When Roald Dahl’s daughter Olivia was seven, she fell ill. At first, the children’s author saw no reason for alarm and would often sit and read to her while they waited for the illness to pass. But one evening, as they were making animals out of coloured pipecleaners, he “noticed that her fingers and her mind were not working together and she couldn’t do anything”. In an hour, she was unconscious. Twelve hours later, she was dead.
Olivia died in 1962 from measles, which until recently had been all but eradicated from Europe by a widespread immunisation programme. A quarter of a century later, Dahl made a heartfelt plea to parents to immunise their children against the tragedy that befell his daughter.
“Every year, around 20 children will die in Britain from measles,” he wrote. “So, what about the risks that your children will run from being immunised? They are almost non-existent.”
Today that message is needed more than ever. Measles outbreaks have been on the rise since 2017, as clusters of unvaccinated people have sprouted in countries around the world. Last year, the World Health Organisation (WHO) recorded more than 82,000 cases in Europe, the highest point this decade and 15 times more than in 2016 (see data graphic, page 47).
Much of the surge has been driven by parents refusing to vaccinate their children. Health workers worry that these “anti-vaxxers” are not only spurring a resurgence in measles, mumps and rubella by refusing the MMR vaccine but are also slowing the uptake of inoculations against flu, meningitis and human papillomavirus (HPV). The WHO has named “vaccine hesitancy” as one of the top 10 global health threats in 2019.
Falling measles vaccination rates are particularly dangerous as the disease is highly contagious and there is no cure. Many people who catch measles end up in hospital with severe diarrhoea, pneumonia and vision loss. In some cases, like Olivia’s, it can prove fatal. Experts say at least 95 per cent of the population needs to be inoculated to ensure protection for everyone.
In the UK, MMR coverage is now at its lowest point for six years. While enough children receive the first vaccine, only 88 per cent get the second dose needed to ensure they are immune. Already, measles is on the rise: last year, there were more than 900 cases, up from around 260 in 2017. And, as a recent outbreak at a school in Chichester, West Sussex, made clear, schools are on the front line.
“As long as a vaccine-preventable disease is spreading anywhere on Earth, it is a threat to anyone who is not immune, no matter where they are,” says Dr Siddhartha Datta, manager of the WHO’s vaccine-preventable diseases and immunisation programme in Europe.
“Measles is exceptionally contagious,” he explains. “The virus will invariably reach an unvaccinated vulnerable population, and if immediate vaccination response is not initiated, its spread in this population will be difficult to control.”
Heidi Larson, director of the Vaccine Confidence Project at the London School of Hygiene and Tropical Medicine, says measles may be the “canary in the mine” for other preventable illnesses.
“It’s a kind of hubris,” she says. “What we will see is the return of some of the oldest diseases that we had under control.”
The modern anti-vaccine movement is widely traced back to Andrew Wakefield, a British gastroenterologist who, in 1998, wrote a now discredited paper claiming that the MMR vaccine caused autism. Since then, it has grown in strength around the world, fuelled by social media conspiracy theories and populist politicians (see box).
In the UK, there are particular pockets of society with potential problems. For example, Rudolf Steiner argued that illnesses such as measles could help a child’s spiritual development, so immunisation rates tend to be lower in the Steiner schools he founded. As such, Public Health England (PHE) notes there are “a number” of Steiner-Waldorf schools in England “where under-vaccinated populations are vulnerable”.
But the lowest rates of MMR vaccination tend to be in the capital, because of its highly mobile population.
“London has population movement of 10 per cent each year between boroughs,” says PHE’s head of immunisations, Mary Ramsay. “As children move, there has been a tendency not to register with a new GP, so invitations to appointments for pre-school boosters will not go to the correct address and children will miss out.”
While schools are on the front line in the fight against measles, they can also be a key part of the solution. Last year, Italy voted to drop a law requiring children to be immunised before they start school that was introduced in 2017 amid a 5,000-strong measles outbreak. Ahead of the vote, deputy prime minister Matteo Salvini told state media that vaccines are “useless and, in many cases, dangerous”.
The decision shocked many in the scientific community. But it also galvanised a backlash from the nation’s teachers and the public against the move. Italy’s association of headteachers has vowed to defy the government and refuse to admit any pupils without an immunisation certificate. They have been joined by more than 230,000 Italians who have signed a petition against scrapping the law. In the US, where vaccines are technically mandatory but many states grant exemptions on medical or religious grounds, some schools have taken matters into their own hands and refused to allow in children whose parents won’t vaccinate them owing to their personal beliefs.
For British schools, the picture is somewhat different. Unlike France and Italy, in the UK, vaccinations are not mandatory, so schools have no right to demand certificates. And unlike the US, schools are not allowed to deny entry to students on the basis of their medical status. An added barrier is that, because the MMR is delivered so young, teachers have limited contact with children at that age. So, what can schools do?
In the event of an outbreak, the priority is to stop it happening again. When 15 pupils at Chichester High School caught measles last year, the school established special “catch-up” vaccination clinics to give its students the MMR jab. Executive head Yasmin Maskatiya said the school had turned the crisis into an opportunity to teach vaccine-sceptic parents about the importance of immunisations.
“We know that some of the parents have concerns and fears about the MMR vaccination and it has been an invaluable opportunity for our parents to talk with health professionals so they can make an informed choice about their child’s health,” she said at the time.
“This has been a great example of the educational and health sectors working together to serve the local community.”
Others say schools’ most important role is to give children the facts. Dr Kumanan Wilson, a physician and scientist at the Ottawa Hospital in Canada, said trying to convince adults about the safety of vaccines can often backfire, leaving them more entrenched in their beliefs. As such, he argues, teachers can play a vital role in educating children about immunisation when they’re still young.
“Given that vaccination is one of the most important public health measures, they should be educated as to its importance,” he says. “By doing so, we may be able to create positive attitudes towards vaccination that can persist into adulthood. The children may perhaps be able to persuade some more ambivalent vaccine-hesitant parents.
“But, perhaps most importantly, it’s their lives that are being affected by the decisions of their parents.”
Kumanan says digital technologies are the best way to teach about vaccines as they are fun, interactive and create an easy-to-follow narrative. He recommends digital comics such as Viral Attack and one he created called Immunity Warriors to help catch children’s attention at an early age, as well as educational videos and video games, such as POX or Vax Pack Hero.
“The current generation of children are digital natives. They have grown up with these technologies, are extremely familiar with them and increasingly expect to have knowledge conveyed to them through these media,” he explains.
“Digital technologies also permit interaction in a way print media cannot. This can make the message more compelling and also can allow for gamification, which could further engage [children]. [These technologies can also] be rapidly iterated to respond to the dynamic nature of vaccine science.”
In the classroom, teachers can encourage students to think critically about vaccines through reasoned discussion. Stephan Neidenbach, a teacher in Maryland in the US and the founder of pro-biotechnology group We Love GMOs and Vaccines, says that he tends to start by raising some legitimate concerns, such as discussing how “big pharmaceutical companies have caused harm in the past”.
“The main trick is to not get too emotional,” he explains. “If a student really feels strongly that you are wrong about something, ask them to address it with you after class. There is only so much you can do if parents are at home giving conflicting information.”
Most people have reacted positively to his posts online, although he warns that emotions can run high. “Many of the conspiracy theories involve the idea that these massive corporations are intentionally killing people. Fight-or-flight kicks in with people who believe, and they see anyone in favour of the technology as part of that conspiracy.”
But the most effective advocates for vaccines are often the pupils themselves. While anti-vaxxers have used social media to great effect to promote their views, some teenagers are also using sites such as Reddit to discuss how to get vaccinated against their parents’ wishes.
Others, such as US teenager Taylor Sharp, have taken a more direct approach to tackling the myths circulating online.
After writing her senior paper on vaccines, the recent graduate of Greensburg Salem High School posted a thread on Twitter about why they are important, illustrated with hilarious GIFs. It swiftly went viral (no pun intended), receiving thousands of retweets and likes.
As one of her hopeful supporters put it, “education always wins”.
Caroline Henshaw is a reporter for Tes
This article originally appeared in the 22 March 2019 issue under the headline “An injection of common sense”
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