Letters

Concerns about immunisation

Breast feeding should be promoted

Is vaccination cause célèbre or bête noire?

Facts are not enough

Authors' reply

Breast feeding should be promoted

EDITORBedford and Elliman make some important statements about immunisation.¹ Certainly, millions of lives have been saved. Smallpox has been eradicated, and polio should be eradicated soon. But are routine vaccines safe? Four months after the Centers for Disease Control and Prevention in the United States recommended that all babies should receive three doses of the rotavirus vaccine, the use of this vaccine was being indefinitely suspended after reports of over 100 cases of intussusception and two deaths resulting from its use.² The manufacturer voluntarily withdrew the vaccine.

In July 1999 the US Public Health Service and the American Academy of Pediatrics asked vaccine manufacturers to eliminate the preservative mercury from vaccines because of concern about its cumulative effects.³ Babies who receive the 15 recommended vaccines in the first six months of their lives have a cumulative mercury exposure that exceeds limits set by the Environmental Protection Agency. What is the impact when, by the age of 5 years, children have received over two dozen doses of vaccines containing mercury and other toxins?

Some scientists say that the massive polio immunisation campaign in Zaire and other African countries in the 1950s accelerated the spread of HIV.⁴ The aerosol vaccine was grown in monkey kidney tissue; that same species of monkey carries a simian immune deficiency virus. The places where the vaccine was administered are the epicentre of the AIDS epidemic. Was the vaccine the vector that carried the immune deficiency virus to humans? The answers to this most important question are inconclusive and controversial.

It costs millions to develop, research, and market a vaccine. Wouldn't it make more sense to spend that money to protect, promote, and support breast feeding for every baby? There is much evidence that breast feeding reduces the incidence and severity of rotavirus, respiratory syncytial virus, and otitis media, without side effects.⁵

There can be conflict when economic and political interests enter the realm of public health. We have seen how important information about safety has been hidden to protect profit; the tobacco industry lawsuits are an illustration. We have seen it when the sons and daughters of the mothers who were given diethylstilbestrol showed up seriously ill a generation later, and when infants whose mothers were given thalidomide were born deformed. How long must a clinical trial be to ensure safety? One generation? Two? More?

Nikki Lee, faculty member. 
Center for Breastfeeding, 8 Jan Sebastian Way, Number 13, Sandwich, MA 02563, USA

Competing interests: None declared

Is vaccination cause célèbre or bête noire?

EDITORBedford and Elliman discuss some of the concerns about immunisation.¹ The Faculty of Homoeopathy speaks for a medically qualified minority. The more numerous medically unqualified homoeopaths belong to the Society of Homoeopaths, the Institute of Complementary Medicine, or the Homoeopathic Medical Association, totalling some 2000 practitioners. None of these bodies supports vaccination. The Society of Homoeopaths, in a leaflet, encouraged parents to seek advice about it. Currently the Homoeopathic Medical Association has no policy on vaccination. The Institute of Complementary Medicine, which has a register of "classical homoeopaths," opposes vaccination.

Homoeopaths' views derive more from leading writers than professional bodies. James Compton Burnett discovered vaccine damage in the 1880s, and Stuart Close denounces all mass treatments as fundamentally unholistic. Harris Coulter, a historian, blames vaccination for mental illness, crime, and social deviance. A prominent Dutch homoeopath describes "post vaccination syndrome," and he claims that potentised vaccines can cure this syndrome and act prophylactically against many infections. This claim was confirmed by Margery Grace Blackie, the Queen's former physician.²

Martin Miles, a London homoeopath, extends Coulter's views, claiming that vaccination causes cancer, meningitis, arthritis, constitutional weaknesses and neurological damage, and increases the level of mucus in the body. A leading homoeopath, George Vithoulkas, thinks that vaccination ignores the susceptibility of individual patients, is fundamentally unhomoeopathic, and leads to the degeneration of whole populations' health. None of them supports vaccination: the original article and the faculty stand alone. From about 1903 until the 1970s, even the faculty endorsed an approach that regarded bacteria as harmless scavengers and opposed vaccination. ^{2 3}

The data presented by Bedford and Elliman do not conclusively show that vaccination caused the decline of infectious diseases. Diphtheria, tuberculosis, and pertussis were virtually extinct before vaccines were introduced. American and British data show similar patterns. More likely causes are improved water supply, sanitation, adequate food supply, and birth control. Many were declining before the immunisation programmes began.⁴ I therefore remain unconvinced and agree with Stacey's assessment that the decline of many infectious diseases is or was as much due to improved sanitation as to anything elseincluding immunisations.⁵

Peter Morrell, honorary research associate, history of medicine. 
Department of Sociology, Staffordshire University, Stoke-on-Trent ST4 2DE peter.morrell{at}tesco.net

Competing interests: None declared.

Facts are not enough

EDITORBedford and Elliman provide a useful summary of the main evidence supporting the safety and effectiveness of vaccines.¹ They suggest that their evidence based refutations of erroneous beliefs commonly expressed by immunisation defaulters are useful in dispelling their concerns. This assumes that those who express these beliefs are simply mistaken and when exposed to counter-arguments will realise this.

Although we believe that it will always be important for scientists and health professionals to refute misleading information, there is little empirical support for the hope that decision making about vaccination is based on "facts" alone. In their research on cognitive processes in vaccination decision making, Meszaros et al showed that when parents opposed to the vaccine for diphtheria, tuberculosis, and pertussis were presented with factual information about risks and benefits they became more committed to their antipathetic position. This response was moderated by underlying values about death and chronic disability.²

Our own research on antivaccination press reportage has shown that manifest claims about vaccines being dangerous and ineffective tend to be located under a canopy of more general discourses about cover up and conspiracy, manipulation by venal private enterprise interests, governments with totalitarian agendas, and the back to nature idyll.³ We argue that what generates the appeal of antivaccination claims is underlying reference to these wider issues. We are now undertaking qualitative research with parents and immunisation providers in an attempt to explore the nature of the appeal of both anti-immunisation rhetoric and reassurances by providers. Although this work is incomplete, we have been impressed by how frequently parents in focus group discussions are adamant that they want to be given the "facts" but demonstrate minimal retention of these when exposed to television items containing pro-immunisation and anti-immunisation claims. What is retained and discussed and prompts strong responses from participants are images of children who have allegedly been damaged by vaccines. In other words, the facts have little potency when competing with the very emotive news stories found in the media.

Any attempt at refuting or deflating the persuasive power of vaccination arguments must address the potential gut level appeal at which anti-immunisation rhetoric tends to operate. What we have learnt about immunisation science will be of no public value ultimately if we ignore key lessons from health communication science.

Julie-Anne Leask, research officer. 
Simon Chapman, associate professor. 
Penelope Hawe, senior lecturer. 
Department of Public Health and Community Medicine, University of Sydney, Sydney NSW, Australia

Competing interests: Dr Leask and Professor Chapman have been reimbursed for attending a conference and have received funds for research from CSL Vaccines.

Authors' reply

EDITORWe welcome the interest taken in our article as we believe immunisation to be very important. Lee concedes that vaccines have been an important health initiative but questions their safety. She rightly points out that rotavirus vaccine was withdrawn after being in use in the United States for less than a year. This is in fact an excellent example of how closely the safety of vaccines is monitored. As soon as there was serious suspicion of a problem, the vaccine was suspended from use and an extensive investigation conducted. When the results of this were announced, the vaccine was permanently withdrawn.¹

Lee also cites other examples of the possible side effects of vaccines. There is no evidence that anyone has come to harm from the mercury in vaccines, but it seems reasonable to eliminate any potential risk, however small. For this reason, many governments have urged vaccine manufacturers to eliminate mercury from vaccines as soon as is practicable. There is no convincing scientific evidence that polio vaccines in Africa had anything to do with the origin or spread of AIDS.

Morrell points out that many homoeopaths advise their clients to avoid conventional vaccines. We were trying to make the point that the common assumption that homoeopathy and orthodox immunisation are incompatible is a myth, a view by which we stand. We do not claim that the only explanation for the fall in the incidence of many diseases is the introduction of vaccination. There is, however, overwhelming evidence of the efficacy of vaccines, both from trials conducted before their widespread introduction and from experience of groups who remain unimmunised when most of the population has accepted vaccine. Outbreaks of disease among communities that reject immunisation have caused not only disease but also death, most recently in an epidemic of measles in the Netherlands.²

Leask et al make a fair point, which we accept. There are many interrelated factors that determine whether or not children are immunised. Parents' attitudes to the safety and efficacy of vaccines and the severity of disease are among the most important determinants of vaccine uptake.³ We need to look no further for evidence of this than the recent decline in uptake of measles, mumps, and rubella vaccine in the United Kingdom, which has followed much publicised claims that the vaccine is linked with autism. Although we recognise that knowledge alone does not change behaviour, there are many myths circulating about immunisation and infectious diseases, and without accurate information it is not possible to make a fully informed decision. The other aspects mentioned by Leask et al are more intangible and may reflect the empathy between parent and professional.⁴ Even that relationship will be influenced in turn by an individual's wider perceptions of governments and industry.

Helen Bedford, senior research fellow. 
Department of Epidemiology and Public Health, Institute of Child Health, London WC1N 1EH

David Elliman, consultant in community child health. 
St George's Hospital, London SW17 0QT

Competing interests: Dr Bedford and Dr Elliman have both been sponsored to attend and speak at educational meetings and have conducted research funded by manufacturers of vaccines.