Prevention starts with childhood immunisation

A prevention-first NHS must tackle vaccination inequalities from birth

MSD immunisation — Photo supplied by MSD

Disclaimer: MSD has funded and had editorial control over this article

The government has rightly placed prevention and reducing health inequalities at the centre of its ambitions for NHS reform, recognising that early intervention, including during the first 1,000 days of life, is critical to improving long-term health outcomes and giving every child the best possible start.¹

Yet, immunisation is still not reaching every child equally. Vaccination coverage rates are now falling below the World Health Organization (WHO) 95 per cent target across all routine programmes and the UK has lost its measles elimination status for a second time.² ³

Persistent inequalities by geography, ethnicity and deprivation mean lower coverage is often seen in the same communities already facing wider health barriers, with these disparities continuing from early childhood through to adolescence.⁴

Recent measles outbreaks illustrate the consequences starkly. During the 2023–24 outbreak in Birmingham, 78 per cent of confirmed cases were concentrated in the city’s most deprived communities.⁵ Meanwhile, adolescent immunisation programmes such as HPV continue to demonstrate unequal coverage – among year 9 girls in London at just 62.6 per cent in 2024/25, compared to 81.1 per cent in the east of England in the same cohort.⁶

The House of Lords inquiry into childhood vaccination therefore comes at a critical moment, as the NHS prepares for changes to how vaccination services are commissioned and delivered across England, with the NHS Modernisation Bill set to grant local health systems greater responsibility and flexibility in designing vaccination provision for their local populations.⁷

These reforms provide an important opportunity to strengthen prevention and improve access for underserved communities – but we cannot ignore the risk that regional variation and inequity may be further entrenched. Action must therefore be taken at every level of the NHS to more firmly embed equity into the design, delivery and evaluation of childhood immunisation programmes – from birth, through infancy, and beyond.

The recent rollout of national infant RSV prevention provides an important example of how programme design and delivery can influence equitable access to immunisation during the earliest stages of life.

The UK infant programme for the prevention of RSV currently consists of indirect coverage via maternal vaccination, supplemented with a monoclonal antibody (mAb) offer directly administered to a smaller cohort of high-risk infants.⁸

However, variation in maternal vaccination coverage has already emerged. In December 2025, maternal vaccination coverage ranged from 54.4 per cent in London to 72.1 per cent in the south west, while coverage was reported at 34.2 per cent among black Caribbean women, compared to 76.2 per cent among women in the Chinese ethnic group.⁹ If we are serious about giving every child the best possible start in life, we cannot accept these gaps in protection from a preventable disease as inevitable.

So what needs to change?

First, immunisation programmes must be designed around the needs of families and local communities.

While lower vaccination coverage may in some cases reflect hesitancy, it is also shaped by a wider set of factors, including awareness of and ability to access vaccination services, fragmented delivery pathways, workforce pressures and local variation.¹⁰ Together, these influence whether families are able to benefit from prevention offers.

To improve coverage and reduce inequalities, immunisation programmes must “meet families where they are”. Experience from other countries suggests that programmes built around locally tailored delivery can support higher and more equitable coverage.

Spain has achieved coverage rates of over 90 per cent among in-season infants during the first year of its RSV infant immunisation programme, which used mAbs for the prevention of RSV directly administered to infants.¹¹

Several Spanish regions supported rollout through parent engagement strategies, including dissemination of healthcare professional-led videos on social media platforms, proactive messaging addressing frequently asked questions, and translated materials texted directly to parents from underserved communities.¹²

This approach has been successful at driving rapid equitable uptake in other countries too.

In advance of the 2024/25 RSV season, Ireland introduced an infant pathfinder programme that offered a mAb for the prevention of RSV directly administered to infants born between September and February. The pathfinder achieved 83 per cent immunisation coverage, with a range of 76.4 to 84.5 per cent across the country’s regions.¹³

Second, data and evaluation must play a greater role in guiding how immunisation services are commissioned and delivered. Future evaluation efforts should focus not only on overall coverage rates, but also on how equitably programmes are reaching different communities. That will require clearer accountability supported by transparency – in a similar manner to national audits – in the evaluation of services, more routine publication of vaccination data by geography, ethnicity and deprivation, and better use of data to guide commissioning decisions and design services around local population need.

Third, maternal vaccination programmes should be treated with the same ambition and accountability as wider childhood immunisation programmes. Increasing coverage of maternal vaccination programmes takes sustained investment, consistent delivery and long-term commitment. The current maternal RSV vaccination programme has already reached approximately 63 per cent coverage after two years of investment,¹⁴ approaching coverage levels seen in the long-established maternal pertussis programme after more than a decade.¹⁵ ¹⁶

However, maternal vaccination programmes are too often considered separately from the broader childhood immunisation agenda, despite their critical role in protecting infants during the earliest stages of life. If the government is serious about delivering a prevention-first NHS, maternal immunisation programmes – including RSV – should be held to the same ambition around coverage, equity and accountability as childhood vaccination programmes more broadly. MSD is committed to supporting efforts across the health system to reduce vaccination inequalities, share learnings from different delivery approaches, and support progress towards more equitable access to protection from birth. Ultimately, efforts to improve childhood vaccination coverage will only succeed if equity is treated not as an outcome of vaccination policy, but as a principle underpinning how programmes are designed and delivered from birth.