Intended for healthcare professionals


MMR vaccine uptake may be lower than reported because of manipulation of target groups

BMJ 2002; 324 doi: (Published 23 March 2002) Cite this as: BMJ 2002;324:733
  1. Thomas J Scanlon, consultant in public health medicine. (toms{at}
  1. East Sussex, Brighton and Hove Health Authority, Lewes, East Sussex BN7 2PB

    EDITOR—One issue seems to have been completely ignored in the current debate on vaccination against measles, mumps, and rubella (MMR). The average uptake of the MMR vaccine across England now stands officially at 84%, some way off the recommended target of 95%. Although this rate is of considerable concern in itself, vaccine uptake may be even lower than reported.

    Falling rates of vaccine uptake and the subsequent loss of income experienced by several general practices failing to reach payment targets have prompted some general practitioners to take unusual measures. They have temporarily removed children whose parents object to vaccination with MMR vaccine from their lists immediately before they would have been included in the target group for vaccination. These children are therefore excluded from the denominator for calculating vaccine uptake. The general practitioners concerned write to parents informing them of the “temporary measure” and undertake to provide all usual services to these children at no cost. The immediate result is that vaccine uptake appears artificially high and general practitioners receive payment for reaching vaccine targets. After the payment deadline is passed the patients are accepted back on to the list.

    As a result of this manipulation of vaccine coverage the population may be at even greater risk of a measles outbreak than has been previously supposed. Furthermore, because these patients are not registered, capitation payments to primary care trusts may be reduced leading to a loss of health care for local people. Such action continues in this health authority area, despite strong advice against it from the Department of Health, the health authority, and the local medical committee. The General Medical Council has written that as long these patients are treated on the same footing as other NHS patients, the doctors' conduct will not give rise to ethical objections from the council. Thus general practitioners engaged in this practice see no reason to stop.

    Although the Department of Health may be correct in its decision to persevere with the MMR vaccine, it is time to review how vaccine target payments are calculated. The Department of Health could consider practices that pool risk. One partner in a practice could carry the financial burden of patients who decline vaccination: currently targets are calculated for the practice. The department could consider accepting a written disclaimer from patients as acceptance that a practice has made every effort to vaccinate the children concerned.

    While the current doubts about MMR vaccine, however unfounded, continue, this manipulation of target figures is likely to increase, leading to more uncertainty about the accuracy of vaccine coverage, and in effect placing the population at greater risk.