Back in 1998 Dr Andrew Wakefield published a paper in the Lancet claiming a link between the vaccine and autism or bowel disease. Wakefield’s study looked at 12 children with autism and suggested that the MMR vaccine had potentially led to the development of autism in 8 of these children. In a press conference after the paper was published Wakefield suggested a much stronger link and called for the MMR vaccine to be suspended until further research could be done. The press latched on to this story despite many other reports and press releases saying the vaccine was safe. As a result many parents lost faith in the vaccine and stopped allowing it to be given to their children.
There have since been a number of very large studies done in a number of different countries, including the UK, that have found no link at all between MMR and autism or bowel disease. In 2004 an investigation was performed by a team from the UK Medical Research Council which compared the vaccination records of 1,294 children diagnosed with autism or related conditions with those of 4,469 children who had no such diagnosis. They concluded that there is no evidence to support a link between MMR and the subsequent development of autism; 78% of the children with autism had received MMR compared to 82% of the other children who did not have autism.
But what about Wakefield’s findings? In 2004 it came to light that Wakefield’s research had received significant funding from the UK's Legal Aid Board (eventually revealed to be £435,643!) to find a link between MMR and autism. It also became apparent that some of the children in the study had been recruited by a lawyer preparing a lawsuit against the manufacturers of MMR. Neither of these major conflicts of interest had been declared to the Lancet. Further twists to the tale came when the UK television program Channel 4’s Dispatches claimed Wakefield had applied for a patent for a single virus vaccine for measles, as an alternative to MMR, raising further concerns about conflicts of interest. In addition the program claimed that the research team actually failed to find any evidence of Measles Virus in the children studied but that Wakefield ignored this and produced his own findings.
So in my opinion, it is apparent Wakefield had essentially been paid to find a link between MMR and autism or bowel diseases, so he did. But what really matters is that the General Medical Council found Wakefield guilty of serious professional misconduct, including dishonesty, and struck him off the medical register.
The result of Wakefield’s publications was a reduction in vaccine coverage in the UK. Many parents turned to single vaccines for each virus in isolation which are unproven because no research has been done in to the correct intervals for immunisation in order to trigger a long-term immune response; in the words of the Department of Health UK “it would be experimental”.
Another problem with single vaccinations is the 6 week delay between vaccinations which left lots of children vulnerable to infection during these periods (6 single vaccines given 6 weeks apart = 36 weeks = approximately 9 months). The result was a rise in the number of cases of mumps and measles across the UK. Single vaccines were stopped in 1988 and are now unlicensed in Britain (although still sold privately and imported from overseas).
The graphs that follow show the number of reported cases of mumps, measles and rubella in England and Wales between 1996 and 2017. It is clear that as vaccine coverage reduced in the UK, mumps and measles were able to cause significant numbers of cases of infection. Viruses tend not to circulate within a population all of the time so the spikes are when the virus entered the population and caused outbreaks. Interestingly rubella cases didn’t increase which suggests they were either not recognised, as Doctors did not expect rubella and so did not send the appropriate diagnostic tests, or that Rubella Virus didn’t enter the population during this time.
Laboratory confirmed cases of mumps, measles and rubella in England and Wales from 1996 to 2017: source Centre for Infectious Diseases Surveillance and Control, Public Health England.
I have even been to a talk given by Fergus Walsh, a senior BBC health correspondent, entitled “Don’t expect the media to promote public health” in which he defended the BBCs coverage of the MMR controversy by saying it was their job to sell a story not to promote public health… the response from the 300 or so Infectious Diseases Physicians, Microbiologists and other Doctors in the audience was very clear… “We don’t expect the media to promote public health but it would be nice if their reporting was balanced, unbiased and representative of the majority opinion”… we can but hope…
So what are the MMR viruses?
When most people think about mumps they imagine the painful swelling of the parotid gland that gives children swollen cheeks or the painful testicular pain (orchitis) or ovary pain (oophoritis). However orchitis and oophoritis are not the main reasons we vaccinate against mumps, more importantly the Mumps Virus used to be the most common cause of meningitis in the UK, occurring in up to 10% of infected children. Most cases of mumps are self-limiting, even with meningitis, but long-term sequelae (a condition which is the consequence of a previous disease) with neurological deficits or subfertility can occur rarely (<1%).
Many people think of measles as just a rash caused by a virus but it can be much more than this. Measles can also cause pneumonia (1 in 15 cases), croup, otitis media and encephalitis (1 in 5,000 cases). The mortality from measles in the developed world is approximately 1%, although in some parts of the world this increases to almost 30%. In Dublin in 2000 the immunisation rates fell to <70% which resulted in a measles outbreak in 1600 children, with 111 admissions to hospital, 13 to the paediatric intensive care unit and 3 deaths. To put Wakefield into a UK context, there were about 10,000 excess cases in the UK over the years following the MMR controversy, which with a mortality of 1% would suggest 11 excess deaths… perhaps something for Wakefield to think about.
In the days before MMR one of the most severe complications of measles was subacute sclerosing panencephalitis (SSPE). SSPE is chronic inflammation of the brain due to persistent measles infection. It takes between 6 and 15 years to present; a long time after the initial infection. The symptoms are personality change, seizures, myoclonus, ataxia, photosensitivity, ocular abnormalities, spasticity and coma. It is usually progressive and fatal but if it is diagnosed early enough there is some evidence that the virus can be held in check using antiviral medication.
The incidence of SSPE following measles is 1 in 10,000 although it is more common in children who had measles during the first two years of life where the rate may be as high as 1 in 600. The MMR is given at 1 year to prevent young children contracting measles. I have seen 1 case of SSPE back in the 1990s; it is yet to be seen if there will be a spike of cases as a result of Wakefield resulting from the outbreaks of 2003, 2008, 2012 and 2016... which puts children at risk until 2031.
Again many people think of rubella as just a rash illness, and the majority of the time they would be right. The reason we vaccinate against rubella is not to prevent children and adults getting a rash but to protect unborn babies from developing congenital rubella syndrome (CRS). During the period 1971–75 there were an average of 48 CRS births and 742 rubella related terminations annually in the UK. CRS occurs in up to 90% of babies born to mothers who acquire rubella in the first 10 weeks of pregnancy when the embryo is developing (after this time most the fetus’ development is really just “growing”).
CRS presents with hearing loss, cataracts, microphthalmia (small eyes), glaucoma, microcephaly (small brain), meningoencephalitis, developmental delay, cardiac defects (patent ductus arteriosus, pulmonary stenosis, atrial and ventricular septal defects), bruising, enlarged liver and spleen, jaundice and abnormal bones (very similar to Zika Virus if you remember when this was causing problems in Brazil prior to the Olympics).
In 1970 immunisation was given to pre-pubertal girls and non-immune women of childbearing age, to prevent rubella infection in pregnancy. The strategy was to directly protect women of childbearing age. It didn’t take too long for public health officials to realise this strategy wasn’t going to work as it didn’t give sufficient herd immunity. Women in early pregnancy were still acquiring rubella infection from their own or other children, both unvaccinated boys and girls yet to receive the vaccine. The single vaccine had little impact on the rate of CRS.
In 1996 when MMR was first given, the rate of Rubella dropped significantly from nearly 4,000 per annum to “10s” per annum. The timing of MMR vaccination was moved earlier (doses given at 1 year and 3 years 4 months) and the MMR coverage included boys so that it became impossible for rubella to circulate in the community and cause infection. CRS is a terrible diagnosis and the MMR vaccine is very good at preventing it; another successful vaccine story.
I have talked a lot about Influenza and Influenza vaccination and infection control in other blogs so I am not going to go into detail here. The vaccine, given to children every year between the ages of 2 and 8 years, is an intranasal spray against Influenza A and B. Influenza Virus has frequent shifts in its genetics whereby two types of Influenza combine to produce a new virus. This allows the new virus to cause infection in people who were previously immune to the two earlier separate viruses. This makes it impossible to make a single one off vaccine that prevents all influenza. The vaccine’s genetic make-up is therefore altered with a “forecast” of the strains likely to be in circulation in the coming influenza season. This has not always been “well matched”, however the vaccine is usually well tolerated and effective.
Again I have blogged about the Human Papilloma Virus (HPV) vaccine recently so I will not write much here. This is another anti-cancer vaccine (remember Hepatitis B vaccine in the 1st childhood vaccine blog?).
HPV types 16 and 18 cause 70% of all cervical cancer with types 31, 33, 45, 52 and 58 bringing this up to 90% of cervical cancer. About 3000 cases of cervical cancer are diagnosed a year in the UK, mainly in sexually active women aged 30-45 years. However of the five million women in the UK invited to cervical screening each year, one in four do not attend. Cervical cancer continues to cause 900 deaths annually despite it being the most preventable form of cancer in women.
The vaccine contains proteins from HPV types 6/11/16/18; it does not contain live virus. In clinical trials it prevented 100% of 16 and 18 infections and it is expected to reduce cervical cancer rates by over 70%. HPV vaccination started in the UK in 2007 for girls aged 12-13 and now these girls are approaching the age for cervical screening. Cervical cancer is still a major problem in young women and a vaccine that can prevent the majority of cases is very welcome.
So there we have it. During childhood kids nowadays get 16 jabs (or 17 if you’re a girl), 2 oral vaccines and 8 squirts of influenza up the nose. This may sound like a lot but consider the consequences. The infections these vaccines prevent are serious and potentially life-threatening so surely it’s better to have the vaccines than the infections themselves?
As a Microbiologist I strongly believe in vaccination but telling parents they “must” do something to their child especially when it’s actually for herd immunity or to “protect” someone else can be a tricky conversation to have. I’ll let you decide for yourselves… after all “choice” is also an important part of healthcare.