Introduction and Background: Measles, mumps and rubella (MMR) are infectious diseases, primarily of childhood, which cause significant mortality and morbidity globally. These infections are, however, vaccine preventable and there is potential for them to be eradicated worldwide through the strategic use of organised population immunisation programmes. Following the introduction of the MMR vaccination in the UK in 1988, uptake was initially good and a high level of population vaccination coverage was achieved. This was sustained until 1998 when a study by Dr Wakefield and colleagues was published in the Lancet suggesting the theoretical possibility of an association between MMR and Autism/bowel disease. Intense media coverage followed, uptake of MMR vaccine fell to less than 80% in Somerset, and community outbreaks of measles, which had almost been eliminated in the UK, began to reappear. The Wakefield study was subsequently discredited and was eventually retracted by the Lancet in 2010. In August 2008 the Chief Medical Officer announced a national MMR catch-up campaign, targeting all children between the age of 13 months and 18 years who had either not been vaccinated against measles, mumps and rubella, or had only partial immunisation. These children were invited again for vaccination and the campaign was completed in January 2009. This study was undertaken to explore, in depth, the quantitative data available in respect of the uptake of MMR at the time of the 2009 campaign, and also to provide new qualitative data in relation to the attitudes, beliefs and experience of MMR and immunisation services of parents who continued to decline MMR for their children after the 2009 campaign, in order to identify factors which affected parental decision-making, add to the wider knowledge base, and to use this knowledge to improve the future development of immunisation services in Somerset. Methods: The overall objective of the study was to investigate a number of social, demographic and geographic characteristics of parents and children associated with MMR uptake, to compare these characteristics within and between defined sub-sets of the Somerset population, and to explore the basis on which parents in Somerset make decisions in relation to MMR immunisation. The study design adopted was a ‘mixed methods’ approach comprising of a cross-sectional design with three sequential phases - an exploration of baseline epidemiological data; a survey conducted with parents of children who remained unimmunised after 2009; and finally, semi-structured interviews with a sub-set of these parents. Results: The key findings from the study are: Parents who decline MMR for their children are not a homogenous group, but consist of a number of sub-groups each of which have different motives, decision pathways and predicted outcomes in relation to potential to change their mind and accept MMR There are differences in geographic distribution between the two age groups investigated Whilst the ‘Wakefield’ study did, and still does have, an impact, it is not the only or most important factor in their continuing decision-making. There is evidence that health professionals have a key role in addressing parental concerns in respect of immunisation. GP practice was the most significant factor associated with uptake in the Phase 1 study, and this was further confirmed in interviews with parents. Parents make decisions through engagement, through communicating and relating to others and this offers a potential mechanism for health professionals to influence decisions through open engagement with parents. Discussion and Conclusions: Three parent sub-groups were identified (Single Vaccines; Medical Comorbidities and Natural Health). These sub-groups were further investigated and factors associated with the decision-making pathways of each group were identified. This resulted in the development of the ‘MMR Parent Engagement Framework’ as a tool for use by professionals in planning their interactions with parents to improve and encourage more open dialogue in order to positively influence parental decision-making in relation to accepting MMR or other vaccinations. From a commissioning perspective, embedding frameworks such as this in service specifications offers a more cost-effective approach to improving immunisation uptake than funding large, poorly targeted catch-up campaigns. It is therefore recommended that further research is undertaken to provide evidence of the effectiveness of the approach in practice, and to inform future commissioning decisions. Additional recommendations to improve the effectiveness and delivery of immunisation services are also made in respect of GP Practice specific factors, independent schools, ethnic minority communities, vaccine overload, media, and data validation. The study has already directly influenced changes in current practice at both a local and a national level.

Submitted by Alexandre Sousa (alexandre.sousa@incqs.fiocruz.br) on 2015-04-07T11:49:38Z No. of bitstreams: 1 Dissertação_Danielle_Almeida.pdf: 2650975 bytes, checksum: 80a18514ce2bd91e7361e6eacc16a783 (MD5) / Approved for entry into archive by Alexandre Sousa (alexandre.sousa@incqs.fiocruz.br) on 2015-04-07T11:49:55Z (GMT) No. of bitstreams: 1 Dissertação_Danielle_Almeida.pdf: 2650975 bytes, checksum: 80a18514ce2bd91e7361e6eacc16a783 (MD5) / Approved for entry into archive by Alexandre Sousa (alexandre.sousa@incqs.fiocruz.br) on 2015-04-07T11:50:12Z (GMT) No. of bitstreams: 1 Dissertação_Danielle_Almeida.pdf: 2650975 bytes, checksum: 80a18514ce2bd91e7361e6eacc16a783 (MD5) / Made available in DSpace on 2015-04-07T11:50:12Z (GMT). No. of bitstreams: 1 Dissertação_Danielle_Almeida.pdf: 2650975 bytes, checksum: 80a18514ce2bd91e7361e6eacc16a783 (MD5) Previous issue date: 2014 / Fundação Oswaldo Cruz. Instituto Nacional de Controle de Qualidade em Saúde / Vacinas são os únicos meios para interromper a cadeia de transmissão de doenças imunopreviníveis. A vacina tríplice viral (contra sarampo, caxumba e rubéola), fornecida por Bio-Manguinhos, é constituída da mistura dos vírus vivos atenuados do sarampo, caxumba e rubéola. É de grande importância o efetivo controle da qualidade deste produto antes do seu ingresso no mercado, sendo necessária a realização do ensaio de potência biológica com a utilização de uma vacina de referência. O presente estudo teve como objetivo principal avaliar um lote vacinal como material de referência de trabalho (MRT) candidato (cMRTBio) para ser utilizado na rotina da determinação de potência da vacina tríplice viral em substituição a vacina disponibilizada pela GlaxoSmithKline (GSK) empregada anteriormente.Este estudo foi baseado nas normativas de compêndios que preconizam os estudos de caracterização do lote candidato quanto à homogeneidade e estabilidade, utilizando-se ferramentas estatísticas adequadas,visando à atribuição do seu valor, atendendo aos propósitos desejados e agregando maior confiabilidade aos ensaios de potência realizados pelo laboratório. O lote designado de 131VVA002Z utilizado como cMRTBio apresentou características como integridade, composição e potência em conformidade com as especificações exigidas. No estudo de homogeneidade, os resultados obtidos foram considerados homogêneos intra-frascos e inter-frascos, já que todos os coeficientes de variação obtidos foram inferiores a 10%, estando dentro do limite de aceitação. A potência estimada de cada componente viral do cMRTBio foi de: 3,73 log10 CCID50 / DH para o vírus do sarampo, 4,75 log10 CCID50 / DH para o vírus da caxumba e 3,67 (log10 CCID50 / DH) para o vírus rubéola, estando dentro das especificações previstas. No estudo de estabilidade verificamos um pequeno decaimento de potência, sendo estes valores considerados irrelevantes, uma vez que a potência encontrada ainda se encontrava dentro dos valores determinados para a especificação da vacina. De acordo com os resultados obtidos, verificamos que o cMRTBio apresentou todas as características exigidas para ser utilizado como MRT, sendo este material protocolado na Instituição como MRT(B)TVV001/13. / Vaccines are the only means to interrupt the transmission chain of transmission of immune predictable diseases. The MMR vaccine (measles, mumps and rubella), supplied by Bio-Manguinhos, is composed of a mixture of live attenuated viruses of measles, mumps and rubella. It is of great importance to the effective control of the quality of this product before its market entrance because it is necessary to perform the test of biological power with the use of a reference vaccine. The main objective of this study was to evaluate a batch vaccine as work reference material (MRT) candidate (cMRTBio) to be used in the routine determination of power of the MMR vaccine in replacing the vaccine made by GlaxoSmithKline (GSK), which was previously employed. This study was based on normative compendia that advocate the studies of characterization of candidate batch homogeneity and stability, using appropriate statistical tools, aiming the allocation of its value, taking into account the purposes intended and aggregating greater reliability to tests of power performed by the laboratory. The batch designated as 131AWV002Z used as cMRTBio presented characteristics such as integrity, composition and power in accordance with the required specifications. In the homogeneity study, the results obtained were considered homogeneous intra-bottles and inter-bottles, considering that all coefficients of variation obtained were lower than 10 %, while within the limit of acceptance. The estimated power of each viral component of cMRTBio was: 3.73 log10 CCID50 / DH for the measles virus, 4.75 log10 CCID50 / DH for the mumps virus and 3.67 (log10 CCID50 / DH) for the rubella virus, being within the specifications provided. In the study of stability we noticed a small decay of power, being these values considered irrelevant, since the power found was still within the values determined for the specification of the vaccine. According to the results obtained, we can notice that the cMRTBio presented all the required characteristics to be used as MRT, being this material filed in the Institution as MRT(B)TVV001/13.