Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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The role of health professionals in decisions about MMR uptake
- Helen Pattison, Manish Pareek (12 January 2001)
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MMR Vaccination: persuasion or dictatorship?
- Roger M Goss (14 January 2001)
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When disability follows vaccination
- Alan Challoner (14 January 2001)
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Only the media wins
- Andrew Winrow (15 January 2001)
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Apathy Rules OK
- Ray O'Connor (15 January 2001)
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Celestial Emporium of Benevolent Knowledge
- Jonathan Kay (19 January 2001)
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Is it time to change the format of the "Green Book"?
- Samuel Ghebrehewet (23 January 2001)
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Medical students' views...
- David Tai Kie (2 February 2001)
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MMR - information overload
- Gill Lewendon (2 February 2001)
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Training for the MMR
- Lisa Blakemore-Brown (3 February 2001)
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Why wait until pre-school for the second MMR?
- C E Clark (11 February 2001)
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Re: Why wait until pre-school for the second MMR?
- John P Heptonstall (14 February 2001)
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Re: Re: Why wait until pre-school for the second MMR?
- C E Clark (28 February 2001)
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Updating the Green Book
- Jonathan Howell (13 March 2001)
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Mothers response to"Questionnaire survey of Health Professionals" BMJ 13 Jan 2001
- Valerie Burnett (13 April 2002)
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An answer
- Ed Cooper (14 April 2002)
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Re: An answer
- Alan Challoner (20 May 2002)
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Helen Pattison, Senior Lecturer (HMP)& Medical Student (MP) Dept of Primary Care and General Practice, The Medical School, University of Birmingham, Manish Pareek
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This interesting paper complements the first study of factors affecting maternal intentions to take up the MMR vaccination, which we published last month1. We found that failure to take up the 2nd dose in particular, is not simply a function of fear of the vaccine. The two-dose schedule is problematic for parents, as it is for the health professionals whose views are reported here. However the reasons for this are different. First, parents have not been educated in the rationale behind the schedule and many seem to believe the 2nd dose is a 'booster'. Therefore, if their child has received the 1st dose, they see the 2nd dose as less important for the health of their child. Furthermore comments from mothers show that they are unconvinced by arguments concerning herd immunity when it comes to decisions about their individual child. Petrovic and his colleagues have revealed that a sizeable proportion of professionals who do understand the rationale feel uncomfortable about the schedule, and explaining it to parents. Second, children receive the 2nd dose at a time when parents have less contact with primary care professionals in regard to the health of their child than during babyhood. Mothers reported obtaining most general information about vaccination from their health visitor. The source they trusted most was their GP. However the actual source of most of their information about the MMR vaccine and side effects was television. Informal comments from GPs, obtained when we were setting up the study, suggest that some GPs are reluctant to raise the issue of the MMR vaccination with parents, fearing that they will be alerted to the controversy of which they were previously unaware. In a world where people are inundated with information from the media, this seems naïve in the extreme. The data presented here raise the further problem of the reluctance of GPs, health visitors and practice nurses to recommend the 2nd dose because they themselves are not convinced of its safety or efficacy. Our conclusion was that health education and advice from primary care professionals, and particularly GPs, could have a considerable impact on the decision to take up the MMR vaccination. Unfortunately the data collected by Petrovic and his colleagues suggest that we need to go some way to educating and training professionals before we can expect them to reliably help parents in this difficult decision. 1 Pareek M, Pattison HM The two-dose measles, mumps and rubella (MMR) immunisation schedule: factors affecting maternal intention to vaccinate. British Journal of General Practice, 2000; 50: 969-971 |
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Roger M Goss, Director Patient Concern
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Editor - In view of the findings of your survey, (1) let alone the public's concerns, the government is wrong - not necessarily medically but certainly on ethical grounds. Unless it is prepared to make having the triple-shot MMR vaccination compulsory, thereby abandoning the principle that patients have a right to decline an intervention for any reason, rational or otherwise, it should make the single-shot product available for all children whose parents will accept nothing else. Rumours of plans to ban its use are outrageous. This will put public health at unnecessary risk. In a democracy, politicians can lead their constituents to water but cannot force them to drink. It must be galling to find that all efforts to assure the public that the MMR vaccination is safe and risk-free have failed. But it is hardly surprising when so many medical professionals have their own doubts. We have the example of assurances in respect of thalidomide, BSE and depleted uranium. And ultimately some parents will consider the risk of autism, whose cause we have yet to identify, more serious than measles. That is their right. If the government is serious about its desire for a patient-centred health service, it must allow citizens to make their own medical choices. Roger M. Goss
(1) Petrovic M. Roberts R. Ramsay M. Second dose of measles, mumps and rubella vaccine; questionnaire survey of health professionals. BMJ 2001; 322: 82-85 (13 January) |
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Alan Challoner, Retired
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The claims and counter-claims about specific childhood vaccinations have missed a very important factor. There can be no doubt that vaccinations have been beneficial to children and communities, but neither the medical profession nor the pharmaceutical industry has accepted any responsibility for the long-term disability of those who have been deemed to be seriously affected by vaccination. The government, through its Vaccine Damage Payments Act 1979, has accepted that some children have been disabled to a level of 80% below normality. In doing so it is now paying £100,000 as a one-off award to those so assessed. As a parent of a vaccine-damaged person who has received the award, I have been pursuing litigation for 15 years, without the case yet coming to court, in an effort to gain compensation that is more appropriate. The annual cost of full-time care for my daughter— just for staff alone— is £50,000. In order to produce that sum, about £750,000 has to be invested. So is it no wonder that parents are apprehensive about taking-up vaccination for their young babies? It is quite clear to them that if a serious reaction disables their child to the degree required to qualify for the Vaccine Damage Payment, several things will follow. Normal education will be impossible; socialisation will be impaired; employment is unlikely; and to cope with the financial implications of that they will get just £7,000 a year from investing the award. Add to that the potential for the disability causing medical or mental health complications, their costs and the stress on the family, it is not unsurprising that faced with such uncertainty of outcome, many are saying ‘no’ to vaccinations. |
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Andrew Winrow, Consultant Paediatrician Kingston Hospital, Surrey
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Whilst the paper by Petrovic et al. highlights several educational issues, it was not designed to shed any further light on the disquiet surrounding the safety of the MMR immunisation. The paper does point to the conclusion that education in primary care has not addressed overall concerns around this immunisation as well as suggesting the those in primary care are not aware of or using available educational material with which to influence their decisions. It remains a mute point whether the clinical decisions made by those in primary care have been unduly influenced by the media. However it is certain that publications such as this are seized upon by the media. Rather than review the paper for its justified conclusions, the media distort the message into another "scare" story about the inadvisability of the MMR vaccine. This was not the point of the article. Thus a self-perpetuating cycle develops. The result - the "consumer" is more confused and concerned than ever before and the newspapers sell more copies. The medical result - increased risk of a measles outbreak, more distrust of health professionals...and more referrals of confused parents to consultant paediatricians for advice. |
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Ray O'Connor, General Practitioner 19 Cregan Ave, Kileely, Limerick city, Ireland
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As an Irish doctor qualifying before Measles vaccine was introduced nationally in Ireland in 1986 I saw many cases of measles. In 1985, the year before the vaccine was introduced there were 9903 cases of measles reported. By 1987, this figure had been reduced to 201 reported cases. This convinced me that measles (and subsequently MMR) vaccine administration was essential for the good health of our children. Unfortunatley, largely due to apathy, our national vaccine uptake rate in Ireland for MMR vaccine has varied from 68% to 86%. This is substantially below the 90% minimum uptake rate needed to prevent an unvaccinated cohort building up into a large enough group to cause an epidemic. We have reaped the rewards of this lax vaccination policy with measles epidemics occurring in 1993 and again in 2000 During this last epidemic, at least 2 children died needlessly of measles. The evidence linking MMR vaccine to autism and Crohns disease has been examined in detail in many different studies and shown to be non existant(Ref 1-3). The fact that Wakefield and colleagues could only come up with 12 cases in their 1998 paper speaks for itself (Ref 4). In Ireland, and I suspect in many other countries, we need the second dose of MMR vaccine to reinforce immunity in those already vaccinated, to immunise the 10% of vaccine recipients who will have not responded to the first measles vaccine, and to give us a second chance to catch the 20 - 30% of children who do not receive the first MMR vaccine. We need to bury these and other vaccine myths for once and for all for the sake of our children. We must not let apathy triumph. References: 1 Taylor B et al. Autism and measles, mumps and rubella vaccine: no epidemiological evidence for a causal association. Lancet 1999; 353: 2026 - 29. 2 Peltola H et al.No evidence for measles, mumps and rubella vaccine- associated inflammatory bowel disease or autism in a 14-year prospective study. Lancet 1998; 351: 1327-8 3 Feeny M et al. A case control study of measles vaccination and inflammatory bowel disease. Lancet 1997; 350:764-66. 4 Wakefield A et al. Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children. Lancet 1998; 351: 637-41 |
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Jonathan Kay, Consultant Chemical Pathologist Oxford Radcliffe Hospitals
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The paper classifies respondents' answers to the questions about the likelihood of an association into "Very likely or possible", "Unlikely and "Don't know". These categories are neither exclusive nor exhaustive. Were these the categories used in the questionnaire or is this a summary of the actual responses? If asked "Is it likely that the next Mars lander will detect signs of life on Mars?" I would answer “Yes” to "Very likely or possible" (it is possible) and "Yes' to "Unlikely", and possibly “Yes” to “Don’t know”. The last of these suffers a possible ambiguity between “I don’t know the likelihood” and “I don’t know if there is an association”: I know there is an association between hyperuricaemia and gout, but I don’t know the likelihood of a patient with one having the other. Connoisseurs of classification will recall Borges' reference to the
Chinese encyclopaedia which classifies animals into:
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Samuel Ghebrehewet, Specialist Registrar in Public Health Medicine CDSC North West, 57A Vernon Pritchard Court, Upper Northgate Street, Chester, CH1 4EF.
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Is it time to change the format of the "Green Book"? Editor - We were pleased to see the publication of the survey of health professionals' knowledge, attitudes, and practices (KAP) regarding the MMR vaccine1, as this is one of the main factors that influences MMR uptake rates2. Petrovic et al point out that knowledge and practice among health professionals regarding the 2nd dose of the MMR vaccine vary widely, and many health professionals are not aware of or do not use the written sources that exist, though local educational initiatives could remedy this1. We conducted a similar questionnaire survey of health professionals [General Practitioners (GPs), Practice nurses (PNs), and Health Visitors (HVs)] KAP regarding the MMR vaccine in the Halton area (North Cheshire) in 19983. Our survey comprised of 62 GPs, 29 PNs, and 25 HVs, and response rates from each of the professional groups were 87%, 66% and 80% respectively. With regard to confidence in the safety of MMR vaccine, 5% of the health professionals stated their level of confidence was 1, in a five-point scale (1=not confident; 5=very confident). The worrying finding from our survey, however, was that over half (57.1%) of all the professionals considered severe egg allergy to be an absolute contraindication to MMR vaccination, which it is not4,5. Our survey also found that a large proportion (56%) of the health professionals had not attended any educational session(s) on vaccination / immunisation during the three years prior to 1998. However, there was no statistically significant difference in terms of professionals' confidence in the safety of MMR vaccine between those who had and those who had not attended educational session(s) on vaccination / immunisation (P=0.75). Similarly, in terms of considering a serious egg allergy as an absolute contraindication for MMR vaccination, there was no statistically significant difference between the two groups (P=0.59). Although we do not have information on the quality and appropriateness of those educational sessions, this raises some important questions about the effectiveness of local/national educational initiatives in raising health professionals' awareness. A large proportion of health professionals involved in the vaccination programme (>90% in our survey) consider the "Green Book" (Immunisation Against Infectious Disease)6 to be the most important source of information. Local educational initiatives, as suggested by Petrovic et al, may improve health professionals' awareness, but in light of the above findings, we also believe that success is more likely if the format of the "Green Book" is changed to enable it to be updated more frequently. The "Green Book" could be modified into a more practical format where new information / supplements (including electronic circulars) could be easily added. This would not only improve professionals' awareness, but would also boost professionals' confidence and promote consistency in the advice given to parents. Competing interests: None Dr Samuel Ghebrehewet
Dr Catherine Quigley
References: 1. Petrovic M, Roberts R, Ramsay M. Second dose of measles, mumps, and rubella vaccine: questionnaire survey of health professionals. BMJ 2001;322:82-85. 2. Lakhani A, Morris R, Morgan M, Dale C, Vaile M. Report of an investigation of the low uptake of measles immunisation in Maidstone Health Authority. London: Department of Community Medicine, St Thomas’ Hospital, 1986. 3. Ghebrehewet S. Investigation into low. MMR vaccination uptake rates, Halton. Submission for the 2nd part of MFPHM, Oct 1999. The MFPHM Part II Submissions. ( http://195.224.168.94/) 4. Watson JC, Hadler SC, Reef S, Phillips L. Measles, Mumps, and Rubella – Vaccine Use and Strategies for Elimination of Measles, Rubella, and Congenital Rubella Syndrome and Control of Mumps. MMWR, 1998; 47(RR- 8): 33-37. 5. Health Education Authority. MMR immunisation factsheet, 1997; 1-8. 6. Department of Health. Immunisation against infectious disease. London: Stationary Office, 1996. |
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David Tai Kie, Stage 3 medical student Medical school, Newcastle upon Tyne
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Sirs, The study by Petrovic et al(1) addressed an important health issue, administration of the 2nd dose of the MMR vaccine. It has demonstrated a discrepancy in opinion among health professionals, highlighting a need for further education and training to enhance the confidence of health professionals in advising parents. It is not discussed whether those professionals who were least confident to advise parents on the MMR vaccine were the same group who had not had access to the Immunisation Against Infectious Diseases booklet provided by the government. If this is so, it indicates better communication and sharing of information between health professionals is needed to promote the uptake of the MMR. We felt two points needed further clarification. Firstly bias was possibly introduced by limiting the study population. No explanation was given as to why the study discarded from analysis those professionals not giving advice to parents on the MMR vaccine. These 35 practice nurses 7 GPs possibly represent those with the strongest reservations about the vaccine and should be taken into account if the full spectrum of opinion is to be illustrated. Secondly, we feel further justification is needed if these results are to be generalised over the country. There is no evidence given to say whether the uptake of the MMR vaccine in North Wales is comparable to that of the rest of the UK. Therefore we do not know if the findings are applicable to the whole country. If the uptake of the MMR vaccine is consistent across the country, applying the results nation-wide is justified. The finding of this study, that further training of professionals is required, will help to minimise uncertainty surrounding the MMR vaccine and prevent reduction in uptake of the vaccine. Yours sincerely, Hannah Davies, May An Lim, David Tai Kie, Yang Yang Zhang
References 1. Petrovic M, Roberts R, Ramsay M. Second dose of measles, mumps, and rubella vaccine: questionnaire survey of health professionals. BMJ 2001;322:82-85. |
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Gill Lewendon, Senior Clinical Medical Officer (Public Health) South and West Devon Health Authority
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Editor, The survey of health professionals’ knowledge and attitudes about the MMR immunisation1 confirms what is already known about one of the most important influences in child immunisation uptake, namely the knowledge of the health professionals2 In our district, in 1998, we surveyed the primary immunisation givers from all the practices. We had 93% response rate and found a marked contrast in the availability of immunisation updating and training between areas of high and low immunisation uptake rates. In the western part of the district where an enthusiastic and committed pediatrician provided regular training sessions for primary care staff, there was a high uptake of all immunisations including the second MMR. In contrast, in the eastern sector, where immunisation training had not been as easily available, there was a consistently lower uptake of immunisations especially the MMR. This was despite the eastern section being a comparatively wealthy area compared to the western area which included a high proportion of practices in deprived inner city areas. Petrovic et al make the point that local education initiatives could remedy the apparent variation in knowledge of practice amongst health professionals. Rather than producing yet more written material to add to the information overload in the health service, we would suggest that more interactive immunisation training and updates should be provided as part of continuous professional development3 - not only to provide information but also to give people an opportunity to discuss with their peers any problems encountered when giving advice to parents about immunisation. We are starting a rolling educational programme this year targetting those areas with low coverage and will be monitoring the effect on immunisation uptake over the coming years. Gill Lewendon Moira Maconachie Kevin Elliston 1 Petrovic M, Roberts R, Ramsay M. Second dose of measles, mumps and rubella vaccine: questionnaire survey of health professionals. BMJ 2001;322:82-85 2 Peckham C, Bedford H, SenturiaY, Ades A. National immunisation study: factors influencing immunisation uptake in childhood. Horsham: Action Research,1989 3 King L,Hawe P, Wise M. Making dissemination a two-way process. Health Promotion International 1998;13: 237-244. |
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Lisa Blakemore-Brown, Independent Psychologist - Specialist in Autism UK
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If appropriate, balanced and honest training is to be put in place it must obviously also include understanding about the children who HAVE been affected by vaccine. In the new dawn of honesty in the NHS I am certain no -one could object to this. Any suggestions as to how we do it? as Government researchers have consistently turned a blind eye to all the suffering children and have made no effort to try to examine the children's cases either in research or in training. Autistic children have been conveniently airbrushed out - as in the remarkable Finnish study. Are they being sacrificed for the perceived `greater good`? |
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C E Clark, General Practitioner School Surgery, Fore Street, Witheridge, Devon, EX16 8AN
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Sir An important finding of this paper is in danger of being overlooked during the current media attention. A significant barrier to giving the second dose of MMr is the timing. Multiple injections of an infant are far easier than a pre-school child, and this has clearly inhibited some of the contributors to this paper in their use of the second dose. This situation worried us when the second dose was introduced. We made extensive enquiries and could find no immunological, legal or other reason to delay the second dose beyond three months after the first. Consequently this has been our practice policy for the last four years. Children are seen at 15 and 18 months for the two MMR injections, leaving us with just one pre-school injection to give. In practical terms this does mean an extra appointment for every child, but the benefits of maintaining high immunisation rates for the MMR, and avoiding a second pre-school jab, with its consequent deterent effect, justify the investment of time. |
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John P Heptonstall, Director of the Morley Acupuncture Clinic and Complementary Therapy Centre West Yorks
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Editor Dr. Clark says that 'extensive enquiries were made into whether any immunological, legal or other reasons' existed for the delay of MMR 2 in the children under his primary care. I assume he also made 'extensive enquiries' since into the scientific arguments for and against MMR vaccinations? Any extensive enquiries ought to have revealed the incidence of autism and IBD for children in his area, and any apparent increase his area may have seen in these disorders in recent years? What is that increase as a percentage of what it was prior to the introduction of MMR 1? One expects that duty of care to patients, for any physician, would see 'extensive enquiries' performed before subjecting children to ongoing vaccinations when serious doubt has been cast on the MMR process by scientists; it is surely unethical for any physician to merely follow a government line when one's first responsibility is to one's patients. If there has been a substantial increase of autism, IBD or indeed any other serious illness (diabetes springs to mind as having recently been cited as a possible 'side effect' of HiB vaccine) amongst his child population, did his extensive enquiries - prior to deciding to vaccinate at all, and children at younger ages than recommended - uncover any possible reason for such increases locally? Regards John H. |
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C E Clark, General Practitioner School Surgery, Fore Street, Witheridge, Devon, EX16 8AH
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Dr Heptonstall makes valid comments about responsibility to patients, with which I agree in principal. There are no patients on our practice list with a current or previous diagnosis of autism, so it is not possible to take a "local" view, and indeed even if there were one or two single cases there would be a risk of mistaking anecdote for robust evidence. As often happens in practice, when faced with a rare condition, one has to read and take a view on the literature. I have a concern to protect my patients from measles mumps and rubella. The dangers of these conditions are not in doubt. The literature, however (peer reviewed, not government led) is very much weighted towards no evidence of an association with autism. This is the information which my patients require and I believe that it is my duty to provide it. Having achieved this, it seems reasonable to act as we did, in reviewing when to give the second dose to maximise uptake and minimise distress and discomfort. Which are the valid concerns cited in the article. |
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Jonathan Howell, Consultant in Public Health Medicine and Medical Adviser South Staffordshire Health Authority
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Dear Sir, The paper published in the BMJ(1) shows some of the uncertainties of professionals involved in giving vaccinations. There is a certain vulnerability here that is reflected in the decrease in the MMR rates and the negative publicity in the media. We would like to make a suggestion of improving the information supply so as to give more confidence in the clinical setting. We have been concerned for some time about the lack of an up to date version of the Department of Health’s Green Book, otherwise known as “Immunisation against Infectious Disease”. These concerns are reinforced when we see more controversy around some of the vaccine programmes such as the MMR. The Green Book is a convenient form of evidence and advice covering the main vaccinations delivered through the NHS and is seen as a Bible by many health professionals. A wide range of NHS staff are given responsibility for implementing these major public health programmes and other protective immunisations and become accountable for the standard of the service provided but are currently impeded by a lack of updated, timely and accessible information. The Green Book has been published in 1990, 1992 and 1996 and actually states on page 13 (1996) that its recommendations, “reflect present national immunisation policy”, although clearly it is 5 years out of date. Updated information has either been sent out in loose-leaf form or is available on the Internet but these may not be readily available to community nurses as they carry out their immunisation clinics. They will be more likely to have access to a copy of the Green Book. There is a comparison with prescribing. If the British National Formulary (BNF) was only published every four years or so and we had to rely on companies sending out individual updates on their products we might feel vulnerable when prescribing. Would it not be possible to publish the Green Book every 6 months with the latest advice and evidence then available to all professionals? A similar initiative has just been funded so that professionals can have access to the BMJ’s “Clinical evidence”, also published every 6 months. We suspect that the cost would be offset by the ability of health professionals to provide consistent and current advice. This would increase the public’s confidence in the effectiveness of the immunisation programmes and be likely to increase compliance to achieve higher levels of vaccination. The least we can do in this area is to offer an improved supply of the best information available for the sake of the professionals, the parents and the patients. Yours sincerely Jonathan Howell
Harsh Duggal
Karen Howell
Ref: (1) Petrovic M, Roberts R, Ramsey M. Second dose of measles, mumps and rubella vaccine: questionnaire survey of health professionals. BMJ 2001; 322: 82-85 |
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Valerie Burnett, Mother Bristol, England
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Dear Marko, I am a mother of a one year old boy who is soon due to have his MMR vaccine so therefore I am doing some reading on studies that have been done. With regards to your survey in BMJ dated 13 January 2001, "Second dose of measles, mumps, and rubella vaccine : questionnaire survey of health profesionals", I would like to ask a question : How can such a high percentage of practice nurses beleive that the MMR triple vaccine be possibly associated with Crohns and Autism? (38% crohns 27% Autism) As people who are working in the medical industry do they see side effects / or are there papers/studies that are not made available to the public? I ask this question as ALL the surveys/reports/letters/articles that I have read conclude that there is no association between the MMR vaccine and IBS/Autism so how can medical staff have such high levels of doubts in links between MMR Vaccine and IBS and Autism? This high percentage of nurses is a really worrying figure and I am a mother who beleives in immunisation and in the MMR vaccine - but have been thrown into doubt. I would be really grateful for your reply, or anyone else who can help me. Valerie Burnett Mother of a boy aged 12 months. |
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Ed Cooper, Consultant Pediatrician Newham General Hospital, London E13
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Let's say a practice has 6,000 registered patients. There might be 500 children under 8. With the widest definition of autism, there might then be 3 children with autism. With a narrow, "classic" definition, perhaps one. It is very unlikely, in the average general practice, that there would be any child with Crohn's Disease. Therefore, Mrs. Burnett's idea that the practice nurse has been observing the associations of disease with MMR vaccination in her professional life is a bit of a non- starter. So what is the answer to her question, how come such a high proportion of practice nurses believe there may be a link between MMR and these diseases? Perhaps the answer has some connection with another topic running in the BMJ's electronic responses, that people like nurses, maybe more than doctors. It is because nurses are close to patients. They read tabloid newspapers - or they might read The Guardian, but without much time to concentrate and question. The television news is on but they are preparing tea and calling the children. They pick up the worries of the public because - they are the public. |
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Alan Challoner, Retired
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In a long thread of responses, there lies a possibility that the original point of, and results from, the research may become blurred. Table1 of Petrovic et al cites "views of health professionals". In responding to the idea of stating one's views. There is a strong likelihood that what will be given is: how I see it; how I believe it to be; my gut feeling; my professional understanding; etc. None of these views will be furnished by personal research, but will by supported by experience and intuition. Before intuition is derided, it should be appreciated that it certainly helps most clinicians to come to a decision on diagnosis, and associations in particular. Dr Cooper's response to Valerie Burnett does not do justice to professional intuition and instinct. I believe that these important responses have not been born whilst reading The Guardian, watching TV news, preparing the children's tea or listening to public and media worries. The object of the research was, "To determine the knowledge, attitudes, and practices among health professionals regarding the measles, mumps, and rubella (MMR) vaccine, particularly the second dose." |
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