Health professionals and the general public have been advised that measles cases in the UK have been increasing. Between October 2023 and March 2024 in England there have been 789 cases of laboratory confirmed cases of measles (GOV.UK, 2024).
The West Midlands has accounted for the majority of the cases but other cases are being reported in clusters in other areas of the UK (GOV.UK, 2024). The majority of these cases have been in children under the age of 10 (63%) (GOV.UK, 2024).
The increase in reported cases has led to NHS England launching a major drive to invite those not fully vaccinated to come forward and catch up on missed doses (NHS, 2024). Measles is one of the world's most infectious diseases, with one infected person infectious to approximately 15 unvaccinated people. Measles has serious risks of complications, and one in five children with the illness require hospital visits (NHS, 2024). Since the introduction of the measles vaccine in 1968 it is estimated that 20 million cases and 4500 deaths have been averted in the UK (Public Health England (PHE), 2019).
Vaccine coverage is the best indicator of the level of protection a population will have against vaccine-preventable communicable diseases (Nuffield Trust, 2024), and MMR uptake has been variable throughout the last 2 decades. Between 1994 and 1997, coverage was around 91% of children reaching their second birthday (Nuffield Trust, 2024). There was then a significant decrease in uptake following a now discredited article claiming links between the vaccine and autism; and uptake decreased to 80% (Nuffield Trust, 2024). It reached 92% in 2013/14 but decreased again by 2022/2023 to 89% (Nuffield Trust, 2024).
» The strategy focuses on four core components that are required to maintain elimination going forward, which includes achieving and sustaining 95% coverage «
The UK achieved measles elimination status in 2017, but increases in cases in 2018 meant that the measles virus was re-established and elimination status was lost (Nuffield Trust, 2024).
The UK measles and rubella elimination strategy was published in 2019 (PHE, 2019). Eliminating measles and rubella is a core goal of the European Vaccine Action Plan 2015–2020 and an important part of global efforts to improve health and reduce inequalities (PHE, 2019). The strategy focuses on four core components required to maintain elimination going forward, including achieving and sustaining 95% coverage, strengthening infection surveillance and ensuring easy access to high-quality, evidence-based information for health professionals and the public (PHE, 2019).
Health visitors are in a unique position when it comes to speaking with parents (Gildea, 2022). The universal service comes into contact with every child in the country and is able to build trust through mandated visits (Gildea, 2022). Health visitors are highly valued by many areas of the community and could provide a bridge to mainstream health services for individuals and families who use healthcare less often (NIHR, 2023).
There is a large evidence base of information regarding vaccinations, and decisions by families to vaccinate their children is a complex issue driven by a variety of contextspecific factors (Larson et al, 2014). It is important to understand the complexities of decision making in order to work both with families and on a community level to increase vaccination uptake. In a qualitative systematic review by Foster et al (2016), the researchers concluded that there were two types of decision making: non-deliberative, where parents feel they have no choice and are happy to comply; and deliberative, which involves weighing up the risks and benefits, considering others' advice/experiences and social judgement. These two types of decision making are not mutually exclusive and some parents in the study adopted both approaches at different times. The researchers concluded that, by understanding the mechanisms of decision making, better interventions can be designed to enhance informed uptake for both non-deliberative and deliberative decision making.
Recommendations of the study were that communicators would introduce vaccination, discuss why it is being offered, help parents assess the appropriateness of vaccination for their child and provide additional information where needed (Foster et al, 2016).
In a systematic review (Brown et al, 2010), the authors concluded that interventions should focus on the decision-making process of parents as well as the belief of some parents that vaccines are unsafe and ineffective and the diseases they are given to prevent are mild. The review found that parents can mistrust health professionals, government and officially endorsed vaccine research, but that they do trust media and non-official information sources. They resent perceived pressure; therefore, exploring the decision with parents and how they came to that conclusion is important (Brown et al, 2010).
A systematic review by Mills et al (2005) concluded that themes of vaccine hesitancy came under four headings: issues of harm; issues of mistrust; access issues; and other issues. Trust in health professionals was also raised by Smith et al (2017). Their systematic review found that other factors associated with vaccine uptake included knowledge about the vaccine, social influences and trust in health professionals. In a review of 34 papers, lack of confidence, complacency, constraints, calculation, and collective responsibility have been highlighted as barriers to vaccination uptake (Obohwemu et al, 2022).
In a systematic review of 46 studies Williams et al (2011) advised that client-based interventions that target the parent and child on an individual level may increase the demand for immunisations. Educating parents and communities on the benefits can empower parents to practise preventive healthcare. Reminders and recalls can be beneficial in increasing uptake. Factors related to ethnicity must also be considered when seeking to understand immunisation decisions and, where appropriate and feasible, vaccination information should be targeted to address beliefs about ethnic differences held by all individuals (Forster et al, 2017).
» The authors advised that client-based interventions that target the parent and child on an individual level may increase the demand for immunisation «
There is a wealth of information online practitioners can use as signposting to support vaccine decisions for families. The NHS gives clear information about vaccines, with videos and information on the site, including ‘Why vaccination is important and the safest way to protect yourself’ (NHS, 2024). The Royal Society for Public Health provides a toolkit, ‘Assuring and Improving Immunisation Services’. This has a series of resources for leaders in local health systems to improve immunisation overall coverage in areas and reduce inequalities and increase uptake (RSPH, 2023). The Care Quality Commission review How to have a good uptake of vaccinations, showed that good immunisation practice was influenced by having patientand family-centred care, trained ‘up-to-date’ staff, planning ahead, an ethos of working together and allowing time for a discussion about vaccinations with patients and parents (McGeown et al, 2016).
Health visitors play a crucial role in supporting families to access evidence-based information and make informed decisions about vaccinating their children. There are pilot studies reviewing the health visitor role and vaccinations, with NHS England launching 12 ‘demonstrator sites’ to test new models for delivering vaccinations. The 12 sites will be testing new and innovative models to deliver vaccination (Colivicchi, 2024).
By recognising and understanding factors associated with suboptimal compliance to vaccinations, we can better approach at-risk populations and target efforts in stressing and reinforcing the importance of vaccinations (Falagas and Zarkadoulia, 2008).