MMR vaccination – still underachieving on a massive scale

November 26, 2010 at 10:57 am (Anti-Vaccination, Vaccines) (, , , , , , , , , , , , , , , , , , , )

Guest blogpost from Peter Flegg, UK doctor.

This week I discovered a new toy to play around with. It’s the new interactive section of the Health Protection Agency website, called Health Protection Profiles.
With it, one can access several interactive maps and data tables covering a range of issues relevant to Health Protection in England. This includes data on vaccination uptake and the incidence of various infections.

Looking at the section on MMR vaccination was enlightening. As you may recall, in 2008 there were widespread outbreaks of measles throughout the UK, mainly because of low MMR vaccination uptake rates and poor levels of herd immunity. As a consequence, measles was declared to be endemic in the UK once again, and many Health Authorities had to implement catch-up vaccination drives to try and get as many unvaccinated children immunised as possible to avert further spread of disease.

So what is the current state of England’s MMR vaccination campaign? MMR vaccine is given twice in infancy, the first injection just after the child turns one year old, and the second one given between 3 and 5 years of age. Using the Health Protection Profiles information, one can see that the latest available data for 2009 show the national average for MMR uptake is as follows:

• Percentage uptake of 1st dose of MMR by 2 years = 84.9%
• Percentage uptake of 2nd dose of MMR by 5 years = 78.0%

You may recall that for measles, the required level of herd immunity within a population to provide decent protection against outbreaks of infection is over 90%. As not everyone who is vaccinated will develop fully protective immunity (there is a small “failure rate” for the measles component of MMR vaccine), this means that we should be aiming to achieve around 95% vaccine uptake to ensure adequate herd protection. Clearly there is still a very long way to go, as the detailed data indicate (around 17% improvement to be precise).

In London, where vaccination rates are traditionally lowest, the uptake of both MMR shots by the age of 5 ranges from a dismal 32% in Brent to a still inadequate 82% in Barnet. The main region of low vaccination is in North London, encompassing the boroughs of Brent, Haringey, (City and) Hackney, Camden and Islington, all of which struggle to even reach a 50% vaccination rate.

This continued failure to get our country’s infants adequately protected is a recipe for future measles outbreaks and potential disaster. That fewer than half the children in some areas of London remain either unvaccinated or incompletely vaccinated will mean a gradual build-up of the pool of susceptible children in these areas, and I predict that in 2 or 3 years time, further measles outbreaks will sweep through the city unless the vaccination rates improve.

Whilst the derisory national vaccination rates that were seen about 8 years ago can be blamed on the scurrilous scaremongering that followed Andrew Wakefield’s discredited notions about MMR and autism, it is clear that this is not still the reason for the continued abysmal vaccine uptake rate we see today. Only a tiny proportion of the public still believe in the “MMR causes autism” myth, though there may be a larger minority who still feel that vaccines are vaguely risky in some nonspecific way. MMR vaccine refusal rates were around 2% in one recent USA survey, an indication how the American public has not yielded significantly to the anti-vaccine scaremongers.

I haven’t seen a comparable survey for the UK, but I suspect that the results would be broadly similar. The anti-vaccine lobby in the UK is quite vociferous, but in reality it is nothing more than the mouse that roared, and its direct influence on the decisions of North London parents about vaccines must be minimal. But in 2009 fully two thirds of the children in Brent are not being adequately vaccinated against measles, which indicates something else is at work other than a conscious and deliberated refusal by parents on the grounds of possible vaccine risk.

The Health Protection Profile maps for MMR vaccine uptake in London in 2005 (when the scares about MMR and autism were still rife, though starting to recede) indicate that it was the more affluent areas like Kensington and Chelsea, and boroughs south of the Thames which had the lowest vaccination rates, while the areas in North London had relatively high rates (Brent actually having the 4th highest uptake at 71%). So what is going on?

The wretched vaccination uptake in these London boroughs is likely to be linked to the high indices of social deprivation and resultant erratic or even non-existent contact with health services, and things would appear to be getting worse, rather than better. Something needs to be done to re-engage with families/parents, and quickly, to establish suitable opportunities to offer vaccinations and other aspects of relevant health care. New and wide-ranging strategies will need to be developed and deployed, and I hope someone in authority is working on the problem as I write.

Introduction of combination vaccines has been shown to significantly reduce the risk of missing vaccines, and parents generally find this convenient and unthreatening to their child’s health. The recent announcement of a change in UK vaccination scheduling to give MMR, pneumococcal (PCV), meningococcal (MenC) and Haemophilus influenza B (HiB) vaccines at the same visit at one year of age rather than at 2 separate visits will undoubtedly help, but I fear a lot more work will need to be done in basic health care access and availability in the London boroughs if we are to avoid further outbreaks of disease.

In 2012 the Olympics will be coming to London. I predict that unless vaccine rates improve, the thousands of tourists and visitors coming to see London and the games will be entering a measles-endemic city that is rife with outbreaks of measles. Not only will we see children in the UK sickening and possibly dying, but the UK will serve (as it has done in recent years) as a source for the spread of measles around the rest of the globe (which does a damn sight better than us at vaccinating against this potentially serious disease).

12 Comments

  1. Helen said,

    Someone has responeded to me on twitter to say that in North London, some of the deficit is made up by children having the single measles jab. I would actually be sceptical as to whether including the single measles jab in the figures would greatly increase the percentage recorded as vaccinated. I’m not aware that it’s widely available here, (Hackney/Islington borders) and I think that issues such as the mobility of the population and other socio-economic factors possibly contribute more to low rates than a wish to avoid the combined vaccine. However, are there any statistics on total percentage of children vaccinated against measles through either vaccination, MMR or single?

  2. Peter Flegg said,

    Good question. Certainly some of the shortfall in MMR uptake might be due to parents sourcing single measles vaccine on a private basis (in the mistaken assumption that this is safer than having MMR).

    I am aware of one UK National survey was conducted on the millennium birth cohort (born 2000-2002), so this coincides with the time in the early 2000s when hysteria about possible autism from MMR was at its peak, and I would say that a survey conducted today would be unlikely to document as many children getting single vaccine.
    http://www.bmj.com/content/336/7647/754.full?rss=1

    Overall, 5.2% of 3 year olds had received at least 1 monovalent measles vaccine shot (5.8% in England and 8% in London). Factors associated with being unimmunised with MMR included lower socio-economic demographic factors, but there was also a link to high maternal education and age, suggesting that for the latter group concern about MMR/autism played a part in refusal of MMR, whereas for the lower socio-economic groups a failure to be immunised probably related to other factors such as lack of opportunity.

    The factors associated with receiving a monovalent measles vaccination were mainly having a highly educated, white mother and a high family income.

    This being the case, the likelihood that the poor vaccine uptake rates in North London would be offset by significant numbers of children getting monovalent vaccine is remote.

  3. Helen said,

    Thank you

  4. jdc325 said,

    HPA report from September here: PDF. London lags behind on pretty much every measure of vaccine coverage.

  5. Ben said,

    I for one think it’s pretty unlikely that the good people of Brent are secretly vaccinating their children with single vaccinations. Social deprivation though? Right on there.

  6. Becky said,

    Excellent post. This would presumably explain the two Ugg-booted mums outside my daughter’s school yesterday (E. London) discussing how badly mumps was affecting their kids (boys).

    Morons, morons.

    Kind regards,

    Becky

  7. Anthony said,

    Excellent post. You do wonder if the second dose could be given at School in a mass vaccination (as with HPV) in areas like Brent.

  8. Arty Peters said,

    Very thoughtful article

  9. Adam said,

    Great post.

    However, I’m not sure I agree with the conclusion that anti-vaccination scare stories don’t have a large part to play. I’m sure they’re not the whole story, but don’t you think they’re a significant part of it?

    Do you know of any data that could shed light on how many people are refusing vaccinations because they believe in the vaccine conspiracy theories?

  10. Peter Flegg said,

    I think that parental fear over vaccine reactions still plays a part, but this seems to be a diminishing one.

    At the peak period of fearmongering about MMR, as many as 24% of parents felt the vaccine was riskier than measles in 2002, but this fell to 14% in 2006.
    http://www.ncbi.nlm.nih.gov/pubmed/17395344?dopt=Abstract

    I am sure this erroneous perception has declined further, what with the realisation in the last few years that measles outbreaks are a phenomenon to be wary of, and the discrediting of Andrew Wakefield and the MMR-autism myth.

    MMR vaccine coverage fell by just over 8% between 1995 and 2001, the period covered by the Wakefield paper (1998) and peak media hype about vaccine reactions/autism (2001-2), so this is a reasonable surrogate of the refusal rate for MMR consequent to the stories about MMR and autism. The rate has recovered somewhat since, but as I pointed out it is still far from satisfactory especially in London.
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1314443/pdf/12434960.pdf

    An interesting insight into parental concerns around the time is shown in this paper, which looked in depth at the attitudes among a small focus group.
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1314147/pdf/11761204.pdf
    The expected reasons for being wary of vaccination include Government distrust and attention to media stories, and there was a perception that measles was a fairly innocuous illness (which it generally is, but if complications occur these can be devastating).

    There have been other surveys in the UK on parental attitudes that I have tracked down. Unfortunately what appears to be a key one is only available through a paywall.
    http://ukpmc.ac.uk/abstract/MED/16157422;jsessionid=C34205E435D9451033C0A6F67C30AC47.jvm1

    One Scottish survey in 2005 showed that parents who do not immunise think the vaccine is more dangerous than the measles (a concept that antivaccine propagandists have been pushing for many years, with some apparent success).
    http://news.bbc.co.uk/1/hi/scotland/4689359.stm

    The point of my original blogpost was to expose the gulf in vaccine uptake that exists for MMR in some areas, primarily in London, and to demonstrate this is likely to be due to socio-economic factors, poor access to health care and inadequate engagement with health srevices in general.

    But I accept there is still a small core of resistance to MMR in particular nationally, since the vaccination rates are generally reasonable for other key performance indicators such as DTaP uptake, indicating that some of the mud that was slung about has still stuck to the MMR vaccine.

  11. Measles Returns « Stuff And Nonsense said,

    […] the South East (86 and 78 cases respectively). As Peter Flegg pointed out in a guest blogpost here last November, the uptake of MMR vaccine in this country was below that required for herd immunity – and […]

  12. Ferg's gaff – Weekly tweets! said,

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