2007 saw the highest number of measles cases reported in England and Wales since current surveillance began in 1995, with 971 confirmed cases reported, compared with 740 reported in 2006 [1]. London was the region with the highest number of cases, and a large outbreak of measles in north-east London contributed to this high number of cases [2]. There were several outbreaks of measles elsewhere in Europe in 2007, and case have been reported this year in Switzerland [3], France [4] and Denmark [5].

Measles also continues to circulate in the greater London area during 2008. In Lewisham, a local authority area in south-east London, there has been a marked increase in cases so far during 2008.

A total of 19 laboratory-confirmed and 63 probable measles cases have been reported in Lewisham between 1 January 2008 and 8 April. This compares with provisional figures of fewer than 20 cases for the whole of 2007. There have been a number of outbreaks this year, including one in the local hospital, where nine cases were linked to a child admitted to the paediatric ward. This child subsequently developed measles. Cases are being seen in all age groups, although children younger than five years old are particularly affected, with six confirmed and 18 probable cases. There are ongoing outbreaks in two schools, reflected in the number of cases in 10-19 year olds, with nine confirmed and 29 probable cases. There have been four probable cases in people older than 20 years. A representative strain has been genotyped, and is identical to MVs/Enfield.GBR/14.07 genotype D4 (GenBank EF 600554) (Health Protection Agency, Virus Reference Department, Centre for Infections).

Lewisham, along with many parts of London, has historically had a low uptake of the measles, mumps and rubella (MMR) vaccine. Coverage of the first dose of MMR vaccine in two-year-olds during 2006-07 was 67 percent [6] and for two doses of MMR in five-year-olds was only 48 percent. The recorded coverage for the September 2007 quarter was 64 percent. Although it is likely that the uptake is in fact higher than this, due to problems in ensuring data accuracy, the uptake remains well below the 95 percent target.

There are several factors likely to have contributed to the low uptake in this area. Traditionally, these include socio-economic factors, such as high population mobility, family size, chronically ill children in the family, affecting access to services. Lewisham is an inner-city area with high levels of deprivation. There are increasing signs that the middle classes in the United Kingdom may also now be an at-risk group [7,8], due to parents' active decisions not to immunise their children with the MMR vaccine. Anecdotal evidence from the follow-up of individual cases in Lewisham by the South East London Health Protection Unit suggests that some parents of cases had also taken this decision.

Control measures
The local health authority, Lewisham Primary Care Trust, has declared a major community outbreak and is putting in place a range of control measures, supported by the Health Protection Unit. These include raising awareness in the population; encouraging MMR uptake with proactive media releases; dissemination of information to schools and nurseries in the area, including advice on exclusion; alerting health professionals; and offering MMR at additional community clinics. The overall aim is to increase MMR uptake in children in Lewisham both in the short and longer term.