Intended for healthcare professionals

Rapid response to:


Comparison of social distribution of immunisation with measles, mumps, and rubella vaccine, England, 1991-2001

BMJ 2003; 326 doi: (Published 19 April 2003) Cite this as: BMJ 2003;326:854

Rapid Response:

Rethinking approaches to increase MMR uptake

As the controversy over the MMR vaccine hits the headlines again, it
is easy to develop a sense of helplessness and hopelessness about the
possibility of changing parents’ attitudes. Reviews of immunisation uptake
rates in Bromley suggest that it may not all be bad news. Figure 1 shows
that the proportion of children who receive MMR by age 2 years continues
to fall rapidly, reflecting the picture seen in many areas in the UK (1).

However, the proportion of children who receive MMR by age 5 years is
substantially higher. This suggests that parents are not deciding against
MMR vaccine per se, but instead are delaying the first MMR vaccination.

This supports research suggesting that fear that the child is too young is
a common reasons for not immunising (2).

We need to rethink our strategies for increasing immunisation uptake.
We have to focus our efforts on parents of young children, explaining the
importance of immunising early, and providing evidence that children aged
12 months are not too young for such vaccines. Despite health
practitioners’ fears that increased provision of information may increase
anxiety (3) and have counter productive effects on uptake of health
behaviours (4), many studies have shown that parents would prefer more
information on immunisations(5). Moreover, recent research has
demonstrated improvements in immunisation behaviour and decreased anxiety
following an antenatal intervention involving the provision of detailed
evidence-based information on risks and benefits of early childhood
immunisation(2). This supports the argument that parents may benefit from
receiving detailed information on MMR, during the antenatal period.

We still need to address the issue of the low proportion of children
who are fully immunised (2 doses of MMR) by age 5 years. Measures should
be implemented to increase the proportion of 5-year olds who have received
both the MMR1 and MMR booster. We suggest that parents are encouraged to
take their child for the MMR booster relatively soon after MMR1, even if
this first MMR is not given until child is of an age when the booster MMR
is scheduled.

In summary, we should like to suggest that health professionals can
feel some optimism regarding MMR immunisation, but that we would benefit
from rethinking our strategies for increasing uptake by placing more
emphasis on the finding that parents appear to be delaying the first
immunisation as opposed to totally rejecting MMR immunisation.


1. Middleton E, Baker D. Comparison of social distribution of immunisation
with measles, mumps, and rubella vaccine, England, 1991-2001. BMJ

2. Wroe AL, Turner N. Evaluation of a decision making aid for parents
regarding childhood immunisations. submitted.

3. Gattellari M, Voigt K, Butow PN, Tattersall MHN. When the treatment
goal is not cure: are cancer patients equipped to make informed decisions?
Journal of Clinical Oncology 2002;20(2):503-513.

4. Wolf A, Nasser J, Wolf A, Schloring J. The impact of informed consent
on patient interest in prostate-specific antigen screening. Archives of
Internal Medicine 1996;156:1333-1336.

5. Wroe AL, Turner N, Salkovskis PM. Understanding and predicting
decisions about early childhood immunisations. Health Psychology in press.

Competing interests:
None declared

Competing interests: No competing interests

02 August 2003
Abigail L Wroe
Consulting Immunisation Facilitator
Angela Bhan