In 2016, the UK managed to eliminate measles for the first time in its history. Transmission of the disease had been disrupted and the vaccination rate in five-year-olds had reached the recommended 95 per cent coverage level required to ensure herd immunity.
Three years later, the UK’s measles-free status has been revoked. This comes after the country has seen measles cases triple in 2018 – with 991 confirmed cases in England and Wales, compared with 284 cases the year before. In the first quarter of 2019 alone, the rash- and fever-causing virus has sickened more than 230 people across the UK.
In countries that have eliminated measles, isolated cases can still occur but transmission is no longer considered endemic, which happens when immunisation rates are high enough to halt the persistent transmission of the disease within a population. All it takes is 12 months of a single strain of virus circulating within its borders for a country to lose the World Health Organisation (WHO) elimination status. Aside from an uptick in recent cases, Public Health England confirmed this week that the UK’s ”measle-free” status was revoked after the same strain of virus – B3 Dublin – was detected for more than 12 months in 2017 and 2018.
Measles is now endemic in ten European countries including Belgium, France and Germany. The increasing number of outbreaks across Europe has meant the UK has lost its ability to stop the virus from spreading, according to Helen Bedford, a professor of child public health at UCL.
“And that’s the result of gaps in immunity,” she says. The most effective way to combat outbreaks of what is one of the world’s most infectious diseases, is for children to get two doses of MMR (measles, mumps, and rubella) jabs. The idea of vaccines like MMR is to reach a threshold of herd immunity, in which a population is protected because the vast majority of people have been vaccinated against it. An estimated 20 million measles cases and 4,500 deaths have been prevented in the UK since a vaccine was introduced in 1968.
But at least 95 per cent of the population need to be vaccinated against measles to interrupt the spread of the disease if cases do start to arise. “While coverage of the first dose in the UK has reached the WHO target of 95 per cent for children aged five, coverage of the second dose is at 87.4 per cent”, Public Health England said in a blog post explaining the reasons for the UK losing the WHO’s elimination status.
While overall vaccination rates haven’t dropped drastically from previous years, Bedford stresses that a 95 per cent uptake of both doses – the first being routinely given to children at one year of age and the second around three – is required to stop the spread of measles. “Although we achieved the measles-free status a few years ago, we need to keep levels of vaccination uptake high to sustain that over the years. Because measles is so highly infectious, any small decline in uptake will threaten a community,” she says. Not only children who miss out on vaccinations are susceptible to catching the disease, but also those who can’t have vaccinations such as people undergoing cancer treatment. A 2017 study showed that a five per cent decrease in MMR vaccines could result in a threefold increase in measles cases.
The gaps in the UK’s immunity seem to be the consequence of a double whammy. Both toddlers and young adults remain unprotected. “We’ve got older adolescents who may not have been immunised when they were toddlers as their parents were scared because of the controversy around the safety of the MMR vaccine,” says Bedford.
But the decline in vaccination rates isn’t just down to people deliberately avoiding vaccinating their children. One explanation for the recent decline in uptake could be a misplaced belief that measles no longer pose a risk. “Once you get high vaccine rates and you don’t see much disease, people start thinking the disease is not around anymore,” says Bedford. She adds that many parents don’t realise when their children are due their second jab. “It’s not parents not wanting the vaccine because otherwise you wouldn’t have 95 per cent [of the population] having one dose at five years,” she says.
GPs often send reminders to parents but have been under growing pressures with practices being shut down and waiting lists growing longer. Doug Brown, chief executive of the British Society for Immunology, underpins that vaccine uptake is primarily about convenience. The underfunded NHS struggles to follow up with patients and send them reminders for the second MMR dose, he says, adding that even simple logistical issues such as a practice’s limited opening hours or the need to pay for a bus fare can result in lower uptake
Since 2015, the number of UK health professionals visiting families with young children has fallen by a quarter. “Immunisation services should be made convenient and accessible and should be funded adequately,” says Brown. In light of the UK losing its measles elimination status, prime minister Boris Johnson ordered GPs to follow up with parents whose children may have missed out on both doses and revealed a campaign to stop the spread of misleading anti-vaccine messages and has ordered.
“The government has made the right commitments, which is a huge step in the right direction,” says Brown. “But they do need to put the money where their mouth is to reverse the year-on-year cuts that have happened to the public health budget.” He believes adequate funding would see a reversal of the downward trend in vaccine uptake, and in turn, a stop in measles outbreaks that would eventually earn the UK its “measle-free” status back.
MMR vaccines are freely accessible through the NHS, but what about making them compulsory? Earlier this year, researchers from the Bruno Kessler Foundation in Italy looked at vaccination trends in multiple countries – including the UK, Ireland, the US and Australia – and suggested introducing compulsory vaccination at school entry to achieve stable herd immunity levels by 2050.
UCL’s Bedford stresses, however, that linking vaccinations to school entry may encourage some parents to take their children out of school and homeschool them. “In those situations, it’s always the disadvantaged that are at more disadvantage,” she says. Wealthy families are able to pay for a private tutor or fines imposed for unvaccinated children. “We need to make it easier for parents to get their children immunised and their questions answered and remind them about it rather than bringing in mandation.”
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