Health and Social Care Committee

Inquiry into the measles outbreak 2013


Helen Bedford PhD., RHV., FFPH., FRCPCH

Senior Lecturer in Children’s Health

UCL Institute of Child Health


David Elliman, MB BS, FRCPCH, FFPH, FRCP, DCH, BA (Open)

Consultant in Community Child Health

Whittington Health &

Immunisation spokesperson for the Royal College of Paediatrics and Child Health


Many of the factors influencing vaccine uptake apply to all vaccines, not just MMR. Presented below is therefore a general discussion as well as some issues specific to MMR vaccine.  However the next vaccine scare may well be to do with another vaccine already in the programme or, bearing in mind the major changes to the schedule currently being implemented, it could be a new vaccine.


Background to the MMR vaccine safety scare

The combined measles, mumps and rubella (MMR) vaccine was introduced to the UK in 1988.

Uptake of the vaccine rose rapidly to a high of 92%. In 1992, two brands containing the Urabe strain of the mumps vaccine virus were withdrawn after it was noted to be associated with an increased risk of aseptic meningitis (Miller et al, 2007). This did not appear to have a deleterious effect on uptake. In 1995, a paper was published suggesting a link between measles vaccines and the development of bowel disorders in adulthood (Thomson et al, 1995). This was associated with a small decline in the uptake of MMR vaccine. In 1998, the same group of researchers published observations on 12 children with pervasive developmental disorders and bowel disease and suggested that the latter may have led to the former (Wakefield et al, 1998). In eight children, the history of the onset of symptoms coincided with receipt of MMR vaccine. Although the researchers stated in the paper that ‘‘we did not prove an association between measles, mumps, and rubella vaccine and the syndrome described’’, and an accompanying commentary was heavily critical of any suggestion of such a link, (Chen and DeStefano, 1998), the story attracted much attention in the media (especially between 2001-2). This was largely fuelled by a paragraph in the press release accompanying a press conference:  ‘‘The majority opinion among the researchers involved in this study supports the continuation of MMR vaccination. Dr Wakefield feels that vaccination against the measles, mumps, and rubella infections should undoubtedly continue but until this issue is resolved by further research there is a case for separating the three vaccines into separate measles, mumps, and rubella components and giving them individually spaced by at least 1 year’’(Horton 2004). Subsequently, public confidence in the vaccine was dented and uptake of the vaccine in England fell to 79%, with some parents seeking the single antigen components. (taken from Elliman and Bedford, 2007).

Factors influencing immunisation uptake


High vaccine uptake depends on a range of inter-related factors:


Good information systems:



Well organised immunisation services:



Well informed, motivated and enthusiastic staff



Vaccine acceptance


beliefs and attitudes (Samad et al 2006b).  Mothers of these children are often older and more highly educated.

o   Children who commence the immunisation course but do not complete it are more likely to have social or practical issues making access to immunisation services difficult (32% of 697 partially immunised children (Samad et al 2000b)). Among this group are parents who do not object to immunisation, but for whom social or family pressures may mean that they do not get round to completing the course.



Parental Factors Affecting Uptake of MMR vaccine




In a systematic review of 31 studies conducted between 1997-2004 exploring parental decisions about combination vaccines including MMR, in comparison with vaccine accepting parents, those who declined combination vaccines were: (Brown et al 2010):






Parents’ Perceptions of vaccines and diseases


effectiveness of vaccines and the seriousness of diseases (Peckham 1989). These will be influenced by prior beliefs and experience as well as by the advice and information they gather from a variety of sources, including health care professionals.










Decision to immunise


The decision to immunise a child is a dynamic process and may change over time. Attitudes to vaccines and diseases are influenced by a range of other factors including prior beliefs about health and medicine, use of alternative or complementary therapies, advice from parents, friends and health care professionals, as well as the influence of the media and more recently the Internet and Social Media. Many studies report health professionals to be the key source of information for parents about immunisation.


The experience of the immunisation process itself may also affect acceptance of further vaccines (Harrington et al 2000).






·         However, studies conducted in the early 2000s at the height of the MMR vaccine safety scare  reported that some health professionals (GPs and Health visitors) were:

·          poorly informed about vaccines (Cotter et al 2003, Harris et al 2001, Henderson et al 2004, Petrovic et al 2001)

·         did not feel completely confident about explaining specific vaccine issues (Henderson et al 2004, Petrovic et al 2001)

·         disagreed with or had reservations with some vaccine policies (Henderson et al 2004, Petrovic et al 2001)

·         did not use or are not aware of nationally available resources on immunisation (Cotter et al 2003, Petrovic et al 2001)

·         believed that single measles, mumps and rubella vaccines should be available on the

·         NHS (Macdonald et al 2004).

·         had lost confidence in the safety of MMR vaccine (Smith et al 2001)

·         expressed reservations about giving their own child specific vaccines (Brownlie & Howson 2006, Petrovic et al 2001).


Although these findings cannot be extrapolated to all health professionals, it may in part explain why the MMR vaccine safety scare took hold.


Lessons for the future

The uptake of MMR and other vaccines, in children going through the system now is good, though there is still room for improvement. It is important to make full use of the guidance already in existence.


2009 - NICE “Reducing Difference in the uptake of immunisations”. This provides guidance on the action that should be taken, and by whom, to optimise immunisation uptake.  This allows one to redirect resources to children less likely to be immunised without increased input. (NICE 2009)


2012 – Health Protection Agency “Quality criteria for an effective immunisation

Programme”. Defines the key elements required for the implementation and delivery of a safe, equitable, high quality, efficient immunisation service which is responsive to the needs of vaccine recipients and/or their carers.


2013 – Monitoring of the media can provide early warning of a potential issue. This may arise within a country or anywhere in the world and with the advent of social media scares can travel faster than any infectious disease, but an issue may be recognised before it ‘takes off’.    A media surveillance system has been established to monitor public concerns about vaccine Globally  (Larson H et al, 2013).


To some extent, the MMR scare was predictable. Prior to the publication of the Lancet paper in 1998, there had been some indication of what was coming. Up to then there was no research into a possible link between MMR vaccine and autism. However, the accompanying commentary in the Lancet, by two American vaccine experts, did point out the limitations of the research. If more experts had been willing to speak out and journalists had been better informed, the scare might have been dealt with quicker. The Science Media Centre trains scientists in presenting their case and how to interact with the media. They also lay on sessions in relation to particular topics where experts are brought together with journalists, so that hopefully the journalists better understand the issues.


Should immunisation be legally required?

Inevitably any outbreak of disease prompts discussion about the need to introduce a legal requirement for immunisation.






Ashton-Key, M., and E. Jorge. "Does providing social services with information and advice on immunisation status of “looked after children” improve uptake?." Archives of disease in childhood 2003; 4: 299-301.


Brown, Katrina F., J. Simon Kroll, Michael J. Hudson, Mary Ramsay, John Green, Susannah J. Long, Charles A. Vincent, Graham Fraser, and Nick Sevdalis. "Factors underlying parental decisions about combination childhood vaccinations including MMR: a systematic review." Vaccine 2010; 28: 4235-4248.


Brown, Katrina F., Susannah J. Long, Mary Ramsay, Michael J. Hudson, John Green, Charles A. Vincent, J. Simon Kroll, Graham Fraser, and Nick Sevdalis. "UK parents’ decision-making about measles–mumps–rubella (MMR) vaccine 10 years after the MMR-autism controversy: A qualitative analysis." Vaccine 2012; 1855-1864.


Brownlie J, Howson A.Between the demands of truth and government: health

practitioners, trust and immunisation work. Social Science and Medicine 2006; 62(2): 433–443


Chen RT, DeStefano F. Vaccine adverse events: causal or coincidental? Lancet 1998;351:611–12.


Chen RT. Creating a new paradigm in vaccine safety: from injection to genetics. Inaugural Catherine Peckham Lecture, Institute of Child Health, London. 7 June 2005.


Cotter S, Ryan F, Hegarty H et al 2003 Immunisation: the view of parents and health professionals in Ireland. Eurosurveillance 8(6): 145–150


Crowcroft NS. Action on immunisation: no data, no action. Arch Dis Child. 2009

Nov;94(11):829-30. doi: 10.1136/adc.2008.138776.


Dar, Osman, Maya Gobin, Sue Hogarth, Chris Lane, and Mary Ramsay. "Mapping the Gypsy Traveller community in England: what we know about their health service provision and childhood immunization uptake." Journal of Public Health (2013).


Dempsey AF, Schaffer S, Singer D, Butchart A, Davis M, Freed GL. Alternative vaccination schedule preferences among parents of young children. Pediatrics. 2011 Nov;128(5):848-56.


Elliman D, Bedford H. MMR: Where are we now? Arch Dis Child 2007: 92: 1055-1057.


Elliman D, Bedford H. Should the UK introduce compulsory vaccination? Lancet. 2013 Apr 27;381(9876):1434-6.


Farrington P, Pugh S, Colville A, Flower A, Nash J, Morgan-Capner P, Rush M, Miller E. A new method for active surveillance of adverse events from diphtheria/tetanus/pertussis and measles/mumps/rubella vaccines. Lancet. 1995;345(8949):567-9.


Evans M, Stoddart H, Condon L et al 2001 Parents' perspectives on the MMR immunisation: a focus group study. British Journal of General Practice 51(472):904-10


Harrington PM, Woodman C, Shannon WF 2000. Low immunisation uptake: is the process the

problem? Journal of Epidemiology and Community Health  54: 394-400


Harris T, Gibbons CR, Churchill M et al 2001 Primary care professionals’ knowledge of

contraindications. Community Practitioner 74: 66–67


Health Protection Agency. National Minimum Standards for Immunisation Training. 2005.


Health Protection Agency. Core Curriculum for Immunisation Training 2005.


Henderson R, Oates K, Macdonald H et al 2004 General practitioners’ concerns about

childhood immunisation and suggestions for improving professional support and

vaccine uptake. Communicable Disease and Public Health 7(4): 260–266


Horton R. MMR: science and fiction. Exploring the vaccine crisis. London: Granta, 2004:24.


Jacobson VannJ, Szilagyi P. Patient reminder and patient recall systems for improving immunization rates. Cochrane Database of Systematic Reviews 2005, Issue 3 Art. No.: CD003941.


Larson HJ, Smith DMD, Paterson P, et al. Measuring vaccine confidence: analysis of data obtained by a media surveillance system used to analyse public concerns about vaccines. The Lancet Infectious Diseases 2013;13:606-613.


Leask J, Kinnersley P, Jackson C, Cheater F, Bedford H, Rowles G. Communicating with parents about vaccination: a framework for health professionals. BMC Pediatr. 2012 Sep 21;12:154.


Li J, Taylor B 1993 Childhood immunisation and family size. Health Trends 25(1):16-9


Macdonald H, Henderson R, Oates K 2004 Low uptake of immunisation: contributing

factors. Community Practitioner 77(3): 95–100


McMurray R, Cheater FM, Weighall A et al 2004 Managing controversy through consultation: a qualitative study of communication and trust around MMR vaccination decisions. British Journal of General Practice 54(504):520-5


Miller E, Andrews N, Stowe J, et al. Risks of convulsion and aseptic meningitis following

measles-mumps-rubella vaccination in the United Kingdom. Am J Epidemiol 2007;165:704–9.


National Institute for Health and Care Excellence (NICE). Reducing differences in the uptake of immunisations . PH21. 2009


Peckham C, Bedford H, Senturia Y et al 1989 The Peckham Report. National Immunisation Study: Factors Affecting Immunisation in Childhood. Action Research for the Crippled Child, Horsham

Petrovic M, Roberts R, Ramsey M. Second dose of measles, mumps and rubella vaccine: survey questionnaire of health professionals. British Medical Journal 2001; 322: 82–85


Raithatha N, Holland R, Gerrard S et al 2003  A qualitative investigation of vaccine risk perception amongst parents who immunize their children: a matter of public health concern. Journal of Public Health Medicine  25(2):161-4


Rogers A, Pilgrim D 1995 Immunisation and its discontents: An examination of dissent from the UK mass childhood immunisation programme. Health Care Analysis 3: 99-115

Salmon DA, Moulton LH, Omer SB et al 2005 Factors associated with refusal of childhood vaccines among parents of school-aged children: a case-control study. Archives of Pediatric and Adolescent Medicine 159(5):470-6


Samad L, Tate AR, Dezateux C, Peckham C, Butler N, Bedford H.  Differences in risk factors for partial and no immunisation in the first year of life: prospective cohort study. BMJ; 2006a 332:1312-3.


Samad L, Butler N, Peckham C, Bedford H; Millennium Cohort Study Child

Health Group. Incomplete immunisation uptake in infancy: maternal reasons. Vaccine. 2006b Nov 17;24(47-48):6823-9.


Scheibner V 1993 Vaccination-100 years of orthodox research shows that vaccines represent a medical assault on the immune system. Australian Print Group, Victoria

Schmidt K, Ernst E 2003 MMR vaccination advice over the Internet. Vaccine 21:1044-1047


Sharland M, Atkinson P, Maguire H et al 1997 Lone parent families are an independent risk factor for lower rates childhood immunisation in London.  Communicable Disease Review (11):R169-72


Smailbegovic MS, Laing GJ, Bedford H 2003 Why do parents decide against immunization? The effect of health beliefs and health professionals. Child:  Care Health and Development  29(4):303-11


Smith A, McCann R, McKinlay I 2001 Second dose of MMR vaccine: health professionals’ level of confidence in the vaccine and attitudes towards the to the second dose. Communicable Disease and Public Health 4(4): 273–277


Smith A., Yarwood J., Salisbury DM. Tracking mothers’ attitudes to MMR immunisation 1996-2006. Vaccine 2007; 25: 3996-4002.


Sutton S, Gill E 1993 Immunisation uptake: the role of parental attitudes. In: Immunisation Research: a Summary Volume (ed. V. Hey), Health Education Authority, London.


The Science Media Centre.


Thompson NP, Montgomery SM, Pounder RE, et al. Is measles vaccination a risk factor for inflammatory bowel disease? Lancet 1995;345:1071–4.


Tuffrey, Catherine, and Fiona Finlay. "Immunisation status amongst children attending special schools." Ambulatory Child Health 7, no. 3‐4 (2001): 213-217.


Wakefield AJ, Murch SH, Anthony A, et al. Ileallymphoid-nodular hyperplasia, non-specific colitis,

and pervasive developmental disorder in children. Lancet 1998;351:637–41.