British Medical Journal
04 May 2013 (Vol 346, Issue 7906)
http://www.bmj.com/content/346/7906
Editorial
Measles in the UK: a test of public health competency in a crisis
Can new agencies work effectively together to meet the challenge?
Felix Greaves, honorary clinical research fellow1, Liam Donaldson, professor of health policy2
Excerpt
The recent surge in measles cases in south Wales signals a discomfiting failure by a G8 nation to control an easily preventable disease. Far from the measles virus being holed up in outposts in poor countries, the spectre of large outbreaks of measles in England is now looming large. By contrast, elimination of endemic measles in the Americas has been achieved by treating it as an emergency.1 Prevention of more measles cases in the United Kingdom, and avoidance of embarrassment for the government, will turn on the effectiveness of the public health delivery system.
In the north of England there have been 354 cases in 2013 so far.2 The pool of vulnerable children nationally is worrying: 8% of those aged 10-16 years have had no measles, mumps, and rubella (MMR) vaccine, and 8% have had only one of the required two doses.3 Susceptible children are distributed throughout the country, making the site of the next outbreak impossible to predict. In London, where immunisation levels for all vaccines are traditionally lower,4 there have been few cases so far. However, London is a prime location for a major outbreak, with its transient and diverse population and its pockets of low MMR vaccination coverage.
It is hard to manage risk in epidemics, is even harder to explain risk to the public. In a well-nourished population, with good healthcare services, measles has a much lower mortality rate than in developing countries. Furthermore, within living memory, it was seen as a natural part of childhood. For most of those who catch it, measles is an unpleasant self-limiting illness. That said, so far in England in 2013, 18% of patients with the disease have been admitted to hospital, and in a small but important minority,3 the possibility of further complications and permanent disability, or even death, is real. The question society needs to answer is whether it is ethically acceptable to tolerate any serious complication, or death, from measles when an effective vaccine is available.
In a public health emergency, which is what the current measles threat is, it is vital that the response is well coordinated. All organisations and professionals involved in managing it must know their own role and each other’s, and they must work well together. Strong leadership, excellent communication, and a modicum of command and control are also essential. There is a concern that, with the recent health system reforms in England, bodies that were key in crises like severe acute respiratory syndrome, pandemic influenza, and foot-and-mouth disease (such as strategic health authorities and primary care trusts) have been devolved and swept away. Public health teams are now spread across local authorities, with links to the NHS much weaker than in the past. A newly established agency, Public Health England, is charged with protecting the population’s health, but resources for immunisation are with NHS England,5 an entity devoid of public health expertise at board level. It is not acceptable for the elements of this new public health system to learn on the job. An agreed operating relationship is needed quickly. There is the opportunity for a natural experiment to compare the performance of the more mature Welsh system and its brand new English equivalent. Rigorous evaluation of health sector reforms in their early stages would be a novel event in recent British public policy…
vaccines and global health :: ethics and policy 