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1.  Characteristics of 5-year-olds who catch-up with MMR: findings from the UK Millennium Cohort Study 
BMJ Open  2013;3(7):e003152.
To examine predictors of partial and full measles, mumps and rubella (MMR) vaccination catch-up between 3 and 5 years.
Secondary data analysis of the nationally representative Millennium Cohort Study (MCS).
Children born in the UK, 2000–2002.
751 MCS children who were unimmunised against MMR at age 3, with immunisation information at age 5.
Main outcome measures
Catch-up status: unimmunised (received no MMR), partial catch-up (received one MMR) or full catch-up (received two MMRs).
At age 5, 60.3% (n=440) children remained unvaccinated, 16.1% (n=127) had partially and 23.6% (n=184) had fully caught-up. Children from families who did not speak English at home were five times as likely to partially catch-up than children living in homes where only English was spoken (risk ratio 4.68 (95% CI 3.63 to 6.03)). Full catch-up was also significantly more likely in those did not speak English at home (adjusted risk ratio 1.90 (1.08 to 3.32)). In addition, those from Pakistan/Bangladesh (2.40 (1.38 to 4.18)) or ‘other’ ethnicities (such as Chinese) (1.88 (1.08 to 3.29)) were more likely to fully catch-up than White British. Those living in socially rented (1.86 (1.34 to 2.56)) or ‘Other’ (2.52 (1.23 to 5.18)) accommodations were more likely to fully catch-up than home owners, and families were more likely to catch-up if they lived outside London (1.95 (1.32 to 2.89)). Full catch-up was less likely if parents reported medical reasons (0.43 (0.25 to 0.74)), a conscious decision (0.33 (0.23 to 0.48)), or ‘other’ reasons (0.46 (0.29 to 0.73)) for not immunising at age 3 (compared with ‘practical’ reasons).
Parents who partially or fully catch-up with MMR experience practical barriers and tend to come from disadvantaged or ethnic minority groups. Families who continue to reject MMR tend to have more advantaged backgrounds and make a conscious decision to not immunise early on. Health professionals should consider these findings in light of the characteristics of their local populations.
PMCID: PMC3717465  PMID: 23864213
Socio-economic factors; immunisation; measles-mumps-rubella vaccine; measles; child health services
2.  Communicating with parents about vaccination: a framework for health professionals 
BMC Pediatrics  2012;12:154.
A critical factor shaping parental attitudes to vaccination is the parent’s interactions with health professionals. An effective interaction can address the concerns of vaccine supportive parents and motivate a hesitant parent towards vaccine acceptance. Poor communication can contribute to rejection of vaccinations or dissatisfaction with care. We sought to provide a framework for health professionals when communicating with parents about vaccination.
Literature review to identify a spectrum of parent attitudes or ‘positions’ on childhood vaccination with estimates of the proportion of each group based on population studies. Development of a framework related to each parental position with determination of key indicators, goals and strategies based on communication science, motivational interviewing and valid consent principles.
Five distinct parental groups were identified: the ‘unquestioning acceptor’ (30–40%), the ‘cautious acceptor’ (25–35%); the ‘hesitant’ (20–30%); the ‘late or selective vaccinator’ (2–27%); and the ‘refuser’ of all vaccines (<2%). The goals of the encounter with each group will vary, depending on the parents’ readiness to vaccinate. In all encounters, health professionals should build rapport, accept questions and concerns, and facilitate valid consent. For the hesitant, late or selective vaccinators, or refusers, strategies should include use of a guiding style and eliciting the parent’s own motivations to vaccinate while, avoiding excessive persuasion and adversarial debates. It may be necessary to book another appointment or offer attendance at a specialised adverse events clinic. Good information resources should also be used.
Health professionals have a central role in maintaining public trust in vaccination, including addressing parents’ concerns. These recommendations are tailored to specific parental positions on vaccination and provide a structured approach to assist professionals. They advocate respectful interactions that aim to guide parents towards quality decisions.
PMCID: PMC3480952  PMID: 22998654
3.  Measles, mumps, and rubella: prevention 
Clinical Evidence  2009;2009:0316.
Measles virus causes an estimated 21 million infections and 345,000 deaths a year worldwide, with increased risks of neurological, respiratory, and bleeding complications in survivors. Mumps can cause neurological problems and hearing loss, orchitis with infertility, and pancreatitis. Rubella infection is usually mild, but can lead to fetal death or severe congenital abnormalities if contracted in early pregnancy. The incidence of all three infections has decreased significantly in countries with routine immunisation programmes targeted at these diseases, but decreased immunisation rates are associated with increased risks of infection.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of measles immunisation? What are the effects of mumps immunisation? What are the effects of rubella immunisation? We searched: Medline, Embase, The Cochrane Library, and other important databases up to June 2007 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
We found 102 systematic reviews, RCTs, or observational studies that met our inclusion criteria.
In this systematic review we present information relating to the effectiveness and safety of the following interventions: MMR immunisation; monovalent measles immunisation; monovalent mumps immunisation; and monovalent rubella immunisation.
Key Points
Measles, mumps, and rubella are viral infections that can all be associated with serious disease in non-immune people. Measles virus causes an estimated 21 million infections and 345,000 deaths a year worldwide, with increased risks of neurological, respiratory, and bleeding complications in survivors.Mumps can cause neurological problems and hearing loss, orchitis with infertility, and pancreatitis.Rubella infection is usually mild, but can lead to fetal death or severe congenital abnormalities if contracted in early pregnancy.The incidence of all three infections has decreased significantly in countries with routine immunisation programmes targeted at these diseases, but decreased immunisation rates are associated with increased risks of infection.
The MMR immunisation is considered to be effective in preventing measles, mumps, and rubella infection, but placebo-controlled studies have not been done and would now be considered unethical. The MMR immunisation can cause fever, febrile seizures, and anaphylaxis, with aseptic meningitis more likely after some strains compared with others.There is no evidence of an association between the MMR immunisation and risks of asthma, Guillain-Barré syndrome, autism, diabetes, gait disturbance, demyelinating disorders, or inflammatory bowel disease.
Measles immunisation with monovalent or MMR immunisation is associated with reduced risks of measles, measles-related mortality, and subacute sclerosing panencephalitis. Seroconversion rates are similar for MMR and monovalent immunisations against measles, mumps, and rubella, but use of monovalent immunisations requires more injections and so may take longer to achieve full protection.Both the MMR immunisation and naturally acquired measles infection may increase the risk of idiopathic thrombocytopenic purpura.
The use of MMR, rather than monovalent measles, mumps, and rubella immunisations, provides earlier protection against all three diseases, requires fewer injections over a shorter period of time, and decreases the pool of individuals susceptible to these infections in the community.
PMCID: PMC2907817
4.  School nurses' experiences of delivering the UK HPV vaccination programme in its first year 
BMC Infectious Diseases  2011;11:226.
In the United Kingdom (UK) in September 2008, school nurses began delivering the HPV immunisation programme for girls aged 12 and 13 years old. This study offers insights from school nurses' perspectives and experiences of delivering this new vaccination programme.
Thirty in-depth telephone interviews were conducted with school nurses working across the UK between September 2008 and May 2009. This time period covers the first year of the HPV vaccination programme in schools. School nurses were recruited via GP practices, the internet and posters targeted at school nurse practitioners.
All the school nurses spoke of readying themselves for a deluge of phone calls from concerned parents, but found that in fact few parents telephoned to ask for more information or express their concerns about the HPV vaccine. Several school nurses mentioned a lack of planning by policy makers and stated that at its introduction they felt ill prepared. The impact on school nurses' workload was spoken about at length by all the school nurses. They believed that the programme had vastly increased their workload leading them to cut back on their core activities and the time they could dedicate to offering support to vulnerable pupils.
Overall the first year of the implementation of the HPV vaccination programme in the UK has exceeded school nurses' expectations and some of its success may be attributed to the school nurses' commitment to the programme. It is also the case that other factors, including positive newsprint media reporting that accompanied the introduction of the HPV vaccination programme may have played a role. Nevertheless, school nurses also believed that the programme had vastly increased their workload leading them to cut back on their core activities and as such they could no longer dedicate time to offer support to vulnerable pupils. This unintentional aspect of the programme may be worthy of further exploration.
PMCID: PMC3176210  PMID: 21864404
HPV vaccination; cervical; cancer; school nurses
5.  MMR: where are we now? 
Archives of Disease in Childhood  2007;92(12):1055-1057.
There is no scientific evidence of a link between bowel disease and/or autism and MMR vaccine. Attainment of a high uptake of the vaccine should be encouraged.
PMCID: PMC2066086  PMID: 17626143
6.  Missed opportunities to vaccinate children admitted to a paediatric tertiary hospital 
Archives of Disease in Childhood  2007;92(7):620-622.
Inequalities in vaccine uptake exist. Studies suggest paediatric inpatients have lower rates of immunisation uptake than the general population. Various UK policies advocate opportunistic immunisation.
To evaluate practice within a paediatric tertiary hospital in identifying and facilitating vaccination of inpatients who were not fully immunised.
Case notes for 225 inpatients were examined. Thirty staff of various professions and grades were interviewed. Policies, forms and documents used in the hospital were reviewed.
Immunisation status was recorded for 71% of children admitted, but for 69% of these immunisations were documented as “up‐to‐date” without any further information recorded. At least 20% of inpatients were incompletely immunised, but very little was done to facilitate vaccination. There was no training for staff either in giving advice or in administering vaccines and staff views differed regarding the hospital's role in immunisations. While there were guidelines for specific groups of patients, there were no general immunisation policies. Incorrect and out‐of‐date immunisation schedules were found on documents.
Opportunities to immunise children continue to be missed by all levels of health care service provision. Tertiary centres have a role to play in supporting primary care services to ensure that these vulnerable children are appropriately immunised. Measures are being taken to address the problems identified in this study and we strongly suspect that other hospitals in the UK ought to be confronting these issues as well.
PMCID: PMC2083800  PMID: 17213260
children; hospitals; inequalities; opportunistic immunisation; vaccinations
7.  Newsprint media representations of the introduction of the HPV vaccination programme for cervical cancer prevention in the UK (2005–2008) 
Social Science & Medicine (1982)  2010;70(6):942-950.
In September 2008, the human papillomavirus (HPV) immunisation programme was introduced in the UK for schoolgirls aged between 12 and 18 years of age. The vaccine shows high efficacy in preventing infection against HPV types 16 and 18 responsible for 70% of cervical cancer. However, to be most effective, the vaccine needs to be administered before exposure to the viruses and therefore, ideally, before young people become sexually active. The introduction of any new vaccine, and perhaps particularly one given to young teenage girls to prevent a sexually transmitted cancer-causing virus, has the potential to attract a great deal of media attention. This paper reports on content analysis of 344 articles published between January 2005 and December 2008 in 15 UK newspapers. It includes both manifest and latent analysis to examine newsprint media coverage of the introduction of the HPV vaccination programme and its role in HPV advocacy. We concluded that the newspapers were generally positive towards the new HPV vaccination and that over the 4 years period the newsworthiness of the HPV vaccination programme increased. In 2008 two events dominated coverage, firstly, the introduction of the HPV programme in September 2008 and secondly, in August 2008 the diagnosis on camera of cervical cancer given to Jade Goody, a 27 year old mother of two, who gained fame and notoriety in the UK through her participation in several reality television shows.
There are two conclusions from this study. Firstly, the positive media coverage surrounding the introduction of the HPV vaccination programme is to be welcomed as it is likely to contribute towards influencing public perceptions about the acceptability and need for HPV vaccination. Secondly, the focus on prevalence rates of HPV infection among women and on women's sexual behaviours, in relation to HPV vaccination ‘encouraging’ promiscuity, is an unhelpful aspect of media coverage.
PMCID: PMC2835855  PMID: 20064682
UK; Human papillomavirus (hpv); Vaccination; Mass media; Content analysis; Cervical cancer
8.  Competency, confidence and conflicting evidence: key issues affecting health visitors' use of research evidence in practice 
BMC Nursing  2009;8:4.
Health visitors play a pivotal position in providing parents with up-to-date evidence-based care on child health. The recent controversy over the safety of the MMR vaccine has drawn attention to the difficulties they face when new research which raises doubts about current guidelines and practices is published. In the aftermath of the MMR controversy, this paper investigates the sources health visitors use to find out about new research evidence on immunisation and examines barriers and facilitators to using evidence in practice. It also assesses health visitors' confidence in using research evidence.
Health visitors were recruited from the 2007 UK Community Practitioners' and Health Visitors' Association conference. All delegates were eligible to complete the questionnaire if in their current professional role they advise parents about childhood immunisation or administer vaccines to children. Of 228 who were eligible, 185 completed the survey (81.1%).
These health visitors used a wide range of resources to find out about new research evidence on childhood immunisation. Popular sources included information leaflets and publications, training days, nursing journals and networking with colleagues. A lack of time was cited as the main barrier to searching for new evidence. The most common reason given for not using research in practice was a perception of conflicting research evidence. Understanding the evidence was a key facilitator. Health visitors expressed less confidence about searching and explaining research on childhood immunisation than evidence on weaning and a baby's sleep position.
Even motivated health visitors feel they lack the time and, in some cases, the skills to locate and appraise research evidence. This research suggests that of the provision of already-appraised research would help to keep busy health professionals informed, up-to-date and confident in responding to public concerns, particularly when there is apparently conflicting evidence. Health visitors' relative lack of confidence about research on immunisation suggests there is still a job to be done in rebuilding confidence in evidence on childhood immunisation. Further research on what makes evidence more comprehensible, convincing and useable would contribute to understanding how to bridge the gulf between evidence and practice.
PMCID: PMC2679743  PMID: 19379494
9.  Treatment of community-onset, childhood convulsive status epilepticus: a prospective, population-based study 
Lancet Neurology  2008;7(8):696-703.
Episodes of childhood convulsive status epilepticus (CSE) commonly start in the community. Treatment of CSE aims to minimise the length of seizures, treat the causes, and reduce adverse outcomes; however, there is a paucity of data on the treatment of childhood CSE. We report the findings from a systematic, population-based study on the treatment of community-onset childhood CSE.
We collected data prospectively on children in north London, UK, who had episodes of CSE (ascertainment 62–84%). The factors associated with seizure termination after first-line and second-line therapies, episodes of CSE lasting for longer than 60 min, and respiratory depression were analysed with logistic regression. Analysis was per protocol, and adjustment was made for repeat episodes in individuals.
182 children of median age 3·24 years (range 0·16–15·98 years) were included in the North London Convulsive Status Epilepticus in Childhood Surveillance Study (NLSTEPSS) between May, 2002, and April, 2004. 61% (147) of 240 episodes were treated prehospital, of which 32 (22%) episodes were terminated. Analysis with multivariable models showed that treatment with intravenous lorazepam (n=107) in the accident and emergency department was associated with a 3·7 times (95% CI 1·7–7·9) greater likelihood of seizure termination than was treatment with rectal diazepam (n=80). Treatment with intravenous phenytoin (n=32) as a second-line therapy was associated with a 9 times (95% CI 3–27) greater likelihood of seizure termination than was treatment with rectal paraldehyde (n=42). No treatment prehospital (odds ratio [OR] 2·4, 95% CI 1·2–4·5) and more than two doses of benzodiazepines (OR 3·6, 1·9–6·7) were associated with episodes that lasted for more than 60 min. Treatment with more than two doses of benzodiazepines was associated with respiratory depression (OR 2·9, 1·4–6·1). Children with intermittent CSE arrived at the accident and emergency department later after seizure onset than children with continuous CSE did (median 45 min [range 11–514 min] vs 30 min [5–90 min]; p<0·0001, Mann-Whitney U test); for each minute delay from onset of CSE to arrival at the accident and emergency department there was a 5% cumulative increase in the risk of the episode lasting more than 60 min.
These data add to the debate on optimum emergency treatment of childhood CSE and suggest that the current guidelines could be updated.
An anonymous donor to UCL Institute of Child Health; the Wellcome Trust; UK Department of Health National Institute for Health Research Biomedical Research Centres Funding Scheme; Medical Research Council.
PMCID: PMC2467454  PMID: 18602345
10.  Factors associated with uptake of measles, mumps, and rubella vaccine (MMR) and use of single antigen vaccines in a contemporary UK cohort: prospective cohort study 
BMJ : British Medical Journal  2008;336(7647):754-757.
Objectives To estimate uptake of the combined measles, mumps, and rubella vaccine (MMR) and single antigen vaccines and explore factors associated with uptake and reasons for not using MMR.
Design Nationally representative cohort study.
Setting Children born in the UK, 2000-2.
Participants 14 578 children for whom data on immunisation were available.
Main outcome measures Immunisation status at 3 years defined as “immunised with MMR,” “immunised with at least one single antigen vaccine,” and “unimmunised.”
Results 88.6% (13 013) were immunised with MMR and 5.2% (634) had received at least one single antigen vaccine. Children were more likely to be unimmunised if they lived in a household with other children (risk ratio 1.74, 95% confidence interval 1.35 to 2.25, for those living with three or more) or a lone parent (1.31, 1.07 to 1.60) or if their mother was under 20 (1.41, 1.08 to 1.85) or over 34 at cohort child’s birth (reaching 2.34, 1.20 to 3.23, for ≥40), more highly educated (1.41, 1.05 to 1.89, for a degree), not employed (1.43, 1.12 to 1.82), or self employed (1.71, 1.18 to 2.47). Use of single vaccines increased with household income (reaching 2.98, 2.05 to 4.32, for incomes of ≥£52 000 (€69 750, $102 190)), maternal age (reaching 3.04, 2.05 to 4.50, for ≥40), and education (reaching 3.15, 1.78 to 5.58, for a degree). Children were less likely to have received single vaccines if they lived with other children (reaching 0.14, 0.07 to 0.29, for three or more), had mothers who were Indian (0.50, 0.25 to 0.99), Pakistani or Bangladeshi (0.13, 0.04 to 0.39), or black (0.31, 0.14 to 0.64), or aged under 25 (reaching 0.14, 0.05 to 0.36, for 14-19). Nearly three quarters (74.4%, 1110) of parents who did not immunise with MMR made a “conscious decision” not to immunise.
Conclusions Although MMR uptake in this cohort is high, a substantial proportion of children remain susceptible to avoidable infection, largely because parents consciously decide not to immunise. Social differentials in uptake could be used to inform targeted interventions to promote uptake.
PMCID: PMC2287222  PMID: 18309964
11.  Differences in risk factors for partial and no immunisation in the first year of life: prospective cohort study 
BMJ : British Medical Journal  2006;332(7553):1312-1313.
Objective To compare demographic, social, maternal, and infant related factors associated with partial immunisation and no immunisation in the first year of life in the United Kingdom.
Design Prospective cohort study.
Setting Sample of electoral wards in England, Wales, Scotland, and Northern Ireland, stratified by measures of ethnic composition and social disadvantage.
Participants 18 488 infants born between September 2000 and January 2002, resident in the UK and eligible to receive child benefit (a universal benefit available to all families) at age 9 months.
Main outcome measure Immunisation status at 9 months of age, defined as fully immunised, partially immunised, or not immunised.
Results Overall in the UK, 3.3% of infants were partially immunised and 1.1% were unimmunised; these rates were highest in England (3.6% and 1.3%, respectively; P < 0.01). Residence in ethnic or disadvantaged wards, larger family size, lone or teenaged parenthood, maternal smoking in pregnancy, and admission to hospital by 9 months of age were independently associated with partial immunisation status. In contrast, a higher proportion of mothers of unimmunised infants were educated to degree level or above (1.9%), were older (3.1%), or were of black Caribbean ethnicity (4.7%).
Conclusions Mothers of unimmunised infants differ in terms of age and education from those of partially immunised infants. Interventions to reduce incomplete immunisation in infancy need different approaches.
PMCID: PMC1473111  PMID: 16740559
12.  Use of personal child health records in the UK: findings from the millennium cohort study 
BMJ : British Medical Journal  2006;332(7536):269-270.
Objectives The personal child health record (PCHR) is a record of a child's growth, development, and uptake of preventive health services, designed to enhance communication between parents and health professionals. We examined its use throughout the United Kingdom with respect to recording children's weight and measures of social disadvantage and infant health.
Design Cross sectional survey within a cohort study.
Setting UK.
Participants Mothers of 18 503 children born between 2000 and 2002, living in the UK at 9 months of age.
Main outcome measures Proportion of mothers able to produce their child's PCHR; proportion of PCHRs consulted containing record of child's last weight; effective use of the PCHR (defined as production, consultation, and child's last weight recorded).
Results In all, 16 917 (93%) mothers produced their child's PCHR and 15 138 (85%) mothers showed effective use of their child's PCHR. Last weight was recorded in 97% of PCHRs consulted. Effective use was less in children previously admitted to hospital, and, in association with factors reflecting social disadvantage, including residence in disadvantaged communities, young maternal age, large family size (four or more children; incidence rate ratio 0.87; 95% confidence interval 0.83 to 0.91), and lone parent status (0.88; 0.86 to 0.91).
Conclusions Use of the PCHR is lower by women living in disadvantaged circumstances, but overall the record is retained and used by a high proportion of all mothers throughout the UK in their child's first year of life. PCHR use is endorsed in the National Service Framework for Children and has potential benefits which extend beyond the direct care of individual children.
PMCID: PMC1360395  PMID: 16455721
15.  Hear the Silence 
BMJ : British Medical Journal  2003;327(7428):1411.
A forthcoming drama about the MMR controversy has angered many doctors. A general practitioner and two child health experts, who have all seen a preview, explain why
Channel 5, 15 December at 9 pm
PMCID: PMC293044
16.  Safety and efficacy of combination vaccines  
BMJ : British Medical Journal  2003;326(7397):995-996.
PMCID: PMC1125960  PMID: 12742896
19.  Meningitis in infancy in England and Wales: follow up at age 5 years 
BMJ : British Medical Journal  2001;323(7312):533.
To describe important sequelae occurring among a cohort of children aged 5 years who had had meningitis during the first year of life and who had been identified by a prospective national study of meningitis in infancy in England and Wales between 1985 and 1987.
Follow up questionnaires asking about the children's health and development were sent to general practitioners and parents of the children and to parents of matched controls. The organism that caused the infection and age at infection were also recorded.
England and Wales.
General practitioners and parents of children who had had meningitis before the age of 1 year and of matched controls.
Main outcome measures
The prevalence of health and developmental problems and overall disability among children who had had meningitis compared with controls.
Altogether, 1584 of 1717 (92.2%) children who had had meningitis and 1391 of 1485 (93.6%) controls were successfully followed up. Among children who survived to age 5 years 247 of 1584 (15.6%) had a disability; there was a 10-fold increase in the risk of severe or moderate disability at 5 years of age among children who had had meningitis (relative risk 10.3, 95% confidence interval 6.7 to 16.0, P<0.001). There was considerable variation in the rates of severe or moderate disability in children infected with different organisms.
The long term consequences of having meningitis during the first year of life are significant: 32 of 1717 (1.8%) children died within five years. Not only did almost a fifth of children with meningitis have a permanent, severe or moderately severe disability, but subtle deficits were also more prevalent.
What is already known on this topicMeningitis in infancy is associated with important long term consequencesThere is considerable variation in outcome depending on which organism caused the infectionWhat this study addsThis follow up study of 1717 children who had meningitis in infancy found that they had a 10-fold increase in risk of severe or moderate disabilities at age 5 years compared with children in the control groupThe outcome of having meningitis was associated with the age at infection, and children who had meningitis in the neonatal period were more likely to have health and development problems than those older than 1 monthSubtle deficits, such as middle ear disease and visual and behavioural problems, were more prevalent among children who had had meningitis in infancy
PMCID: PMC48156  PMID: 11546697
20.  MMR vaccine: the continuing saga  
BMJ : British Medical Journal  2001;322(7280):183-184.
PMCID: PMC1119452  PMID: 11159597
22.  Concerns about immunisation 
BMJ : British Medical Journal  2000;320(7229):240-243.
PMCID: PMC1117437  PMID: 10642238
23.  The national filth 
British Medical Journal  1979;2(6200):1295.
PMCID: PMC1596878

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