Silent myocardial ischaemia.

worth remembering that in children of this age convulsions are 10 times more common with natural measles than after vaccination. 10 An additional symptom to be reported after the vaccine was parotitis, which occurred in less than 1% of children-usually between two and three weeks after the vaccine. Some of these cases may have resulted from natural infection, but the appreciable clustering suggests that they were probably caused by the vaccine. Many of the symptoms reported were trivial, but parents should be warned about the possibility ofa reaction a week after vaccination and reassured that the child will not come to harm and is not infectious. In 1987 three cases of meningoencephalitis were reported from Canada after the combined vaccine. "I All recovered without sequelae.1" This was calculated to occur in one in 100 000 doses ofvaccine, which might mean six cases a year in Britain if uptake of the vaccine is as high as we hope. At the moment there are about 1000 cases a year of meningoencephalitis caused by mumps, some of which have an unfavourable outcome. To assess the impact of the new vaccine a comprehensive surveillance programme has already been set up. Uptake of vaccination by age and district will be monitored; susceptibility to rubella and infections in pregnancy, cases of congenital rubella syndrome, and terminations of pregnancy for rubella will continue to be recorded and investigated. Rubella and mumps will be notifiable. A scheme to monitor prevalence of antibodies to measles, mumps, and rubella by age in about 800 yearly serum specimens from public health laboratories began in 1987 (p 770). This surveillance should identify susceptible cohorts to allow their selective vaccination if necessary. A few years ago doubts were expressed about changing our rubella vaccination policy. '2 13 It was feared that an uptake of vaccination of around 60% in the second year of life-the figure then for measles vaccine-might increase the age incidence of rubella and thus the risk of rubella in pregnancy. In England and Wales, however, the uptake of measles vaccine reached 71% in 1986, and further steps have been taken to achieve the target of 90% by 1990. Immunisation is now included in the review process of regional health authorities and the Department ofHealth and Social Security. Each district now has a named immunisation coordinator who is responsible for immunisation by both general practitioners and clinical medical officers. The coordinators' duties include training medical and nursing staff, investigating and remedying poor local immunisation rates, and establishing a positive attitude towards immunisation inprofessionals and the public. In some districts uptake of measles vaccine has already reached 90%, but in others it is still unacceptably low. In 1987 around 42 000 cases of measles were notified in England and Wales; this was the lowest yearly figure recorded, but in the first half of 1988 notifications already exceeded 52 000 and by May six children had died. Since then three more have died, which may result in 1988 having more than the average 20 deaths a year. After 20 years of measles vaccination this is a poor performance. Britain lags behind most developed countries-and, it must be said, many developing countries. The introduction of the new vaccine must provide the impetus to improve our record. Every child without a valid contraindication-and this means 98% of all children-is entitled to vaccination against three preventable diseases and their potentially disastrous consequences.