Measles in the UK: a test of public health competency in a crisisBMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f2793 (Published 01 May 2013) Cite this as: BMJ 2013;346:f2793
All rapid responses
In 1985 and 1986, the British National Formulary (BNF) stated that:
"Since mumps and its complications are very rarely serious there is little indication for the routine use of mumps vaccine”.
It is clear that a mumps vaccine was never needed. Nevertheless, in 1988, the mumps joined measles and rubella antigens in a highly controversial combination vaccine. Pat Tookey et al, however, have belatedly made a compelling argument for the withdrawal of the MMR and the re-introduction of single measles and rubella vaccines.
Competing interests: No competing interests
Uptake of MMR vaccine among two year olds has returned to its former high levels, but the recent outbreaks of measles in the UK associated with inadequate MMR uptake throughout the 2000s also highlight the potential for the re-emergence of rubella infection, and congenital rubella [1,2]. However, in view of earlier rubella immunisation policy, which differed from that of measles, adult men are an additional group capable of helping to sustain the spread of rubella infection.
A selective single antigen rubella vaccination programme was first introduced in the UK in 1970 for 11-14 year old schoolgirls, and later extended to include susceptible women. This policy allowed for continued circulation of rubella virus: most people acquired natural immunity in childhood, but girls who had escaped natural infection were protected through vaccination. This approach was adopted because of uncertainty about the duration of vaccine immunity and the need to ensure that women remained protected in their childbearing years. Over time this selective vaccination programme resulted in a marked reduction in the number of infants born with congenital rubella and also in the number of terminations associated with rubella infection in pregnancy.
In 1988 the combined measles, mumps and rubella (MMR) vaccine was introduced for all children aged 12-15 months, with a second dose for pre-school children added in 1996 when the schoolgirl rubella vaccination programme was discontinued. Females born between about 1958 and 1985 therefore benefitted from natural immunity to rubella, topped up by the schoolgirl vaccination programme, while their male counterparts were wholly reliant on acquisition of natural immunity. Measles and rubella vaccine offered to both sexes aged 5-16 in 1994, to avert a predicted measles epidemic, will have provided an opportunity for rubella susceptible boys born after 1978 to acquire vaccine-induced immunity. But there remains a cohort of men born in the 1960s and 1970s who did not receive any rubella-containing vaccine. Those who did not acquire natural immunity in childhood will have had little exposure to circulating virus in the last 30 years.
This phenomenon of higher susceptibility rates in males than females helped sustain small outbreaks of rubella in the UK in the 1990s and more recently in Poland and also in Japan where 10 cases of CRS have been reported between October 2012 and May 2013 . The considerably improved uptake of MMR in young children and the current catch up programme for older unvaccinated children and young people is important for the prevention of measles, mumps and rubella, but it does not address the potential problem of higher susceptibility rates in men and in first generation migrants from countries without effective rubella vaccination programmes, many of whom are clustered in areas where MMR uptake has historically been low .
The World Health Organization has a target date of 2015 for the elimination of measles and rubella, and prevention of congenital rubella infection (<1 case of congenital rubella syndrome per 100,000 births) in Europe . Congenital rubella has already been virtually eliminated in the UK with only 20 cases reported to the National Congenital Rubella Surveillance Programme since 1999, and none in 2012. Only four of these affected infants’ mothers were born in the UK, but while twelve women caught rubella in early pregnancy outside the UK, mostly in their countries of origin, in eight cases maternal infection occurred in the UK .
Although rubella is less infectious than measles and congenital rubella births are at an all-time low, we must not be complacent. When MMR was introduced in 1988 it came with a health warning that inadequate uptake could facilitate clusters of congenital rubella cases at some point in the distant future . CDC has urged countries to review their immunisation polices, past and present, and identify those who may require vaccination in order to ensure high population immunity in males and females of all ages . Encouraging and facilitating MMR vaccination more widely in the population, especially among first generation immigrants and adult males, would be a wise move.
1. Greaves F, Donaldson L. Measles in the UK: a test of public health competency in a crisis. BMJ 2013; 1 May 2013 http://www.bmj.com/content/346/bmj.f2793
2. Blakemore C, quoted in The Times Thursday May 30th 2013 (Babies at risk from MMR timebomb)
3. Centers for Disease Control and Prevention. Nationwide Rubella Epidemic — Japan, 2013. MMWR Weekly 14 June 2013; 62(23):457-462 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6223a1.htm?s_cid=mm6223a1_e
4. Hardelid P, Cortina-Borja M, Williams D, Tookey PA, Peckham CS, Cubitt WD, Dezateux C. Rubella susceptibility in pregnancy: estimates based on new born screening samples. J Medical Screening 2009; 16(1):1-6
5. World Health Organisation. A report on the epidemiology of selected vaccine-preventable diseases in the European region. WHO EpiBrief 2013, 1:1-4 http://www.euro.who.int/__data/assets/pdf_file/0011/187571/EpiBrief-Issu...
6. Congenital Rubella, in BPSU Annual Report 2011-2012 http://www.rcpch.ac.uk/system/files/protected/page/BPSU%202012_v6_low%20... (2012-2013 in press)
7. Nokes DJ, Anderson Rm. Rubella vaccination policy: a note of caution. Lancet 1987;(i)1441-1442
Competing interests: No competing interests
Following up on Mrs. Fletcher's well documented remarks, I would like to add that both the FDA and Merck have always stated the following:
From the MMR-II package insert:
Clinical studies of 284 triple seronegative children, 11 months to 7 years of age, demonstrated that M-M-R II is highly immunogenic and generally well tolerated. In these studies, a single injection of the vaccine induced measles hemagglutination-inhibition (HI) antibodies in 95%, mumps neutralizing antibodies in 96%, and rubella HI antibodies in 99% of susceptible persons. http://www.merck.com/product/usa/pi_circulars/m/mmr_ii/mmr_ii_pi.pdf
From the Attenuevax package insert:
Extensive clinical trials have demonstrated that ATTENUVAX is highly immunogenic and generally well tolerated. A single injection of the vaccine has been shown to induce measles hemagglutination-inhibition (HI) antibodies in 97% or more of susceptible persons.
The monovalent measles vaccine would have been a smart addition to the MMR campaign in the recent measles outbreak,because:
1. It is much cheaper than the MMR
2. It is more effective against measles
3. It has been more extensively investigated in clinical trials
4. It would have been acceptable to those who still had concerns about the triple vaccine
It is regrettable that the decision makers opted again to completely ignore this information that they have always been aware of.
Competing interests: Grandfather of a young man with Regressive Autism who was perfectly fine until age 15 months
In my opinion public health competency has been tested and it has unequivocally failed the British public.
The authors refer to 'Wakefield's legacy' and seem to imply that problems with MMR vaccine started with the publication of The Lancet case series report in February 1998. This is their preferred start of the MMR controversy because it is more convenient to destroy one man's character than deal with the failings of the DH policy makers.
The DH and JCVI knew before the MMR programme began in October 1988 that 2 of the 3 brands carried a risk of meningitis and the third brand was linked with neurological complications, yet they sanctioned the use of all three brands.  
During the first week of the new MMR campaign in 1988 an eighteen month old infant was given it, started with severe convulsions and subsequently died during a seizure. This child was one of a number of children awarded Government recognition of MMR vaccine-damage through vaccine damage payments following medical assessment of the individual cases.
The two Urabe mumps containing brands were subsequently withdrawn in September 1992 after four years of use and having had an 85% share of the MMR UK immunisation programme. As mentioned, the DH and JCVI knew of the link with mumps meningitis from these brands. They also knew it was down to a chance finding due to a cluster of meningitis cases in a short period of time coming to light in a Nottingham hospital which finally led to the full exposure of the problems. The hospital had a strict policy of routinely conducting lumbar punctures whenever a child was brought in following a febrile convulsion and the Urabe mumps vaccine strain showed up in the spinal fluid samples.
And what of the Urabe mumps MMR withdrawal? Did the DH contact every doctor in the country to cross check their patient records to determine if each child who had received either of the brands was developmentally well and thriving to the same degree as before the vaccine was given? The answer is no!
In 1995 the vaccine policy-makers were advised by the Health Protection Agency that the adverse event reporting system needed to be urgently improved because there was a serious under-reporting of side effects. Did they act urgently to make it absolutely compulsory for every serious side effect to be reported and investigated thoroughly. The answer is no!
During a meeting in 1997 with the health minister and top level DH officers the details of 1200 children suspected of suffering MMR/MR life changing or life ending adverse reactions were provided and a specific clinical investigation of each of the children was requested. Did they do this? The answer is no!
The parents of these children called for the continuation of single dose vaccines on the NHS as an acceptable alternative for any new parents concerned about MMR vaccines. Did the DH policy-makers do all in their power to stop the single vaccines from being phased out when the licences came up for renewal? The answer is no!
There was also an attempt to remove the licence from the importers of vaccines for private clinics just for the single measles, mumps and rubella components. Extreme measures to negate parental choice.
And now, when we are told there is an outbreak of measles in the UK there is no let-up by the DH. They continue to spend huge amounts of tax-payers' money to press home the MMR or nothing policy when the simple and money-friendly solution would be to re-instate the single dose vaccines ordered from the same companies currently supplying MMR for the UK market.
The World Health Organisation states in relation to measles vaccine :
'...The measles vaccine has been in use for over 40 years. It is safe, effective and inexpensive. It costs less than one US dollar to immunize a child against measles.
The measles vaccine is often incorporated with rubella and/or mumps vaccines in countries where these illnesses are problems. It is equally effective in the single or combined form...'
Even now, after almost 25 years of the MMR controversy, Public Health spokespersons refer to MMR vaccine as 'perfectly safe'.
Recent press statements include: "...[MMR] is perfectly safe and perfectly effective." "That may mean that some young children will have three MMR jabs....That is not a problem. It is perfectly safe and perfectly effective." and one of the strongest claims: "There's no adverse effect to this extra jab [3rd MMR]....".
These statements should be challenged by everyone as they are totally at odds with the MMR vaccine manufacturers' product sheets and dismiss out of hand the acceptance and payments made by the Government's DWP Vaccine Damage Payment Unit.
The DH vaccine policy-makers continue to blatantly mislead UK parents about vaccine risks putting the MMR programme above informed consent.
Parents should not have to accept their children being sacrificed and dismissed as insignificant casualties by vaccine policy makers in an effort to promote MMR vaccine. These people take no responsibility for vaccine damaged children and then add further insult to injury by denying their very existence.
Sir Liam Donaldson stated this in his opinion piece:
'..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...'
As the mother of a child brain damaged by MMR vaccine I would re-phrase his words:
The question Sir Liam Donaldson needs to answer is why it is ethically acceptable to tolerate serious complication and death from MMR when an effective single dose vaccine is available for those parents who shun the MMR?
And while we are on the subject I would be very grateful if Sir Liam could explain why the answers to my questions are 'no' instead of 'yes'.
 JCVI minutes of meeting February 1988
 Joint Sub-committee on Adverse Reactions to Vaccination and Immunisation
Minutes of the meeting held on Tuesday 8 March 1988 at 10:30am in
Room 1612, Market Towers
'...8. Measles, Mumps, Rubella (MMR) Vaccines
(c) Five cases of mumps encephalitis following MMR have been reported from Canada. Four of these cases definitely followed the use of vaccine containing Urabe 9 mumps virus and the fifth probably did. This corresponded to a frequency of one per 100,000 doses and no sequelae had been reported in the sufferers. [name omitted] had discussed the incidence of mumps related complications from MMR with the Communicable Disease Center, Atlanta, whose data were unfortunately only superficial on this issue. In the United States, Jeryl Lynn mumps virus is included in MMR but no data were available on parotitis following MMR and many of the reported neurological complications were clearly related to the measles component....'
Competing interests: Mother of MMR vaccine damaged son
Ms Fletcher is not alone in waiting for answers.
It is of course perfectly legitimate for a Pope to stay silent. However the men and women who have inhabited Whitehall and have acted as advisors and executive arms of Her Majesty's Government ought to explain their actions.
Public Health, even though a branch of State Medicine ought to be open to public gaze. We should not wait for legal moves.
Competing interests: Seeking truth
Despite the fact that a recent national survey1 concluded that vitamin A intakes by UK adolescents were adequate, it should not be forgotten that the requirement is increased by infection. Since Hussey and Klein2 demonstrated that Vitamin A supplementation reduces morbidity and mortality due to acute severe measles, the vitamin has been routinely administered to children in developing countries immediately upon diagnosis. During the present epidemic among older children, might there be a case for a single supplementary dose e.g. 200,000 IU (700 µmol.) of Vitamin A at the onset of measles, especially in vulnerable adolescents?
1 Foods Standards Agency: Nelson M, Evans B, Bates B et al., Low income, Diet
and Nutrition Survey. Publ. London.2007 FSA
2 Hussey GD, Klein M A randomised controlled trial of vitamin A in children
with severe measles New England Journal of Medicine 1990;232:160-164
Competing interests: No competing interests
Doctors van der Venter and Pankhania laud the sentiments in the paper by Greaves and Donaldson. The purpose of the Rapid Responses section of the bmj is DISCUSSION.
Before submitting their own response they would have read the other responses, notably, those by Robson, del Mar and Chalmers, and by Anand (ie, myself).
I note that Dr van der Venter and Dr Pankhania are expressing personal views. Would they care to respond to del Mar and Chalmers and to Anand also?
Discussion would be helpful and presumably the OSA does not limit an exchange of information in our transparent society in this scientific journal.
Competing interests: Seeking full facts
We commend the swift response of NHS England and its key players, the newly established Public Health England and Local Authority Public Health teams, to the current upsurge in number of measles cases. We also endorse the views of Greaves and Donaldson that we must not be complacent about the seriousness of measles and must ensure that there is a well-coordinated response by parties in the new health system. We must learn lessons to maximise the effectiveness of NHS vaccination programmes.
The Chief Medical Officer has written to GPs and others to urge them to proactively seek and immunise their non-vaccinated population, particularly targeting 10-16yr olds. This age group were most affected by the drop off in vaccine uptake following the (now retracted) 1998 Lancet publication of the paper by Dr Andrew Wakefield which erroneously suggested a link between the combined MMR vaccine, autism and bowel disorder.
The public concern initiated by the Wakefield publication, and subsequent media reporting, left a cohort of unimmunised individuals. It was really only a matter of time before they were exposed to the highly infectious measles virus. We have had many years of grace whilst the measles virus was not in circulation in the UK but the impacts of low MMR uptake are now being seen. Once vaccinations rates dropped below 93-95% the benefit of heard immunity, as demonstrated by Brisson and Edmunds , would not apply and thus we have had many years with a large cohort of now young adults at risk of infection.
We have had more than ten years in which to plan and address the issue of vaccinating the now young adults who had not been immunised. Whilst a catch up campaign in 2008 went some way to address the dip in vaccination uptake there has remained around 300,000 unvaccinated young people who remain susceptible to a measles infection. Thus perhaps the efforts to improve vaccination rates in this cohort should have been sustained until higher vaccine coverage was achieved, potentially preventing the current increase in measles cases.
Our failure to ensure vaccination coverage for a very infectious disease achieved the herd immunity threshold perhaps highlights that we, as a profession, still have lessons to learn about how to effectively communicate risk and ensure greater uptake of vaccination. Perhaps we could have presented and communicated the science more effectively and made sustained efforts to improve the vaccine uptake rate in the population at risk. Perhaps there are examples of good practice we can draw upon from Wales, Scotland and Northern Ireland where we understand there has been greater integration and closer working between their Primary Care and equivalent Public Health Departments.
Whilst we are currently focused on measles with the current increase in cases we must not forget there remains a population of young women of child bearing age who are susceptible to rubella. A rubella infection acquired in pregnancy can have catastrophic consequences for the unborn child.
Finally we note that primary prevention of illness via vaccination is an enormously cost effective public health measure and thus this measure ought to be followed with greater resolve. We should not forget how lucky we are to have vaccines that enable us to protect ourselves, our families and our communities from the suffering caused by a number of serious infectious diseases.
Emily van de Venter (Public Health Speciality Registrar)
Bharat Pankhania (Consultant in Communicable Disease Control)
Competing interests: No competing interests
In 1993, a WHO working group concluded that a controlled trial of prophylactic antibiotics was the most urgent research need to inform the treatment of measles (1). A trial was subsequently done in Guinea-Bissau (2), and, as shown in the relevant Cochrane Review (3), its results reinforced the findings of earlier studies, showing a reduction in pneumonia and other manifestations of bacterial superinfection. What are the implications of this evidence for the management of cases of measles in the current epidemic in the UK, particularly given the spectre of its spread from South Wales to larger conurbations (4)?
One of us wrote to the Chief Medical Officer of England to raise this question, and she referred our enquiry to one of her specialist advisers, Professor David Salisbury. Professor Salisbury questioned the relevance of controlled trials done in other countries to the situation in the UK on three main grounds. First, the risk of bacterial superinfection in UK cases of measles has been reduced by the pneumococcal vaccination programme. Second, not all hospital admissions for measles are for pneumonia. Third, the benefit from preventing pneumonia has to be balanced against the downside of widespread prophylactic use of antibiotics.
Measles is a horrible disease, made even more horrible by the complications associated with bacterial superinfection. We suggest that the appropriate public health response to differences of opinion about the value of antibiotic prophylaxis in the UK is (i) to use the Clinical Practice Research Datalink to find out the extent to which antibiotic prophylaxis is already being used; and (ii) concurrently, to evaluate the effects of prophylaxis in the hundreds of cases currently being diagnosed, recognising that a 18% hospital admission rate(4) represents a lot of measles complications.
What about the concern that prophylactic antibiotics in proven cases of measles would contribute to the development of antibiotic resistance? The Chief Medical Officer has recently expressed special concern about this. A generation of general practitioners has hardly ever seen measles, so over-prescription of antibiotics is likely to be greater than the number of cases of measles. But this is likely to be very small compared to the vast over-prescribing going on currently for non-specific acute respiratory infections, acute otitis media and other conditions for which, unlike measles, there is no convincing evidence that antibiotics reduce serious morbidity. We owe it to those currently experiencing measles as a result of the influence of misleading research evidence to find out whether antibiotic prophylaxis can reduce complications of the disease.
Iain Chalmers, Coordinator, James Lind Initiative, Oxford OX2 7LG, UK.
Chris Del Mar, professor of public health, Bond University, Queensland 4226 Australia
1. World Health Organisation. Clinical Research on the Treatment of Measles: report of a meeting. Geneva: WHO, 1995. WHO/CDR/95.15.
2. Garly M, Balé C, Martins LC, Whittle HC, Nielsen J, Lisse IM, et al. Prophylactic antibiotics to prevent pneumonia and other complications after measles: community based randomised double blind placebo controlled trial in Guinea-Bissau. BMJ 2006;333(7581):1245.
3. Kabra SK, Lodha R. Antibiotics for preventing complications in children with measles. Cochrane Database of Systematic Reviews 2008, Issue 3. Art. No.: CD001477. DOI: 10.1002/14651858.CD001477.pub3.
4. Greaves F, Donaldson L. Measles in the UK: a test of public health competency in a crisis. Can new agencies work effectively together to meet the challenge. BMJ 2013;346:7.
Competing interests: No competing interests
Dear Dr Robson and co-authors
I accept your bona fides. However, I find it a little odd that you say there is no incentive for GPs to record the immunisation status of patients registering over the age of five. Surely, it is part of good practice to establish a base-line of the child's health status?
Secondly, may I ask whether, in the case of patients you immunise, you ask the parents to report adverse reactions? I like to think you do. If you do, are you able to tell us the readers, please, what the data relating to the reported reactions are?
Competing interests: Establishing facts about immunisation practice