Measles Outbreak in Birmingham and Effectiveness of Vaccination: Analytical Essay

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Measles is a dangerous and highly contagious viral disease causing major morbidity and mortality among children and adults if not controlled by the vaccine (Gay et al., 1995). Measles is one of the most disturbing and unpleasant communicable diseases that can cause serious illness with many complications, including the caused of millions of deaths globally (Griffin, 2012). Before measles vaccination was introduced, more than 100 deaths are reported annually in the United Kingdom (Jansen et al., 2003). Measles vaccination in England was introduced in 1968 and ever since, vaccine uptake has risen higher and the immunization coverage is widely achieved among the population, leading to the reduction of measles cases and death drastically (Manikkavasagan and Ramsay, 2009).

Over the past year, despite the availability of free and effective vaccination programme, there has been a constant increase in measles cases across England (Smith, 2018). Outbreaks have been confirmed in Birmingham and other four areas across the country where all cases are as a result of children and adults haven’t received the 2 recommended doses of measles, mumps, and rubella (MMR) vaccine (Michael, 2017). Gastañaduy et al., (2018) stated, “In elimination settings, a single measles case is a public health priority.” In this context, there is a high need to communicate the significance of vaccine uptake among all non-immunized people especially among parents of young children and increase public awareness to prevent and the spread of the disease among communities (Smith, 2018). This report will focus on educational and health campaign on preschool children that are at high risk of measles disease.

Epidemiology and disease burden:

Measles virus is particularly infectious that can be easily transmitted from one person to another via the airborne respiratory droplets spread by coughing and sneezing or through direct contact with an infected person (Moss and Griffin, 2012; WHO, 2019). The sign and symptoms include high fever, runny nose, conjunctivitis, cough and rashes usually appears about 10 to 14 days after exposure. Complications include respiratory and neurological diseases such as pneumonia and encephalitis (Sanondaf UK, 2019; WHO, 2019). Measles is virtually the most spreadable diseases with an average case capable of infecting between 12 and 20 other vulnerable people and 90% secondary infection rate in susceptible exposes individual (Michael, 2017).

In 2017, the World Health Organization (WHO) stated that the UK had attained measles elimination base on the report from 2014-2016 (see table 1.) However, the measles elimination status has not been maintained with the recent new development on measles outbreaks (PHE, 2019a). There have been multiple outbreaks within European countries and the recent measles cases is linked to the outbreak in Europe mainly in Italy and Romania (Michael, 2017; PHE, 2018). The number of reported measles cases in England has escalated from 284 cases in 2017 to 991 confirmed cases in 2018 (PHE, 2019a). Since then, there have been a series of outbreak in the west midlands especially in Birmingham.

Table 1: Measles limination status in the UK (PHE, 2019b)

The problem: Measles outbreak in Birmingham

Birmingham is a city in the west midlands of England with about 1,141,400 people in population, out of which 259,000 (22.8%) are children (Council, 2018). According Miller and Rodger (2019) Measles cases in Birmingham has hit a high record of about 97 cases in 2018, more than twice of the reported 47 cases in 2017. The recent epidemiological studies of measles cases illustrated the incidence rate in Birmingham is significantly worse than National average (see figure 2) (PHE, 2018a)

Source: Measles distribution rate in Birmingham (PHE, 2018a).

All most all unvaccinated people contact measles if exposed to the virus.

Evidence and justification

More recent attention has focused on the vaccine uptakes that have placed many children at the risk of measles infection. According to NHS and PHE, Factors that could contribute to the decline in uptakes are poor access to health care, poor out keeping of vaccination reminder by health professionals, antivaccination messages and media misconceptions that led to vaccine hesitancy among some parents (Mahase, 2019). Researchers believe the rise in measles cases was as a result of parents change in behavior and concern about the widespread of debunked link between autism and the vaccine in the early 2000s (PHE, 2013). Parents’ change in behavior is incomprehensible if they are regarded as acting to protect their children from a non-existent risk of vaccination created by bad research and media misconception (Bellaby, 2003). A survey was conducted on vaccine confidence among public and the report in UK discovered that 90% of people still have high confidence that vaccine is safe and effective (Larson et al., 2019).

According to The National Audit Office report, public Health England data revealed that there is a steady decline of vaccination uptakes among preschool children and have estimated about 90,000 children in England of age five are not vaccinated with both MMR vaccine (NAO, 2019). Mahase, (2019) claim that NHS neglected the performance standard set across all preschool vaccinations in England that resulted in massive decline of vaccine uptakes because of the inconsistency in way the GPs and health care professionals reminded parents to vaccinated their children. Furthermore, NAO, (2019) report on investigating preschool vaccination stated that the time and availability of vaccination programs is become difficult for some parents to access vaccination services for their children.

Additionally, PHE, (2018b) revealed a correlation between measles outbreak and travelers. The observed decreased among unvaccinated people could be attributed to travelers’ communities in England. The report stated that the Irish travelers, Gypsies and Roma have the worst outcomes in terms of health status and low immunization coverage compare to other communities. Therefore, to ensure

Measles Vaccination: Effectiveness and Coverage

Measles can be easily prevented by the Measles, mumps and rubella (MMR) vaccine (Smith, 2018). The 2 MMR vaccination dose are widely used in many countries to prevent the spread of the Measles disease. One does of MMR vaccines has about 95% effectiveness at preventing Measles (Bester, 2016). With the first dose, about 90% of induvial are protected and 99% are protected with the second dose (Choi et al.2008). It is believed that measles outbreaks can be ascribed to the drop in vaccine uptake among the population (Jansen et al., 2003). Even with the high coverage of the vaccination in England, Measles still remains a threat to the unvaccinated preschool children. To ensure Measles elimination and protection satisfactory, WHO (2017) recommended the vaccination coverage among the communities in every country should be at least 95%.

However, the data from public health England in 2018 shows that the national measles Population vaccination coverage - MMR for one dose (2 years old) were 90.3% and 86.4% MMR for two doses (5 years old) while the Birmingham coverage of 86.8% and 82.3% fell lower than National level and the target goal. (See figure 3)

Figure 3: vaccination coverage across the population in Birmingham (PHE, 2018a)

Aims and Objectives:

The aim of this report is to design and create an awareness raising campaign that promotes the importance of Measles vaccination among parent of preschool children. Health promotion aims to improve the vaccine coverage and children health in the population by reminding and encouraging parents to get their children vaccinated at every available opportunity.

Campaign Process:

An effective health promotion campaign generally begins with planning and setting a priority by identifying the target audience and as well as setting goals and objectives to be achieved (round at el., 2005). To ensure success in health promotion campaigns, it is important to identify the main problem and solution and ensure the effective use of resources and the right implementation (Corcoran, 2010). A systematic total planning process model will be used to achieved the aim and objectives of the campaign (see figure 4)

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Planning is essential to ensure success in health campaigns.

Planning models typically follow a series of steps in a logical order

[image: Figure A1. Total process planning model of social marketing ]

Figure 4: Total process planning model


Prior to start a health campaign, it is always important to analyses reliable epidemiological data and conduct an evidence-based research on the risk group to identify the behavioral change and determine the right approach and solutions through a series step of planning (Loti Popescu and Daniel Verman, 2000). The review of the literature on the recent measles outbreak in England shows that Parents are finding it difficult to access vaccination services and get GP appointments to vaccinate their children which has resulted to a decline in vaccination coverage among children (mahase 2019). Therefore, the campaign aimed to target parents as they are mainly responsible in making decision for their children and their attitudes affected the vaccination coverage among children at risk.

Social marketing:

Social Marketing approach has been recently used to systematically define people’s needs and impact their behavior change through the application of commercial marketing concepts for the benefits and greater good of the people. (Evans WD1, McCormack and chau et al.,) There are 8 set of social marketing intervention criteria to be accessed in promoting and improving the behavior of children vaccination uptakes among the target audience. (see figure 5)

Audience segmentation and insight:

One of the main decisions in social marketing approach is the understanding and segmentation of the target audience. According to ECDC (2010) An effective Health promotion campaign must have a distinctive way of identifying the target audience and identify who is affected. It also vital to know who makes the decisions, whose attitudes and behaviors needs to be changed to achieved the aims of the campaign (ecdc, 2010). PHE (2019) conducted a survey to know the present mindset of parents on vaccination uptakes and the report provided useful facts and highlighted that 95% of the target group still have confidence on vaccination. The report further listed some factors that could be a barrier from reaching the target of vaccination coverage such as difficulty in access to desirable vaccination service for parents and inconsistency in a way of healthcare professions remind parents of their children vaccination. Moreover, there are different attitudes and of different in reasons on why parents missing to have their children vaccinated. For example, some parents still hold a positive attitude towards vaccination but the challenges were the time and availability. According to a survey by the royal society for public health found out that some parents mentioned the availability and timing of vaccination appointments is not desirable and therefore it become a barrier to get their children vaccinated. (NAO, 2019)

The audience are classified into two target group in this campaign. Parents of the children are considered as the primary target group while the GPs and school teachers are secondary target groups. Primary target audience are inhomogeneous and segmenting them in groups requires more research on the socio demographic data of the parents. Therefore, this campaign is planned to encourage and communicate the importance of Measles vaccination particularly among parents of unvaccinated preschool children through the influence of healthcare professionals (GPs) and teachers in schools by offering support and vaccine uptakes.

Behavioral model:

One of the main focus of social marketing intervention in health promotion is the ability to achieve an effective behavioral change that are suitable to people’s settings. The behavior change method promotes health through changes in attitudes, belief and life style of the audience and also proper access to services by developing implemented intervention. As mentioned before, children vaccination depends on the decision and behaviors of their parents and health care professionals play a vital role in influencing parent’s decision. (ecdc, 2010). It is appropriate to consider the GPs as a primary target of communications in influencing parents to a desired behavior change on vaccine uptakes.

In order to persuade and encourage the audience, the health belief model (HBM) is applied in this campaign (see figure). The HBM has been broadly used in health promotion vaccination research to study behaviors and identify people’s perception on the disease and vaccination. The basic stages of health belief model have been summarized in appendix (3). This outline has been used to understand and addressed the desire mindset of the audience by communicating and motivate them to get their children vaccinated. As already mentioned earlier, most parents still have positive view and intention to vaccinate their children. According to survey conducted on health professional who worked in giving vaccination in UK, the respondents acknowledged parents forgetting vaccination appointment is the biggest barrier of vaccination uptake among working age adults and followed by timing and availability of the vaccination services. The campaign focus on implementing strategies and cues actions of communicating vaccination awareness and reminding parents that could increase the vaccination uptakes among children.


This is the activation of all the plans and strategies that were developed to achieve the aims and objectives of the campaign. Marketing mix is an effective tool to increasing vaccination awareness and places emphasis on the consumer. The health promotion activities require the effective use of marketing mix principles of six P’s that are integrated to satisfy the consumer needs. Figure 6 shows the description of marketing mix.

Strategy description:

The communication and awareness campaign will be conducted in three different types of interventional strategies to be able to convey the message to as many people as possible.

First, health care professionals will be generally informed through emails to seize all opportunity and make efforts in communicating the risk of the disease and importance of vaccination. It is important for the health professionals to use the tools of effective communication to convince parents. Additionally, Health authorities need to inform all GPS and set a requirement to follow up and strengthened the good use of invite - reminder systems for children vaccinations. Evidence have shown that most parents need to be reminded constantly and provision of flexible vaccinations services need to be in place to improve uptakes among busy parents.

Secondly, Schools will be contacted through emails and will be informed to communicate the message of vaccination to parents and priorities children immunization to protect and ensure the safety of the child from the disease.


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