Comment

For the Measles and Rubella Initiative see http://www. measlesrubellainitiative.org For GAVI Alliance see http:// www.gavialliance.org

action towards regional goals. The Measles and Rubella Initiative, which has helped deliver more than 11 billion doses of measles vaccine in the past decade, has funding and expertise on oer. The GAVI Alliance is oering nancing for eligible countries to introduce measles-rubella vaccine and a measles second dose. Measles campaigns remain a critical component of public health. They must reach all susceptible populations as indicated by the epidemiology. Encouraged by reducing measles deaths by more than 70% globally since 2001,4 countries and partners must also do their utmost to ensure campaigns are of the highest quality and close the immunity gap once and for all. The 2015 deadline is fast approaching and if we miss children today, they will get measles tomorrow. *Zsuzsanna Jakab, David M Salisbury
WHO Regional Oce for Europe, DK-2100, Copenhagen, Denmark (ZJ); and Department of Health, London, UK (DMS) zja@euro.who.int
ZJ is WHO Regional Director for Europe. DMS is Director of Immunisation for the UK Department of Health. We declare that we have no conicts of interest.

WHO. Global eradication of measles: report by the Secretariat. Geneva, Switzerland: World Health Organization, 2010. http://apps.who.int/gb/ ebwha/pdf_les/wha63/a63_18-en.pdf (accessed April 19, 2013). PAHO. Plan of action for maintaining measles, rubella and congenital rubella syndrome elimination in the Region of the Americas. Washington, DC: Pan American Health Organization, 2012. http://new.paho.org/hq/ index.php?option=com_docman&task=doc_download&gid=18542& itemid=&lang=en (accessed April 19, 2013). WHO Regional Oce for Europe. Centralized information system for infectious diseases (CISID). http://data.euro.who.int/CISID (accessed April 19, 2013). Centers for Disease Control and Prevention. Global control and regional elimination of measles, 20002011. MMWR Morb Mortal Wkly Rep 2013; 62: 2731. Simons E, Ferrari M, Fricks J, et al. Assessment of the 2010 global measles mortality reduction goal: results from a model of surveillance data. Lancet 2012; 379: 217378. Measles and Rubella Initiative. Fact sheet January, 2013. http://www. measlesrubellainitiative.org/mi-les/Reports/Measles%20Initiative/ Measles_Fact%20Sheet.pdf (accessed April 19, 2013). Public Health England. Number of laboratory conrmed measles cases in England and Wales. 2013. http://www.hpa.org.uk/web/HPAweb& HPAwebStandard/HPAweb_C/1223019390211 (accessed April 22, 2013). WHO. Regional Committee for Europe. Sixtieth session. Renewed commitment to elimination of measles and rubella and prevention of congenital rubella syndrome by 2015 and sustained support for polio-free status in the WHO European Region. Sept 16, 2010. http://www.euro.who. int/__data/assets/pdf_le/0016/122236/RC60_eRes12.pdf (accessed April 19, 2013).

2013. World Health Organization. Published by Elsevier Ltd/Inc/BV. All rights reserved.

Should the UK introduce compulsory vaccination?

Published Online April 25, 2013 http://dx.doi.org/10.1016/ S0140-6736(13)60907-1 See Comment page 1433

Inevitably, an outbreak of a vaccine-preventable disease in the UK triggers calls for compulsory vaccination. As of April 17, 2013, 808 cases of measles have been reported in the Swansea area, about 10% of which have led to hospital admission.1 One young adult who died is known to have had measles at the time, but it has not yet been conrmed if he died because of measles. Large outbreaks of measles have also occurred in northern England, with 865 conrmed cases in northwest England.2 Measles has a case fatality rate of between 1 per 1000 and 1 per 3000 reported measles cases,3 and unless the outbreaks are brought to a halt, more deaths will result. The lack of compulsory childhood vaccination in the UK has been called into question: commentators look to the USA where there is an element of compulsion and ask why the UK does not go down that route.4 Although arguments for compulsory vaccination are supercially compelling, further examination suggests it is not so straightforward. In the USA, stronger enforcement of immunisation laws in a state before entry to public school are associated with higher vaccine coverage and lower incidence of some vaccine-preventable infections in those

states.5 However, these comparisons fall down when comparisons are made between countries. In 2011, the uptake of the rst dose of measles, mumps, and rubella (MMR) vaccine among 2 year olds in the UK was similar to that in the USA (891% vs 897%).6,7 The Nordic countries successfully eliminated all three diseases8 without compulsory vaccination, while high vaccine uptake is achieved in other parts of Europe without compulsion.9 100 years of compulsory smallpox vaccination in the UK was a mixed blessing. Although some parents were persuaded to have their children immunised, the law turned others into martyrs and disproportionately aected the poor for whom the nes were a signicant burden. Over the years, enforcement of compulsory smallpox vaccination became less rigorous and more exemptions were granted.10 What impact might mandatory vaccination or penalties for non-uptake have in the 21st century? Underimmunised children comprise two main groups: those who are partially vaccinated because their parents have diculties in accessing services or for other practical reasons, and those whose parents have decided to reject immunisation, often due to their perceptions of the
www.thelancet.com Vol 381 April 27, 2013

1434

Comment

risk-benet equation.11 The former group tend to be from socially disadvantaged backgrounds, whereas the latter often have advantaged, more highly educated parents.12 Although a school entry requirement might provide a stimulus to parents who simply fail to get around to immunisation, compulsion would not provide a suitable solution for people who have genuine diculties in accessing health services; service provision would also need to be radically overhauled with more opportunities for immunisation oered and in a wider variety of settings frequented by families. Failure to take up immunisations, with penalties such as barring school entry or removing benet payments, could widen inequalities in child health. In the USA, although state immunisation laws help to ensure that children are fully protected by school entry, they have had little impact on ensuring timely immunisation among younger children,13 which in the past allowed measles to continue circulating. Acceptance of vaccination partly relies on a trusting relationship with health advisers.14 Mandatory immunisation might compromise this relationship of trust or entrench a resistant parents views even further, thereby perversely reducing vaccine uptake. Conscientious exemptions will always have to be allowed, and in the USA, where there is evidence of an increase in vaccine exemptions,13 some people go to extreme lengths, such as home schooling, to be able to exempt their children. Policing the system would require more robust information systems than we have at present in the UK. All forms of compulsion, whether linked to school entry or to welfare benets, would hit the poor hardest and in terms of the overall wellbeing of those members of the community. Before 1998, uptake of MMR vaccine in the UK was good and increasing, and measles was well controlled. However, in view of the intense media publicity during the early 2000s at the height of the MMR vaccine safety scare, it can come as no surprise that many parents chose not to immunise their child; even some health professionals were unsure about the safety of the vaccine15 and rates of uptake of the rst dose of MMR in 2 year olds fell to 80% in 2003.16 At that time compulsion would have been inappropriate. The current outbreaks are the legacy from this low vaccine uptake 1012 years ago, and largely involve unimmunised children who have never caught up with missed immunisation. In the UK, we have achieved high uptake rates of childhood immunisation with strategies that include
www.thelancet.com Vol 381 April 27, 2013

improved information systems, use of vaccination reminders, and provision of immunisation services by well trained, enthusiastic health professionals who are able to discuss parents concerns and questions eectively. It is this sustained work at a local level that has ensured current high rates of MMR vaccination in young children. More work is needed to reach the ultimate goals of achieving herd immunity and eliminating measles as well as rubella and mumps. It is unlikely that compulsory immunisation would progress these goals; to the contrary, we believe it could be detrimental. David Elliman, *Helen Bedford
Community Child Health, Whittington Health, London, UK (DE); and Centre for Epidemiology and Biostatistics, UCL Institute of Child Health, London WC1N 1EH, UK (HB) h.bedford@ucl.ac.uk
We declare that we have no conicts of interest. 1 2 Public Health Wales. Measles outbreak. 2013. http://www. publichealthwales.wales.nhs.uk (accessed April 22, 2013). Health Protection Agency. Measles at highest level for 18 years. Feb 8, 2013. http://http://www.hpa.org.uk/NewsCentre/NationalPressReleases/ 2013PressReleases/130208Measlesathighestlevelfor18years (accessed April 22, 2013). Strebel PM, Papania MJ, Dayan GH, Halsey NA. Measles vaccine. In: Plotkin S, Orenstein W, Ot P, eds. Vaccines, 5th edn. Philadelphia, PA: Saunders/Elsevier Inc, 2008: 35598. Ot PA. Should childhood vaccination be mandatory? Yes. BMJ 2012; 344: e2434. Robbins KB, Brandling-Bennett D, Hinman AR. Low measles incidence: association with enforcement of school immunization laws. Am J Public Health 1981; 71: 27074. Health and Social Care Information Centre, Screening and Immunisations team. NHS immunisation statistics, England 201112. Nov 27, 2012. https://catalogue.ic.nhs.uk/publications/public-health/immunisation/ nhs-immu-stat-eng-2011-2012/nhs-immu-stat-eng-2011-12-rep.pdf (accessed April 19, 2013).

4 5

1435

Rebecca Naden/Reuters/Corbis

Comment

10

11 12

Centers for Disease Control and Prevention. National immunization survey (NIS)children (1935 months). 2012. http://www.cdc.gov/vaccines/ stats-surv/nis/default.htm#nis (accessed April 19, 2013). Peltola H, Heinonen OP, Valle M, et al. The elimination of indigenous measles, mumps, and rubella from Finland by a 12-year, two-dose vaccination program. N Engl J Med 1994; 331: 1397402. Haverkate M, DAncona F, Giambi C, et al. Mandatory and recommended vaccination in the EU, Iceland and Norway: results of the VENICE 2010 survey on the ways of implementing national vaccination programmes. Euro Surveill 2012; 17: pii 20183. Salmon DA, Teret SP, MacIntyre CR, Salisbury D, Burgess MA, Halsey NA. Compulsory vaccination and conscientious or philosophical exemptions: past, present, and future. Lancet 2006; 367: 43642. Samad L, Butler N, Peckham C, Bedford H. Incomplete immunisation uptake in infancy: maternal reasons. Vaccine 2006; 24: 682329. Samad L, Tate AR, Dezateux C, Peckham C, Butler N, Bedford H. Dierences in risk factors for partial and no immunisation in the rst year of life: prospective cohort study. BMJ 2006; 332: 131213.

13

14

15

16

Omer SB, Salmon DA, Orenstein WA, deHart MP, Halsey N. Vaccine refusal, mandatory immunization, and the risks of vaccine-preventable diseases. N Engl J Med 2009; 360: 198188. Benin AL, Wisler-Scher DJ, Colson E, Shapiro ED, Holmboe ES. Qualitative analysis of mothers decision-making about vaccines for infants: the importance of trust. Pediatrics 2006; 117: 153241. Petrovic M, Roberts R, Ramsay M. Second dose of measles, mumps, and rubella vaccine: questionnaire survey of health professionals. BMJ 2001; 322: 82. Health Protection Agency/Public Health England. Completed primary courses at two years of age: England and Wales, 19661977, England only 1978 onwards. http://www.hpa.org.uk/web/HPAweb&HPAwebStandard/ HPAweb_C/1195733819251 (accessed April 19, 2013).

Integrated action for the prevention and control of pneumonia and diarrhoea
Some 19 000 children under the age of 5 years die each and every day, with 5500 of these deaths caused by pneumonia and diarrhoea.1 These are not mere statistics. 2 million young lives are lost each year from these two eminently preventable causes of death.2 This situation is completely unacceptable. Despite the fact that the basic elements needed to reduce childhood deaths from pneumonia and diarrhoea are well known and of low cost, current coverage is appallingly low. We welcome the Lancet Series on Childhood Pneumonia and Diarrhoea.14 The Series provides the evidence base to make the case that ending preventable child deaths from pneumonia and diarrhoea within the next 12 years is ambitious but achievable and necessary. Momentum to reduce child mortality continues to build, and it is imperative for the worlds children that we take advantage of this opportunity. As we approach the 1000-day mark before the Millennium Development Goal deadline, a raft of interconnected initiatives provides a platform to accelerate progress. The UN Secretary-Generals widely endorsed Global Strategy for Womens and Childrens Health aims to save 16 million lives through a continuum of care approach; a Global Vaccine Action Plan is working towards universal access to immunisation by 2020; more than 170 countries have signed on to A Promise Renewed, the call to action spearheaded by the Governments of Ethiopia and India, UNICEF, and USAID to end all preventable child deaths by 2035; and the UN Commission on Life-Saving Commodities for Women and Children is helping to improve access to priority medicines. In this context, it is critical to intensify eorts to tackle pneumonia and diarrhoeathe two biggest killers of children younger than 5 years after the newborn period, which account for about 29% of all under-5 deaths.1 A new WHO/UNICEF Integrated Global Action Plan for the Prevention and Control of Pneumonia and Diarrhoea5 aims to help countries meet this goal by establishing healthy environments to protect children from pneumonia and diarrhoea and by increasing access to cost-eective interventions for both prevention and treatment. The Integrated Plan builds upon two previous plans from 2009: the Global Action Plan for the Prevention and Control of Pneumonia6 and Why Children are Still Dying and What Can be Done,7 a seven-point plan for comprehensive diarrhoea control. We have encouraged the use of cost-eective preventioneg, exclusive breastfeeding, vaccines, and access to clean waterand treatment with simple, inexpensive antibiotics, oral rehydration salts, and zinc. Now we must help countries unplug the bottlenecks that are keeping these services from the children who need them. Children who are poor, hungry, and living in remote areas are most likely to suer from these forgotten killers, and the burden that pneumonia and diarrhoea places on their families and on health systems aggravates existing inequalities. Identifying the children at
www.thelancet.com Vol 381 April 27, 2013

Published Online April 12, 2013 http://dx.doi.org/10.1016/ S0140-6736(13)60692-3 See Series pages 1487 and 1499 See Series Lancet 2013; 381: 1487 and 1499

1436