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Association Between Thimerosal-Containing Vaccine and Autism

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Association Between Thimerosal-Containing Vaccine and Autism BRIEF REPORT Association Between Thimerosal-Containing Vaccine and Autism Anders Hviid, MSc Context Mercuric compounds are nephrotoxic and neurotoxic at high doses. Thi- Michael Stellfeld, MD merosal, a preservative used widely in vaccine formulations, contains ethylmercury. Thus it has been suggested that childhood vaccination with thimerosal-containing vac- Jan Wohlfahrt, MSc cine could be causally related to neurodevelopmental disorders such as autism. Mads Melbye, MD, PhD Objective To determine whether vaccination with a thimerosal-containing vaccine is associated with development of autism. IGH DOSES OF MERCURIC COM- Design, Setting, and Participants Population-based cohort study of all children pounds are nephrotoxic and born in Denmark from January 1, 1990, until December 31, 1996 (N=467450) com- neurotoxic.1 Thimerosal, an paring children vaccinated with a thimerosal-containing vaccine with children vacci- organic compound that con- nated with a thimerosal-free formulation of the same vaccine. Htains ethylmercury, has been widely used Main Outcome Measures Rate ratio (RR) for autism and other autistic-spectrum since the 1930s as a preservative in cer- disorders, including trend with dose of ethylmercury. tain vaccines. In the 1990s, an increas- Results During 2986654 person-years, we identified 440 autism cases and 787 cases ing number of different vaccines con- of other autistic-spectrum disorders. The risk of autism and other autistic-spectrum taining thimerosal were introduced in disorders did not differ significantly between children vaccinated with thimerosal- immunization schedules around the containing vaccine and children vaccinated with thimerosal-free vaccine (RR, 0.85 [95% world, and thus the average cumula- confidence interval {CI}, 0.60-1.20] for autism; RR, 1.12 [95% CI, 0.88-1.43] for other tive exposure to thimerosal in infants has autistic-spectrum disorders). Furthermore, we found no evidence of a dose-response association (increase in RR per 25 µg of ethylmercury, 0.98 [95% CI, 0.90-1.06] for increased in recent years. This has led autism and 1.03 [95% CI, 0.98-1.09] for other autistic-spectrum disorders). to the suggestion that childhood vacci- nation with thimerosal-containing vac- Conclusion The results do not support a causal relationship between childhood vac- cination with thimerosal-containing vaccines and development of autistic-spectrum cines increases the risk of neurodevel- disorders. opmental disorders, such as autism, JAMA. 2003;290:1763-1766 www.jama.com attention-deficit/hyperactivity disor- der, and language and speech delay. In a recent independent review con- of autism and other autistic-spectrum has been used in Denmark. The same ducted by the Immunization Safety disorders. vaccine was reformulated without thi- Committee, on behalf of the Institute merosal and used until January 1, 1997, of Medicine, it was concluded that the METHODS when it was replaced with an acellular evidence was inadequate to accept or The Danish childhood vaccination pro- pertussis vaccine.4 The whole-cell vac- reject a causal relationship between thi- gram is voluntary and free of charge to cine was administered at 5 weeks, 9 merosal-containing vaccine and neu- the vaccinees. Vaccines against diph- weeks, and 10 months from 1970 and rodevelopmental disorders.2 How- theria, tetanus, polio, measles, mumps, until it was replaced, irrespective of thi- ever, based on comparison with the rubella, pertussis, and Haemophilus in- merosal content.3 The thimerosal for- toxicology of methylmercury, the bio- fluenzae type b are administered by gen- mulation contained 50 µg of thimero- logical plausibility of a link remained. eral practitioners.3 From 1970, the only sal (∼25 µg of ethylmercury) in the first Further research was recommended. thimerosal-containing vaccine in the We examined the hypothesized asso- program has been the whole-cell per- Author Affiliations: Danish Epidemiology Science Cen- tre, Department of Epidemiology Research (Messrs ciation by comparing children vacci- tussis vaccine. In late March 1992, the Hviid, Wohlfahrt, and Dr Melbye) and Medical De- nated with a thimerosal-containing per- last batch of thimerosal-containing partment (Dr Stellfeld), Statens Serum Institut, Co- penhagen, Denmark. tussis vaccine with children vaccinated whole-cell pertussis vaccine was re- Corresponding Author and Reprints: Anders Hviid, with the same pertussis vaccine formu- leased and distributed from Statens Se- MSc, Danish Epidemiology Science Centre, Depart- ment of Epidemiology Research, Statens Serum Insti- lated without thimerosal and follow- rum Institut. Only the whole-cell vac- tut, Artillerivej 5, DK-2300 Copenhagen S, Denmark ing them with respect to development cine produced by Statens Serum Institut (e-mail: [email protected]). ©2003 American Medical Association. All rights reserved. (Reprinted) JAMA, October 1, 2003—Vol 290, No. 13 1763 Downloaded From: https://jamanetwork.com/ on 09/30/2021 THIMEROSAL-CONTAINING VACCINE AND AUTISM dose and 100 µg (∼50 µg of ethylmer- tral Register. From 1995, both inpa- all RRs for age (1-9 years of age,1⁄2-year cury) in each of the succeeding 2 doses. tients and outpatients were included. intervals; 10 years of age, 1-year inter- Since April 1968, all persons in Den- Information on diagnoses of tuberous val) and calendar period (1991-1993, mark have been given a unique identi- sclerosis, Angelman syndrome, fragile 1994, 1995, 1996, 1997, 1998, 1999, fication number in the Danish Civil Reg- X syndrome, and congenital rubella, 2000). We further adjusted our esti- istration System.5 Based on this registry, conditions associated with autism, was mates for the potential confounding we constructed a cohort consisting of all obtained from the National Hospital variables previously listed. Statistical children born in Denmark in the period Discharge Register.8 Information on analysis was performed using PROC from January 1, 1990, to December 31, possible confounding factors was ob- GENMOD in SAS version 6.12 (SAS 1996. Using the unique personal iden- tained from the Danish Civil Registra- Institute Inc, Cary, NC). tification number, we were able to link tion System and the Danish Medical information on vaccinations, diag- Birth Registry,9 as follows: child’s sex, RESULTS noses of autism, diagnoses of other autis- child’s place of birth (Copenhagen, Co- A total of 467450 children were born in tic-spectrum disorders, other relevant penhagen suburbs, area with Ն100000 Denmark between January 1, 1990, and diagnoses, and potential confounders to population, area with population of December 31, 1996. During 2986654 the children in the cohort. The dates of 10000-99999, area with population of person-years of follow-up, we identi- vaccination with 1, 2, or 3 doses of Ͻ10000), birth weight (Ͻ2500, 2500- fied 440 cases of autism and 787 cases whole-cell pertussis vaccine were 2999, 3000-3499, 3500-3999, Ն4000 of other autistic-spectrum disorders. The obtained from the National Board of g), 5-minute Apgar score (0-7, 8-9, 10), mean (SD) age at diagnosis was 4.7 (1.7) Health. We have published details of this gestational age (Ͻ37, 37-41, Ն42 years for autism and 6.0 (1.9) years for process in a study of autistic-spectrum weeks), mother’s age at birth of child other autistic-spectrum disorders. The disorders and measles-mumps-rubella (Ͻ20, 20-24, 25-29, 30-34, 35-39, and follow-up of 5770 children was prema- vaccine.6 Doses administered before June Ն40 years), and mother’s country of turely terminated because of death 1, 1992, were considered to contain thi- birth (Danish or not).The percentage (n=579), emigration (n=5035), disap- merosal, and doses administered after of missing values for the variables birth pearance (n=87), tuberous sclerosis June 1, 1992, were considered thimero- weight, gestational age, 5-minute Ap- (n=51), Angelman syndrome (n=17), sal-free. Children who received thimero- gar score, mother’s country of birth, and or congenital rubella (n=1). sal-free vaccine after 1 or 2 doses of thi- child’s place of birth were 6.6%, 6.9%, In our cohort, only 20755 (4.4%) merosal-containing vaccine were 6.9%, 0.3%, and 0.03%, respectively. children did not receive any whole- classified only according to receipt of thi- Children in our cohort contributed cell pertussis vaccine, 446695 (95.6%) merosal-containing vaccine. person-time to follow-up from 1 year of were vaccinated at least once, 416081 Information on autism and other au- age or January 1, 1991, whichever (89.0%) were vaccinated twice, and tistic-spectrum disorder diagnoses was occurred last, until a diagnosis of autism, 293186 (62.7%) received 3 doses of obtained from the Danish Psychiatric other autistic-spectrum disorder, tuber- whole-cell pertussis vaccine. Among Central Register.6,7 Child psychiatrists ous sclerosis, Angelman syndrome, frag- those who received at least 1 thimero- make the diagnosis and assign diagnos- ile X syndrome or congenital rubella, sal-containing pertussis vaccine tic codes for this register. In the pe- possible death, disappearance or emi- (n=138953), 118593 received 1 sub- riod 1991-1993, the International Clas- gration, 11 years of age, or until Decem- sequent dose and 65725 received 2 sub- sification of Diseases, 8th Revision ber 31, 2000, whichever occurred first. sequent doses of thimerosal-contain- (ICD-8) was used. In the period 1994 Follow-up was begun at 1 year of age ing vaccine. Furthermore, 42032 through 2000, the International Clas- because indications for an evaluation of children who received at least 1 dose sification of Diseases, 10th Revision (ICD- a possible case of autistic-spectrum dis- of thimerosal-containing vaccine sub- 10) was used. All cases of autism and order typically occur after the first year sequently received at least 1 dose of thi- other autistic-spectrum disorders in our of life. The resulting incidence rates for merosal-free vaccine. In those receiv- study have been ascertained using ICD- autism and other autistic-spectrum dis- ing at least 1 dose of whole-cell pertussis 10.
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