Editorials

Measles in the UK: a test of public health competency in a crisis

BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f2793 (Published 01 May 2013) Cite this as: BMJ 2013;346:f2793
  1. Felix Greaves, honorary clinical research fellow1,
  2. Liam Donaldson, professor of health policy2
  1. 1Department of Primary Care and Public Health, Imperial College London, London W6 8RF, UK
  2. 2Institute for Global Health Innovation, Imperial College London, London, UK
  1. felix.greaves08{at}imperial.ac.uk

Can new agencies work effectively together to meet the challenge?

The recent surge in measles cases in south Wales signals a discomfiting failure by a G8 nation to control an easily preventable disease. Far from the measles virus being holed up in outposts in poor countries, the spectre of large outbreaks of measles in England is now looming large. By contrast, elimination of endemic measles in the Americas has been achieved by treating it as an emergency.1 Prevention of more measles cases in the United Kingdom, and avoidance of embarrassment for the government, will turn on the effectiveness of the public health delivery system.

In the north of England there have been 354 cases in 2013 so far.2 The pool of vulnerable children nationally is worrying: 8% of those aged 10-16 years have had no measles, mumps, and rubella (MMR) vaccine, and 8% have had only one of the required two doses.3 Susceptible children are distributed throughout the country, making the site of the next outbreak impossible to predict. In London, where immunisation levels for all vaccines are traditionally lower,4 there have been few cases so far. However, London is a prime location for a major outbreak, with its transient and diverse population and its pockets of low MMR vaccination coverage.

It is hard to manage risk in epidemics, is even harder to explain risk to the public. In a well nourished population, with good healthcare services, measles has a much lower mortality rate than in developing countries. Furthermore, within living memory, it was seen as a natural part of childhood. For most of those who catch it, measles is an unpleasant self limiting illness. That said, so far in England in 2013, 18% of patients with the disease have been admitted to hospital, and in a small but important minority,3 the possibility of further complications and permanent disability, or even death, is real. The question society needs to answer is whether it is ethically acceptable to tolerate any serious complication, or death, from measles when an effective vaccine is available.

In a public health emergency, which is what the current measles threat is, it is vital that the response is well coordinated. All organisations and professionals involved in managing it must know their own role and each other’s, and they must work well together. Strong leadership, excellent communication, and a modicum of command and control are also essential. There is a concern that, with the recent health system reforms in England, bodies that were key in crises like severe acute respiratory syndrome, pandemic influenza, and foot-and-mouth disease (such as strategic health authorities and primary care trusts) have been devolved and swept away. Public health teams are now spread across local authorities, with links to the NHS much weaker than in the past. A newly established agency, Public Health England, is charged with protecting the population’s health, but resources for immunisation are with NHS England,5 an entity devoid of public health expertise at board level. It is not acceptable for the elements of this new public health system to learn on the job. An agreed operating relationship is needed quickly. There is the opportunity for a natural experiment to compare the performance of the more mature Welsh system and its brand new English equivalent. Rigorous evaluation of health sector reforms in their early stages would be a novel event in recent British public policy.

Although the risks of serious complications from measles are low, it is not easy for public health policy makers in modern times to justify inaction on grounds of low risk, because public expectation is rightly that any avoidable child death should be secured. And measles will almost certainly be the next disease to be targeted for global eradication once polio has followed smallpox into the history books. Moreover, the current cohort of unvaccinated teenagers is also vulnerable to mumps and rubella, and as they edge towards adulthood the threat of the devastating congenital rubella syndrome is also a real danger.

After the influenza A/H1N1 epidemic of 2009, the government was accused of over-reaction because of the mildness of the disease, as money was spent buying unused vaccine and stockpiling antivirals. Yet 70 children died in England.6 Without the robust action that was taken more may have died. Seventy child deaths is a major incident, particularly in light of the new national patient safety initiative’s aim of zero harm. It would be complacent and irresponsible if we failed to act resolutely in the current threat on grounds of low relative severity. It would set a poor example to other countries given the UK’s global health positioning as a voice calling for better vaccination performance in low and middle income countries. It would sit uneasily with the UK’s prominent commitment to initiatives such as the “decade of vaccination.”7

The government’s catch-up immunisation campaigns must build on the lessons learnt from other vaccination programmes around the world. The first phase of the emergency response in England, which will target a third of a million older children, will probably take some months to achieve. In India, millions are vaccinated in a few days, which is a powerful demonstration of what it takes to get ahead of the proverbial curve. Perhaps more dynamism and innovation as well as good organisation is needed in the UK if Wakefield’s legacy is to become a footnote in public health history rather than a tragedy writ large in the public psyche.

Notes

Cite this as: BMJ 2013;346:f2793

Footnotes

  • Competing interests: We have read and understood the BMJ Group policy on declaration of interests and declare the following interests: LD has previously served as chief medical officer for England and is currently chair of the independent monitoring board for the Global Polio Eradication Initiative. FG has an honorary contract with Public Health England and takes part in regular on-call activity.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

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