This study investigates the background to low uptake of nasal influenza vaccination in Polish pupils in Edinburgh, Scotland. In autumn 2018, one week after their child's nasal flu vaccination sessions, 365 Polish parents were sent a questionnaire exploring influences on their vaccination choices. The questionnaire included a series of 10 vaccine hesitancy questions recommended by the WHO SAGE Working Group on Vaccine Hesitancy. 128 questionnaires were returned representing 43.4% of vaccinated, 41.9% of refusing and 23.8% of non-consent form returning parents. Responses highlighted concerns about side effects, new vaccines and the accuracy of professional advice and information sources. There was complacency expressed about vaccination against diseases that are not common any more. Vaccine refusers were consistently more negative about all aspects vaccination and more likely to answer 'don't know'. Almost half of refusers were uncertain about the quality of health information offered to them. Polish migrants in Scotland come with their beliefs about vaccination and modify these as they acculturate to the UK system. They also continue to be influenced by developments and opinions, norms and values from their home country, as well as diaspora media. We have highlighted issues of concern among Polish migrants as a group and gained additional insights by comparing responses of parents who have refused or accepted vaccination. These insights can inform and target messages and strategies to build confidence and encourage immunisation, which should lead to improved vaccine uptake among ethnic population groups.

Background In Edinburgh, Scotland, lower influenza vaccine uptake has been observed in primary school children in the Polish community. Methods To address this disparity, the Polish-language version of the NHS Health Scotland influenza information pamphlet was updated and distributed in 2018 to all identified Polish pupils attending three pilot schools. The impact of the revised pamphlet was evaluated by examining changes in vaccine uptake in these schools as compared to a control group of schools, and a questionnaire was issued to all Polish parents in the pilot schools to explore their opinions of the pamphlet and preferred sources of immunisation information. Results On average uptake was 7.4% (95% CI 1.0–13.8%, p < 0.05) higher in the three pilot schools in which the Polish-language pamphlet was distributed (28.7%) than control schools (21.3%). The questionnaire feedback was that 37.3% of respondents felt better-informed about the influenza vaccine following the pamphlet. The respondents reported that the most important information source in deciding whether to vaccinate is previous experience. Healthcare professionals were ranked lower in importance when making a decision. Parents, who refused consent ( n = 65) were more likely to source information from social media, friends and family, and Polish websites compared with those who consented ( n = 45). Conclusions These findings suggest that issuing new Polish health literature was associated with a large increase in consent form return rate and a modest increase in uptake of the influenza vaccine by Polish pupils in the pilot schools. Social media and Polish websites were found to have a greater influence over Polish parents’ decision to immunise than UK healthcare staff and health authority information. Intensive effort is required to encourage parents towards information sources where more accurate pro-vaccination messages can be promulgated by national health services and independent expert groups. The role of social media for migrant communities requires careful consideration, especially for vaccine programmes not delivered in their country of birth.

Another large outbreak of mumps occurred in Lothian from October 2017, which coincided with the commencement of the higher education term. During this period 324 cases were notified, most of whom were aged 18-22 years old. Although previous outbreaks had a focus in student populations, 43% of current cases reported that they were not a student. There has been increases in private student housing where students from all universities live, which may have contributed to the wide spread of the outbreak and complicated outbreak control. Information on vaccination status was available for 244 cases (75%), of whom the majority (75.8%) reported having two MMR doses. To investigate potential waning vaccine immunity the mean length of time since last mumps containing vaccine was calculated as 14.3 years. The outbreak was declared over in May 2018 after case numbers returned to background levels. This outbreak highlighted that mumps outbreaks occur cyclically coinciding with new cohorts of susceptible students entering the Lothian population. The lessons from this outbreak are to encourage students to have two MMR doses and also be prepared for mumps outbreaks in the near future. In future outbreaks the utility of a third MMR for outbreak control could be examined.

Vaccine hesitancy is increasing and failure to vaccinate is well-recognised in Europe as a contributing factor to outbreaks of infectious diseases. In Lothian and Scotland, low vaccine uptake has been seen in migrants - notably in the Polish group who have arrived since 2004. The recent Vaccine Confidence in European Union report highlights a concerning recent decline in vaccine confidence in Poland. We held three focus groups containing 13 Polish women about the childhood vaccination programme in Lothian, with specific focus on influenza and Human Papillomavirus vaccinations. Key emergent themes were: trust in the national vaccination policy, trust in the vaccination providers (health professionals), trust in the individual vaccines, balancing the risk of disease, and language and communication. Polish norms, beliefs and behaviours shape how Polish migrants navigate the UK health system and its vaccination programme. While not confident in the Scottish primary care model and its generalist practitioners, the participants liked the ethos of informed consent in Scotland and compared this favourably with the compulsory vaccination policy in Poland. There was a belief that vaccines in Scotland were of higher quality than Poland and with fewer adverse effects. Respondents reported returning to Poland for specialist clinical appointments and diagnostic testing. They regularly access Polish clinical expertise and their opinions about health are influenced by Polish friends and family. They say they have difficulty finding official UK Government and health authority vaccination material and often access Polish media, online resources and information. They are familiar with anti-vaccination activities in Poland. Consequently, there are important unmet information needs for this group of parents who may not be making truly informed choices about vaccination. This requires further investigation especially as migration continues and declining immunisation uptake is reported in many countries across Europe.

Failure to vaccinate is well-recognised in Europe as a contributing factor to outbreaks of infectious diseases. Low immunisation rates are often associated with religious, social and ethnic minorities, including refugees or migrant groups. Polish people form Scotland's newest and largest migrant group. They have moved to Scotland since 2004, joining established ethnic minorities from China, the Indian subcontinent and Africa. Scotland has had a seasonal influenza nasal vaccination programme for all primary school children since 2013. We investigated three primary schools in Edinburgh, which had reported low influenza vaccination uptake rates in 2016 and 2017 and found that these schools contained many pupils from ethnic minorities, the majority of whom were Polish. Pupils were categorized as one of three ethnic groupings: White British, Polish and Other Identified Ethnic Minority (OIEM). We ascertained ethnicity using NHS and Education Department information sources and name recognition. We examined vaccine acceptance, declination and non-return of consent forms. In 2017, nasal influenza vaccine uptake was 70.7% (65.2-75.6%, p < 0.001) in White British, 60.9% (53.9-67.6%%, p < 0.001) in other identified ethnic minorities and 25.0% (20.9-29.6%, p > 0.001) in Polish children. White British children were more likely to return completed forms (78.9%) than other groups (OIEM 68.2% and Polish 61.8%). 36.8% of Polish families completed a consent form declining vaccination compared to 6.2% of White British families. These findings demonstrate that significant differences exist in nasal influenza vaccination uptake rates, which have important implications for the trans-national study of vaccine hesitancy. Further qualitative work and an investigation of uptake rates of other childhood immunisations in Polish and other migrant groups is required to assess differences in uptake and behaviours.

In September 2016, an imported case of measles in Edinburgh in a university student resulted in a further 17 confirmed cases during October and November 2016. All cases were genotype D8 and were associated with a virus strain most commonly seen in South East Asia. Twelve of the 18 cases were staff or students at a university in Edinburgh and 17 cases had incomplete or unknown measles mumps rubella (MMR) vaccination status. The public health response included mass follow-up of all identified contacts, widespread communications throughout universities in Edinburgh and prompt vaccination clinics at affected campuses. Imported cases of measles pose a significant risk to university student cohorts who may be undervaccinated, include a large number of international students and have a highly mobile population. Public health departments should work closely with universities to promote MMR uptake and put in place mass vaccination plans to prevent rapidly spreading measles outbreaks in higher educational settings in future.

SUMMARY An outbreak of mumps within a student population in Scotland was investigated to assess the effect of previous vaccination on infection and clinical presentation, and any genotypic variation. Of the 341 cases, 79% were aged 18–24. Vaccination status was available for 278 cases of whom 84% had received at least one dose of mumps containing vaccine and 62% had received two. The complication rate was 5·3% (mainly orchitis), and 1·2% were admitted to hospital. Genetic sequencing of mumps virus isolated from cases across Scotland classified 97% of the samples as genotype G. Two distinct clusters of genotype G were identified, one circulating before the outbreak and the other thereafter, suggesting the virus that caused this outbreak was genetically different from the previously circulating virus. Whilst the poor vaccine effectiveness we found may be due to waning immunity over time, a contributing factor may be that the current mumps vaccine is less effective against some genotypes. Although the general benefits of the measles–mumps–rubella (MMR) vaccine should continue to be promoted, there may be value in reassessing the UK vaccination schedule and the current mumps component of the MMR vaccine.

This paper outlines the risk assessment and communication strategy carried out by the Lothian Health Protection Team after notification of a probable case of meningococcal disease (later confirmed as Neisseria meningitidis) in a resident of a city centre backpackers hostel. Six close contacts were identified from the hostel and given rifampicin prophylaxis. Two days after commencing rifampicin one of these contacts was admitted to hospital with a purpuric/petechial rash and thrombocytopenia. The final diagnosis for this contact was thrombocytopenia, either idiopathic or secondary to rifampicin. This example and the potential side effects of administering rifampicin prophylaxis highlight the importance of a thorough risk assessment of contacts of a case to avoid prescribing prophylaxis to anyone other than those at highest risk of becoming a subsequent case.

A retrospective study of notified hepatitis B virus (HBV) infection in Edinburgh during 1975-92 identified 525 acute cases. For 343 where a probable transmission route could be determined, 215 were due to shared equipment by injection drug users (IDUs), 29 to homosexual intercourse, 25 to heterosexual or household contact with IDUs, 21 to heterosexual contact with infected non-IDU partners and 53 to various other or multiple routes. Cases were unevenly distributed geographically, particularly those among IDUs. The highest incidence within a post code district was approximately 2.5 times that for all Edinburgh. Annual cases peaked in 1984 then declined to low levels in the early 1990s. This reduction was most marked among IDUs, and may be ascribed both to changed injecting behaviour and decreased susceptibility within this group. The latter factor implies that HBV infections may be an unreliable guide to human immunodeficiency virus (HIV) infection in populations where HBV is highly prevalent.