Health and Social Care Committee

Inquiry into the measles outbreak 2013 – Evidence from Abertawe Bro Morganwwg University Health Board

Introduction

From mid November to date Swansea has been at the centre of the largest measles outbreak in Wales for many years. This report outlines why Swansea was vulnerable and the actions taken by Abertawe Bro Morgannwg University Health Board (ABM), in partnership with Public Health Wales (PHW), our three coterminous local authorities, Swansea, Neath Port Talbot and Bridgend, NHS Direct, Welsh Ambulance Service, National Welsh Information System (NWIS) and our voluntary agency partners to bring the outbreak under control.

At the start of the outbreak it was identified that there were over 14,000 unvaccinated or under-vaccinated children and young people in our area. By the end of May 2013, 60% of 9,000 susceptible children and young people aged 10 to 18 years had been given at least one dose of MMR through a community vaccination programme. The proportion of children and young people who are now fully protected with two doses of MMR has risen from 79.9% to 85.0% and it is estimated that over 95% of all children and young people aged 2 to 18 years have had one dose of MMR.

Independent analysis commissioned by PHW suggests the control measures decreased the number of affected cases twenty fold and brought the outbreak under control many weeks earlier than if no action had been taken. 

The following is an account of the measures we took in response to the measles outbreak and the ways we have adapted to improve our response. Copies of interim data reports, Silver and Bronze Team minutes and actions are available on request.

Setting the scene

The reasons for the low uptake in ABM have been reported in detail by PHW elsewhere. They were related to concerns about the safety of MMR voiced ten years previously by local activists in the Swansea and Neath Port Talbot area, and by adverse local press coverage at that time. The result was that MMR uptake fell further than that experienced by other areas in Wales.

The measures to improve MMR uptake taken by successive health services, public health agencies and Welsh Government throughout the last ten years have also been reported elsewhere by PHW.

Actions taken in the Swansea area since 1998

· In 1997/98 there was a 13.5% drop in MMR uptake in the Morgannwg area compared to a 2.2% drop elsewhere in Wales. The Iechyd Morgannwg Health Director of Public Health Annual Report of 1998, Bethan’s Story included a chapter on MMR vaccine and the controversy. Comment was made that this drop may be the result of the South Wales Evening Post (J Epidemiol Community Health 2000;54:473-474 doi:10.1136/jech.54.6.473).

http://jech.bmj.com/content/54/6/473/T1.expansion

Meetings were held for health visitors, community nurses and practice nurses across the area and they were given detailed fact sheets for parents.

· The Consultant in Communicable Disease Control (CCDC) reported quarterly and annual progress in MMR uptake to the three local Health Boards when they were formed. She briefed voluntary groups and health professionals regularly.

Actions to enhance the routine MMR programme included agreeing uniform procedures in follow- up of children who had missed doses, including review of immunisation records in health professional immunisation training, and Trust community staff started to review MMR status at primary and secondary school entry. An outbreak Local Enhanced Service (LES) was approved. A catch-up MMR session was run in a comprehensive school where mumps was circulating. MMR sessions were run by public health immunisers, in partnership with the local GP practice, for freshers in University of Swansea and the welcome packs for new students started to include advice on being up-to-date with immunizations before coming to university.

· In the mid 2,000s the Consultant in Communicable Disease (CCDC) and Local Public Health Director (LPHD) mounted a local population community campaign on all three diseases which led to the posters with florid photos designed by Helen Bartlett and Dr Annie Delahunty.

· Strategy to improve uptake was further developed by Swansea Local Health Board in 2008 following research undertaken to identify reasons for poor uptake.  Anonymised practice specific data on MMR was used with GPs in Swansea and Neath Port Talbot.

· In 2009 the Chief Executive reported to the Board on the measles outbreak – parents of unprotected children received measles fact sheets and letters.

· Health Social Care and Well Being (HSCWB) needs assessments and strategies have highlighted immunisation uptake as a major issue from 2003 – 2012.

· High profile on immunisation maintained from the creation of Abertawe Bro Morgannwg University Health Board with the formation of a Strategic Immunisation Group, Locality immunisation Groups and the appointment of an Immunisation Coordinator, initially appointed part-time but full time from October 2012. There is a rolling programme of policies being updated as needed. The Cold Chain Policy was updated in February 2013. Immunisation was included in the Director of Public Health 2011 Annual Report.

· The most recent vaccination action plan (Appendix 1) is for the year 2011/12. There has been some progress in the plan but the key objectives remain for this year. 

· Following the positive experience of Betsi Cadwaladr UHB in bringing the High School booster dose from Year 10 into Year 9, ABM initiated this change for the school year 2012/13, therefore running two years activity in parallel for this year.

The position in November 2012

In the months leading up to the measles outbreak MMR uptake rates for ABM had been steadily improving but were below the Wales average:

• First dose MMR at second birthday 93.5% (94.2% for Wales)
• Second dose MMR at fifth birthday 86.4% (89.1% for Wales)
• First dose MMR at sixteenth birthday 89.4% (91.4% for Wales)
• Second dose MMR at sixteenth birthday 81.1% (82.7% for Wales).

Source: Vaccine uptake in Children in Wales COVER Report 104 November 2012

By 2012 parents of new babies were far more confident in MMR but there was a large cohort of high school children who were still susceptible to measles, as shown in Table 1. These children had missed out on MMR before starting school. MMR levels were lowest in the Swansea area.

Table 1. Children with second dose MMR by fifteenth birthday

Bridgend	85.1%
Neath Port Talbot	76.3%
Swansea	74.5%
ABM	77.9%
Wales	81.8%

Source: Vaccine uptake in Children in Wales COVER Report 104 November 2012

The Board’s Response to the measles outbreak November 2012 onwards

A full description of the progress of the outbreak and the public health actions taken to limit spread, test cases and protect vulnerable contacts is given by Public Health Wales (PHW).

In summary, of the 1202 cases overall in ABM, Hywel Dda and Powys Health Board areas, 906 cases were notified in ABM from mid-November 2012 to mid June 2013, of which 336 were confirmed by laboratory tests. The peak age group affected was 10 to 18 years but there were cases across all age groups from babies under 1 up to 50 years +. There were 66 hospitalisations, often due to severe dehydration. One person aged 25 years died with measles but the cause of death is still to be determined by the coroner. No cases of long-term complication have been identified to date but investigations are ongoing with local clinicians.

Outbreak management was lead locally by the PHW Consultant in Communicable Disease Control (CCDC) and consisted of investigating notified cases, identifying and protecting vulnerable contacts and giving exclusion advice. Un- or under-vaccinated members of the public were encouraged to catch up with MMR vaccination through primary care practitioners.

The first Outbreak Control Meeting was convened on 28 November in response to evidence of transmission in a school setting. On PHW advice ABM agreed to provide a vaccination session for all susceptible pupils in the affected school as an analysis of vaccination uptake rates in the pupils suggested a large number were susceptible. This vaccination session was run the following week using staff drawn from the community, primary and secondary care. PHW officers were present to provide advice and support. Other measures agreed were letters to Primary Care, letters to all schools and tailored letters to schools in which measles cases had been notified. Following the outbreak meeting, it was also agreed that vaccination sessions would be offered to any school with evidence of measles circulation.

In the first weeks of 2013 around 10 to 20 notifications for suspected measles were received per week. The CCDC and Director of Public Health (DPH) liaised and ABM ran vaccination sessions in a further two schools in February.

Following discussions between the CCDC and the central PHW team, a multiagency Senior Response Team was convened by PHW on 18^th February 2013 to co-ordinate and strengthen the outbreak response in co-operation with partner organisations. The formal outbreak area was defined by Public Health Wales, based on the numbers of cases, as being Swansea, Neath Port Talbot and Llanelli but they supported ABM’s decision to treat the whole of its area, Swansea, Neath Port Talbot and Bridgend, as an outbreak area as cases were occurring in the Bridgend area and there were low rates of Measles Mumps Rubella (MMR) uptake across the whole ABM childhood population. This allowed ABM to design and deliver consistent control measures for the at-risk population wherever they lived within the ABM area.

Discussions over the next weeks covered communications with professionals and the public, advice over exclusions and the arrangements for testing and for offering immunoglobulin to vulnerable contacts. A further school vaccination session was run in early March in ABM. A weekly newsletter for health professionals was started in the first week of March, carrying updates and advice as the outbreak progressed. GPs were encouraged to vaccinate susceptible children who had missed MMR in the routine schedule.  

The vaccination sessions in the four ABM schools had demonstrated there was missing data on the child health system and it was agreed that ABM GPs would be asked to review their records and update the Child Health Service. The CCDC and DPH met the LMC to agree these arrangements and also agreed to circulate a letter to parents of all children identified as susceptible to advise them to be vaccinated as quickly as possible. The outbreak LES was also amended to remove the restriction to vaccinate only those of who were aged under 40 years. 

At the PHW Senior Response Team meeting on 26 March a high schools vaccination programme was discussed, in recognition that the peak number of cases was occurring in this age group. In response to this advice, ABM, PHW and local authority officials met to plan the required local actions. They decided that community drop-in clinics should be arranged during the Easter holidays, to avoid any delay before the schools returned.

From this point ABM followed emergency planning principles and, in particular, the Pandemic Framework, to deliver an integrated community response, working with healthcare staff drawn from primary, secondary and community care, and with Public Health Wales, Education officers from the three coterminous local authorities, NHS Direct, WAST and voluntary organizations. Where possible, equality and diversity principles were followed to reach as many groups as possible.  The Council for Voluntary Services assisted with this wide dissemination.

The subsequent response included:

1. GP vaccination under an updated Outbreak LES. The Child Health Service provided GPs with lists of susceptible children. A range of approaches was used in general practice to provide vaccination including special MMR clinics, existing child health clinics and also vaccination during routine surgeries and nurse clinics. This component of the MMR campaign is still in place and MMR vaccination of people outside the routine schedules is continuing in general practice.

2. Drop-in clinics run by staff drawn from primary and community care as well as hospital staff in out-patient clinics in Singleton, Morriston, Neath Port Talbot and Princess of Wales Hospitals. These were open for all who wished to have an MMR, regardless of where they lived and no-one was turned away unless MMR was contraindicated. The benefits of using outpatient departments were that they were clinical settings and could accommodate large numbers of people. One of the long-term benefits of this approach was that around 50 people from community and primary care were recruited into a newly established immunisation bank and issued with honorary contracts to cover liability. These experienced staff can be called on in the future to support mass vaccination programmes.

3. School vaccinations, led by school nurses but supported by immunisers drawn from primary care. Vaccinating teams went into all comprehensive schools, special schools and colleges. Primary school children were advised to attend their GP or drop-in clinics. Members of the local public health team and local Healthy Schools Coordinators supported the communications and also helped tailor the clinics. Pharmacy worked closely with local authority transport to manage the logistical challenges of moving large numbers of vaccines around the community while maintaining the cold chain. This entailed supplying secure vaccine fridges to schools and the use of a refrigerated van, which was seen to be very successful. School staff supported the process throughout, including making vaccination areas available, sometimes at very short notice, texting parents to inform them of the programme and prompting parents to return consent forms.

4. Occupational health programmes for ABM and Welsh Ambulance staff to minimize risk of ongoing spread of measles by susceptible healthcare workers in health care settings. The Occupational Health Service provided open-access vaccination clinics in easily-accessed sites and on selected wards, using their own staff and immunisers drawn from elsewhere. They offered MMR to all healthcare workers who wished to receive it, though it was targeted at those unvaccinated or under-vaccinated born from 1970 onwards working in high risk areas. They excluded 112 healthcare staff who had been exposed to measles with no clear evidence of being immune, and managed their return to work as quickly as possible through testing for immunity and giving MMR to those who were excluded.

5. Vaccine provided to the 2 local prisons for prisoner and staff vaccination. The local Homelessness nurse vaccinated susceptible homeless clients.

6. The Head of Health Visiting asked all health visitors to identify under-vaccinated children on their case loads and to have personal contact with those parents to inform them of the measles outbreak and encourage vaccination for their children.

7. The Head of Midwifery asked all midwives to advise pregnant mums under their care of the risks to themselves and their unborn babies and to encourage them to have any children in their households vaccinated if not already done so.

8. The three ABM localities liaised with long-stay residential and nursing home facilities to encourage any unvaccinated or under-vaccinated care staff, clients and patients born from 1970 onwards to have MMR. This included those in NHS facilities such as psychiatric and learning disability units.

9. The University promoted MMR vaccine and directed students to their GPs or drop-in sessions. The main campus university has an on-campus GP.

Throughout the response the ABM Communication Team made announcements and encouraged discussion with the public through social media. The public used the sites to raise their concerns and supported each other. Numerous press interviews were given and the press were invited to observe the drop-in and school sessions. A full report on the communication campaign is included in Appendix 2.

These actions have resulted in delivering around 30,500 MMR vaccinations to all ages, including 5553 to those aged 10 – 18 years. The main MMR vaccination programmes resulted in the following doses being given:   

GP programme                         16,500

Outreach clinics                       8674

Schools programme                 1749

Occupational health clinics      3571

Data collection is ongoing in the prisons.  MMR doses for HMP Swansea and HMP Parc are as shown in Tables 2 and 3. There were no cases of measles in these prisons.

Table 2. HMP Swansea

	April 2013	May 2013
Number of 1^st dose MMR given	60	53
Number of 2^nd dose MMR given	2	13
Number of prisoners declining	44	64

Table 3. HMP Parc

	April 2013	May 2013
Number of 1^st dose MMR given	873	91
Number of 2^nd dose MMR given	1	10
Number of prisoners declining	118	21

The result of the enhanced vaccination programme

For children and young people aged 4 to 18 years, we estimate that 95.8% have had one dose of MMR and 89.5% have had two doses. Work is continuing to increase these rates further. More young adults are also protected due to open access to the vaccine.

Costs of the outbreak for ABM

Table 4 sets out the costs incurred to date or expected based on the activity undertaken to the end of May 2013.

Table 4. Costs incurred

	£000
Vaccines	180	Based on numbers administered
Staff Costs	75	Based on actual costs + estimate of outstanding claims
Vehicle/Transport	8	Includes rental of a refrigerated van
Other Equipment	3	Includes Fridges and Bags
Advertising	4	Based on current costs
GMS LES	100	Based on number of unscheduled vaccinations in primary care
Total	370

Please note that these costs only include direct additional costs to the Health Board and do not include cost of staff members which were not additional costs to the organisation or the impact of work done in managing this outbreak for which staff have not been paid (i.e. time in lieu).  This would increase the costs by an estimated £100k.

The costs also do not include the increased vaccine costs associated with the general increase in uptake for scheduled vaccination programme.

Debrief

Though the outbreak has not yet been declared over, and there is more to do to increase MMR coverage, an interim multiagency debrief was held on 17 June 2013 to capture the learning points to date. There was recognition that people across all agencies had demonstrated enthusiasm and commitment in responding to the outbreak. The report is in preparation but the overall conclusions are:

1. The pandemic framework structure worked well and allowed strong partnership working to develop. This facilitated open discussion of problems and helped realistic solutions to be generated.

2. Increased resilience to deliver mass vaccination programmes was provided by drawing in staff from across community, primary care and hospital services. The approach of using relevant staff to lead vaccination sessions (i.e. school nurses to lead sessions in schools, Occupational Health nurses to lead staff vaccination sessions), supported by immunisation staff drawn from all health sectors was valuable. It was noted that payment to some staff has been slow and arrangements are in place to resolve this.

3. It was helpful that many vaccinators were confident in assessing children’s competency to give their own consent for vaccination. 

4. The use of hospital outpatient sites was helpful as they were accessible and well-known for the public and were able to accommodate high patient flows.

5. Occupational health found the use of peer vaccinators at Ward level was very effective and needs to be encouraged. A supportive culture from senior clinicians helps immunisation programmes run efficiently and effectively.

6. The infection control requirements to prevent spread of measles were made more difficult when staff were unsure whether they had previously had measles or MMR immunization. Staff exclusions had the potential to threaten business continuity and had to be managed very tightly, using antibody testing to demonstrate whether they were immune and able to return to work.

7. Realistic expectations, timescales and lead names need to be agreed for actions to ensure progress is made at the agreed pace. Progress needs to be recorded to demonstrate how much has been achieved.

8. Data quality is important. Poorly matched data between GP records and the Child Health Service led to many children being written to who had already received 2 MMR doses.

9. Transporting vaccines within the cold chain gave logistical challenges. The transport of bulky refrigerators, supported by local authority colleagues, allowed vaccination in schools and outpatient departments to get underway within days of planning. Hiring a refrigerated van was a great success. It allowed vaccination to proceed at several sites without compromising the temperature control of the vaccine.

10. Though this was a regional outbreak managed by PHW, it was also a local health incident requiring a local health service response. The local communications were vital to inform and advise the public.

Initial recommendations

1. Lessons learnt from dealing with this outbreak will be incorporated into ABM’s Pandemic Framework, including the Mass Vaccination plan, and into plans for dealing with other infectious disease incidents. Outpatient departments will be included as possible venues for delivering mass vaccination and mass prophyllaxis.

2. The new bank of immunising staff need to be maintained in readiness for further mass vaccination campaigns.

3. The Occupational Health Department needs to explore how to maximize the value of pre-employment checks and immunisation programmes for existing staff. Mass staff vaccination programmes should include peer vaccination at ward level and immunisation champions.

4. Build on the many examples of improved practice and increased confidence in immunisation to improve vaccination coverage across the childhood schedule. This would include a review of how to facilitate and enable children to give their own consent for vaccination if they are judged able to understand the risks and benefits of what they are consenting for.

5. In population vaccination programmes, arrangements need to be made for vaccination of people in long-term residential settings, including hospitals, care homes and prisons.

6. Discussion needs to take place over how to improve the child health data system to improve the quality of the data.

7. In the immediate short term, a Wales-wide Mumps and Rubella MMR PR campaign should be launched urgently. It should target teenagers and young people in its design and approach; and capitalise from the publicity surrounding measles to further boost MMR uptake, particularly in the target 10-18 year old age group.

8. A joint strategic Communications approach should be taken between Public Health Wales and Health Boards from the outset, in the event of similar outbreak situations in future.

Further work will be done with local and national colleagues to capture all learning points from the outbreak and to consider opportunities for improving practice.

Appendix 1

Strategic  Immunisation and Vaccination Action Plan 2011/2012

Objectives:

· To achieve and maintain uptake rates of 95% for all routine childhood vaccinations in ABM Health Board

· To achieve and maintain  an uptake rate of 75% for seasonal flu vaccinations in people aged over 65 years and over and for those younger people in at risk groups outlined by CMO 2011/2012

· To achieve an uptake rate of 50% for seasonal flu vaccinations in frontline staff across ABM Health Board

· To achieve an uptake rate of 90% for routine vaccination of girls aged 12 to 13 years for the HPV Immunisation programme

Key Action points:

· Establish local Immunisation Groups (LIG, one in each locality) that can follow up and lead on Immunisation matters that are identified from the Strategic Immunisation Group (SIG).

1. Provide an Immunisation lead in their locality to attend SIG

2. Liaise with Immunisation Coordinator on practice level and Cover reports that are published from PHW on a quarterly basis

3. Identify practices that are not achieving uptake rates and investigate reasons for this.

· Provide a seasonal flu plan to identify how the locality will help to achieve targets identified by CMO with regard to vaccination of the targeted populations

· Liaise with Immunisation coordinator on the following:

1. Reviewing cold chain policy for the HB

2. Developing BCG policy

· Support the school nursing service to deliver the HPV vaccination programme

· Support the improvement of information recording into the Child Health System

· To increase uptake of all immunisations in hard to reach and vulnerable populations of all ages using a consistent approach across the ABM community

· Maximise uptake of joint training programmes for all staff involved in immunisations

Risk Assessment and management

· LIGs unable to support SIG actions

· Immunisation and vaccination coordinator unable to fulfil whole role part time if not supported by the SIG and LIGs

· Unable to address the anomalies across the CHS

· Unable to support immunisation and vaccination coordinator in undertaking and acting on audit findings

Appendix 2   Measles/MMR – ABMU Communications

1) BACKGROUND

Nationally, Public Health Wales (PHW) is responsible for communications about notifiable diseases like measles. Initially PHW managed all outbreak press and media communications, issued all media releases, and provided media interviews with Public Health experts, as per standard practice.

The ABMU Communications team was asked to become pro-actively involved locally in March, 2013, and this paper summarises the ABMU communications work over March, April and May, 2013 when the outbreak was at its peak. 

2) BRIEF AND OBJECTIVES

• To help to end the measles outbreak in the ABMU area as soon as possible, by encouraging the urgent uptake of MMR in the measles particularly amongst 10-18 year olds;
• To help increase overall MMR coverage closer to 95% herd immunity.

3) ABMU MEASLES/MMR COMMUNICATIONS STRATEGY

· Engage openly and transparently with the public via social networking; answering questions and offering reliable information to support balanced debate and informed decision-making. This was a new way of working but the ABMU Communications team felt that open dialogue was essential.

· Maximise publicity of vaccinations at MMR clinics to encourage attendance and ‘show by example’ to undecided parents

· Promote interviews with local doctors and with people whose lives have been affected by measles, to make the issue more personally relevant for people in the ABMU area

· Provide clear, accessible, information for schools/parents

· Develop a dedicated Measles/MMR webpage

4) METHODS USED

a) Social Media

Social networking had been used positively by ABMU previously for other urgent issues, e.g. service changes, and it was a medium which local patients and members of the public routinely use to comment and ask questions on service issues. Early in February questions started being posted on our two Facebook sites, and also on local newspaper online stories about measles. In short, local people had expectations of social media usage for the measles/MMR issue.

ABMU began proactively posting information about measles/MMR (in addition to links to PHW press releases etc) in March, and endeavoured to provide answers to queries as quickly as possible.

Some ABMU Facebook Q&A sessions lasted throughout the day until as late as 11pm. This real-time access was important to maximise engagement opportunities, and build trust by responding quickly. Parents readily joined in discussions, supporting peer-to-peer dialogue. Over the March-May timescale, the ABMU Facebook reach on measles/MMR topics was over half a million views.

During March-May the two ABMU Facebook sites – ‘ABMU Healthboard’ and ‘ABMU Child and Family Health’ – had a total of:

· Measles/MMR posts/stories: 109

· ‘Likes’ on individual posts: 1,315

· Post shares by followers: 4,001

· Comments: 1,039

· Total Facebook ‘reach’ on MMR/measles posts: 541,275

Source, Facebook analytics

Key posts, and a targeted advert for local teenagers, were also promoted through Facebook advertising, cost: £128.

The post with the largest single reach during the campaign – 133,331 across both our Facebook sites - attracted 1,313 shares by followers, and 351 comments.

The MMR Facebook advert specifically targeting teenagers in the ABMU area only, directly reached 13,163 13-18 year olds.

Twitter was also used and the 85 ABMU measles/MMR Tweets received 497 re-tweets by range of followers, including GP surgeries and voluntary organisations.

The ABMU Communications team also posted 10 comments on the South Wales Evening Post website, on measles/MMR stories.

b) Press and Media

ABMU MMR drop-in clinics and school/colleges clinics in Swansea, Neath Port Talbot and Bridgend attracted widespread national and international media coverage and a great deal of television coverage.

It was vital to welcome media. As well as publicising clinics, the coverage ‘showed by example’ to parents - who may have been undecided – peer families having their children vaccinated. Interviews with parents and young people explaining why they had made their choice also helped.

This media access - managed by the ABMU team, with key local authority input at school sessions - was essential for television in particular. Without substantial video footage available for broadcasters to illustrate the story, it would wither. Journalists also needed direct access to families for interviews and pictures (with consent). ABMU’s Director of Public Health, Sara Hayes, and local GPs were available at clinic sites thus maximising the opportunity for extended coverage.

Approximately 30 sets of TV, radio, press and photographers attended, including BBC, ITV, Sky, Reuters, the Press Association, and national, regional and local press. International media included Al Jazeer, Russia Today, ABC Australia, the Wall Street Journal and Central China TV.

The media access helped keep the story at the top of the news agenda for several weeks, and included a dedicated BBC Newsnight programme on measles and national breakfast TV discussions.

c) Schools pages and ABMU website Measles/MMR webpage

41 individual schools’/college pages were developed on the ABMU website for local comprehensive schools. Each had a message from our Director of Public Health and also the Headteacher, along with key information about the school’s MMR sessions, measles and PHW advice.

This approach promoted a local community response to the measles outbreak, demonstrating schools, local authorities and the NHS working together.

Each school page was given an individual URL, and schools used their text-messaging systems to text parents with links to the pages, so they could access the information at a click. During the period of the schools MMR clinics, the 41 schools pages received 8,850 hits.

(The schools’ pages infrastructure will now remain on our website to be used for future health promotion campaigns.)

A general Measles/MMR information page was also set up on the ABMU website and received 16,263 visits.

d) Measles/MMR press releases

ABMU generated 19 dedicated measles/MMR press releases including stories of people who had been damaged by measles, which were reported widely by the press and media.

5) EXAMPLES OF ABMU MEASLES/MMR COMMUNICATIONS COVERAGE

Sustained, widespread media cover - TV, press and radio, local, national and international was achieved throughout March, April and May 2013, and is continuing. A ‘Measles Swansea’ search on Google news provides 2,800 results (note – many of these results also include Public Health Wales press releases or interviews; or contain a combination of PHW and ABMU information.)

i) Examples of media coverage:

This ‘Newsnight’ story covered on BBC news online is an example of national and international coverage of the story.	A ‘Daily Telegraph’ story, typical of the national coverage of the issue, and which publicised the drop-in clinics.
A story from the regional newspaper at the epicentre of the measles outbreak, the ‘South Wales Evening Post’. It carried over 100 measles/MMR stories from March-May.	A detailed measles/MMR analysis article on BBC news online by one of the BBC’s leading medical reporters.

ii) Examples of Social Media

We used both our ABMU Facebook sites extensively: www.facebook.com/ABM.healthboard and www.facebook.com/ABM.Family.Health  to support a transparent and open platform for debate to tackle any doubts parents may still have over MMR safety.

(Left)

This is a section of our main ABMU Facebook page, with the campaign logo as its central graphic, and a picture of a local teenager getting her MMR as the second illustration.

On 4^th April 2013 we shared the same post (above) on both our Facebook sites giving details of the first hospital drop in MMR clinics, and between them they received over 133,000 views and attracted 351 comments – our biggest single reach of the campaign.

In all, we sent out 109 measles/MMR posts and our total Facebook reach on this subject was 541,275

(Left) This is the Facebook advert which targeted teenagers (our target audience) in the Swansea measles epicentre area only. It reached over 13,163 youngsters. Cost: £40. Just under £100 was also spent ‘sponsoring’ key posts to give them an additional boost and supplement organic coverage.

(Right)Twitter – we also used our @ABMhealth Twitter account to publicise the issue widely, particularly the MMR clinics (85 Tweets and 497 re-tweets)

iii) 41 Schools pages

41 individual schools/college pages were developed on the ABMU website.

Here is a screen shot of part of a school page as an indication of content.

The pages were individualised to support a community feel, and encourage schools, parents and the health service to

pull together to combat measles.

The schools pages received 8,850 hits during the schools’ MMR clinics campaign.

This example school page (above) can also be viewed directly:

www.abm.wales.nhs.uk/maestegcomp

iv) General measles/MMR page on ABMU website

Our general ABM website Measles/MMR information page (above) received 16,263 hits March-May 2013. It can also be viewed:

http://www.wales.nhs.uk/sitesplus/863/page/66210

v) Media Releases

ABMU produced and released 19 ABMU measles/MMR press releases. Here are a few, mainly ‘human interest’, examples:

A nurse who lost her hearing because of measles as a child warns about the consequences of the disease: http://www.wales.nhs.uk/sitesplus/863/news/26849

A retired GP talks about his experiences caring for children with measles, including one who sadly died: http://www.wales.nhs.uk/sitesplus/863/news/26569

Long queues outside our first MMR drop-in clinic:

http://www.wales.nhs.uk/sitesplus/863/news/26646

A teacher talks about the long term damage to her health from measles: http://www.wales.nhs.uk/sitesplus/863/news/26911

A former Welsh international rugby player reveals he’s deaf in one ear following measles: http://www.wales.nhs.uk/sitesplus/863/news/26883

vi) Some feedback examples

Use of Social media:

“The effective use of media and the ABMU Facebook sites gave the population consistent messages highlighting measles and importance of vaccination.” – Swansea GP Charlotte Jones

“The social media programme provided an opportunity to answer questions in a timely and efficient way and allowed the public to interact openly, which was valuable.” – Dr Sarah Hayes, ABMU Public Health Director

“Really helpful to have this info!” – Comment on Facebook MMR post

Schools’ pages:

“The rapid feedback you were able to provide us with … was brilliant.  I also thought the dedicated schools web-pages was an excellent idea.” – Neath Port Talbot Local Education Authority lead, John Burge

“Information sent out was clear and useful and feedback has been positive.” – Alan Rowlands, Headteacher.

Examples of Social Media feedback for drop-in clinics:

“Well done guys. I turned up at 3.30 and the guys on front reception were ready and waiting, they greeted me and my son with warmth and friendliness. The forms and ticket were waiting and my son was seen in less than 5 mins …. Made the thought of having the injection a lot less daunting for me as the atmosphere was relaxed and not frantic. Thanks guys xx” – comment on ABMU Facebook site.

“We went today and all ready for a long wait. We both and the jab and were in and out in half an hour … Glad I got us done, they were great there x” – comment on ABMU Facebook site

“Well done ABMU for putting on this invaluable service.” – comment on ABMU Facebook site

6) Recommendations

There are two key Communications recommendations for the future:

i) In the immediate short term, a Wales-wide Mumps and Rubella MMR PR campaign should be launched urgently. It should target teenagers and young people in its design and approach; and capitalise from the publicity surrounding measles to further boost MMR uptake, particularly in the target 10-18 year old age group.

ii) A joint strategic Communications approach should be taken between Public Health Wales and Health Boards from the outset, in the event of similar outbreak situations in future.

Susan Bailey,

Head of Communications,

ABM University Health Board

June, 2013