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Mutuality: investment for long term benefit

Measles is a highly infectious disease with an incubation period of 6-19 days (median 13 days)1, with upper respiratory tract symptoms, conjunctivitis, characteristic spots in places such as inside the cheeks of the mouth, and high fever, followed by a widespread rash that persists, with fever, for 5-6 days. Worldwide, there are around 30 million cases per year and it is estimated that in the year 2000 it caused 777,000 deaths and 27.5 million disability adjusted life years. The overall complication rate is 6.7% with encephalitis in 1.2 per 1000 people infected.

Measles is almost entirely preventable by immunisation. The level of preventable harm from outbreaks of measles is a good example of what can happen when continued vigilance is not maintained, or where there is a problem with a service or intervention that has become less effective than it might. When that loss of effectiveness is the consequence of a loss of confidence in the service by parts of the population, then it also illustrates the consequences of a loss of trust in the healthcare system. In the case of measles there are times when we seem to have forgotten that it is a highly infectious disease that can have serious, long term health consequences. The need for continued vigilance and ensuring effective immunisation uptake remains clear. Only then can we all have the benefit of being safe from measles.

The outbreak

On the 13th February 2008, the Lothian Health Protection Team (HPT) was informed of a clinical case of measles from a Gypsy Traveller community. Whilst any single case of measles requires further investigation, the fact that this case was drawn from the Gypsy Traveller community was important as travelling families are known to be less likely to have completed primary immunization programmes.

The reasons for this are complex, but include the simple fact that many travelling families simply do not trust the NHS and the healthcare that is offered. Their experiences of seeking help, which are all too often negative ones, reinforce this view. The first case and their family had contacts with other travelling communities who had been staying in the same area in northern England and who had been diagnosed and confirmed with measles. In total, 46 cases of suspected measles from the Lothian area were notified to the Health Protection Team between February and March 2008.

A total of 25 cases were confirmed by the laboratories as being positive for measles. A further 17 clinical cases were not confirmed as measles by the laboratories. Four were lost to follow up. Of the positive cases, 21 came from the travelling community and the remaining four cases from the local communities. Typing results showed that they had the same genotype as the travelling community cases and were therefore likely to be associated with those cases. In all of the confirmed cases, only three were known to have had at least one dose of MMR vaccination, suggesting that immunisation coverage was low for the group. Most cases recovered fully, but four cases suffered more serious illness.

NHS Lothian employs a specialist Health Visitor for Gypsy Travellers. She was instrumental in assisting with the control of this outbreak. She, and a team of local health visitors, visited and vaccinated unvaccinated individuals where possible. She also took samples from individuals with symptoms suggestive of measles. She identified at risk individuals who might have been exposed to measles and raised awareness among the travelling community and voluntary groups who work with them.

The Health Protection Team liaised with all other nearby Health Boards and those potentially affected by the outbreak, as well as with Health Protection Scotland and Health Protection Agency. We also looked into the possibility of articles on measles in Connect and Travellers' Times. After the outbreak the specialist health visitor liaised with members of the travelling community who had contracted measles. They agreed to write an article for the Travellers Times to raise awareness of measles and the need for vaccination.

Continued vigilance

This outbreak demonstrated that although endemic transmission of measles no longer occurs in Scotland, this highly infectious disease is still a threat from importation from other countries and from UK residents in risk groups. Many GPs are too young to have seen measles therefore accurate diagnosis via lab testing is essential. Co-ordination with other Health Boards can assist everybody in the control of an outbreak, it is vital to maintain good lines of communication with all healthcare professionals involved. It is also important to ensure enough vaccine and immunoglobulin is available and to encourage GPs to take samples immediately to prevent loss to follow up.

Communities seek to protect themselves first and foremost and in a highly mobile, unvaccinated population like the travelling community, it can be difficult to get on top of a measles outbreak. However, if we are to maintain the current, low levels of measles infection in Lothian, then this is exactly the type of situation that we have to address.

[ Table 1 ] Summary of incidents involving Health Protection Team (HPT) 2008
Gastrointestina (e.g. norovirus, E.coli, salmonella) 8 incidents
Tuberculosis (TB). 8 incidents
Vaccine preventable incidents (e.g. measles, rubella). 7 incidents
Environmental (e.g. contaminated land, radiation). 4 incidents
Healthcare Associated Infection (HAI) 4 incidents
Water (e.g.cryptosporidium) 3 incidents
Blood Borne Viruses (BBV) 3 incidents
Creutzfeldt Jakob Disease (CJD) 2 incidents
Business Continuity 2 incidents

Source: NHS Lothian Health Protection Team

Key messages

  • Measles remains a highly infectious and serious illness that affects Lothian.
  • Outbreaks amongst un-immunised sections of our society are more likely: the travelling community is one such part of our society.
  • In 2008, a large outbreak amongst the travelling community in Lothian was managed - a spread of the disease into the wider community was avoided by prompt and effective action.
  • Seeking to rebuild trust and confidence in healthcare provision was an important part of that action.
  • Staff who already had the trust of the community were an essential part of the public health team.
  • If we are to maintain the current, low levels of measles infection in Lothian, we must be able to work proactively with individuals and communities that have found traditional NHS responses unhelpful.