QUALITY IMPROVEMENT REPORT Improving MMR vaccination rates: herd immunity is a realistic goal

Problem As measles is a highly infectious disease, the United Kingdom recommendation is for at least 95% of children to receive a first vaccination with the measles, mumps, and rubella (MMR) vaccine before age 2 years and a booster before age 5 years to achieve herd immunity and prevent outbreaks. Reported vaccination rates for England have improved since a low level in 2003-4. Coverage for London is consistently lower than for England, however, and concerns have been expressed that there could be an epidemic of measles in the capital. Design Observational time series study. Setting London Borough of Tower Hamlets. Key measurements for improvement Uptake rates for childhood vaccinations. The key target was to reach 95% coverage for the first MMR vaccine before age 2 years. Strategies for change Financial support for the development of geographically based networks of general practices. Commissioning of care packages, incentivising delivery of high quality integrated care with network level vaccination targets of 95%. Innovative use of information technology to enable robust call and recall processes, active follow-up of defaulters, and increased knowledge about the demography of the children most difficult to reach. Effects of change The development of networks of practices facilitated collaborative working among primary care clinicians and other stakeholders; peer review of achievements; and an element of healthy competition. Uptake improved for all childhood vaccinations, and to herd immunity levels for most. Uptake of the first MMR vaccine before age 2 years rose from 80% in September 2009 to 94% in March 2011. Lessons learnt Achieving herd immunity for childhood vaccinations is an achievable target in an ethnically mixed, socially deprived inner city borough. The ability to identify characteristics of the difficult to reach groups, including significant differences in uptake across different ethnicities, will allow targeted interventions that may further improve overall coverage. Vaccination programmes are cost effective and have been shown to reduce health inequality worldwide. 1 As measles is a highly contagious disease(2) it requires vaccination levels to be at least 95% to maintain herd immunity and prevent outbreaks.(3) These levels of vaccination will also be needed to achieve the World Health Organization's goal of elimination of measles worldwide. The measles, mumps, and rubella (MMR) vaccine was introduced in the United Kingdom in 1988 and the booster dose was added to the programme in 1996.(4) Current recommendations are that every child should receive a first dose of MMR vaccine before the age of 2 years and a booster dose before the age of 5 years.(4) Uptake for the first dose of MMR vaccine (MMR1) in England reached 92% in 1992, and stayed above 90% until 1998 when rates started falling, down to 79% by 2003.(5) The decline in uptake of the MMR vaccine is thought to be caused partly by safety concerns but also, ironically, by the success of vaccination programmes leading to the impression that these childhood diseases are mild and uncommon.(6) MMR vaccination uptake rates are now increasing in England. However, the effects of the vaccine scare in the UK that followed Andrew Wakefield and colleagues' now discredited 1998 article (which had raised the possibility of a link between MMR vaccine and autism) are still present over a decade later.(7) Reported rates of uptake of all childhood vaccinations in London remain below those for England.(8) Ongoing low levels of MMR vaccination in London have raised concerns of the possibility of a serious outbreak of measles in the city.(9) The year 2008 saw the highest number of recorded confirmed cases of measles (1370) in England and Wales since the introduction of disease monitoring in 1995.(10) Most of the cases were concentrated in London.(11) Between 2006 and 2008 the inner London borough of Tower Hamlets had the highest rates of confirmed measles,(12) with 24.6 cases per 100 000 (46 confirmed cases) compared with a national figure of 2 per 100 000.