Tailoring immunisation programmes: Using behavioural insights to identify barriers and enablers to childhood immunisations in a Jewish community in London, UK.

INTRODUCTION: Due to regular vaccine preventable disease outbreaks and sub-optimal immunisation uptake in the London borough of Hackney, home to the largest Charedi Orthodox Jewish community in Europe, it was decided, in consultation with the community, to implement the WHO Tailoring Immunization Programmes approach (TIP). DESIGN: The WHO Tailoring Immunization Programmes (TIP) approach was used. TIP provides a framework based on behavioural insights methodology to identify populations susceptible to vaccine preventable diseases, diagnose supply and demand side barriers and enablers to vaccination and recommend evidence-informed responses to improve vaccination coverage. RESULTS: The results of the formative research and behavioural analysis challenged the assumption that a cultural or religious anti-vaccination sentiment existed within the community. Critical issues related to access to and convenience of immunisation services. Service providers in the area have challenges due to having to deliver immunisation services to the large numbers of children without additional resource. Where mothers were choosing to delay or refuse vaccinations their reasons were broadly similar to the wider population. The behavioural analysis identified potential categorisation of subgroups within the community enabling a more tailored approach to addressing concerns and meeting parents' needs. CONCLUSION: The TIP approach was an effective way of investigating factors linked to sub-optimal immunisation within the Charedi community. The use of behavioural insights enabled the categorisation of subgroups so that more targeted interventions could be developed. The comprehensive stakeholder engagement which is a key pillar of the TIP approach ensured a deeper understanding of the barriers and enablers to vaccination as well as increasing the level of ownership in the community. TIP should be considered as a useful approach to identify main facilitators and barriers to vaccination in communities with suboptimal immunisation uptake.

Whole-genome sequencing revealed concurrent outbreaks of shigellosis in the English Orthodox Jewish Community caused by multiple importations of Shigella sonnei from Israel.

In December 2013, Public Health England (PHE) observed an increase in the number of cases of Shigella sonnei linked to the Orthodox Jewish Community (OJC). Ultimately, 52 cases of S. sonnei phage type (PT) P and PT7 were notified between November 2013 and July 2014. Whole-genome sequencing (WGS) was performed on a HiSeq 2500 platform (Illumina) on isolates of S. sonnei submitted to PHE during the investigation. Quality trimmed sequence reads were mapped to a reference genome using BWA-MEM, and single-nucleotide polymorphisms (SNPs) were identified using GATK2. Analysis of the core genome SNP positions (>90 % consensus, minimum depth 10×, MQ≥30) revealed that isolates linked to the outbreak could be categorized as members of distinct monophyletic clusters (MPCs) representing concurrent regional outbreaks occurring in the OJCs across the United Kingdom. A dated phylogeny predicted the date of the most recent common ancestor of the MPCs to be approximately 3.1 years previously [95 % highest posterior density (HPD), 2.4-3.4]. Isolates of S. sonnei from cases from the OJCs in Israel included in the phylogeny, branched from nodes basal to the UK OJC outbreak clusters, indicating they were ancestral to the UK OJC isolates, and that the UK isolates represented multiple importations of S. sonnei into the UK population from Israel. The level of discrimination exhibited by WGS facilitated the identification of clusters of isolates within the closely related bacterial populations circulating in the OJC that may be linked to a unique point sources or transmission routes, thus enabling a more appropriate public health response and targeted interventions.