Chapter 2: Literature review
Section 2.1: Introduction
This chapter reviews the literature covered in relation to the research objective of this study. The study seeks to answer the question: “what are the factors influencing measles immunization in the UK?” Several recent studies have covered the area of the study and their related findings have been covered in the literature review section. This chapter does this by looking at the resurgence of measles in the UK and worldwide, some controversies about the use of MMR vaccine, and factors influencing immunization of children in the UK. In so doing, the literature reveals the extent to which the research has already been done, existing gaps, and the dimension of this research. The literature review begins by looking at the resurgence (revival) of measles in the UK, then world before looking at factors influencing measles immunization.
Section 2.2: Resurgence of measles in the UK
As earlier noted, the UK has an organized childhood immunization programme that goes on to evolve as well as develop in satisfying the demand to enhance and manage preventable infectious diseases such as measles, mumps and rubella (Austin, et al., 2008). This programme is taken care of by the Health protection Authority in the government department of health. The programme is meant to protect children against all infectious diseases. This noble objective saw the introduction of the MMR vaccine in 1988 and a second dose of it in 1996. Although, reports released by the government and other sources indicate increased uptake of MMR vaccine, the recommended herd immunity has never been achieved. The herd immunity recommended is 95% of target population (Hill & Cox, 2013). Herd immunity level, means that the child immunization program has succeeded in preventing disease outbreaks of infectious diseases such as measles.
Cases of infectious disease identified as measles were notified in England and Wales first in 1940. In an effort to curb the prevalence of the disease, a single monovalent (antigen) measles vaccine was included in the childhood program of immunization in the UK after 28 years (Schoenbaum, 1976). Nonetheless, the coverage of the vaccine was not encouraging over the subsequent 20 years. This made curbing of measles transmission over the 20 year period impossible (Hill & Cox, 2013). As a result, between 50,000 and 100,000 measles cases were notified yearly. This forced the government to think about a way of increasing the use of the measles vaccine, which led to the introduction of MMR vaccine in October 1988 in the place of the measles vaccine. The introduction of MMR vaccine was also expected to help reduce mortality rates. After a measles outbreak was reported in Quebec, Canada in 1989 (one year down the line), it was proposed that a single MMR vaccine was not able to offer adequate seroprotection to reach herd immunity levels of 95 percent (Austin, et al., 2008).
A two dose schedule has been tested, proved, and demonstrated in the United States of America and Finland to be more effective (Petrovic, et al., 2001). Thus, a second dose of the MMR vaccine was included in the UK immunization programme for children in October 1996 (Hackett, 2008). In the beginning, the inclusion of a second MMR vaccine showed a decrease in outbreaks of rubella and measles from 1996-1998. However, the decrease in the incidences of rubella and measles did not reflect on the case of mumps. Mumps cases were continually notified rising during this period with 94 mumps confirmed in 1996 and up to 121 cases in 1998 (Demicheli, et al., 2005).
Section 2.2: MMR vaccination issues
Section 2.2.1: MMR vaccine controversy
Following the intrigues that marred the introduction of MMR vaccine, Wakefield and colleagues in 1998, published a paper in The Lancet concerning side effects associated with MMR vaccine (Horton, 2004). The researcher had learnt that the vaccine was introduced in three brands. However, two brands were quickly withdrawn four years afterward because they were causing children to suffer from meningitis at an alarming and unacceptable rate (Wakefield, 2010). This is to say that only a third of the vaccines licensed in the UK were useful for immunization whereas two thirds had to be removed from the system because they were dangerous. This coupled with the issue that the government must have been aware of the dangers, raises serious concerns about the safety of MMR vaccination. The government had to allow the MMR vaccination to go on, whereas it banned the single antigen measles vaccine (Wakefield, 2010).
The public reaction to the article was much similar to the response they gave to the pertussis vaccine. Pertussis vaccine caused considerable public and professional anxiety concerning its efficacy and safety (Hackett, 2008). Consequently, major epidemics of pertussis broke out in 1977 to 1979 and again in 1981 to 1983 with more than 68,000 notifications and 14 deaths. In the same way the reactions were towards a pertussis vaccine, the publicity created by the Wakefield publication caused skepticism amongst parents concerning the safety of the vaccination administered using MMR vaccine and the vaccine’s alleged link between the vaccine, Crohn’s disease (bowl) and autism (Skea, et al., 2008).
As a result, this concern became visible in a reduction in the use of MMR vaccinations in the UK. The coverage dropped from 95% in 1993 to 80% in 2003 to 2004 (Simons, 2012). Despite attempts by a large number of the researchers through an article later published in The Lancet to eliminate a connection of any of the identified syndromes in the original study, the decrease in the use of the MMR vaccine continued. It is not surprising that the decrease in MMR vaccination rates has resulted in a resurgence of mumps and measles specifically (Pearce, et al., 2008). Confirmed cases in 1998 were as follows: measles n=42; mumps n=67 and rubella n=28. The confirmed cases that were reported by the Health Prevention Authority (HPA) in 2009 were: measles n=876; mumps n=5695 and rubella n=9 (Wolfson, 2009). The augment in the infectious diseases of mumps and measles particularly, is happening despite extensive campaigns to promote the MMR vaccine and the evidence on the safety and effectiveness of the vaccine (Larson, 2011).
The statistics of the confirmed cases measles show that the government is running away from a worthy criticism. It seems its main concern is to allow the MMR vaccination programme to go on. Stopping or halting the MMR vaccination means that an important component of childhood immunization has not been considered (Semba & Bloem, 2004). MMR vaccination is very vital in preventing infection of infectious diseases such as measles (Wakefield, 2010). The outbreak of measles in south Wales was very difficult for the government because the coverage of measles containing vaccine is a problematic issue yet to be solved. This suggests that the Wakefield factor cannot be wished away simply that way but critically re-examined to restore confidence of both the public and professionals (Fitzpatrick, 2004).
Section 2.2.2: Making sense of reported and confirmed measles cases in the UK
It is challenging to make sense of the number as well as percentage of confirmed cases of measles in the UK since 1998. The number as well as the percentage of confirmed cases in the UK spiked in 2002 and once more in 2006 to 2007. This is shown in the table below
Table 1-Health protection Authority (HPA): Reported and confirmed cases of measles-England and Wales
Total
Year
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
Reported
3,729
2,439
2,379
2,251
3,188
2,489
2,357
2,090
3,706
3,671
28,299
Confirmed
57
93
101
71
320
438
189
79
740
991
3,080
Percentage confirmed
1.52
3.81
4.22
3.12
10.1
17.7
8.1
3.8
20.1
27.1
11.0
Examining the data in the table one finds it difficult to draw conclusions on the data relating to the two spikes in 2002 and 2007 (Wolfson, 2009). Whereas the reported cases went up by 15% from 3,188 to 3, 671, confirmed cases rose disproportionately by 210% from 320 to 991. Considering the 2002 spike and comparing it with the previous year, reported cases rose by 42% from 2,251 to 3,188 whereas confirmed cases rose by 355% from 71 to 320 (Stefanoff, et al., 2010). Furthermore, comparing the first three months of both years also had some insight into the matter. There were 742 measles cases that were notified and 570 (72.1%) that were tested. Only 3 showed positive saliva test, a result of 0.5% throughout the first 13 weeks of 2001. During the same period of 2002, there were 1,200 notified cases and 1,387 (116.2%) tested cases.
As an attempt to explain the strange situation the Public Health Laboratory Services (PHLS) produced a statement on the issue (featherstone, et al., 2003). They said that because of the increase in confirmed measles cases in that quarter a lot of oral fluid tests were presented early for uncovering of IGM antibody for alleged cases of measles, some of which were not later notified, therefore more samples were presented than notified during that period (Salisbury, et al., 2013). The explanation given is very hard for professionals and the public make a conclusion on it. The government of the day seemed to come up with an explanation to every contagious issue. One real thing that is forthcoming is that the reality of measles situation was either being underplayed or not properly researched on. For instance, Wakefield and colleagues noticed that instead of having an independent surveillance to monitor the coverage and effects of the MMR vaccine, the government chose to rely on doctors and professionals in public service (F, 2013). This brings more speculation on the infectious disease potential outbreak and a sort of blame game being played by the authority to avoid responsibility for any effects on children.
In addition the government always denied liability for the alleged increase in autism cases that were caused by the MMR vaccine even when evidence presented in the US courts had found MMR responsible for the cases (F, 2013). The children who were facing such conditions were paid millions of dollars they were awarded as compensation by the courts (Parker, 2006). This meant that those with the problems had to be sidelined and left to suffer in the UK even though they were using a lot of money in treatment of their conditions.
In any case, out of the 1, 387 tested cases, 6.6% or 92 were positive, an outcome 13 times more than the case in the first three months of 2001 (World Health Organization, 2009). Due to the fact that 10 cases had newly been vaccinated, Public Health Laboratory services recorded 83 as the number of confirmed saliva-test cases. Unlike the first three months of 2001, PHLS then increased the lab confirmed cases by 45 to increase the number of cases confirmed for the quarter to 126 (Griffin, 2008). Despite all the changes and the absence of conformity, the numbers of confirmed cases were fewer in England and Wales in 2005 as compared to the case in 1999. Moreover, the data in the table also illustrates that the percentages of confirmed cases stayed low throughout the four years that right away followed Wakefield study publication (Wakefield, et al., 1998).
The fact that only 2,090 cases of measles were notified and 79 confirmed in 2005, whereas the same modalities of diagnosis as in 2002 to 2004 were used, strongly illustrates that seven years following the Lancet publication, the commonly known as Wakefield Factor did not hold weight. A close look given to the first quarter of 2005 attempts to give insight on the issue of confirming cases in the United Kingdom through saliva testing (Anon., 2009). In the first 13 weeks of 2005, there were 592 measles cases reported of which 576 (97.4%) were tested. Positive saliva test results were only 21 (3.6%) (World Health Organization, 2011). The same happened with rubella: out of the 300 cases of clinical rubella that were reported by physicians throughout the quarter, 221 went through saliva testing and only (1.0%) of the 221 tested positive. Mumps testing results significant differed with this (Jick & Hagberg, 2010). Throughout the same quarter, 5, 946 mumps cases were reported, 56.6% or 3,357 were tested and 41% or 1,382 produced positive results by the saliva test. Apparently, the validity of rubella, mumps and measles reporting is suspect. The same picture replicated itself in the second as well as third quarters of 2005 (Baron-Cohen, et al., 2009). Saliva (oral fluid) testing for measles, rubella and mumps started in the UK in 1995. Interesting to note is that health authorities went on to avail to the World health Organization counts of reported as opposed to confirmed measles cases. (Lamden & Gemmell, 2008) This can be observed in the WHO table below.
Table 2-WHO: reported measles cases-North Ireland and UK
Totals
10 years before Wakefield
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
Last 5
The entire 10
88, 260
30,161
28,229
11,728
12,317
12,018
23,526
9018
6,867
4,845
56,271
226,971
10 years
After Wakefield
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
First five
The entire tank
75
–
105
74
315
461
190
80
774
1024
566
3,089
…………………………………………………….
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