Intended for healthcare professionals

Practice Quality Improvement Report

Improving MMR vaccination rates: herd immunity is a realistic goal

BMJ 2011; 343 doi: (Published 04 October 2011) Cite this as: BMJ 2011;343:d5703
  1. Philippa Cockman, general practitioner and clinical lead for immunisation1,
  2. Luise Dawson, public health nurse2,
  3. Rohini Mathur, research fellow3,
  4. Sally Hull, senior clinical lecturer3
  1. 1St Stephen’s Health Centre, London E3 5ED, UK
  2. 2NHS Tower Hamlets, London E1 1RD
  3. 3Blizard Institute, Queen Mary University of London, London E1 2AT
  1. Correspondence to: P Cockman Philippa.Cockman{at}
  • Accepted 20 August 2011


Problem As measles is a highly infectious disease, the United Kingdom recommendation is for at least 95% of children to receive a first vaccination with the measles, mumps, and rubella (MMR) vaccine before age 2 years and a booster before age 5 years to achieve herd immunity and prevent outbreaks. Reported vaccination rates for England have improved since a low level in 2003-4. Coverage for London is consistently lower than for England, however, and concerns have been expressed that there could be an epidemic of measles in the capital.

Design Observational time series study.

Setting London Borough of Tower Hamlets.

Key measurements for improvement Uptake rates for childhood vaccinations. The key target was to reach 95% coverage for the first MMR vaccine before age 2 years.

Strategies for change Financial support for the development of geographically based networks of general practices. Commissioning of care packages, incentivising delivery of high quality integrated care with network level vaccination targets of 95%. Innovative use of information technology to enable robust call and recall processes, active follow-up of defaulters, and increased knowledge about the demography of the children most difficult to reach.

Effects of change The development of networks of practices facilitated collaborative working among primary care clinicians and other stakeholders; peer review of achievements; and an element of healthy competition. Uptake improved for all childhood vaccinations, and to herd immunity levels for most. Uptake of the first MMR vaccine before age 2 years rose from 80% in September 2009 to 94% in March 2011.

Lessons learnt Achieving herd immunity for childhood vaccinations is an achievable target in an ethnically mixed, socially deprived inner city borough. The ability to identify characteristics of the difficult to reach groups, including significant differences in uptake across different ethnicities, will allow targeted interventions that may further improve overall coverage.


  • Contributors: PC, LD, and SH had the original idea for the paper. RM provided the analysis, interpretation, and presentation of the data. PC wrote the first and final drafts and is guarantor. SH acted as coordinator and editor.

  • Funding: None.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Provenance and peer review: Not commissioned; externally peer reviewed.

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