Vaccine

disputes G ES I M A As the MMR health scare retreats in the UK, doctors Y ETT/G

fear it will migrate to the USA. Rebecca Coombes A F P A MM/ K

investigates the role played by the AS

anti- lobby NIC HOL

n 2008, paediatrician had a the was not dangerous. The study, MMR timeline book published—not exactly uncommon which followed 1.8 million people, found that 1988: MMR introduced for a doctor near the top of his ­specialty. serious adverse events were rare and greatly into the UK But the situation was complicated for outweighed by the risks of disease. The author 1992: Brands of MMR Dr Offit. As chief of the division of of study, , is still containing the Urabe strain I­infectious diseases at the Children’s Hospital embroiled in a case of the vaccine of Philadelphia, he is the most prominent—and over research misconduct. virus were withdrawn some would say most fearless—spokesperson In the UK, experts are signalling what they after research found that for vaccine science and safety in the United call a “burning off” of the health scare, as the it was associated with an increased risk of aseptic meningitis States today. His book ’s False Prophets, protest base diminishes, press interest drops 1998: Publication of Lancet paper linking deals with the false alarm that cause back, and immunisation rates recover, albeit MMR with autism autism and how antivaccine activists, and an slowly. An unpublished Department of Health 2001: “Leogate”— easily duped media, are sowing the seeds of a survey of over 1000 parents in 2008 assess- Tony Blair, the UK’s health scare similar to, if not worse than, the ing the effect of the childhood immunisation then prime minister, one that the UK is just recovering from. So programme found that 73% had their child and his wife wouldn’t inflammatory is this issue that Dr Offit opted immunised without seeking advice. The sur- say if their youngest out of the big city publicity tour that is usual vey concluded: “It’s possible that, as fewer child Leo had been for most authors. scare stories appear in the press, the deci- vaccinated “I do radio and television but not appear- sion over whether to immunise has become 2004: Fathers won right to get MMR for ances in book stores. I’ve had a few incidences easier.” In the second half of 2008, the UK children (if mothers disagreed). A doctor was G ES where I get heckled by people who disagree provided 350 000 more doses of MMR than sent to prison for administering faulty single I M A Y Y vaccines and struck off with me strongly, almost religiously, and over the same period the year before. MMR disrupt my capacity to express my point of coverage fell from 91% to 80.7% in 2003-4 ETT/G 2005: Cochrane review published of evidence a k of MMR link to autism view,” he explains. He also receives a lot of and is now creeping up to 85.5%, according 2006: 13 year old dies of , the first hate mail—after one credible death threat, he to the Department of Health. be r e h u l death from the virus in the UK for 14 years was accompanied at official meetings by an At the end of June, the BMA will debate 2006: Andrew Wakefield armed guard. mandatory vaccination at its annual confer- first appears in front of the The health scare linking the combined ence. Former BMA chair Sandy Macara, who GMC accused of research measles, mumps, and rubella (MMR) vaccine has proposed the motion, said he didn’t mind misconduct to autism is more than a decade old. A large being called draconian “as long as this issue

l ande r esen/danie o dd 2008: Measles outbreaks in body of evidence has built up to discredit is taken seriously.” The Welsh health minister ; ; US, including 11 children in the decade old Lancet paper that linked the Edwina Hart last week ruled out introducing l g e/sp San Diego measles virus with irritable bowel syndrome compulsory MMR . “It would,

i m a 2008: The UK recorded the and autism. This includes a 2005 Cochrane on the advice I have received, make matters same number of measles systematic review of 139 studies to assess the worse, not better,” she said. Measles cases in p: te k o p: t cases in one month effects of the MMR vaccine in children, and a Wales are at their highest for 20 years, with (November) as in the whole of 1996

F rom 14 year long Finnish study that concluded that 302 current cases.

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answers as baby dies regularly appears on top rated US shows such from vaccine,” is as Oprah and Good Morning America to air her one recent headline views. Founder J B Handley has a blog on taken from a local CNN.com. paper in Trinidad In June last year, Ms McCarthy led a “green and Tobago. The our vaccines” rally of a reported 8500 fami- group has emailed lies in Washington, DC. The rally demanded several members that congress re-enact legislation eliminating of BMJ staff, all of and other “toxins” from children’s whom found them- vaccines, study the incidence of autism in selves unable to vaccinated versus unvaccinated children, and unsubscribe from allow more families to file for compensation the unsolicited for “vaccine induced autism.” email. The group, Less new age is the long established run by a former pub- National Vaccine Information Center (NVIC), lic ­relations worker, set up in 1982, which has its roots in the Jane Bryant, is ­pertussis vaccination health scare of the 1970s. especially uncom- A key function of the NVIC, run by Barbara promising in its Loe Fisher, is its vaccine reaction registry: message. Ms Bryant “When parents report a death or regression first came to promi- into chronic poor health after vaccination to nence campaigning NVIC, we document the report and advise to get chronic fatigue parents to also make a report to the federal Demonstrators protest against the use of mercury ­syndrome treated as a medical condition. Reporting System,” in vaccines at the US Capitol, July 2005 The US has also witnessed a growth in says Mrs Loe Fisher. antivaccination organisations since the late Dr Offit dislikes the NVIC (“the national But while data from the UK suggest a 1990s, including the high profile Generation vaccine mis-information centre more like,” he renewal of public confidence in the MMR Rescue, whose slogan is “Autism is revers- says) but says at least the website has links to vaccine, doctors in the US fear a slide in the ible.” The organisation is fronted by former federal agencies such as the Centers for Dis- opposite direction. Figures from the Centers Playboy model Jenny McCarthy, who has an ease Control (CDC) vaccine information site. for Disease Control and Prevention report autistic son and is the girlfriend of Hollywood But he’s very concerned about the vaccine that the number of measles cases in early actor Jim Carrey. Some of these groups have registry. 2008 was at a 10 year high. During 2000-7, noticeably deeper pockets than their British “Barbara is a very powerful parent advo- the mean number of measles cases each year counterparts. , for exam- cate. But if a parent contacts her to say that in the US was 62. In 2008, 131 cases had been ple, was founded by a wealthy financier from their child has had an adverse reaction to vac- confirmed by 31 July, including outbreaks in northern California called J B Handley, whose cines, she simply believes them. If the data San Diego (11 children), New York (27 cases), son has autism. Mr Handley and his wife are show the problem was not vaccine related she and Illinois (32 cases). This spike was not convinced that mercury has tends to say the data were manufactured by the result of an increase in imported cases successfully treated their son. In ­February, those [who gain from vaccines].” but higher numbers of unvaccinated school Generation Rescue took out a one page adver- age children. Sixty one of the 83 US citizens tisement in USA Today costing a six figure sum. aged 1-19 years who caught measles during Activist and blogger Gary Kompothecras, a this period had not been vaccinated because millionaire and political donor, calls himself their parents claimed exemption for religious “warrior dad.” Doctors who disagree that vac- or personal reasons. cines led to his son’s autism are “dirtbags,” he says. The message is typically hard edged and Campaigners against vaccines uncompromising. One of the main drivers of the safety fears Generation Rescue’s position is that autism are antivaccine groups. Prominent among is caused by “environmental illnesses caused the UK groups is Warrington based JABS, by an overload of heavy metals, live viruses, G ES

whose website still maintains that “some and bacteria.” Ms McCarthy also implicates I M A children have and will continue to be dam- “the tripling of vaccines given to children in Y aged by combined and single dose vaccines.” the past 15 years (with unstudied ingredients ETT/G G E I M A Founder Jackie Fletcher has a son with epi- like mercury, aluminium, and live viruses).” lepsy and brain damage, which she blames The website recommends “biomedical inter- /W I R E on the MMR vaccine. Her views are widely vention,” saying it “is leading to recovery for quoted by the mainstream media. thousands.” To this end, the website’s online

Another group is the One Click Group, shop sells suppositories for children at $109 MOR I G L PAU whose tactic is to circulate by email a digest of (£66; €78) for 15, “to remove excessive levels Activist, model, and mother to a son with autism, antivaccination press cuttings, “Mother wants of toxic metals from the body.” Ms McCarthy Jenny McCarthy and boyfriend Jim Carrey

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Influence “I get emails legitimate right to It’s not a controversy—only one side is sup- But are these campaign ask questions; to ask ported by the science. It’s like screaming into groups really a risk to which liken a scientific question the wind on some level. The trouble is that mass childhood vac- me to the and to be answered people still get their information from enter- cination? And how far in a scientific venue. tainment media.”

has it threatened vacci- PA devil. It is We certainly have Professor Salisbury says: “There is no nation programmes? the answers. But doubt that the media give disproportionate AND OV/ unsettling” Julie Leask is from /L there are a core weight to the [antivaccine position]. Look at the National Centre Dr Paul Offit, group of people that the frequency that journalists writing articles for Immunisation M E RG EN simply don’t want to about immunisation go to Jackie Fletcher for Research and Sur- M I K E Philadelphia believe it. a ­comment.” veillance, Australia. She is an expert on the “I’ve been asked three times to be on the “For some campaigners no study is accept- antivaccination movement in Australia and Larry King show, with Jenny McCarthy and able if it continues to show no link—you get identifies themes in the rhetoric used by these then with Andrew Wakefield. McCarthy is answers by rote: the study was weak, didn’t groups: “The subtext to messages is always the very angry, mean spirited on Larry King Live. look at the right children, didn’t use the right same, there are the universal themes of cover She is rude, cuts across people, curses, and method. It’s like AIDS denialists, and there up; vaccines as poisonous chemical cocktails; has no respect for authority. But she is still are evidence denialists. The constituency base an unholy alliance for profit; the threat of a mother of a child with autism and she is [of these groups] has got narrower and nar- excessive government control; and the back therefore a sympathetic character. That leaves rower. There are a diminishing number of to nature idyll.” only one role for me—that of the villain. You people who think [there is a link]. Look at the Says Ms Leask: “Antivaccine groups have are there to tell her she is wrong. She’s got all number of people who contribute to the JABS always consisted of people who refuse to sup- these ways of making her son better and what website; it’s down to a tiny number.” port medicine’s dominance and are also anti- can I offer? There is no cure. It is sad that it’s But what can doctors do? These groups establishment, anti-government. Alternative come to this, that we have to look to celebri- can be tough opponents for doctors—they are therapies give them a convenient and more ties to give us our healthcare advocacy.” web literate, with some offering hard and fast appealing strategy for preventing and man- David Salisbury, director of immunisation answers to concerned parents, others adding aging the vaccine preventable diseases in at the Department of Health, says he has to existing doubts so carers opt to delay or do children.” received threats at home and at work from nothing about vaccination. Professor Salisbury Pru Hobson-West, a senior research fellow activists. He says the “degree of anger” seems agrees that it can be very hard for doctors to at the Centre for Applied Bioethics, University similar to that of animal rights activists. “One challenge antivaccine campaigners, especially of Nottingham, has identified and studied 19 GP who used to be connected to JABS recom- those who are parents of autistic children. groups in the UK that are critical of vaccina- mended that capital punishment was appro- “Stories are very powerful and persuasive. tions. They included Action against Autism in priate for me. Why should I accept it? This It is very hard to dislodge these stories with Glasgow and the London based vaccination. degree of personalisation.” cold scientific studies. If a parent says, ‘I know co.uk. She found the groups were all relatively Neither Generation Rescue nor JABS that x did y,’ it’s hard to say no to their face,” small and led by one or two parents, with a replied to my questions. he says. membership base ranging from 60 to 2000. The One Click Group was hostile when I Another doctor, who asked to remain Ms Hobson-West discovered the more approached them with some straightforward anonymous after a bruising battle with a radi- radical groups didn’t necessarily have per- questions. I was directed to another charity cal antivaccine group, says it’s important that sonal experience of vaccine damage but and, bizarrely, Peter Fletcher, former chief medics don’t engage with certain groups. “You were often seasoned campaigners for causes scientific officer at the Department of Health. must never care about this as much as they such as alternative health and animal testing. When I asked to be taken off its mailing list I do. What is vital to them is the existence of a Importantly she found the groups “did not was told: “Unsubscribing from the One Click heretic—the doctor—because you are dealing make their case by arguing that the risks of News Alerts requires one mouse click. If this with a faith here. They do nothing but trouble. vaccination outweighed the benefits. Instead is beyond you, never mind eh?” I would not take legal action, for example, it they talked about risks as unknowns. Lack of Barbara Loe Fisher of the National Vac- would be a pyrrhic victory.” knowledge is used by the groups to explain cine Information Center said her organisa- their wariness in advising vaccination.” The tion did not “advocate or condone” threats Harm to health leader of autism group the Informed Parent against anyone. But, she added: “Every week There is evidence of the harm that false claims told Ms Hobson-West: “The more you read we receive reports from parents, who are against vaccines can do. Although the UK has on it, the more you realise what little we know being demonised, harassed, threatened, and semi-recovered from the MMR scare, the about the body and health. There’s so much even reported to health authorities for making damage continues: herd immunity has been we don’t understand.” informed, independent vaccination choices lost and there has been an increasing number The vigour with which some of these for their children.” of outbreaks, including one death. Despite the groups pursue their message can dissuade The situation is not helped by a media recent increase in the proportion of children doctors from challenging unscientific and often happy to engage with groups without vaccinated, measles cases in England and incorrect views in public. As mentioned, Dr regard to scientific knowledge. Dr Offit and Wales rose sharply in 2008 compared with the Offit has given up appearing opposite vaccine colleagues opened the Vaccine Education previous year—a total of 1348 cases, accord- dissenters. “I get emails which liken me to the Center in 2000, in response to scientific mis- ing to the Health Protection Agency. The UK devil. It is unsettling. Parents have a perfectly information. “The media likes controversy. has no hope of reaching the World Health

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­Organization’s goal of eliminating measles in or later this virus had nowhere to go. It’s a Professor Salisbury says the Department Europe by 2010, said Professor Salisbury. ­teaching moment. Parents today forget this is of Health’s fight back was in part helped by Across Europe, national surveillance organ- a real disease where some people do OK, but the uncompromising position it took on the isations reported 12 132 cases of measles in some don’t. combined MMR vaccination, refusing to fund 2006 and 2007, 26% of them in the UK. “People get further and further away from single vaccines. “The government did not In the US, vaccination rates are still rela- what these diseases are; they forget the impor- appease—we didn’t change policies. We did tively high but there are clusters of anti- tance of vaccines. They look at these black not offer a choice, despite the existence of sin- vaccine communities across the country. and white photographs of children [with gle vaccines. [With , patients Vaccination is compulsory for school entry, tuberculosis] in an iron lung, and think ‘not were offered vaccine without pertussis.] We although Dr Offit points to an erosion of relevant to me.’ had no close links with dissenters.” mandation: “In 48 of 50 states you can get “Nationally about 2% of children in the What are US public health officials doing to a religious exemption and 21 out of 50 states USA have a non-medical exemption. In fight back? The federal response was recently allow philosophical or personal exemptions. Washington State that figures goes up to 5.7% damned in as “muted and If you look at outbreak states, they are where in 2007-8, and some counties of Washington couched in dull scientific jargon.” philosophical exemption is easier to obtain. as high as 15%.” At the Centers for Disease Control, officials Key parts of the coun- A note of caution is say its efforts are targeted on supporting family try are relatively unvac- provided by Howard doctors on the ground. cinated: Oregon, south Bauchner, professor of According to Melinda Wharton, act- California, New York paediatrics and pub- ing director of immunisation safety office, State, Minnesota. I lic health at Boston CDC, “when push comes to shove it is about think it is getting worse, University School of individual families in the doctor’s office and yes. Is it a growing Medicine and Boston they have to say yes or no to immunisation.” trend? Yes.” Medical Center, editor She says it is difficult for people like her to There is evidence of of the BMJ Group jour- understand why parents would say no, “It’s a link between clusters nal Archives of Diseases in why I went to medical school—I have a cer- of non-medical exemp- Childhood. He wonders tain approach to the world, [an evidence tion to school immuni- if parents are being put based approach to] looking at information sation and clusters of off by the sheer number and evidence.”

CDC Mandatory Vaccine Schedule Comparison diseases in the US. The Children birth to 6 years, by year (recommended month) of vaccinations children Bruce Gellin agrees: “Some of these con- Since 1983, the number of USA 1983 USA 2007 We commissioned a market DTP (2) Influenza (prenatal) vaccines the Centers for OPV (2) Hep B (birth) research firm to survey DTP (4) Hep B (1) Centers for Disease OPV (4) are expected to have. versations [between patients and doctor] can DTaP (2) Disease Control recommends DTP (6) Hib (2) more than 17,000 children in MMR (15) IPV (2) DTP (18) PCV (2) OPV (18) Rotavrus (2) for our kids has more than DTP (48) California and Oregon. We Control has warned: Hep B (4) “Over the past 10 years, be quite detailed and not all have OPV (48) DTaP (4) tripled. During this same time Hib (4) found that vaccinated boys IPV (4) PCV (4) “Increases in the pro- period, we’ve seen an explo- Rotavirus (4) had more than a 2.5-times new immunisations adequate time to do that. We have developed Hep B (6) DTaP (6) sion in neurological disorders Hib (6) greater rate of neurological IPV (6) portion of persons like ADHD and autism, partic- PCV (6) disorders than unvaccinated have been introduced a toolkit with the American Academy of Pedi- Influenza (6) Rotavirus (6) ularly with our boys, who Hib (12) boys. We believe a national MMR (12) declining vaccination Varicella (12) at a dizzying pace. Is atrics.” He also praises tear sheets designed represent 4 out of 5 cases. PCV (12) study must be done to fur- Hep A (12) DTaP (15) Hep A (18) ther explore these disturb- for themselves or their Influenza (18) vaccine fatigue—among by Dr Offit—pre-printed information that pae- Influenza (30) Are these increases related? Influenza (42) ing results. MMR (48) Can there be too much of a DTaP (48) children might lead to IPV (48) parents and physi- diatricians can tear off and hand to parents. Influenza (54) good thing? Until now, no Influenza (66) Visit our site and read the 10 36 large-scale outbreaks one could know for sure, results of our survey, as well cians—impacting immu- “Patients feel that there is an ‘us and them’ because no study had ever been done to com- as find helpful information on how to vaccinate

in the .” pare the rate of neurological disorders between your child more safely. Learn more at nisation rates? The barrier, that a lot of stuff goes on behind closed And this is exactly what vaccinated and unvaccinated children. www.generationrescue.org immunisation schedule doors. We need to open the doors, and we are happened in San Diego A NEW SURVEY OF KIDS IN CALIFORNIA AND OREGON SAYS WE MAY WELL BE. used to be relatively doing lots of outreach work, regular interviews

last year. An unvacci- GENERATION RESCUE easy to follow—now with thousands of parents.” nated child contracted www.generationrescue.org there are three separate There are reasons to be cheerful. In Febru- measles on holiday in USA Today advertisement paid for by schedules, followed by ary, the two year Autism Omnibus hearing in Switzerland and back Generation Rescue detailed notes.” the US ruled there was no evidence for either home, the virus spread This migration of the MMR or causing autism. The case to his sibling, school friends, and children who MMR autism scare to the US has worrying involved 5000 children. had been at his paediatrician’s office at the characteristics, ones which will make it harder Professor Salisbury agrees the autism rul- same time as his visit. At the San Diego school for doctors to reassure concerned parents, says ing was “absolutely damning” for antivaccina- almost 10% of the pupils had an exemption to Professor Salisbury. “Here in the UK, vaccine tion campaigners but adds “It’s like holding vaccination on their file. was an individual, narrow, problem; when the mercury in your hand: just when you think Bruce Gellin, deputy assistant secretary for science unpicked it, and Andrew Wakefield you have it, it metamorphoses into something health and director of the National ­Vaccine was in turn unpicked by the press, it became else.” Program Office in Washington, DC, is very difficult to advance the argument that Rebecca Coombes is an associate editor, BMJ ­concerned: MMR causes autism. [email protected] “San Diego is an opportunity to show “But it is more diffuse in the US. First there Competing interests: None declared. ­people what happens when a significant was the concern about the mercury preserva- See also the discussion on doc2doc “Bad Science” columnist talks about number of people are not vaccinated,” he tive thiomersal in vaccines, then MMR and MMR at bmj.com/video says. “We were lucky here. There was a large autism, and then about the dangers of multi- References are on bmj.com vaccinated population but it could have turned ple vaccines—it makes it much harder to pick Cite this as: BMJ 2009;338:b2435 into a massive outbreak but fortunately sooner off what parents’ concerns are.” See Review of the week, p 1568

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