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Making measles history

07 September 2018

Measles has almost disappeared from the UK, but how can it be totally eradicated so it’s no longer an issue? Michelle Falconer and David Green of Public Health England show how CPs can help.

Measles is a highly infectious virus that can be very serious and even fatal, but which can be easily prevented by the measles, mumps and rubella (MMR) vaccine. Recently, the WHO confirmed that the UK had eliminated measles, which is no longer endemic in the UK (WHO, 2017).

This is a huge achievement and testimony to the hard work of health professionals in the NHS; this led to uptake of the first dose of the MMR (MMR1) vaccine in five-year-olds reaching the 95% WHO target for the first time in England in 2016. However, we cannot be complacent; measles has not been wiped out. In 2017, 277 laboratory-confirmed measles cases were reported in England and Wales. This number had already gone up to 807 by 6 August 2018 (Public Health England (PHE), 2018a), with several outbreaks linked to importations from Europe (see Table 1 below).

Young people and adults aged 15 years and over who missed out on the MMR vaccine when they were younger, as well as some under-vaccinated communities, have been particularly affected. As a result, PHE has declared a ‘national measles incident’.


Vaccine coverage

MMR vaccine is routinely offered to all children at 12 months of age, with a second dose offered at three years and four months of age.

The combined MMR vaccine was introduced in 1988, with a second dose added in 1996 to provide optimal protection and pave the way towards measles and rubella elimination (PHE, 2013a).

MMR vaccine coverage in England is currently high in young children; however, coverage levels dipped to a low of 80% in 2003 and 2004 (PHE, 2014). This means that there are significant numbers of unprotected teenagers and young adults who could catch measles both in England, particularly in environments of close mixing such as summer festivals, and during foreign travel.

The WHO target of 95% coverage with MMR1 at two years of age has never been achieved, but in 2015-16 seven of the nine regions in England had an estimated coverage of over 95% at five years. London and the South East were the two regions that did not achieve this target. Worryingly, MMR1 coverage at two years has been decreasing since 2013-14, a reversal of the long trend of year-on-year improvement in uptake (NHS Digital, 2017).

Measles vaccine coverage has also been suboptimal in several European countries, with only five EU/EEA countries reporting at least 95% vaccination coverage for both doses of measles-containing vaccine (European Centre for Disease Prevention and Control (ECDC), 2018a). Thus, measles continues to spread across Europe, with ongoing potential for arriving in the UK.

Measles cases

Romania (4317), France (2588), Greece (2238) and Italy (1716) have reported the highest number of measles cases so far this year, and 31 people have died across Europe (ECDC, 2018b).

Measles is often thought of as a disease of childhood by health professionals; however, more than half of cases in England and Europe are in young people and adults over the age of 15 years who missed out on their MMR vaccines when they were younger (ECDC, 2018a).

Children under one year remain particularly vulnerable to measles. The first dose of MMR vaccine is not routinely given until infants reach one year of age because the presence of circulating maternal antibodies may interfere with the child’s response to the vaccine. They can only be protected by herd immunity and very high (95%) vaccine uptake in all other age groups.

Infants are more likely to have potentially serious long-term complications of measles. Infection can also lead to serious complications in immunosuppressed people and pregnant women, increasing their risk of miscarriage, stillbirth or preterm delivery.

The measles disease burden

There are inequalities in vaccine uptake by ethnicity, deprivation and geography, and the burden of measles falls disproportionately on some communities. NICE guidance (2009) identifies groups of under-19s who are at risk of not being fully immunised: for example, children not registered with a GP, younger children from large families, children with learning disabilities and those from non-English-speaking families.

The main barrier to vaccination is access to immunisation services that meet the needs of different communities. However, there are also communities whose religious or cultural beliefs result in low or delayed vaccine uptake. Herd immunity extends the benefits of immunisation to unvaccinated individuals, thus reducing inequalities; however, the full effect will depend on overall vaccine coverage and population-mixing patterns. When large numbers of unvaccinated individuals live in close proximity, their communities become vulnerable to outbreaks (see At-risk groups, below).


 

At-risk Groups: those disproportionately affected by measles outbreaks

  • The Charedi Orthodox Jewish community in Hackney, London, is the largest of its kind in Europe, with an average of seven children in each family. Reasons for non-vaccination may include difficulty accessing health services; a large family of many pre-school children can make accessing primary care services difficult. Birth order may also determine whether a child is vaccinated, with younger siblings in large families being less likely to be immunised. Reasons for deferring or delaying vaccination were broadly similar to the wider population (Letley et al, 2018).
  • Irish Traveller families are a highly mobile population that may attend mass gatherings such as horse fairs, weddings, funerals, birthday and christening parties.
  • Children attending schools based on the teachings of Rudolf Steiner are at risk. Steiner proposed that febrile illnesses such as measles were related to a child’s spiritual development. The child experiencing the infection is seen as being a positive opportunity for the child to benefit from the illness, so these communities are not receptive to vaccination recommendations.
  • Migrant subgroups where a small number of measles cases have been detected are at risk: usually, adults who have not received the MMR vaccine in their country of origin (for example, Poland or Romania) rather than have failed to be immunised in the UK.

 

Several measles outbreaks in hospitals have occurred, and transmission of measles between healthcare workers and patients has also been reported (Department of Health, 2008).

For this reason, all healthcare workers and staff who have direct contact with patients in the UK are recommended to have two documented doses of MMR vaccine or serological evidence of immunity to measles and rubella (PHE, 2013b), and employers are required to protect staff and patients under the Health and Safety at Work Act 1974 and the Health and Social Care Act 2008. Susceptible staff exposed to measles may need to be excluded from the workplace for a period of time.

Optimising MMR vaccine coverage

The WHO Global vaccine action plan 2011-2020 recommends an increase in efforts to improve awareness of the benefits of vaccination, particularly among parents (WHO, 2013).

Community practitioners are ideally placed to do this by:

  • Prompting parents to register their baby with a GP as soon as possible after birth as the first doses of routine vaccines are scheduled for eight weeks of age. Infants need to be registered with a GP to be invited for vaccination.
  • Reminding parents of the benefits of vaccination at all child health appointments.
  • Informing parents that measles cases are occurring in the UK and across Europe and that children travelling abroad should have a travel health assessment. Travel abroad may mean that infants require their first dose of MMR vaccine before the age of 12 months (it can be given from six months). Doses given before 12 months should be discounted; the child will still require the two routinely scheduled MMR vaccines.
  • Supporting families, including those who are vulnerable for whatever reason: those who may not speak English or who are not registered with a GP to access alternative immunisation services that are appropriate to their needs. If trained in administering vaccines and commissioned to do so, community practitioners are well placed to offer MMR vaccine to children who are unlikely to take up vaccination through their GP.
  • Reminding parents that anyone who has not had two doses of MMR vaccine can contract measles and that many of the measles cases we are currently seeing are in adults. Anyone who is unsure if they have had two doses of the MMR vaccine should be advised to contact their GP practice to check and, if needed, get the vaccine for free on the NHS.
  • Checking that you are fully protected with two doses of the MMR vaccine (or have serological evidence of immunity) so that you cannot transmit measles to pregnant women, infants or other patients on your caseload.

Health visitors and other community practitioners such as general practice staff have a vital role to play in the control of measles by supporting parents in ensuring that children and young people are fully immunised according to the UK immunisation schedule.

Michelle Falconer is an immunisation nurse specialist, and David Green is nurse consultant for immunisations, both at Public Health England.

 

Image credit | iStock

 


 

References

Department of Health and Social Care. (2015) The NHS constitution for England.
See: gov.uk/government/publications/the-nhs-constitution-for-england (accessed 7 August 2018).

Department of Health. (2008) Letter to medical directors from Professor David Salisbury. See: webarchive.nationalarchives.gov.uk/20130124014213/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_085585.pdf (accessed 7 August 2018).

European Centre for Disease Prevention and Control. (2018a) Monthly measles and rubella monitoring report. See: ecdc.europa.eu/sites/portal/files/documents/Monthly-Measles-Rubella-monitoring-report-June-2018.pdf (accessed 7 August 2018).

European Centre for Disease Prevention and Control. (2018b) Measles continues to circulate in the EU/EEA, with new outbreaks reported. See: ecdc.europa.eu/sites/portal/files/documents/Monthly-Measles-Rubella-monitoring-report-June-2018.pdf (accessed 7 August 2018).

Letley L, Rew V, Ahmed R, Bach Habersaat K, Paterson P, Chantler T, Saavedra-Campos M, Butler R. (2018) Tailoring immunisation programmes: using behavioural insights to identify barriers and enablers to childhood immunisations in a Jewish community in London, UK. Vaccine 36(31): 4687-92.

NHS Digital. (2017) Childhood vaccination coverage statistics, England, 2016-17. See: digital.nhs.uk/data-and-information/publications/statistical/childhood-vaccination-coverage-statistics/childhood-vaccination-coverage-statistics-england-2016-17 (accessed 7 August 2018).

NICE. (2009) Immunisations: reducing differences in uptake in under 19s. See: nice.org.uk/guidance/ph21 (accessed 7 August 2018).

Public Health England. (2018a) Measles outbreaks across England. See: gov.uk/government/news/measles-outbreaks-across-england (accessed 7 August 2018).

Public Health England. (2018b) Confirmed cases of measles in England and Wales by region and age: 2012 to 2017. See: gov.uk/government/publications/measles-confirmed-cases/confirmed-cases-of-measles-in-england-and-wales-by-region-and-age-2012-to-2014 (accessed 6 August 2018).

Public Health England. (2014) Measles, mumps, rubella (MMR): use of combined vaccine instead of single vaccines. See: gov.uk/government/publications/mmr-vaccine-dispelling-myths/measles-mumps-rubella-mmr-maintaining-uptake-of-vaccine (accessed 7 August 2018).

Public Health England. (2013a) Measles: the green book, chapter 21. See: assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/147968/Green-Book-Chapter-21-v2_0.pdf (accessed 6 August 2018).

Public Health England. (2013b) Immunisation of healthcare and laboratory staff: the green book, chapter 12. See: assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/147882/Green-Book-Chapter-12.pdf (accessed 7 August 2018).

WHO. (2017) Measles no longer endemic in 79% of the WHO European region. See: euro.who.int/en/media-centre/sections/press-releases/2017/measles-no-longer-endemic-in-79-of-the-who-european-region (accessed 6 August 2018).

WHO. (2013) Global vaccine action plan 2011-2020. See: who.int/immunization/global_vaccine_action_plan/GVAP_doc_2011_2020/en (accessed 7 August 2018).

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