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EDITORIALS: Susan King Vaccination policies: individual rights v community health BMJ 1999; 319: 1448-1449 [Full text]

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Immunisation and informed consent

Gregory Rose   (13 December 1999)

Vaccination policies: individual rights v. community health

Gordon T Stewart   (13 December 1999)

Immunisation and informed consent 13 December 1999
Gregory Rose, not currently employed in the health sector recently graduated (see above) Send response to journal: Re: Immunisation and informed consent	King (Editorial 4/12/99) oversimplifies the debate surrounding rubella vaccination. In 1970 a rubella vaccine was recommended by the Department of Health for 11-13 year old girls. Subsequently 10% of 11 year olds, 14% of 12 year olds and 10% of 13 year olds were vaccinated.[1] In 1972 coverage was extended to sero-negative women of childbearing age in special occupations, such as teachers and nurses. In 1974 this was extended to include sero-negative women of childbearing age. In 1976 the advice was repeated and augmented. [2] From the year of the vaccine’s introduction rubella-associated abortions were declining, despite only school-aged children being widely vaccinated; evidence that rubella terminations were decreasing anyway (in 1971 1,018 rubella terminations, in 1972 738, in 1974 633 and in 1976 273). [3] Since rubella was not notifiable and there were no adequate records of rubella-related terminations prior to 1971, it is impossible to establish whether this decrease was due to the vaccine. It can be said that it was probably not. When the campaign began, the Department of Health did not expect results until the mid 1980s. Between 1970 and 1977 the live birth rate dropped from 83.3 to 58.1 (live births per 1,000 women aged 15 to 44) and this is when the greatest decrease in terminations (and probably congenital rubella) occurred. The birth rate increased in the late 1970s, as did terminations, and declined again in the early 1980s, as did terminations. Since there was no mass vaccination programme of adults, and since those vaccinated had not yet reached adulthood, the at-risk population was not protected. From 1979 school leavers, women attending family planning clinics, and female university students were given the rubella vaccine.[4] The new policy caused an increase in the number of vaccine-associated terminations.[5] In 1971 vaccine associated terminations formed 4% of all rubella-related terminations, and by 1992 83%, a total of 954 in just over 2 decades. This is disappointing given that the motivation for the campaign was to prevent the need for abortions. By 1987 the number of rubella-associated terminations nationally had fallen below 100. When the JCVI chose to introduce a combined measles, mumps and rubella vaccine (MMR) for infants of 15 months in 1988, the downwards trend continued. This is similar to the strategy employed in Greece, yet which the editorial by King, contradictorily, cites as the reason for the success of the British programme. Some studies report a high proportion of rubella among the vaccinated, with as high as 80% of recently vaccinated populations contracting the disease during epidemics.[6] In Glasgow it was almost impossible, serologically, to determine whether a woman was vaccinated since men (unvaccinated) and women had similar rubella antibody levels, and records of vaccination were seldom complete.[7] The trend is to classify all cases as unvaccinated unless the person demands that they have been vaccinated or if records are clear; this is a potential bias in any evaluation. King described the US programme as reducing the annual number of babies with congenital rubella syndrome. The figures quoted for 1964 (an estimate) and 1983 are fortuitous. The general fertility rate (GFR) for the latter was at its lowest. By 1991 the GFR had increased and so too had congenital rubella, with trends in GFR, rubella notifications and congenital rubella mirroring one another.[8] The constant changes in strategy reflect an administration failing to achieve goals in the face of rising costs and a nebulous task. i.e. how to protect an age-group 30 years wide from a disease carried by an even wider age-group? The role of adults in rubella transmission is known[9] but this is rarely given due consideration in programmes. Not only this, but rubella is one of many teratogenic infections, including cytomegalovirus, treponema pallidum, parvovirus B19 (which causes 150 foetal deaths annually) and toxoplasma gondii. The decreased pertussis vaccine uptake in the 1970s leading to “epidemics” is regularly erected as a justification for the suppression of information. It is seldom mentioned that there was no proportionate increase in mortality or hospital admissions[10] [11] compared to previous secular rises. Even if all of the 45% who defaulted had been in social classes I and II (an impossibility), such a disparity is highly improbable and is more likely ascribed to an artefactual epidemic, the result of over -notification. This is a recognised phenomenon which follows increased awareness, such as after an official warning.[12] Many years of changes in rubella vaccination policy inevitably must lead to some favourable correlations. There is, however, no credible evidence of the interruption of transmission or a significant reduction in infection. The high toll and emotional distress from the accidental vaccination of pregnant women, and the risk of arthritis which is either transient[13] [14] or chronic,[15] [16] means that the question of rubella vaccination should be met with debate and balanced information. I oppose the veiled suggestion, and disagree with the evidence, that it is better to suppress debate because vaccination programmes offer a known and quantifiable benefit which would be threatened by informed consent. Gregory Rose MPH No competing interests 1. Department of Health and Social Security. On the State of the Public Health. DHSS: London 1970. 2. Department of Health and Social Security. On the State of the Public Health. DHSS: London 1978. 3. OPCS. England and Wales: Rubella-associated terminations of pregnancy. Office of Population, Censuses and Surveys: London 1994. 4. Department of Health and Social Security. On the State of the Public Health. DHSS: London1974. 5. Department of Health and Social Security. On the State of the Public Health. DHSS: London1986. 6. Allan B. Aust Nurs J 1978. May. 7. Gilmore D, Robinson ET, Gilmour WH, Urquhart GE. Effect of rubella vaccination programme in schools on rubella immunity in a general practice population. BMJ (Clin Res Ed) 1982; 284: 628-30. 8. Centers for Disease Control. MMWR Morb Mortal Wkly Rep [Summ.] 1984, 1994. 9. Schoenbaum SC, Biano S, Mack T. Epidemiology of congenital rubella syndrome: The role of maternal parity. JAMA. 1975; 233: 151-155. 10. Barrie H. Campaign of Terror. Am J Dis Child 1983; 137: 922-3. 11. Stewart GT. 1984, 135. Whooping cough and the whooping cough vaccine: the risks and benefits debate. (Letter) Am J Epidemiol 1984; 119: 135. 12. Coggon D, Rose G, Barker DJP. Epidemiology for the Uninitiated. 3rd Edition. BMJ: London 1993, 57. 13. Cooper LZ, Ziring PR, Weiss HJ et al. Transient arthritis after rubella vaccination. Am J Dis Child 1969; 118: 218. 14. Grand MG, Wyll SA, Gehlbach, SH et al. Clinical reactions following rubella vaccination. A prospective analysis of joint, muscular, and neuritic symptoms. JAMA 1970; 220: 2287. 15. Tingle AJ, Chantler JK, Pot KH et al. Postpartum rubella immunization: Association with development of prolonged arthritis, neurological sequelae and chronic rubella viremia. J Infect Dis 1985; 152: 606. 16. Howson CP, Fineberg HV. Adverse events following pertussis and rubella vaccines. Summary of a report of the Institute of Medicine. JAMA 1992; 267 (3): 392-6.
Vaccination policies: individual rights v. community health 13 December 1999
Gordon T Stewart Send response to journal: Re: Vaccination policies: individual rights v. community health	In an otherwise thoughtful editorial comment (p 1448, 4th December) on international data, Susan King repeats the fallacy that a fall in acceptance of triple vaccine (DTP) in the UK in the early 1970's led to "Pertussis epidemics". This is incorrect. Pertussis epidemics continued, as before and subsequently with a rise in unvalidated notifications in 1977-79 but hardly or not at all in validated hospital admissions or deaths (1). A similar rise in validated cases occurred in Sweden (2) where acceptance of standard DTP exceeded 80%. There was no increase in West Germany where DTP was not given as a routine (3). In the USA, with high acceptance of five, not three injections of DTP, often compulsorily for school entry, hospital admissions for whooping cough exceeded those in the UK, pro rata, during this period (4). The effectiveness of Rubella vaccine varies similarly, as described by Dr King. Your sub-title that "We can't afford to be half-hearted about vaccination programmes" implies that risks of infection and disease are constant everywhere and that all of the 8 - 10 recommended childhood vaccines are equally effective, necessary and safe. In fact, there are differentials influenced strongly by Bayesian variations in trends, notifications and morbidity of target infections, and also by contraindications, living conditions, manufacture of vaccines, batch differences and other unmentioned aspects of usage. All of these require discriminate monitoring and the option of informed consent without which vaccination programmes cannot respect individual rights, be more than half-hearted or protect community health.. Gordon T. Stewart, M.D. (conflict of interest: none; support: none). References: 1 Morbidity and mortality of notifiable infectious diseases, 1970-90. Office of National Statistics and the Public Health Laboratory Service. 2 Romanus V, Jonsell R, Bergquist S-E. Pertussis in Sweden after the cessation of general immunization in 1979. Ped Inf Dis J 1987; 6; 364- 371. 3 Ehrengut W. Convulsive reactons after pertussis immunization. Dtsch Med Wochenschrif 1974; 99; 2273-2275. 4 Stewart GT. Whooping cough in the United States and Britain. New Eng J Med 1983; 308; 464.