Elsevier

Vaccine

Volume 40, Issue 3, 24 January 2022, Pages 444-449
Vaccine

Impact of an accelerated measles-mumps-rubella (MMR) vaccine schedule on vaccine coverage: An ecological study among London children, 2012–2018

https://doi.org/10.1016/j.vaccine.2021.12.011Get rights and content

Abstract

Background

Vaccination coverage of dose two of MMR (MMR2) at 5th birthday has been consistently low in London and measured 76.3% in 2018/19. Since the early 2000s seven boroughs in London started offering dose two earlier, from 15 to 18 months onwards instead of the recommended 3 years 4 months. In this study we investigate whether the accelerated schedule of MMR2 leads to a change in coverage of MMR2 and other childhood vaccines with an ecological study using childhood immunisation data from 2009 to 2018 in London.

Methods

We modelled coverage used generalized estimating equations (GEE) adjusted for year and DTaP/IPV/Hib3 coverage measured at 2nd birthday as a proxy for baseline local vaccination programme performance to determine the percentage point difference in coverage of MMR2 and other childhood vaccines.

Results

Average MMR2 coverage was higher among early implementing boroughs from 2012/13 onwards. Coverage difference was highest in 2017/18 (9.2 percentage points, 95% CI 4.8, 13.5, p < 0.001). On average over the 6 years, compared to London boroughs on the routine schedule, MMR2 coverage among early implementing boroughs was 3.3 percentage points higher (95% CI 1.3, 5.3, p = 0.01) after adjusting for DTaP/IPV/Hib3 coverage, IMD score and year.

Conclusion

Earlier vaccination of MMR2 is associated with significantly higher coverage at five years for this vaccine in London. Further research is needed to assess the association at a more granular level, but our findings underline a potential opportunity to increase MMR coverage.

Introduction

In England, children are offered dose one of the Measles, Mumps and Rubella (MMR) vaccine at 12 months and dose two from 3 years and 4 months at the same time as the booster dose of diphtheria, tetanus, pertussis and polio (DTaP/IPV) pre-school booster. The MMR vaccine is more than 95% effective against measles [1], almost 100% against rubella [2], and 61–91% against mumps [3]. However, neither national coverage for dose one (MMR1) measured at 2nd birthday nor for dose two (MMR2), measured at 5th birthday, have ever reached the 95% target set by the World Health Organization (WHO) to achieve measles elimination in England [4]. MMR1 coverage in England decreased from 92.7% in 2013/14 to 90.3% in 2018/19 and MMR2 coverage decreased from 88.3% to 86.4% during the same time period [5]. London has the lowest coverage of all England regions with 90.4% and 76.3% vaccinated with dose one and two at 2 and 5 years of age respectively in 2018/19.

Sustained low coverage contributes to the increasing incidence of measles and the emergence of outbreaks through the accumulation of susceptible individuals. In England, cohorts born in the 1990s and early 2000s are the most susceptible [6] and in 2018 England reported 968 confirmed measles cases, mostly over the age of 15, the highest number of cases for five years [7]. Ongoing measles transmission in the UK has led to the country losing its WHO-conferred elimination status in 2019[8]. The increase in UK cases occurred in the context of 83,540 measles cases and 74 deaths reported in the WHO European region in 2018, compared to 5273 cases and 13 deaths in 2016.[9]

Around the world MMR vaccination schedules vary considerably; in Europe, Germany and Luxembourg offer dose two from 15 months, and France from 16 months [10], while Australia offers dose two as MMRV at 18 months [11]. Spain offers dose two from 3 to 4 years old, Ireland, from 4 to 5 years old [10] and the USA routinely offers dose two from 4 to 6 years old although the second dose can be administered from 4 weeks after dose one [12]. The WHO recommends a minimum interval between the first and second dose of MMR vaccine of at least 4 weeks and that offering dose two between 15 and 18 months can lead to early protection in infants and slows the accumulation of susceptible children [13].

In the UK, the ‘Green Book’ states that although dose two is normally given before school entry, it can be given routinely from eighteen months of age [14]. In the late 2000′s after several local outbreaks of measles, seven boroughs in South East London began offering MMR2 on an accelerated schedule [15]. Dose two was offered opportunistically from when children reached 15 months old or once they reached 18 months old however the exact schedule varied between boroughs [16], [17], [18]. There is no record of the exact timing of the change of schedule for each borough, but by 2012/13, these seven boroughs were offering the accelerated MMR schedule. Meanwhile, the remaining 26 boroughs in London continued offering the vaccine according to the routine schedule at 3 years and 4 months. The impact of an early MMR2 offer on coverage for MMR and other vaccines in the routine schedule has not previously been evaluated.

In this study we aimed to determine whether offering MMR2 early as an additional GP visit impacted on coverage for MMR2 as well as MMR1 and DTaP/IPV pre-school booster.

Section snippets

Methods

Vaccine coverage data for each of London’s 32 boroughs were routinely collected through COVER (Cover of Vaccination Evaluated Rapidly), Public Health England’s national coverage surveillance programme, between 2009/10 and 2017/18[20]. We initially used a wide date range because of the uncertainty around when the early schedule was implemented in each borough, although retrospectively it is not clear whether all the seven boroughs had introduced the accelerated schedule by 2009/10. Data from the

Results

Following an assessment of data quality, 2008/09 data was not included in the final analysis due to inaccurate coverage for that year [26]. In 2013, due to geography changes, Sutton and Merton were merged into a single borough in the analysis and are therefore a single data point from 2013 onwards.

Within the boroughs on the accelerated schedule, four boroughs’ IMD scores indicated a higher level of deprivation (range 25.5–29.5) while the other three boroughs had much lower IMD scores (range

Discussion

In London, vaccination coverage for second dose of MMR remains well below the 95% recommended target, with coverage decreasing from a peak of 81.4% in 2015/16 to 76.3% in the 2018/9 financial year. Between 2012/13 and 2017/18, vaccination coverage for dose two of MMR was on average 3.3 percentage points (95% CI 1.3, 5.3, p = 0.001) higher in London boroughs that offered dose two on the early schedule than average coverage in boroughs on the routine schedule after adjusting for year, IMD score

Conclusions

This study has shown that offering dose two of MMR early results in higher coverage. Despite limitations of the data, the magnitude of the effect and the consistency of the effect in areas implementing the earlier vaccine schedule, after adjusting for other factors, suggest a policy of early MMR2 should be considered. London consistently has lower coverage than the national average for all childhood vaccinations therefore it is unknown if an accelerated schedule would have a similar impact on

CRediT authorship contribution statement

Joanne Lacy: Data curation, Methodology, Validation, Writing – original draft, Writing – review & editing. Elise Tessier: Methodology, Validation, Writing – original draft, Writing – review & editing. Nick Andrews: Validation, Methodology. Joanne White: Writing – original draft, Writing – review & editing. Mary Ramsay: Writing – review & editing. Michael Edelstein: Methodology, Validation, Writing – original draft, Writing – review & editing.

Declaration of Competing Interest

The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: The Immunisation and Countermeasures Division has provided vaccine manufactures with post-marketing surveillance reports, not related to measles, mumps or rubella, which the Marketing Authorization Holders are required to submit to the UK Licensing authority in compliance with their Risk Management Strategy. A cost recovery charge is made for these reports. This

Acknowledgements

We would like to acknowledge Dr David Elliman for providing information on how the accelerated schedule developed.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Ethical approval

As this study uses open, publicly available data, no ethical approval was required.

References (28)

  • World Health Organization

    Measles vaccines: WHO position paper, April 2017 – Recommendations

    Vaccine

    (2019)
  • V. Demicheli et al.

    Vaccines for measles, mumps and rubella in children

    Cochrane Database Syst Rev

    (2012)
  • Reef SE, Plotkin SA. 53 - Rubella Vaccines. In: Plotkin SA, Orenstein W, Offit P, Edwards KM, editors. Plotkin’s...
  • Rubin SA. 40 - Mumps Vaccines. In: Plotkin SA, Orenstein W, Offit P, Edwards KM, editors. Plotkin’s Vaccines, 7th Ed....
  • England. Public Health

    Measles and rubella elimination UK strategy -

    GOV.UK

    (2019)
  • Childhood Vaccination Coverage Statistics - England 2018-19 - NHS Digital n.d....
  • M. Edelstein et al.

    Triangulation of measles vaccination data in the United Kingdom of Great Britain and Northern Ireland

    Bull World Health Organ

    (2019)
  • Confirmed cases of measles, mumps and rubella in England and Wales: 1996 to 2019 - GOV.UK n.d....
  • UK measles and rubella elimination indicators and status - GOV.UK n.d....
  • WHO | Measles – European Region. WHO 2019. https://www.who.int/csr/don/06-may-2019-measles-euro/en/ (accessed June 27,...
  • Vaccine Scheduler | ECDC n.d. https://vaccine-schedule.ecdc.europa.eu/ (accessed April 1,...
  • National Immunisation Program schedule (portrait) | Australian Government Department of Health n.d....
  • Birth-18 Years Immunization Schedule | CDC n.d. https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html...
  • Ramsay M, Parry R. Green Book of Immunisation - Chapter 21 - Measles n.d....
  • Cited by (6)

    • Child and adolescent immunisation in the UK: current issues

      2024, Paediatrics and Child Health (United Kingdom)
    View full text