The UK was once so good at dealing with measles that in 2017 and 2021 the World Health Organization declared that we had successfully attained “elimination status” for the disease, meaning that not one endemic case had been detected in the prior year. But those days are over, with more than 200 children diagnosed with measles in England and Wales in the last four weeks of 2023. The UK Health Security Agency has declared a national incident not only because of the cases appearing, but also owing to overall low MMR vaccination rates, which leave a very large population of children at risk of infection.
Incredibly, about 25% of children in parts of London enter school unvaccinated. NHS England data suggests that more than 3.4 million children under 16 across the country are unvaccinated. This puts them at considerable risk, and measles is incredibly infectious. One person can infect about 12 to 18 others, and it spreads through respiratory means, such as coughing, sneezing and breathing. If about 95% of the population is vaccinated the virus stops circulating as it can’t find susceptible hosts, but it appears vaccination rates in many areas are below that number.
Just two doses of vaccine should confer lifelong sterilising immunity, meaning those fully vaccinated are not only protected from infection but are also very unlikely to transmit the virus to anyone else. So what’s the best way to get kids vaccinated? Scotland offers a lesson here. In Scotland, 95.9% of children had one dose by the time they were five years old, while 89.7% had two doses. The result? There was only one laboratory-confirmed case of measles in Scotland during all of 2023. Edinburgh University researchers suggest that Scotland’s increase in vaccination rates during the Covid-19 pandemic may have been linked to flexible working for parents (which meant they could attend vaccination appointments) and mobile vaccination centres.
This is a basic premise in global health: if you want parents to vaccinate their children, make it accessible, free and easy, so it can fit within their daily commitments and constraints. And that’s true whether it’s Uganda, Pakistan, Scotland or England. As Kirsten Watters, Camden’s council director of health and wellbeing, said: “When talking to parents, we know that most do intend to vaccinate their children, and they’ve got high levels of confidence and trust. It’s just that they’re finding it difficult to organise those appointments.” The majority of parents do end up vaccinating their children, but it only takes a few barriers – inability to make an easy appointment, faraway vaccine centres, confusing or inaccessible messaging – to drop the vaccination rate a few percentage points below the critical 95% threshold, and the virus can begin to take hold.
And yes, there are other issues, such as general hesitancy about vaccines after Covid-19 and the growing online conspiracy movement, as well as genuine concerns about whether vaccines are necessary, given potential side effects. The pandemic definitely introduced many people to the world of anti-vax theory and doubt, to say nothing of previous issues such as Andrew Wakefield’s study in 1998 falsely linking MMR vaccination to autism, the influence of which has proved stubbornly hard to dislodge despite its having been discredited. But we shouldn’t overstate “antivax sentiment”. The fact that vaccination rates are vastly different in some pockets of the UK – coverage is about 90% in the south-west, for instance – tells us the main difference is probably logistical. We need outreach to communities and better rollout of vaccines to areas of low coverage, all mediated through trusted health professionals.
Fortunately, the government has announced a vaccination campaign in England, recruiting teachers, GPs, and community leaders to promote vaccination, and rolling out pop-up vaccination centres in convenient locations such as schools. If the approach works, it needs to be built into the yearly campaign, so that vaccination rates never dip this low again.
I remember giving talks at global health meetings in 2003 and 2004, making the case for reducing the price of the measles vaccine for poor countries so that health ministries could acquire doses and save children’s lives. At that time, measles was considered a problem in low- and middle-income countries. We thought the problem had been solved in Britain and the United States.
Measles was once a common and deadly disease for children here. In 1962, Roald Dahl’s daughter Olivia died at the age of seven from measles complications. When a safe combined MMR vaccine was approved, the beloved children’s author advocated for parents to take it up. In a letter reflecting on the low uptake of measles vaccination in 1986, he wrote: “It is not yet generally accepted that measles can be a dangerous illness. Believe me, it is. In my opinion, parents who now refuse to have their children immunised are putting the lives of those children at risk.”
Eliminating most viruses is a tall order, but it’s a realistic target for measles given the MMR vaccine. Measles, mumps and rubella are all nasty diseases that should be stuck in the past. Dahl’s daughter didn’t have the choice of a vaccine, but children in Britain today don’t have to suffer the same fate. They live in 2024, not 1962.
Prof Devi Sridhar is chair of global public health at the University of Edinburgh
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