Taking steps to reduce the risk of measles in Scotland

As outbreaks of measles continue to rage across Europe, the World Health Organisation has called on countries to step up their responses.

In 2010 over 30,000 cases were reported in Europe – a fivefold increase on the preceding five years, while during the first six months of 2011 the figure reached 26,000. France has been particularly affected with WHO noting that over five thousand cases were reported in 2010 and more than 14,000 in the first seven months of 2011; while measles cases rose tenfold in England and Wales in the first four months of last year. With 90 per cent of European cases amongst adolescents and adults who had not been vaccinated or for whom vaccination history was not reported, questions have been raised about what steps are being taken to protect children and young adults should the disease spread to Scotland.

In Scotland, uptake of the first dose of the MMR vaccine – which when given in two doses protects 99 per cent of vaccine recipients from measles, mumps and rubella (MMR) – at both 2 and 5 years of age has now reached “historically high levels”, according to Health Protection Scotland, at 93.3 and 96.2 per cent respectively.

However, among older children it is a different story.

Amidst the adverse publicity that accompanied the publication of Dr Andrew Wakefield’s 1998 Lancet paper claiming a link between MMR and autism – a paper that has since been rubbished and retracted while Wakefield himself was found to have been “dishonest and irresponsible” by the GMC – uptake of the vaccine fell to as low as 86 per cent in Scotland. According to Scottish Government figures, over 30,000 children in Scotland between the ages of 10 and 16 – 8.4 per cent of the age group – had not received any doses of MMR vaccine as of the end of March last year.

Last year the Scottish Government announced that the MMR status of older children will be checked at the teenage booster point in school and last week NHS Greater Glasgow and Clyde (NHS GGC) began writing to secondary pupils whose immunisation records are incomplete.

Dr Syed Ahmed, consultant in public health medicine for NHS GGC, said: “The upsurge in cases of measles across Europe is particularly worrying and we desperately want parents whose children have not completed the two-dose vaccine to take the opportunity now.” In contrast to experiences elsewhere in Europe, Scotland has not seen a “significant” number of measles cases. In the first six months of 2011 there were 60 measles notifications in Scotland, with 23 laboratory confirmed cases and one probable case.

However, measles is a preventable disease and so it is a “scandal” that we still have it at all, states Professor Hugh Pennington, Emeritus Professor of Bacteriology, University of Aberdeen.

“That we have any at all is a scandal because it is a preventable disease by immunisation so if we have our immunisation strategy right we shouldn’t be having any cases at all. The caveat there is there is measles elsewhere in the world and people are bringing it or most cases are associated with travel abroad. But nevertheless if we had our population solidly immunised there would be so few cases it would be notable as being a rare disease.” The Wakefield incident “gave the virus a good leg up”, says Pennington, however, he adds that Scotland fared better than England where uptake fell to as low as 50 per cent in London in the aftermath of the controversy.

“It is hard to explain why,” she says, “Perhaps you could say the Scots have more common sense, but I don’t know!” While this ‘Wakefield generation’ is still at school there is an opportunity to maximise uptake of MMR1 and MMR2 and so in October Scotland’s Chief Medical Officer Dr Harry Burns wrote to NHS boards to inform them of measures aimed at reducing measles risk among those age groups with increased levels of susceptibility and advised that “for the foreseeable future, boards should take all necessary steps to ensure that children presenting for their teenage booster have their MMR vaccination status checked. Under-immunised children should be vaccinated.” The vaccine should also continue to be offered ‘opportunistically’ to those in the 18-24 age range.

“For young adults (18-24), the Chief Medical Officer has recommended that vaccination continues to be offered opportunistically, particularly for those who may be travelling to areas with high incidence of measles,” a Scottish Government spokesman said.

“Health Protection Scotland also wrote to all universities and colleges to make them aware of the increased risk of measles. This opportunistic vaccination is also supported by robust measles control strategies being deployed in the event of any cases or outbreaks.” However, Scottish Labour public health spokesperson Dr Richard Simpson says he is concerned that the rising number of incidents in Europe could lead to the disease also gathering momentum in Scotland and calls the Scottish Government’s response “frankly, complacent”.

“They should be writing to the 30,000 families in a one-off letter, saying, ‘Go to your doctor. This is the danger. The vaccine is as safe as any vaccine and is certainly not associated with autism as was the original scare.’ But I think they should also run a college campaign in the universities and colleges, really among young people aged 16-24 as well, saying go get a catch-up vaccine.” He adds: “Simply writing a letter from the Health Secretary to the health boards and then from Health Protection Scotland to the universities is, in my view, a really minimalist approach.” However, while Health Protection Scotland noted in its recently updated risk assessment for measles transmission in Scotland that reducing the current and probable future incidence of measles in those aged 18-24 years could be achieved by supplementary immunisation activities, it added that “past experience with other vaccine preventable diseases has shown that these are unlikely to be fully effective”.

“The HPS expert view is that uptake of targeted vaccination activity is likely to be very low.

Given the very low incidence of measles cases in Scotland – indeed we have had no new cases since the summer – such initiatives are unlikely to be of public health benefit,” a Scottish Government spokesperson said.

However, Pennington insists there is a case for a more “aggressive” programme.

“I’m a real enthusiast for any kind of aggressive immunisation programme. I think for measles, forget about the other viruses, for measles, I think we really have to keep blasting away at it and take up any opportunity. If there are two options and one is a more rigorous approach, then take that one because at the end of the day we really do want to see this virus off.” With the countries in the European Region of the WHO committed to eliminating measles by 2015 – a target that the Scottish Government also supports – Pennington says Scotland must play its part in dispatching the virus permanently.

“I think we can make a very strong case for saying here is a preventable disease. Ok, it costs money to prevent. It may be quite hard work for some health service professionals to ratchet that vaccination programme up, but it is worth doing because the benefits not just to the people who are immunised but to society as a whole are substantial. It is something you can do and I think it is morally wrong not to do it.”