Social class and height.

I agree with Drs A M Dixon and J A Bibby (3 September, p 598) that low rates of tetanus immunisation can be improved and that one approach is to target women attending for cervical smear tests. This has been my policy for the past two years and is generally accepted and, indeed, welcomed by the patients. Not all women will attend for these tests, however, despite various approaches, 2and I think that expecting patients to attend the surgery for tetanus immunisation alone or to attend to complete immunisation courses without explanation, encouragement, and reminders is unrealistic. General practitioners are ideally placed to organise a broad opportunistic approach offering instant immunisation to those eligible (identified by scrutinising the medical records, including health questionnaires completed by new patients on registering) during a wide range of contacts with patients. These include parents when bringing children for primary and other vaccinations, patients attending contraceptive, postnatal, and well person clinics, those requiring travel immunisation and influenza vaccination, and those attending for routine consultations and consultations with the practice nurse. More than 70-80% of the practice population would be seen within one year,3 ensuring a significant impact. Invitations could be attached to repeat prescriptions and there should be a willingness to immunise those who are comparatively immobile and housebound during routine visiting. Even when the opportunity is missed during an initial contact with a patient because of distractions or pressure ofwork or when the procedure is inappropriate because of illness the records should be flagged to remind the doctor or nurse to be prepared when the next opportunity arises-for example, a return consultation to discuss results or monitor progress. The preliminary findings of a current audit of the effect of such an opportunistic policy on the immunisation state of the adults in my practice shows an encouraging improvement in the section audited so far-from 24% to 70% in those aged more than 65-and is also identifying those in this other high risk group45 who remain unprotected and require additional targeting. Few patients declined the offer, only 3% of those audited to date.