Understanding the crisis in immunisation

There is a story that I tell to students about two men on a train in Africa. One of them is throwing powder out of the window to the bemusement of the other who asks him what he is doing. ‘Throwing powder to keep the elephants away’, his friend explains. ‘But there are no elephants’, the first insists. ‘There you are, it works’, comes the rejoinder.

The news that there have been two cases of diphtheria reported in Scotland has added to a concern that has been a regular theme of the media in 2019, and a reminder of the need to maintain constant vigilance against infectious diseases. The truth of the matter is that one of the greatest challenges in public health is in making the invisible, visible, not least when a childhood killer is deemed to be a thing of the past. A vivid memory from my childhood is of my father telling me about an outbreak of diphtheria in the 1920s in my home village of Woolton, now absorbed into the administrative area of the city of Liverpool, in which 11 children died. The outbreak was blamed on stagnant water in the village pond that was drained and is now a car park. This was in the days before the widespread miracle of vaccination against a range of potentially lethal childhood infections became available.

That so many parents have apparently been turning their backs on this wondrous technology has been a source of puzzlement. The received wisdom has been that it has come about as the result of one maverick former doctor, Andrew Wakefield, following the publication of his flawed research findings linking the MMR vaccine to autism in the Lancet in 1998. The reality now seems to have as much to do with the machinations of another maverick, the former Secretary of State for Health, Andrew Lansley, and his reckless reorganisation of both the NHS and the wider arrangements for public health in England.

In October, the National Audit Office published a report on the falling vaccination rates that supports the view that the Lansley ‘reforms’ had a devastating impact on the coverage of measles, mumps and rubella vaccine.  The coverage rate for two-year-olds in 2019 dropped for the fifth successive year to 90.3% , well below the 95% target for herd immunity. Only 86.4% of children now receive the second dose by their fifth birthday. A graph in the Audit Office Report shows the ‘Wakefield effect’, which was indeed dramatic, bottomed-out around 2004 – with coverage rates as low as 80%, but that this was followed by a sustained recovery until after the change of government in 2010 and the subsequent NHS changes.

None of this should really come as a surprise to those of us who are familiar with the system we led in the early years of the new century. This system gave us the ability to engage with clinicians across the NHS, our colleagues in local government, schools and the mass media. This coordination enabled us to take on the anti-health forces and deliver a recovery plan almost in the same breath, before those functioning arrangements were wantonly cast aside by a politician on a mission.

So, what are the lessons of this debacle? First of all, that public health is too important to be left to the whims of politicians in a hurry to make a reputation for change; that evolution must be better than revolution when it comes to peoples’ health and wellbeing; and that we neglect the clinical dimensions of public health services at our peril. Finally, that we all have a duty to speak out when public health is compromised by credible charlatans.

Fortunately, the Scottish cases of diphtheria seem to have not been home grown but to have been brought into the country from elsewhere; however, before we become complacent we should make sure our services are sufficiently robust to prevent secondary cases from such an event. At the present time, with the attrition of staff,  funding, and morale in public health and the NHS, can anybody put their hand on their heart and guarantee that?

What are your thoughts? Do let us know in the comment section underneath. 

Comments (9) Add yours ↓
  1. Hannah Warren Urology registrar

    Social media platforms have also played a worrying role in the spread of the ‘anti-vaxxer’ message. They have allowed pockets of the internet to carry unchallenged and unchecked messages on the perceived harms of vaccination. Presented as both fact and a legitimate counter argument to vaccination, parents are uncertain of the best way to protect their children. Certainly, that epidemics of these lethal childhood disease are fading from living memory is no help. Sadly it seems that outbreaks of these once-eradicated diseases may be what is required to make us wake up to the threat of these preventable, communicable diseases.

    Conversely, it would be interesting to know what the uptake of the quadrivalent HPV vaccination is in older children. Both cancer, and sexually transmitted infection are very much in the public consciousness and I wonder if uptake of this vaccination is therefore better.

    November 15, 2019 Reply
  2. Patricia Schartau GP

    “…public health is too important to be left to the whims of politicians in a hurry to make a reputation for change”. Thank you for your thought provoking article and for highlighting the importance of a solid well-funded public health system.

    Over the next decade, many populations including the UK will face a variety of old and novel highly complex health challenges, such as resistant infections, older populations with many co-morbidities, obesity and sedentary lifestyles, climate change, health inequalities to name but a few. However, many of these are challenges that can be addressed by public health and by addressing population health as a whole. As GPs (and a population as a whole), we rely on short and long-term public health support to improve our patients’/the population’s physical and mental health, health-related quality of life and health equity. We also need a strong public health system to work on reversing the falling vaccination rates we are currently experiencing, and to collaborate with other HCPs to optimise participation in national screening programmes. It is all our responsibilities to ensure that public health services, the backbone of a healthy happy society, is not compromised.

    November 16, 2019 Reply
  3. Michael Kirby Professor

    Vaccine safety scares can undermine public confidence in vaccines and decrease immunisation rates. Understanding and addressing parental concerns arising during such scares can assist in lessening their impact.
    We have been there before!!!
    The United Kingdom’s (UK) measles-mumps-rubella vaccine (MMR) scare began in 1998 with an assertion that the vaccine could cause autism. This was refuted in further studies, but still led to a reduction in MMR vaccine coverage in England from 91.8% prior to the scare to a low of 79.9% in 2004 and resultant disease outbreaks. The UK experienced a prior vaccine scare in the 1970s when the diphtheria-tetanus-pertussis (DTP) vaccine was associated with encephalopathy. Despite eventual evidence that this possible association was extremely rare, public confidence in the vaccine was eroded, including by negative media reporting, and immunisation rates dropped from 80 to 30%. Subsequently, there was an outbreak of more than 300,000 pertussis cases, including 70 deaths. In 1975 Japan suspended its whole-cell DTP vaccination program following the deaths of two children in December 1974 and January 1975 shortly after they received the DTP vaccine. The program resumed in April 1975 with a revised schedule delaying the first dose until 2 years of age. Pertussis cases soared to over 13,000 in 1979, with 41 deaths compared to pre-scare levels of 393 cases and no deaths in 1974.

    I think the case is made!!!!

    November 17, 2019 Reply
  4. Gabriel Scally Professor

    Great piece. It appears to me that when rates of screening or immunisation go down it is claimed that it is due to the malign influence of scare-merchants on gullible members of the public. When the rates go up it is attributed to the efforts of dedicated members clinical and public health systems. That is very convenient. The current set of declines in immunisation and screening are due to the steady deterioration in systems that started in 2012 with the Lansley Act. Try asking the question, “Who is responsible for the screening and immunisation rates in city X? You will not get an answer. Prior to 2012 it was the Director of Public Health, and above them the Regional Director of Public Health, and above them the CMO. If you destroy the public health system you, sure as night follows day, see the decline in the state of the public health.

    November 18, 2019 Reply
  5. Jonny Coxon GP

    This is a really interesting take on the highly worrying downward trend in vaccination figures. The dislocation of public health services, moving from CCGs to local authorities has had several consequences, and it makes perfect sense that this would be one of them. Squeezed budgets will always take their toll.
    As with so many big problems, there will not be one cause at play, and more than one solution. Putting public health concerns briefly aside, there is much more going on when I see parents who remain clear and adamant that they believe they are doing the best thing for their children by not exposing them to the “poison” of vaccination. There is a not uncommon suspicion that the drive for vaccination stems mainly from big pharmaceutical companies and blinkered health professionals. And there is not always regret even when the same parents bring in their child with measles or mumps.
    Time to get the history books out and revere Edward Jenner once again??

    November 19, 2019 Reply
  6. nicola stingelin Ethicist

    This perceptive text and comments raise important points on the roots of the dangerous anti-vac zeitgeist. Other issues that require consideration might include the following?

    – What role does the situation that the media and people in power show degrees of disdain for fact-based, qualified arguments play? Does the internet encourage a belief that a fleeting grasp of an issue equals well founded knowledge?

    – Do we have a society focused on entitlement rather than responsibilities? If yes, why?

    – In the anti-vac movement best seen as an understandable complacency in societies blessed with high health standards?

    – Are experts blameless? Do we effectively communicate what is known, and differentiate from what is probable, what is uncertain, and what is unknown? Are we ,experts, somehow falling-short of acting like role models?

    – Are we inadequately educating our young people so that they cannot appreciate and take part in scientific reasoning?

    There are surely a range of determinants and contexts that affect vaccination rates: the action plans clear urgently needed must likewise be nuanced, targeted and multi- faceted.

    All of the disciplines privileged to hold one of the relevant strands of knowledge must now collaborate with a degree of urgency in analysing the causes of anti-vaccination sentiments so that appropriate interventions can be designed.

    November 21, 2019 Reply
  7. Roger Kirby Professor of Urology

    A global measles crisis caused more than 140,000 deaths last year, with most of them children under the age of five, figures suggest.

    A new report from the World Health Organisation (WHO) and the US Centres for Disease Control and Prevention (CDC) said the “unprecedented global measles crisis” is set to enter its third year, with no signs of improvement.

    Parents are being urged to vaccinate their children where vaccines are available, including the UK, while efforts are stepped up to vaccinate youngsters in countries without ready access to the jabs.

    Unicef said poor vaccination coverage had led to “devastating measles outbreaks in many parts of the world – including in countries that had high coverage rates or had previously eliminated the disease”.

    December 6, 2019 Reply
  8. Roger Kirby Professor of Urology

    The number of measles cases in England has risen six-fold since 2014, with health officials urging the public to check their vaccinations are up to date.
    Public Health England also warned of outbreaks in areas where vaccination coverage was low and revealed a 61-year-old man died from measles-related complications in August this year.
    There had been 667 confirmed cases of measles by September compared with 101 cases for the whole of 2014.
    Although numbers are down compared with last year, which saw 829 cases by September, Public Health England data shows the vaccination rate for England is falling, meaning more people are at risk from the disease, which is thought to have killed 140,000 people worldwide last year. Most of those who died were children aged under five.

    December 28, 2019 Reply
  9. Lawrence King GP (retired)

    As a recently retired GP, working in a deprived urban area, I think there are two issues here that maybe many politicians are ignoring.

    The first is the under- resourcing of primary care in the past decade. While the population has grown by millions, numbers of primary care clinicians have fallen, and funding for new or enlarged premises has been absent. Practices have closed, and people struggle to find a new practice. Waiting times for appointments have consequently grown ever longer, and I suspect some parents just give up trying, or even forget.

    The second is that many urban practices have huge patient turnover, so vaccination figures are always out of date. If one adds to this the issue that families moving to the UK, especially asylum seekers, often have absent or incomplete vaccination records, it becomes clear why the national figures have not only fallen in the past decade, but are also probably very inaccurate.

    January 24, 2020 Reply

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