May 17, 2019

expert reaction to study looking at vaccination policies and measles resurgence

Research published in BMC Medicine claims that current vaccination policies may not be sufficient to achieve and maintain measles elimination in Australia, Ireland, Italy, the UK and the US.

Dr Jonathan Kennedy, Lecturer in Global Health, Queen Mary University of London, said:

“Trentini and colleagues’ paper argue that compulsory vaccinations are an effective strategy for tackling the surge in measles cases that we have seen in many high income countries over the last couple of years.

“There is a strong argument for mandatory vaccinations.  The scientific consensus is clear: there is no evidence of a link between MMR and autism, and the benefits of MMR far outweigh any risks.  But we are living in what some people have called a “post-truth” era where appeals to emotion are often more influential in shaping public opinion than objective facts.  For example, last month Eurobarometer published a report showing that 48% of the 27,000 EU citizens interviewed wrongly believed the statement that “vaccines can often produce serious side-effects” to be true.  At 54%, the figure was even higher when we look at the UK on its own.

“Individual decisions about vaccination children are a problem for the state because  coverage needs to be above 95% in order to ensure “herd immunity”, the point at which outbreaks no longer occur.  When rates fall below this level, children who cannot be vaccinated – for example, because they are too young or because they are undergoing chemotherapy – are put at risk.  Laws enforcing mandatory vaccinations therefore protect the most vulnerable members of society from potential harm due to irresponsible choices by uninformed individuals.

“However, laws enforcing mandatory vaccinations can be highly contentious and play into the hands of populist politicians.  This is what happened in Italy where the decision by the former Democratic Party-led government to fine parents who sent unvaccinated children to school became an important issue in the 2018 elections.  The law was seized upon by the Five Star Movement and presented as an intrusion on parents’ freedom to decide what is right for their children.  Interestingly, the law was successful at increasing coverage and, since being in government, the Five Star Movement have not repealed it.”

Dr David Elliman, Consultant in Community Child Health, Great Ormond Street Hospital, and RCPCH (Royal College of Paediatrics and Child Health), said:

“The UK has not escaped the worrying global increase in measles cases.  Clearly, the only way to counter this and prevent future deaths is to increase vaccine uptake.  However the conclusion drawn by Trentini and colleagues that the only way to achieve this is through a ‘No jab, No, school’ policy lacks evidence for UK.

“Only about 1-2% of UK parents refuse all immunisations.  A larger proportion may have concerns that are readily addressed by health care professionals, while a significant number still have problems accessing appropriate family friendly services.  Introducing compulsory vaccination in this country might reduce the very high level of trust that people have in the NHS and prove counterproductive.  It could even result in lower levels of vaccination.

“Before we even consider going down this route, we should ensure that we have efficient appointments systems and reminders and adequate numbers of well-trained staff, with time to talk to parents in family friendly clinics.

“Compulsion may work in some countries, but it is not for us.”

Prof Sonia Saxena, Professor of Primary Care, Imperial College London, said:

“This is very useful research that models country level data and tells us that we would need to keep vaccine coverage rates to over 95% to prevent outbreaks.

“However, the researchers are suggesting that the developed countries in this study would ‘strongly benefit from the introduction of compulsory vaccination at school entry’.

“Making vaccination mandatory might have unintended consequences.  It risks disenfranchising parents and carers, as well as risking a rise in unvaccinated children being excluded from school — which could carry stigma for children whose parents do not comply.

“More effective approaches would include reminding parents and providers of upcoming and overdue immunisations, as well as educating and providing feedback to the doctors, nurses and healthcare staff providing vaccinations.

“Targeted approaches might also be more efficiently directed at children with additional health conditions, such as asthma or immunodeficiency, who are at very high risk of diseases that can be prevented through vaccination, such as measles.”

“The most important message for parents is that for MMR, two doses by age 2 is the thing to remember.  If everyone did this they would protect their child and also the whole community from outbreaks of measles.”*

*Comment updated at authors request on 17/05/19 – 09:17

Prof Andrew Pollard, Professor of Paediatric Infection and Immunity, University of Oxford, said:

“The modelling exercise undertaken by the authors highlights the threat to the health of our children from the current ongoing resurgence in cases and deaths from the disease around the world.  There is also a moral obligation for society to protect those with conditions which mean they cannot be vaccinated, such as children who are receiving chemotherapy for cancer and those born with immune system problems – their lives are put at risk by those who are unvaccinated and can spread the disease.

“While mandatory vaccination has been shown to raise immunisation rates in various settings, and is supported by this mathematical exercise, it seems sensible to first understand why vaccine uptake has fallen across the UK and address these factors.  We must prioritise improving access to immunisation services in the NHS and communicating the importance and value of vaccination for the individual child and for the wider community.”

Prof Adam Finn, Professor of Paediatrics, University of Bristol, said:

“The authors of this paper, observing the inadequate measles vaccine uptake in several countries which have inevitably led to recent outbreaks, have projected different scenarios over the next 30 years and used them to predict the likelihood of more measles problems.  They assume that control can be achieved by protecting 92.5% of the population at any one time with 2 vaccine doses.  As you might expect, they conclude that if things don’t improve, there will be ongoing problems in most places.  They are almost certainly right about this.

“However they also suggest that the solution is to make school entry measles vaccination mandatory even though their study does not examine the effectiveness of this approach to solving the problem.  Mandatory immunisation is certainly one way to try and increase coverage but it’s far from clear how well it works or whether it would work at all in many places.  If the reasons that the vaccine is not getting into the children relate to easy access, vaccine supply or clarity of information available to parents, then making it compulsory will do nothing to alleviate such obstacles.  If there is widespread mistrust of authority or of the motivation behind any such requirements, it could actually make things worse.

“Accordingly the authors might have done better to confine themselves to drawing conclusions from the predictions of their model and summarising its limitations, rather than making proposals about social policy that their work does nothing to evaluate.”

Prof Arne Akbar, President of the British Society for Immunology, said:

“Measles is a highly contagious disease that can lead to serious consequences including death.  Since 1968, we have had an effective vaccine to protect people from contracting measles.  To achieve maximum effectiveness, two doses of this vaccine need to be given – the first at one year of age and the second at three years four months.

“As measles is so infectious, a high percentage of the population needs to be vaccinated to stop the disease spreading within our communities – the World Health Organization recommends 95%.  We know that, in the UK and in other developed nations, annual childhood vaccination rates have fallen below this target for a number of years.  In the UK, we have witnessed the impact of this lower level of immunity with a high number of measles cases reported in 2018.

“This new study has modelled how levels of immunity against measles in different countries may develop over the next 50 years given different vaccination level scenarios, examining whether these would be sufficient to stop measles outbreaks.  Their finding that, if immunisation policies remain as now, the UK (and other countries) would continue to see measles outbreaks is not surprising as we already know that current immunisation rates are below the WHO recommended levels.

“The good news is that there are many actions that our government, working with partners both in the healthcare space and in communities, can take to increase vaccination rates, preventing the spread of disease and ultimately saving lives.  This is an area that is focused on in the recently published NHS 10-year plan.  These include providing more accessible and co-ordinated services to patients, providing the public with better information on the benefits of vaccination and providing more training to healthcare workers to be able to discuss vaccinations with patients.  By improving services in all of these areas, we have the potential to significantly increase vaccination rates in the UK.  The paper authors put forward the prospect of mandatory vaccination but the British Society for Immunology would argue that there are many actions that governments can take first to improve vaccination rates before resorting to this extreme measure.”

‘The introduction of ‘No jab, No school’ policy and the refinement of measles immunisation strategies in high-income countries’ by Filippo Trentini et al. was published in BMC Medicine at 01:00 UK time on Friday 17 May 2019.

Declared interests

Dr David Elliman: “None.”

Prof Sonia Saxena: “Prof Saxena is a practising GP and has carried out research on the effectiveness of childhood vaccines.”

Prof Andrew Pollard: “I am speaking in a personal capacity with my University of Oxford affiliation.  I am also Chair of the Joint Committee on Vaccination and Immunisation, an Independent Departmental Expert Committee which reports to the Department of Health and Social Care, Member of the WHO Strategic Advisory Group of Experts and Chair of the European Medicines Agency Scientific Advisory Group on Vaccines – but I am not speaking on behalf of any of these organisations.”

Prof Adam Finn: “Adam Finn does advisory work related to vaccines for the UK government, the World Health Organisation and several companies developing vaccines.  He also leads clinical trials of vaccines funded by the UK government, charities and vaccine manufacturers.  He receives no personal remuneration or benefits in kind for any of this work apart from his salary via the University of Bristol from the Higher Education Funding Council and the NHS.”

Prof Arne Akbar: “Arne receives grant funding from the BBSRC, MRC and Dermatrust.”