Does the UK Need Compulsory Measles Vaccination?

Tim Locke

June 06, 2019

Imagine if parents couldn't send their children to school or nursery unless they'd had their measles jabs. Compulsory vaccination is now being hotly debated as cases of measles continue to rise.

At the end of this article we'll ask what you think in a reader poll.

Public Health England (PHE) recently reported that in the first quarter of 2019, there were 231 confirmed cases of measles in England.

Many UK cases are linked to under-vaccinated European populations, including Romania, France, Poland, and Lithuania.

While PHE urges parents to see their GP to make sure children's vaccinations are up-to-date, some experts say mandatory measles immunisation is the only way to prevent an epidemic.

Mandation Debate

The vaccine issue is debated in the BMJ today, while yesterday writing in the Journal of the Royal Society of Medicine , public health expert Professor John Ashton called for more action from health officials. The former PHE regional director wrote: "Part of the problem is making the seeming invisibility of prevention, visible; this requires imagination and creativity, together with leadership and the effective delivery of services."

He continued: "That it does not have to be like this is shown by the recovery in the measles, mumps and rubella vaccination in the north-west of England, with one of the strongest public health systems and visible public health leadership, to herd immunity levels, following the initial dip after the publication of the claims of discredited former doctor Andrew Wakefield."

Current UK MMR vaccine coverage is 94.9% for the first dose, but 87.4% for the second dose, below the level needed to ensure herd immunity.

A spokesperson for PHE said: "Vaccinations are not compulsory in the UK; we operate a system of informed consent. Parents can decide whether or not to have their children immunised, and almost all parents do. Vaccination is recommended because it provides the best protection against serious diseases, most of which can kill.

"Evidence from other countries where mandatory vaccination has been introduced suggests that this is not always effective in increasing uptake and it could risk causing people to become more resistant to receiving vaccines."

The BMJ debate puts sexual health doctor and medical writer Dr Eleanor Draeger who is for mandatory jabs head-to-head with two experts who oppose it: Helen Bedford, professor of children's health and consultant paediatrician Dr David Elliman at UCL Great Ormond Street Institute of Child Health and Great Ormond Street Hospital.

Dr Draeger, whose son caught measles when he was too young to havehad the vaccine, and Dr Elliman, who has acted as an expert witness or provided reports for a number of legal cases involving vaccination, also spoke to Medscape News UK.

For Mandatory Vaccination - Dr Eleanor Draeger

Why do we need mandatory measles vaccination now?

So what we've seen over the last couple of years is a decline in the percentage of young children who've been vaccinated, and it has fallen below the level that's needed to provide herd immunity. And what that means is that children who can't be vaccinated for medical reasons are being exposed to measles unnecessarily.

By suggesting mandatory vaccination, does that suggest that other methods have failed or would not succeed?

There are lots of methods of trying to increase vaccination rates which have been tried in many different countries around the world. And the method that I'm suggesting is saying that if you want your child to go to school or nursery, then they have to be vaccinated. You can choose to not send your child to school or nursery and not to have a vaccination.

That is a method which has been tried in Australia and has been very successful. In Italy, they've gone further and they've said that you must vaccinate your children before they go to school. And if you don’t then they fine you, which is a step further than I'm suggesting.

That step further has been very successful in Italy though.

So for older children home schooling would be the only answer for parents who refused vaccination?

They could home educate if they wanted to. It's perfectly legal in this country.

Opponents of mandatory vaccination are warning of unintended consequences with a breakdown of trust with health care professionals. Do you see that argument?

The breakdown of trust that you describe is something that can happen anyway whether or not you have compulsory vaccination.

And the other unintended consequences that they talked about were that people might have to home school. But actually, in my proposal, you wouldn't have to home school your children because you could vaccinate them.

Is enough being done to combat fake news about vaccination that's been circulating ever since Wakefield's Lancet article?

I wouldn't say that enough is being done. But I would say that there's been quite a lot of encouraging things that have happened recently. So Instagram and Facebook saying that they will block anti-vax hashtags for example, and they won't allow fake news to be published on their websites is a real, positive step forward. I would also like to see the mainstream media follow suit and not publicise anti-vax opinions.

So I think what is being done is really encouraging but from my perspective, I would prefer more to be done.

I would urge you to look at the current epidemic that is happening in the Philippines, where hundreds of children have died of measles over the last year.

Not enough people have vaccinated their children.

If immunisation rates continue to decline that absolutely can and will happen here.

There are many countries in the world that have even lower vaccination rates than us, and there's a lot of global travel, and so if our vaccination rates fall and then someone comes in on a plane, he's got measles. In an unvaccinated population, if a measles case comes into contact with you, you have a 90% chance of catching measles.

Against Mandatory Vaccination – Dr David Elliman

Why is mandatory vaccination a bad idea?

One is - do we need it? And the answer at the moment is 'no'. We've got moderately good uptake rates already, and we haven't exhausted the things that it should be an obligation of the NHS to do, like make sure there are proper appointment systems, make sure that we've got clinics that are family friendly at an appropriate time, and that parents are provided with the opportunity to ask appropriate questions. And only then should we even consider mandation.

And then you would have to say, well, would it work? The fact that it may or may not have worked in other countries doesn't necessarily transfer to the UK. The experience of mandatory smallpox vaccination was that it literally caused riots, that the rich paid their fines, and the poor went to jail and had their property taken away from them, which is not what most of us would want.

And one would have to be very clear what was meant by mandation. Was it denying people welfare benefits? In which case the poor may suffer even more. Or would it be denying school entry? In which case the people who are really adamant would say, 'OK, we'll home school my child'. And that's not necessarily a good thing for the child. And then there may well be people who were a bit iffy, and in essence say, 'Well, I'm not going to do what the State says, so I'm not going to have my child vaccinated', which would be potentially counterproductive. So is it necessary? Would it work? And then there's the ethical issue, which is more complicated. But I don't think we even get as far as 'would it work?', because we haven't done all the other things we need to do.

What are the unintended consequences?

Those would be who ends up getting fined? Would it mean home schooling? And would there be people who would dig their feet in and say, 'I am not going to have my child vaccinated because the State says I should do it'.

And what kind of position does that put doctors and other health care professionals in?

It means they should make sure they've got proper call/recall systems. Are they sending appointments to people? When people don't come, are they following them up?

When they are organising immunisation clinics, are they at the right time? Are they at the same time as they're having the elderly sitting in their clinics, coughing and spluttering all over the place?

Is there enough time for the practice nurse to talk through parents' concerns? So you'd have to have a system whereby for the first set of vaccinations you would want longer, because this is the first encounter, than you would with subsequent immunisations.

If we're heading to dangerously low levels of vaccination, a tipping point, would you reconsider?

I would still ask the question, are we doing all the things in terms of appointments, etc? Because I think one of the limitations is that we don't do that. And, for example, there's a low rate of immunisation amongst some of the Jewish populations in East London. Now when people have gone into that, that is nothing to do with objecting to immunisations, it's that they have large families and it's physically difficult to get to an appointment. When people have offered to go to them, and this has happened with other groups, the uptake has gone up.

If it fell, we should look at our facilities and what we are doing as the first thing.

Is enough being done to combat Andrew Wakefield's legacy on MMR and fake news about vaccination?

I think Andrew Wakefield's legacy in terms of MMR is a historical thing. Now that doesn't mean that it doesn't still have any effect. But I don't mean on current parents. But what we are seeing in current outbreaks is children who were born in what you might call the Wakefield era, now coming through secondary school, young adults, who have missed out on immunisation, because probably the peak scare was 2002-3, that's when the lowest uptake was. Those children would have been a year or so old at that stage, they will now be 18-19 and they haven't caught up.

So one of the things I think we need to do is not only make sure our infant vaccination processes are OK, but we've got in place processes for catching up on people who missed out in the past. And that means when someone goes to school, not denying them school entry, but the school health system checking whether they have been immunised. When they go to nursery, when they go into secondary school, whenever someone has a contact with them within the healthcare setting, to make sure they've been immunised.

So there's a legacy effect if you like. The stuff that's going around social media currently is not particularly related to the Lancet article 1998. There are other bits and pieces around different vaccines and it's difficult to know actually how much effect that has.

Is enough being done on the social media front?

I think it is quite difficult because the way social media works is the way you choose your friends. You choose people who have the same views as you. So breaking in on that sort of bubble effect is quite difficult. And I do think that some of the people who've done that are not necessarily very helpful on 'either side' of the discussion because they have been rude, derogatory, and that is not the way to go about it.

And of course, something like Twitter does not give you the opportunity to have a proper nuanced discussion.

Competing interests: ED’s son caught measles when he was too young to have had the vaccine himself. DE has acted as an expert witness or provided reports for a number of legal cases involving vaccination. HB has no competing interests.

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