58, p < 0.001). In the UK, an estimated five thousand more children per year would be vaccinated if children with MMI had the same vaccination rates as children with well mothers. Maternal mental illness is a hitherto largely unrecognised reason that children may be missing vital vaccinations at two and five years of age. This risk is highest for those children living with maternal alcohol or substance misuse.

MMR Vaccine Attitude and Uptake Research in the United Kingdom: A Critical Review

“…Secondly, immigration status, most directly in the form of language barriers but also in relation to limited trust of, and access to, British healthcare, introduces barriers to vaccination that antedate the first GP appointment [34; 38; 40; 43; 54]. Finally, maternal mental illness has an underexplored impact on uptake that has not yet been fully explained [36]. These access issues are often ignored within the public "anti-vax" discourse, possibly because they are more hidden, whereas public debates about outright vaccine refusal are more overt [3].…”

“…Some of the studies used private longitudinal health data such as the Millennium Cohort Study of ~19,000 children born in 2000-1 [29; 30] or the Secure Anonymised Information Linkage (SAIL) databank of 800,000 children living in Wales [31]. Others used public National Health Service (NHS) health data through the Child Health Information Systems [32][33][34], the Scottish Immunisation and Recall System (SIRS) [35], primary care data of the Clinical Practice Research Datalink (CPRD) [36] or the Cover of Vaccination Evaluated Rapidly (COVER) dataset produced by PHE [37]. All of the studies used these datasets to examine a particular cross-section of children and the degree to which MMR uptake covaried with other quantitative variables.…”

“…Emerson et al [29] focused on children with intellectual disabilities and found that they were at increased risk for low uptake, although this may be partially explained by the positive association between intellectual disabilities and lower family socioeconomic position. Osam et al [36] used primary care data from 400,000 motherbaby pairs and found that maternal mental illness, even when adjusting for deprivation factors, had a significant negative effect on routine MMR vaccine uptake.…”

“…Occasionally, they also revise expectations: Hungerford's [32] conclusion that low income has always been associated with low uptake, even throughout the Wakefield controversy, is a striking result that calls into question common assumptions about vaccine hesitancy. Similarly, Osam's work describing the impact of maternal mental illness on uptake suggests more focus should be given to this area [36].…”

“…Perry et al [34] found that children of asylum seekers display substantially reduced uptake; their odds of being vaccinated against key infections is around three times lower than the general population, likely because they are not as well engaged by public health services [71]. Osam et al [36] found that children of mothers with alcohol or substance use disorders are half as likely to be fully vaccinated compared with children of mothers without such disorders, even when adjusting for other confounders. In PHE's measles and rubella elimination strategy, reaching these minority, at-risk and under-privileged communities is key to the overall effort for elimination; access, and not attitude, is cited as a key barrier to vaccination in the 2020s, especially as general public trust in MMR has largely recovered [70].…”