25th February 2022
In support of the current campaign for parents and guardians to ensure that their children are up to date with routine measles, mumps and rubella (MMR) immunisations, we are delighted to share this blog by Helen Bedford, Professor of Children’s Health at UCL Great Ormond Street Institute of Child Health, and Helen Donovan, Professional Lead for Public Health Nursing at the Royal College of Nursing.
A decline in routine vaccine uptake has been one of the many impacts of the pandemic on the health and wellbeing of children and young people. The exact cause of this decline is unclear, but some recent media coverage suggests it is due to ‘vaccine fatigue’ or increased ‘vaccine hesitancy’. Here we discuss the possible reasons for the decline and actions to remedy the situation.
First, what is the problem?
Latest quarterly figures published by PHE, and now the UKHSA, show a small yet worrying decline in coverage at 12 months of age in UK of the completed course of the 6-in-1 vaccine by 0.2% to 91.9%. Coverage of the first dose of MMR vaccine at 24 months has also declined by 0.4% to 89.4% and for the 2nd dose at 5 years by 0.8% to 86.3% 1. On first glance these figures, although lower than in previous quarters, may still seem high and the decline very small. Relative to many other countries they are, but these are averages and so they mask wide variation in uptake between districts.
The lowest vaccine uptake rates in the UK are, and always have been, in London where the current coverage of the 6-in-1 at 12 months is 85.5% and of MMR vaccine at 24 months, only 77.5%. According to annual vaccine coverage for 2020-21, almost one third of 2-year olds in City and Hackney, have not have their first MMR vaccine while in Camden it’s a quarter of 2-year olds who remain unprotected 2.
School closures in March 2020 had a significant impact on HPV vaccine uptake too with coverage rates for the first dose only 59.2% in year 8 females in 2019/20, this represents a decline of 30% on the previous year. 2019/20 was the first year that boys were offered HPV vaccine and only 54.4% had their first dose. Although HPV vaccine rates improved in 2020/21 3, there is a lot of catch up to be done to ensure young people do not remain unprotected against HPV infection. We have known for some time that the vaccine protects against HPV infection, and as data begins to accumulate showing impressive declines in cases of cancer of the cervix, it would be tragic if all young people don’t have the benefit of this protection because of the pandemic.
Why is it a problem?
To keep diseases controlled, we need sustained high vaccine uptake; any decline in vaccine uptake is worrying no matter how small, because it may signal something wrong in the system. This is particularly the case for measles which is highly infectious, and this is why MMR is the focus of the new campaign to increase MMR vaccine uptake which was launched on 1 February by the Office for Health Improvement and Disparities (OHID), supported by the UK Health Security Agency (UKHSA) and NHS. There has been much discussion during the pandemic about the infectivity of COVID, with an R number of about 2.5 in May 2020 (R, reproduction number = how many people an infected person will infect on average). Measles has an R number of about 15-18 and is considered to be the most infectious disease there is. Because of this, even a small decline in vaccine uptake can herald outbreaks. This fall in uptake is sometimes referred to as the ‘canary in the coalmine’, i.e. an early warning of potential danger. Recently, there have been very few cases of confirmed measles, just two since early 2020 and very few cases of pertussis. However, this doesn’t mean they are not circulating somewhere; and with the lifting of public health measures and travel restrictions, and children mixing more on top of the decline in vaccine uptake, the conditions are set for these infections to re-emerge.
Measles is nasty, even an uncomplicated case makes children feel very ill and complications, including ear infections, pneumonia and encephalitis, are common. Between 2018-2020 nine children and adults died from measles in England and Wales, three due to acute measles and the remainder due to its late effects 4.
What is the cause of the decline in vaccine uptake?
It has been suggested that the recent declines are due to ‘vaccine fatigue’ or increased ‘vaccine hesitancy’. These suggestions are based on anecdote. For example, some practitioners feel they are getting more questions from parents and this is interpreted as vaccine hesitancy. COVID disease and then COVID vaccines have resulted in an intense focus on vaccines such as never seen before – so is one result of so much public discussion about vaccines simply that people have previously not given it quite so much thought and now have more questions? Other important factors may have had an impact and be more relevant. Research early on the pandemic, after the first lockdown when we were urged to stay at home, showed that many parents did not think vaccine services were available, or they were scared to attend health services for fear of infection or simply did not want to overload the NHS 5. This, combined with an intense and unremitting focus on COVID and COVID vaccines to the exclusion of any other vaccine, may have given the impression that other diseases are no longer around. We have also always known that vaccine programmes are, also almost by definition, a victim of their own success. As the prevalence of these diseases diminish, the need to vaccinate may seem less important for many parents.
In the UK, generally, there is high vaccine confidence, with some of the highest uptake rates in the world. The success of our vaccine programmes is based on public trust in the NHS, dedicated health professionals and efficient systems. Before COVID, apart from the occasional high-profile story, the childhood vaccine programme almost just ticked along in the background. Part of its success is that the programmes are largely run by nurses.
General practice nurses provide the majority of vaccines given to children – these staff and primary care services have been significantly impacted by the pandemic. Health services have been further challenged by already depleted health visitor numbers pre-pandemic, being further reduced with many teams redeployed to support other parts of the health service 6,7. This resulted in many families missing out on the early support and advice they provide, including information and promotion of vaccination. In 2020/21, 33% of children did not receive a health and development review at 12 months (a decline of 10% on the previous year) when parents are reminded about MMR vaccine 8.
How can we recover?
Fortunately, we have not seen an increase in measles cases yet, so we have time to act. Lessons learnt from possibly the most serious public health crisis before the current pandemic (the controversy around MMR vaccine safety starting in 1998 which resulted in a significant decline in vaccine uptake and confidence) show that recovery is possible but only by taking a concerted approach. For example, health visitors working with their general practice nurse and school nursing colleagues to ensure that parents are aware of the importance of immunisation. Equally essential, they need to ensure that parents know which vaccines are due and when, as some report they don’t always know. The vaccine is detailed in the red book so it would be useful to direct parents to this information and to the links also provided there to information resources. Reminding parents of the vaccine schedule is particularly important with respect to the pre-school booster and 2nd MMR vaccine, due at 3 years 4 months, which are often forgotten. We also need to ensure that vaccination services are well signposted, easily accessible and family friendly, and offer discussion about any vaccine questions and concerns. The onus is on us all to know how and where to access reliable and evidenced-based information so we can properly support parents and young people.
We do completely understand that with busy caseloads, reduced HV numbers and other pressures, all this can seem like just yet more work – but time spent supporting parents with vaccination is time well spent. Vaccination is one of the most effective public health interventions available, prevents illness and disability, and saves live and has been shown to be safe. Research shows that parents trust and value the advice they receive from health visitors. Indeed, in one recent study focusing on parents who had chosen not to vaccinate their children, health visitors were singled out as the healthcare professionals with whom parents had the most positive experiences, where they felt listened to and an attempt had been made to understand their concerns 9. Sadly, it often takes an outbreak of disease to prompt vaccine uptake, we must act now to prevent re-emergence of these potentially devastating infections by improving vaccine uptake.
Helen Bedford PhD, RHV, FiHV, Professor of Children’s Health, UCL Great Ormond Street Institute of Child Health
Helen Donovan M.Ed, RN, RHV, Professional Lead for Public Health Nursing, Royal College of Nursing
Resources and sources of information to support conversations with parents:
- Immunisation against infectious disease – The Green Book and the government immunisation hub
- RCN Immunisation clinical pages
- The Oxford Vaccine Group (OVG): Vaccine Knowledge Project – this site is aimed at parents with information about vaccine preventable diseases and vaccines and has useful films on decision making
- Bedford, H.E. and Elliman, D.A., 2020. Fifteen-minute consultation: Vaccine-hesitant parents. Archives of Disease in Childhood-Education and Practice, 105(4), pp.194-199.
- UKHSA. Quarterly vaccination coverage statistics for children aged up to 5 years in the UK (COVER programme): July to September 2021. Health Protection Report Volume 15 Number 20
- NHS Digital. Childhood vaccination coverage statistics. 2020-21.
- UKHSA. Human Papillomavirus (HPV) vaccination in adolescent females and males in England: 2020-2021. Health Protection Report Volume 15 Number 19 14 December 2021
- UKHSA measles notification and deaths in England and Wales: 1940- 2020
- Bell, S., Clarke, R., Paterson, P. and Mounier-Jack, S., 2020. Parents’ and guardians’ views and experiences of accessing routine childhood vaccinations during the coronavirus (COVID-19) pandemic: A mixed methods study in England. PloS one, 15(12), p.e0244049.
- Institute of Health visiting. Survey confirms babies and young children have been forgotten and failed in the nation’s pandemic response. December 2020.
- Conti, G; Dow, A; (2020) The impacts of COVID-19 on Health Visiting Services in England: FOI Evidence for the First Wave. UCL Department of Economics: London, UK
- OHID Health Visitor Service Delivery Metrics 2020/21.
- Sythes, L. and Bedford, H., 2022. Motherhood and vaccine refusal in the UK: a new examination of gender, identity and the journey to contemporary non‐vaccination. Child: Care, Health and Development.