Sense
Cymru
Ty Penderyn, 26 High Street
Merthyr Tydfil CF47 8DP
Email: cymruenquiries@sense.org.uk
Voice/text: 0845 127 0090/0092
www.sense.org.uk
Health and Social Care Committee
Inquiry into measles outbreak 2013 – Evidence from Sense
Paper to Health & Social Care Committee inquiry into measles
July 2013
About Sense
Sense is a national charity that supports and campaigns for children and adults who are deafblind. We provide tailored support, advice and information as well as specialist services to all deafblind people, their families, carers and the professionals who work with them. In addition, we support people who have a single sensory impairment with additional needs.
About deafblindness
Deafblindness is a combination of both sight and hearing difficulties. The complex impact of dual sensory loss means that it is a unique disability. Deafblind people often need support with communication, access to information and mobility.
About rubella
Sense was founded as the ‘The Rubella Group’ in 1955 by parents who had deafblind children after catching rubella while pregnant. One of the parents said: “It is difficult to believe that a minute virus, so small it can only be seen with a microscope of great magnitude, could cause impairments to the vision and hearing of a child even before it is born.”[1]
A baby born affected by rubella is said to have congenital rubella syndrome (CRS). Many will have hearing loss, cataracts, other eye conditions, and heart problems that require significant hospital treatment - and other support - and will affect the child throughout their life. A baby’s brain can also be affected. Vaccination means congenital rubella syndrome is now very rare in the UK.
Key points
The measles outbreak in Swansea was a warning about people who are unvaccinated against MMR. When the vaccination rate dips over a period of time or when particular groups of people are unvaccinated this can lead to outbreaks.
A catch up programme is needed to address immunisation gaps. Lower uptake of childhood MMR vaccination over an extended period in Wales means that it is no longer just a childhood issue. Unvaccinated children and babies have become unvaccinated young adults. In particular, we would recommend the programme targets people we know are likely to be susceptible to measles, mumps and rubella.
Wales has been rubella-free since 2006 but there is no room for complacency. We cannot rely on unvaccinated people avoiding exposure to measles, mumps or rubella. Last year saw more cases of rubella in England than in any year since 1999. The first notifications of measles in Swansea came from children who had caught measles while in England.
Single vaccinations are less effective than combined MMR and health professionals should continue to inform parents about this fact. Data in one study suggest that nearly half of children who had started to have single jabs did not receive the maximum possible protection against MMR. Six single jabs are needed to achieve the equivalent protection given by only two MMR jabs.
Response to the committee’s terms of reference
1) Factors that led to the current measles outbreak
We would draw the committee’s attention to the Welsh Health & Social Service Minister’s description of the outbreak in Assembly plenary on 11 June 2013:
“The recent outbreak in the Swansea area started last November when a small number of children returned home infected with measles from a holiday camp in south-west England. Those young people were drawn from an age group most susceptible to the disease because of low vaccination levels in earlier years. Moreover, they lived in a part of Wales especially vulnerable to a measles outbreak. The 1997 controversy about the MMR vaccine reduced the take-up of that vaccine everywhere, but particularly so in Swansea and Neath Port Talbot.”
Sense Cymru thinks this description effectively summarises the main factors in the outbreak:
a) Lower uptake of MMR vaccination over an extended period of time
In 1990-2000 the proportion of children in Wales vaccinated once by two years old was 85.3% but had dropped to 80.1% by 2003-04, which was the lowest rate since 1989-90.[2] It increased in the years following this period but the drop off left a significant proportion of the teenage and young adult population susceptible to measles, mumps and rubella.
b) Very close links between England and Wales
The Health Minister said that the children were infected with measles while in the south-west of England. Unvaccinated people are susceptible to measles, mumps and rubella regardless of where they are encountered.
We cannot take for granted that unvaccinated children from Wales will not catch mumps or rubella just because the numbers of cases in Wales has been low. If the vaccination rates drops the prospect of outbreaks increases. Wales is an internationally linked nation with considerable daily population movements into and from England and close links with Europe and the wider world.
In particular Sense Cymru would also draw the committee’s attention to rubella in England. There were 65 laboratory confirmed cases of rubella in England in 2012 – more than in any other year since 1999.[3] In the first quarter of 2013 there were four cases in England, including in two pregnant women.[4] The measles outbreak was a warning: despite the absence of recent rubella cases in Wales rubella could follow if vaccination rates drop.
c) Groups of unvaccinated people
We are concerned that the outbreak shows that there was a significant geographic cluster of unvaccinated people in the wider Swansea area who were susceptible to measles, mumps and rubella.
The pan-Wales dip around 2003 in first MMR vaccinations for children aged two years was shared in the Swansea area, where the outbreak occurred. However, Public Health Wales data show vaccination rates in the Iechyd Morgannwg/Abertawe Bro Morgannwg UHB area fell further than the overall Wales rate of 80.1%, to around 73.0% between 2002 and 2004.[5]
Sense Cymru is concerned about particular cohorts of people who may be susceptible to rubella, mumps and measles or who may be at greater risk if there are outbreak. These groups include:
· 10-18 year olds.
· People born in the 1980s with incomplete MMR vaccination history.
· Ethnic minority people.
· People in areas where vaccination rates are known to be too low. The Welsh Health Minister’s letter to the committee mentioned “particular concern” about susceptibility to MMR in Gwent.[6]
· Health professionals and workers
· Women thinking about becoming pregnant, and their families, and women identified as susceptible during antenatal health checks.
Sense Cymru was concerned to note the establishment of a private clinic offering single vaccinations. We would draw the committee’s attention to evidence in the British Medical Journal from a UK study (2008). It suggests only 52% of children having the single jabs had been fully immunised against measles, mumps and rubella by having six jabs.[7] By contrast recent data from Public Health Wales show that during Q1 2013 the proportion of five year olds getting their second MMR jab was 90%.[8]
d) Reasons for not seeking immunisation
We know there are various factors for parents or adults not seeking vaccination. They include:
· Lingering concerns about the safety of the MMR vaccination.
· Reduced awareness of the impact of measles, mumps and rubella, partly because the MMR vaccination has made them rarer. This potentially applies to younger healthcare staff as well as the wider population.
· People whose opportunities to be immunised or informed about immunisation are reduced, e.g. unvaccinated young adults no longer in education.
· Socio-economic reasons, e.g. ethnic minority people who have moved from countries where vaccination is not commonplace or people with restricted access to health information.
2) Actions taken by public health professionals, in partnership with other agencies, in response to the outbreak
Public health messages are critical to the success of immunisation. Sense Cymru was pleased to work with Public Health Wales to raise awareness of rubella during the measles outbreak. We also noted Public Health Wales’ awareness raising about mumps, which was a significant cause of viral meningitis and hearing loss in the pre-vaccination era.[9]
The Health Minister’s statement in May 2013 contained very welcome messages about MMR vaccination.[10] We were also pleased to note that local Assembly Members in the Swansea, Neath Port Talbot and Bridgend areas - and relevant party spokespeople – offered helpful public interventions to encourage further MMR vaccination uptake.
The successful containment of the outbreak is a testament to the hard work of Welsh NHS staff and Public Health Wales. The challenge is sustain a high level of vaccination and address any concerns or questions people have. The concept of herd immunity (‘community immunity’) is important and could be used as a driver to increasing take up of the vaccination across Wales. For example, the case study reported of a parent of a six year old child with leukaemia was potent. The parent spoke very strongly about the impact on his family and risks to his child because people in his community had not sought MMR vaccination.[11]
3) Lessons that could be learned in order to prevent future outbreaks
Sense Cymru thinks the lessons of the outbreak are:
· Wales must sustain the current high vaccination rate to minimise the risk of outbreaks of measles, mumps and rubella and to contain outbreaks that might occur. Enough people were unvaccinated for a measles outbreak to occur around Swansea. These people are almost definitely susceptible to rubella and mumps too. If the vaccination rate drops there is a risk of outbreaks of rubella and mumps.
· The current national MMR vaccination rate is high but it conceals particular localities and groups or cohorts for which vaccination rates are currently too low. We must concentrate resources on identifying them and offering opportunities to immunise.
· There are a variety of reasons why people have not sought MMR vaccination and these must be addressed. Public Health Wales and the Welsh Government must continue to engage with the public about the dangers of the diseases and importance of vaccination as well as responding to any questions or concerns that people have.
· As direct experience of measles, mumps and rubella diminishes people might give more weight to concerns about vaccination. Public health messages about the dangers of the diseases are critical.
Following these lessons Sense Cymru would make the following recommendations, particularly to public health professionals and Public Health Wales:
Undertake a systematic MMR vaccination catch up programme to target people particularly at risk. We know that during the outbreak Abertawe Bro Morgannwg UHB identified young people under 18 with no evidence of MMR vaccination on their records and sent them a personalised letter.[12] We would like to see this kind of approach adopted more widely.
Address general fears and people who feel like they have unanswered questions about MMR. Fears or feelings of uncertainty can cause people to turn to poor alternatives, such as clinics offering single vaccinations in Wales. Elected representatives, such as councillors and Assembly Members, also have a responsibility to do address concerns.
The NHS and Public Health Wales should work with others to promote uptake of the MMR vaccination. This could include colleagues in education and social services. Sense Cymru and others are willing to help develop public health messages around rubella, the dangers of the disease and the importance of vaccination.
Sense Cymru suggests the Health and Social Care Committee monitors vaccination rates. If the rate drops or when particular concerns are brought to the committee’s attention it could seek urgent clarification from the Health and Social Services Minister and Public Health Wales. We suggest also that the committee revisits the issue periodically to assess actions taken in reaction to the outbreak.