The 5-year-old looked nervously at her older siblings, scanning their faces for any signs of distress as needles were quickly stuck into their arms, syringe plungers were pushed in, and the measles, mumps, and rubella vaccine was administered. Whether it was for her benefit or not, they barely flinched.
Then it was her turn. The girl, Oma Nnagbo, looked wide-eyed at the cheerful nurse who shortly afterwards declared: “Finally, very brave!”
Michael Nnagbo, 40, had brought his three children to this pop-up vaccine clinic in Wolverhampton in England’s West Midlands after receiving an alert from their school about a measles outbreak in the nearby Birmingham area.
“It is what we have to do and it is important to do,” Mr Nnagbo said. “I just want them to be safe. And it was easy, you could just walk in.”
Outbreaks of measles, a highly contagious but easily preventable disease, have started to appear in clusters as the number of children receiving the combined measles, mumps and rubella vaccine has fallen worldwide. The trend has been exacerbated since the coronavirus pandemic due to lack of access and reluctance among some groups. The measles virus can cause serious illness and, in the most extreme cases, death.
Across Europe, measles cases increased more than 40-fold in 2023 compared to a year earlier – from fewer than 1,000 to more than 40,000 – according to the World Health Organization. And while much of that increase has been concentrated in lower-income countries like Kazakhstan, more prosperous nations, where higher vaccination rates had long made measles cases rare, are also experiencing alarming outbreaks.
In Britain, 650 cases of measles were confirmed between October 1 and the end of February, according to the UK Health Security Agency, which declared a national emergency in January. The increase in cases was initially due to an outbreak in the West Midlands, but has spread to other parts of the country. Most cases in Britain involve children under the age of 10.
Vaccine coverage has fallen to precarious rates in some communities, particularly those facing the highest levels of deprivation. That was less the result of a growing anti-vaccine movement, experts said, than a lack of resources, a lack of awareness and some cultural reluctance.
The proportion of children vaccinated through the country’s routine vaccination program has fallen over the past decade for all diseases, including whooping cough, measles, mumps and rubella, polio, meningitis and diphtheria.
England no longer has vaccination coverage levels recommended by the World Health Organisation, which advises that more than 95 per cent of people must have had two doses of a measles vaccine containing weakened amounts of the virus to prevent outbreaks.
England had 84.5 per cent measles vaccine coverage by the end of 2023, but in some areas it was much lower. London had a coverage rate of 73.1 per cent overall, even lower than the West Midlands, where coverage was 83.6 per cent at the end of last year.
Jenny Harris, chief executive of the health insurance agency, said in a statement that lower vaccination rates are linked to inequality.
“While the majority of the country is protected, there are still large numbers of children in some areas who continue to be unprotected from preventable diseases,” he said. “If uptake doesn’t improve, we will start to see the diseases that these vaccines protect against reemerge and cause more serious diseases.”
Carol Dezateux, professor of pediatric epidemiology at Queen Mary University of London, said the current measles outbreak was “completely predictable” as vaccinations had fallen to alarmingly low levels even before the pandemic. The causes were complex, he said, but lockdowns and concerns about exposure to the coronavirus made the problem worse.
Vaccination rates for children in England have fallen steadily over the past decade, partly due to reluctance to vaccinate but also due to a lack of resources and logistical issues in the most deprived areas. It’s not just the MMR vaccine, Dr Dezateux said, as there is evidence of widening inequalities between rich and poor children across Britain in all five key childhood vaccinations.
“We can’t think of how we can move the dial on that,” in a more coordinated way, Dr. Dezateux, adding, “You might want to climb a high mountain, but if you don’t even have perspective by the time you get to the first base camp, you’re never going to try, you know?”
The coverage gap has been difficult to close in some areas, Dr Dezateux said, because so much pressure has fallen on GPs in the country’s NHS, which are already severely stretched.
However, the cost of prevention in the form of vaccines is about 4 percent of the cost of an outbreak, he said, pointing to the need for a coherent and coordinated plan to improve vaccine uptake.
“We know that where resources come, then people can do more. It’s not rocket science,” Dr. Dezateux said.
Dr Milena Marszalek, a researcher at Queen Mary who is a GP in north-east London in an area that has one of the worst vaccination rates in the country, said it was a logistical struggle to combat falling vaccine coverage.
“There is a real problem with a lack of capacity, a lack of appointments,” he said. “We don’t have the resources needed to bring children in for vaccination.”
But some things have worked, he said, citing pop-up clinics and contacting local imams to relay information about the vaccine’s safety to the region’s large South Asian Muslim community.
Local Haredi Jewish families told her that flexible clinic hours and walk-in appointments also removed a barrier.
However, it is often only after a major outbreak that the issue of vaccination becomes more urgent. Nicole Miles, the chief nurse for Vaccination UK, a team commissioned by Britain’s National Health Service to deliver childhood vaccines and which ran the Wolverhampton clinic, said an accessible, sensitive and tailored approach was important.
“What people don’t realize is how sick it makes you,” Ms Miles said of the measles virus. “There’s this idea that, ‘Well, it’s just measles,’ because we haven’t seen cases of measles in years like we have now. So people don’t realize how dangerous it can be because it just wasn’t here.”
Ms Miles, 34, and two other nurses working on distributing the vaccines discussed how vaccine hesitancy among their patients was actually quite rare.
“There will always be cohorts of people who don’t want to be vaccinated,” Ms Miles said. “And basically, there’s nothing we can do about it, can we? But we have to vaccinate the people who want to be vaccinated and who somehow missed it.”
At the Wolverhampton clinic, many of the families who came in said they weren’t against it but hadn’t been vaccinated for one reason or another. Like Mr. Nnago, many had heard of school vaccination.
The Okusanya family, originally from Nigeria, have been living in Wolverhampton for two years. Oluwafunmilayo Okusanya, 42, said none of her three children had received the MMR vaccine back home, so when she heard about the measles outbreak locally, she knew it was important to get them.
“When the opportunity came, I felt it was good for them to have it,” he said. “He made it very convenient. Although some may not see the need to find it, we just have to protect the children.”
