immunisation attitudes, knowledge and practices of health professionals in regional nsw
TRANSCRIPT
224 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 2008 vol. 32 no. 3© 2008 The Authors. Journal Compilation © 2008 Public Health Association of Australia
Immunisation attitudes, knowledge and practices of
health professionals in regional NSW
Julie LeaskNational Centre for Immunisation Research and Surveillance of Vaccine Preventable Diseases (NCIRS), The Children’s Hospital at Westmead and the Discipline of Paediatrics and Child Health, University of Sydney, New South Wales
Helen E. QuinnNational Centre for Immunisation Research and Surveillance of Vaccine Preventable Diseases (NCIRS), The Children’s Hospital at Westmead and the University of Sydney, New South Wales
Kristine MacartneyNational Centre for Immunisation Research and Surveillance of Vaccine Preventable Diseases (NCIRS), Department of Infectious Diseases and Microbiology, The Children’s Hospital at Westmead and the University of Sydney, New South Wales
Marianne TrentNorth Coast Population Health, New South Wales
Peter Massey and Chris CarrHunter New England Population Health, New South Wales
John TurahuiNorth Coast Population Health, New South Wales
Abstract
Objective: This study investigated the
immunisation knowledge, attitudes and
practices among health professionals in
two regional Area Health Services of NSW
with low and high immunisation rates. It also
compared these factors between the areas
and between the health professional groups.
Methods: A self-administered
questionnaire was posted in 2006 to
health professionals, located within the
North Coast and Hunter New England
Area Health Services, whose practice
could include immunisation. This included
general practitioners (GPs), practice
nurses, community nurses, hospital nurses
and midwives.
Results: Out of 926 surveys sent, 434
were returned (47%). The great majority
of the health professionals (97%) believed
that vaccines were safe, effective and
necessary. However, in approximately one-
third of respondents, there were specific
concerns about additives, immune system
overload and the number of vaccines.
Significantly more health professionals in
the North Coast area believed that additives
in vaccines may be harmful and that adding
more vaccines to the schedule would make
immunisation too complex. Among GPs,
over half felt uncomfortable about giving
more than two injections at the one visit.
Conclusions: Health professionals in this
study had overall confidence in vaccines
but had specific concerns about the number
of vaccines given to children and vaccine
content. These unfounded concerns may
reduce parental confidence in immunisation.
Implications: There is value in
governments and immunisation support
workers continuing their efforts to maintain
up-to-date knowledge among health
professionals and support the delivery of
appropriate and targeted information to
address concerns about vaccines.
Keywords: Health Care Surveys;
Health Knowledge, Attitudes, Practice;
Vaccination; Australia; Health Personnel;
Measles-Mumps-Rubella Vaccine
Aust N Z Public Health. 2008; 32:224-9
doi: 10.1111/j.1753-6405.2008.00220.x
Submitted: September 2007 Revision requested: January 2008 Accepted: March 2008Correspondence to: J. Leask, NCIRS, The Children’s Hospital at Westmead, University of Sydney, Locked Bag 4001, Westmead NSW 2145, Australia. Fax: (02) 9845 1418; e-mail: [email protected]
Australia currently enjoys high
immunisation rates with 94% of
2-year-old being fully vaccinated.1
Most vaccines for children are publicly
funded and provided free at point of care
under the National Immunisation Program
(NIP), and vaccine coverage is recorded
and reported by the national population-
based Australian Childhood Immunisation
Register (ACIR). Despite high vaccination
rates, pockets of opposition to vaccination
exist in some communities in Australia,
where lower coverage rates are known to
occur. Communities with low vaccination
coverage experience outbreaks of vaccine-
preventable diseases.2
Concerns about vaccine safety significantly
contribute to under-immunisation of
children. A 2001 Australian study found
that 58% of parents of children not up-to-
date for immunisation cited disagreement or
concerns about immunisation as their main
reason.3 For advice regarding the safety of
vaccines, parents look foremost to health
professionals.4-6 Therefore, it is essential
that health professionals are equipped to
respond confidently to a wide range of
parental concerns. Instances where health
professional confidence in immunisation
safety has declined have been followed by
major reductions in immunisation rates.7
Few studies have compared attitudes
between health professionals in areas of low
and high immunisation rates. This study
Infants and Children Article
2008 vol. 32 no. 3 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 225© 2008 The Authors. Journal Compilation © 2008 Public Health Association of Australia
aimed to describe differences in attitudes between two regional
areas in New South Wales (NSW) where, in 2005, immunisation
coverage rates by two years of age differed at 86% for the North
Coast (NC) and 93% for the Hunter New England (HNE).8
The second aim of the study was to identify the immunisation
knowledge, attitudes and practices among health professionals
who provide immunisation in regional NSW, with a focus on
differences between professional groups. The goal was to improve
the existing support of health professionals and ultimately to find
targeted ways to improve immunisation rates, particularly in areas
with sub-optimal coverage.
A particular focus of this study was to examine beliefs about the
safety of the MMR vaccine in the light of an alleged but unfounded
link to inflammatory bowel disease and autism, and evidence of the
impact of this concern on UK health professionals.9,10 In addition,
we examined the impact that the changes to the immunisation
schedule prior to the survey had had on health professionals. This
included the introduction of new vaccines and many schedule
changes. Meningococcal C and pneumococcal conjugate vaccines
and varicella zoster vaccines were recommended as part of the
schedule but, for a time, not funded under the NIP.11 A funded
program for hepatitis B vaccination of all neonates, rather than just
those at risk, also commenced. With this change, midwives became
the first provider of immunisation to infants. As a relatively new
immunisation provider in Australia, our study sought information
on the extent of midwives’ concerns about vaccine safety.
MethodsData collection
The study was an anonymous self-completed postal survey of
immunisation health professionals from the Hunter New England
and North Coast Area Health Services (AHS) in NSW. The target
population for the survey was health care providers involved in
immunisation. This included general practitioners (GP), practice
nurses (PN), early childhood nurses, generalist community nurses,
midwives, and hospital nurses from paediatrics wards, neonatal
intensive care and emergency departments. Approval was gained
from the Hunter, New England, and the North Coast Area Research
Ethics Committees.
Survey developmentA range of data informed development of the survey including
the findings of previous studies and the in-depth knowledge of local
immunisation coordinators (MT, CC, JT, PM).10,12-14 Many of the
questions were adapted from a 2002 unpublished survey of health
care workers in Western Sydney, NSW and a 1998 survey of health
professionals in Quebec, Canada.15,16 The survey was pre-tested with
a sub-sample of 11 health professionals from each AHS.
The survey covered five major areas:
1. Knowledge regarding vaccine contraindications.
2. Beliefs and attitudes about safety and necessity of certain
vaccines.
3. Practices in recommending unfunded vaccines.
4. Practices in communicating with parents about
immunisation.
5. Resources currently utilised.
Sampling procedurePrevious research in Western Sydney indicated that, in an area of
high vaccine coverage, such as the Hunter New England, 95% of health
professionals would be supportive of immunisation.15 We assessed
that if only 88% of health professionals in the North Coast were to
support immunisation, this 7% difference may influence coverage.
To detect this difference with 80% power at a significance level of
0.05, 248 health professionals were required from each area. The
sampling procedure involved stratifying by each AHS and sampling
each health professional group proportionally to the population
distribution of all health professionals within that area. The exception
to this was midwives, who were ‘over sampled’ in each area to allow
precise estimates for this group alone. After taking into account
likely response rates, 507 health professionals from the NC and 419
health professionals from HNE were mailed the questionnaire. For
each health professional group, participants were randomly selected
from records kept by public health units. Surveys were sent in April
2006 with a follow-up mailout to non-respondents.
Data analysisCompleted questionnaires were reviewed and information
entered into an EpiInfo database. Data cleaning, recoding and
statistical analysis were performed using SAS v9.1.3. Samples were
weighted to take into account non-response and disproportionate
sampling of health professionals from each AHS. Where possible,
response variables, including 5 point Likert scales for agreement,
were collapsed into dichotomous variables. Unless otherwise
stated, those reporting ‘agree strongly’ or ‘agree somewhat’
were recoded as ‘agree’ and compared with all others (including
‘disagree strongly’, ‘disagree somewhat’ and ‘unsure’). Where
results for early childhood nurses and generalist community nurses
were combined a new group was named ‘Community Nurses’.
Point estimates and 95% confidence intervals (CI) were
calculated where appropriate. When comparing the two areas,
point estimates and confidence intervals were used to determine
signif icance. Non-overlapping conf idence intervals were
considered significant. When comparing dichotomous variables,
an odds ratio was calculated and a chi square test used to assess
statistical significance. A p value less than 0.05 was considered
statistically significant. Content analysis was performed on text
responses and included grouping answers into common themes.
ResultsOf 926 surveys sent, 427 were returned completed (47%).
Response rates to the survey varied between the AHS and health
professionals (Table 1). In comparison with population data on
GPs, our survey over-represented females (43% this study versus
33% NSW medical workforce census data).17
Infants and children Immunisation attitudes of health professionals
226 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 2008 vol. 32 no. 3© 2008 The Authors. Journal Compilation © 2008 Public Health Association of Australia
Immunisation attitudes Childhood vaccines in the National Immunisation Program at
the time of the survey were considered to be safe by 414 of the 427
respondents (97%), effective by 416 (98%) and necessary by 409
(96%). No significant difference was found between HNE and NC
areas. Table 2 shows these findings by professional group.
Respondents rated their level of agreement with a number of
commonly held concerns about vaccines (Figure 1). Significant
proportions agreed that children get too many vaccines in the
first two years of life. Consistently more health professionals in
the NC area compared with HNE agreed with these statements
of concern; however, these differences were only statistically
significant regarding the statement that additives in vaccines may
be harmful (23%, [95% CI: 16.9-28.7%] versus 10%, [95% CI:
6.3-14.0%]). When examining these results by health professional
category, hospital nurses were more likely to agree or be unsure
about all the statements than those in general practice. In addition,
midwives were significantly more likely than all other respondents
to agree that the additives in vaccines may be harmful (53% versus
36% [OR: 2.0, 95% CI: 1.3-3.0]) and that concurrent immunisation
might overload the immune system (56% versus 28% [OR: 3.3,
95% CI 2.1-5.1].
Respondents were asked about the importance of vaccinating
young children against specific diseases. Vaccination against polio
was most strongly supported (95% agreed completely) followed
by pertussis (94%), measles (92%), pneumococcal disease (85%),
hepatitis B (84%), meningococcal type C disease (80%), and
varicella (79%).
When examining the attitudes of specific health professionals,
both early childhood nurses and practice nurses were significantly
more likely than GPs to agree completely about the importance
of vaccinating young children against varicella (early childhood
nurses 94% versus GPs 73% [OR: 5.7, 95% CI: 1.2-26.1] and
practice nurses 89% versus GPs 73% [OR: 3.0, 95% CI: 1.4-6.6]).
Similarly, practice nurses were significantly more likely than GPs
to agree completely about the importance of vaccinating young
children against meningococcal C (PNs 98% versus GPs 77% [OR:
2.4, 95% CI: 1.1-5.3]) and hepatitis B (PNs 92% versus GPs 80%
[OR: 3.0, 95% CI: 1.2-7.4]).
There was general support for the neonatal hepatitis B vaccine
for newborns with overall 83% agreeing it was necessary and 85%
agreeing it was safe. While 88% of midwives felt the vaccine was
necessary, slightly fewer (81%) believed it was safe and 35% felt
it was given too young. GPs had the least support for the vaccine,
with only 77% believing the newborn dose to be necessary for
disease control.
Immunisation knowledge and beliefsWith regard to true and false contraindications to vaccination,
based on the NHMRC Australian Immunisation Handbook 8th
edition, the majority of GPs and PNs correctly believed that
vaccines could still be given with antibiotic use (86%); temperature
of 37°C and runny nose (90%); family history of convulsions
(87%); and child’s mother being pregnant (89%); and should
not be given when the child had a temperature of 38°C and felt
unwell (95%). There were no significant differences in these
results between areas.
Table 3 shows beliefs about an association between MMR
vaccine, inflammatory bowel disease and autism. Only 59% of
respondents believed there was no association, with little difference
between the two areas. Overall, hospital nurses and midwives had
Table 1: Survey response rates by area and health professional category.
Complete Surveys sent Rate %Area response ratesHunter New England 221 419 53
North Coast 213 507 42
Health professional group response ratesGeneral Practitioner 95 260 37
Practice Nurse 81 136 60
Early Childhood Nurses 30 45 67
Generalist Community Nurses 40 69 58
Hospital Nurses 76 141 54
Midwives 112 275 41
Table 2: Proportions of health professionals in regional NSW agreeing that childhood vaccines are safe, effective and necessary.
%a
Health professionalb Safe Effective Necessary
Practice Nurse n=81 100 100 97
General Practitioner n=95 100 97 97
Hospital Nurses n=74 97 92 97
Generalist Community Nurses n=39 96 96 96
Early Childhood Nurses n=30 94 91 98
Midwives n=109 92 98 93
OVERALL 97 98 96
Notes:(a) Weighted percentages (b) Total for each group vary due to missing data
0% 20% 40% 60% 80% 100%
Complementary health practicesreduce need for immunisation
Good eating habits/healthy lifestylereduce need for immunisation
Children get too many vaccines inthe first two years of life
Concurrent immunisation mightoverload immune system
Additives in vaccines may be harmful
AgreeUnsureDisagree
Figure 1: Proportion of NSW regional health professionals who agree with, are unsure about, or disagree with specific statements about vaccination.
Leask et al. Article
2008 vol. 32 no. 3 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 227© 2008 The Authors. Journal Compilation © 2008 Public Health Association of Australia
the most uncertainty with 57% and 40% respectively, being unsure.
Community nurses were the group most likely to believe in an
association with 21% responding “yes”. Of all respondents, only
7% correctly answered that there was an association between
MMR vaccine and a rare bleeding disorder, thombocytopenic
purpura, despite the established link being listed in the Australian
Immunisation Handbook 8th edition.11
Responding to concerned parents and conscientious objectors
Respondents were given a list of all current vaccines on the
schedule and asked which ones raised the most questions and
concerns from parents and what these concerns were. Of the
eight vaccines listed (Table 4), respondents noted the MMR
vaccine as most frequently raised by parents, with the majority
of concerns about a link to autism. For hepatitis B vaccine, the
most commonly reported questions were about necessity and the
view that the vaccine was given “too young”. The question of
vaccine necessity was the most commonly reported issue regarding
varicella, pneumococcal and polio vaccines.
In their discussions with parents, most respondents felt confident
answering questions about immunisation. Community nurses
reported significantly more confidence (99%) than hospital
nurses and midwives combined (77%) [OR: 23.0, 95% CI 3.6-
146.7]. GPs and PNs combined also reported significantly more
confidence than hospital nurses and midwives combined (91%)
[OR: 3.2, 95% CI 1.7-5.8]. When parents refused immunisation
for their child, only 2% of GPs would refuse to treat the child
in the future and 18% would never sign the form required by
vaccination conscientious objectors to receive government family
assistance payments.
The vaccine scheduleOne-third of all respondents felt that adding more vaccines to
the schedule would make immunisation too complex for health
professionals. This was reported significantly less often in HNE
(28%, 95% CI: 22-34%) when compared with NC (43%, 95%
CI: 36-50%).
GPs and PNs were asked about their practices and feelings about
giving more than two injections at the one visit. The majority said
they would give more than two injections if needed (89% for GPs
and 91% for PNs), but almost half (46%) of all GPs and one-third
(35%) of PNs reported feeling uncomfortable doing so.
During the time that certain vaccines were recommended as
part of the Australian Standard Vaccination Schedule but were not
publicly funded under the National Immunisation Program, only
around half of all GPs would “mostly or always” recommend them
(meningococcal C vaccine [57%], pneumococcal vaccine [46%],
and varicella vaccine [47%]).
Use of resourcesThe utilisation of immunisation resources is shown in Figure 2.
The Australian Immunisation Handbook 8th edition in hardcopy
was rated as useful by 93% of health professionals, while the
accompanying CD and online version were less often reported
as useful. The second most useful resource was a booklet
for consumers, Understanding Childhood Immunisation and
telephone advice from the public health unit (PHU), whereas
websites were the least used resource.
When examining the popularity of resources by health
professional group, 94% of GPs and 95% of PNs found newsletters
from Divisions of General Practice (DGP) a useful source of
information on immunisation. Between 86% and 100% of
community nurses found the local immunisation coordinator, PHU
telephone advice, and the Understanding Childhood Immunisation
booklet useful.
Continuing educationThe highest rate of accreditation training occurred among
community nurses, with 93% reporting having undergone or
undergoing the immunisation accreditation course. This was
followed by practice nurses (69%), midwives (39%) and hospital
nurses (26%). Nurses who received accreditation training
Table 3: Beliefs about MMR vaccine among NSW regional health professionals.
%a
Inflammatory Autism Idiopathic bowel thrombocytopenic disease purpura
Beliefs about an yes 17 12 7
association between MMR unsure 37 29 45
vaccine and each condition no 59 59 48
Note:(a) Weighted percentages
Table 4: Specific vaccine concerns or questions raised by parents according to NSW regional health professionals.
Childhood vaccine Number of respondents raised by parent nominating concerns about vaccine raised by parents
MMR 174
Hepatitis B 133
Varicella 94
Meningococcal C 73
DTPa 52
Pneumococcal conjugate 33
Polio 21
Hib 10
Infants and children Immunisation attitudes of health professionals
228 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 2008 vol. 32 no. 3© 2008 The Authors. Journal Compilation © 2008 Public Health Association of Australia
reported significantly more confidence in answering parental
questions about immunisation (p<0.001), compared with nurses
who did not receive such training. They were also more likely
to answer correctly that a family history of convulsions was not
a contraindication to vaccination (p<0.001) but were not more
likely to believe that immunisation was safe, effective or necessary
(p=0.16, p=0.10 and p= 0.44, respectively).
While GPs wanted more workshops and/or seminars (43%),
inservice and/or updates were the most popular form of continuing
education for PNs (58%), community nurses (51%), midwives
(74%) and hospital nurses (70%).
DiscussionIn this study, health professionals in the region with relatively
low immunisation rates (North Coast) were slightly but consistently
less confident in vaccine safety compared to the region with higher
immunisation rates (Hunter New England). While it is possible the
differences in confidence levels may partly explain the differences
in immunisation coverage, other differences between the areas may
also contribute, including transience, and social and economic
disadvantage, in addition to health care utilisation and access. The
slight attitudinal differences between areas indicate that health
professionals are situated in their community contexts and both
reflect and influence community opinion about immunisation.
Indeed, an overall figure of 3% of health professionals in this
study disagreed that vaccines on the ASVS were safe and this is
the same small but significant proportion of parents who actively
refuse immunisation in Australia.3
With respect to the study’s overall findings on attitudes, the vast
majority of health professionals felt vaccines to be safe, effective and
necessary. However, despite these attitudes, a significant proportion
held unwarranted concerns about the content, timing and number of
vaccines given to children, and a smaller proportion believed that
there were suitable alternatives to vaccination. These findings are
similar to a previous study of health professionals in Western Sydney
and to those of studies with parents.6,15 Overall, health professionals
tended to have greater support for older, more established vaccines,
again similar to studies of parents.18,19 GP respondents, in particular,
had limited support for the varicella vaccine which could indicate
the need for further education about program rationale.
While studies have repeatedly failed to confirm a link between
MMR vaccine, inflammatory bowel disease and autism, our study
found a number of health professionals are still unsure about the
association.20 That the majority were unaware of an established link
between MMR vaccine and thrombocytopenic purpura demonstrated
a lack of factual knowledge, or easy access to factual knowledge,
a finding consistent with a similar UK study.10 This may indicate
a propensity for ongoing media coverage to influence their beliefs
and highlights the need for continued education. In addition, timely
and targeted information would be of value for health professionals
when the media raises their concerns and those of parents.21
The views of midwives regarding vaccination are important. As the
health professionals now at the first vaccine encounter for parents,
there is the potential for midwives’ attitudes to have an impact on
parent vaccine acceptance throughout the rest of childhood. Also,
completion of the hepatitis B vaccination series is more likely
among those receiving the first dose at birth.22 Midwives in this study
had overall confidence in the neonatal hepatitis B vaccine’s safety,
although more than one-third believed that the vaccine was given
too young. In addition, their concern about concurrent immunisation
has implications for how midwives would support additions to the
infant schedule. Given the low response rate among midwives, further
research is needed to determine the extent of such views.
Our study indicated good levels of knowledge about vaccine
contraindications and indicated an improvement in knowledge
since Herceg et al.’s survey in 1997.13 The persistence of the belief
that a family history of convulsions contraindicated vaccination
is likely to be a lingering effect of the disquiet over the safety of
the no-longer used whole cell pertussis vaccine.23
A recent study found that immunisation providers in general
practice are delaying the meningococcal C vaccination at 12
months of age, possibly to avoid giving three injections at the one
visit.24 Our finding that nearly a half of GPs were uncomfortable
giving more than two injections at the one visit indicates where
some of this delay might originate, although the preferences of
parents will also be a factor.14
This study is limited due to the low GP response rate but it
has raised an important area for closer consideration: while the
introduction of multivalent vaccines, particularly in the first year
of life, has the potential to alleviate this problem temporarily, new
vaccines in the pipeline may make multiple injections a persistent
issue for health professionals.
The existence of recommendations for the use of vaccines not
funded under the NIP showed that vaccine funding significantly
affects the propensity for a GP to suggest vaccine/s to a child.
The anticipated availability of new vaccines is likely to continue
to challenge policy makers, funding mechanisms, and health
professionals in this regard.
to “Public Health Unit telephone advice” for clarity.
0 20 40 60 80 100
Australian Immunisation Handbook
Handbook CD/Online
Myths and Realities
Understanding ChildhoodImmunisation
Division of General Practicenewsletters
Local immunisation coordinator
Public Health Unit telephone advice
Pharmaceutical company
Websites
%
UsefulNot usefulUnawareDid not answer
Figure 2: Usefulness of immunisation information proportions as reported by NSW regional health professionals.
Leask et al. Article
2008 vol. 32 no. 3 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 229© 2008 The Authors. Journal Compilation © 2008 Public Health Association of Australia
The Australian Immunisation Handbook continues to be the
most important resource for health professionals. However, this
survey shows that local support workers, such as immunisation
coordinators, public health units and divisions of general practice,
are an important conduit for, and source of, information. In addition,
immunisation accreditation training for nurses improved knowledge
about one contraindication and confidence in addressing parents’
concerns but did not change attitudes to vaccination.
While this study had adequate response rates for nurses, there
was a low response rate among GPs and midwives. This limits
the extent to which the findings for these professionals can be
generalised and further information is needed. It is possible that
non-respondents were less engaged with, or less supportive of,
immunisation. Hence, this study may over-estimate confidence
in vaccines. However, a previous study with high response rates
indicated similar findings.15 Our study may also have limited
generalisability to other Australian health professionals involved in
immunisation, as it was undertaken in regional NSW. Application
of these study methods to other areas is currently occurring.
ImplicationsHealth professionals influence parents to immunise or
not immunise their children.4-6,25 Therefore, there is value in
governments and immunisation support workers continuing their
efforts to maintain up-to-date knowledge and support the delivery
of targeted information to health professionals.
Current investment in the dissemination of recommendations
via avenues such as the Australian Immunisation Handbook and
local support personnel should continue. The introduction of more
vaccines to the childhood schedule will continue to challenge
health professionals in terms of coverage and complexity. This
impact needs to be considered in making decisions about future
vaccine programs.
As vaccine-preventable diseases have become less common in
Australia, the focus increasingly has moved to vaccine safety and
necessity. Increased effort in ensuring health professionals are
better informed about the benefits and safety of immunisation and
are kept up-to-date with changes will help to maintain the currently
high immunisation coverage needed to protect Australians against
potentially serious vaccine-preventable diseases.
AcknowledgementsWe are grateful to Glenda Lawrence, Nick Wood, Sean Gibney,
Peter Eisenberg and Sue Campbell-Lloyd who provided input into
the survey content, Christine Staples, Penny Cox and Kylie Parsons
who assisted in survey mailouts, Melissa Helferty who undertook
data entry and cleaning, Cornelis Biesheuvel and Jennifer Peat who
provided statistical advice, and four peer reviewers who provided
helpful feedback.
NCIRS is supported by The Australian Government Department
of Health and Ageing, The NSW Department of Health and The
Children’s Hospital at Westmead.
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Infants and children Immunisation attitudes of health professionals