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Press releases Saturday 1 March 2008

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(1) Many children still susceptible to measles, mumps and rubella infection
(2) Has the hunt for conflicts of interest gone too far?
(3) Could half bottles of wine help cut alcohol-related harm?

(1) Many children still susceptible to measles, mumps and rubella infection
(Factors associated with uptake of measles, mumps, and rubella vaccine (MMR) in the UK and use of single antigen vaccines in a contemporary UK cohort: prospective cohort study)
http://www.bmj.com/cgi/short/bmj.39489.590671.25v1
(Editorial: Improving uptake of MMR vaccine)
http://www.bmj.com/cgi/short/bmj.39503.508484.80v1

Not enough children are being immunised against measles, mumps and rubella to ensure adequate control of the diseases, finds a large study of children born 2000-2002 in the UK.

Researchers at the UCL Institute of Child Health and Great Ormond Street Hospital for Children found that 88.6% of children had been immunised with MMR by the age of three. 5.2% had received at least one of the single vaccines, and 6.1% were unimmunised. Of the 634 children who had received at least one single vaccine, just over half (52%) had received all three.

The study published on bmj.com today emphasises that this is well below the level needed to prevent outbreaks of the diseases. Although the uptake of MMR vaccine has increased recently, there have been more cases of measles in 2007 than in any year for the past decade so further improvement is essential, say the authors.

The combined measles, mumps and rubella vaccine (MMR) was introduced in 1988 in the UK. Following the publication of research in 1998, which was interpreted as suggesting a link between the vaccine and autism and bowel disease, uptake fell from a high of 92% in 1995 to a low of 79% in 2003.

The UCL researchers explored social, economic and cultural factors associated with uptake as well as parents’ reasons for not having MMR vaccine for the 14,578 children in the study. They only looked at uptake of the first dose of MMR vaccine. Uptake of the second dose is much lower, say the authors, but is necessary to ensure all children are adequately protected.

Children who had not received any MMR vaccine were more likely to come from a large family, their mother was more likely to smoke, and was either younger (under 20) or older (over 34) than average when she gave birth.

In contrast they found that parents who chose single vaccines were significantly more likely to be white, well educated, affluent, older, and have just one child compared with parents who fully immunised their child. The authors stress that single antigen vaccines are not licensed for use in this country and are not a good substitute for the combined MMR vaccine. They are only available on a private basis.

Of the parents who chose not to have their child immunised with the MMR vaccine, nearly three quarters (74.4%) said it was due to a "conscious decision." Common reasons given were being too scared, thinking the vaccine was too dangerous, links with autism, and negative media attention.

Although MMR uptake in this study is high, say the authors, a substantial proportion of children remain susceptible to avoidable infection, largely because parents consciously decide not to immunise.

They conclude, as does an accompanying editorial, that to achieve the best possible control of vaccine preventable diseases, a variety of measures may be required to target the different groups where uptake of the vaccine is low.

Contact:
Helen Bedford, Senior Lecturer, Centre for Paediatric Epidemiology and Biostatistics, UCL Institute of Child Health, London, UK
Email: h.bedford{at}ich.ucl.ac.uk

(2) Has the hunt for conflicts of interest gone too far?
(Head to Head: Has the hunt for conflicts of interest gone too far?)
Yes: http://www.bmj.com/cgi/content/short/336/7642/476
No: http://www.bmj.com/cgi/content/short/336/7642/477

Are restrictions on doctors' and academics' interaction with commercial companies damaging research, or is it a price worth paying to maintain public trust?

Two experts debate the issue in this week's BMJ.

Conflicts of interest occur in health care when clinicians or researchers have personal, professional, or financial interests that could interfere with their professional obligation to act in the best interests of patients or objectively conduct, present, review, or publish research.

Professor Thomas Stossel of Harvard Medical School believes that detailed disclosure of conflicts of interest are damaging research.

The most extreme rationale for conflict of interest management is that companies distort evidence and flout safety to promote products without substantive benefits and probable harms, he says. Yet these charges obscure the fact that only private companies bring new products to patients and that medical care has improved steadily and spectacularly because of them.

He points out that no evidence supports that corporate detailing and gifting adversely affect patient care, while medical journals waste space on meaningless compilations of who receives what payments from companies and dubious "social science research" claims to prove that most doctors lack the intelligence or character to be wary of promotional claims.

These attitudes and regulations are not only ill founded but also harmful to the public's interest in medical innovation, he argues. The measures exclude the best experts from providing education and advice, cost time and money, and are deeply disrespectful of physicians and researchers.

The University of California System's Academic Senate recently rejected intrusive conflict of interest regulations as vague, overbroad, addressing perceived rather than real concerns, and in violation of academic freedom. This is a step in the right direction, says Stossel, and he calls on others to follow this enlightened lead.

But Kirby Lee, Assistant Professor at the University of California, San Francisco argues that such requirements help to maintain public trust in science and medicine.

Evidence is growing, he says, to demonstrate the negative consequences of certain marketing practices and other interactions with industry on clinician behaviour. For example, clinicians with ties to industry are more likely to prescribe the company's brand name product rather than cheaper generic drugs when there is no therapeutic advantage.

Such influence is a serious concern because nearly all doctors have some type of relationship with industry, he writes.

He acknowledges that the drug and medical device industry has made large contributions to improving public health through beneficial relationships with clinicians and researchers on product development. However, despite guidelines for appropriate relationships and gift giving between industry and healthcare professionals, problematic conflicts continue to arise.

He points out that the US has recently proposed a law mandating disclosure of payments to clinicians by drug companies, and there are proposals to ban all gifts to clinicians and prohibit healthcare professionals who have ties with drug companies from making certain medical decisions (such as drug formularies and clinical practice guidelines) and publishing articles that have been ghostwritten by industry.

Such requirements may frustrate clinicians and researchers but, in doing so, will help to ensure the safety and welfare of the public, uphold scientific integrity, and preserve trust, he concludes.

Contacts:
Professor Thomas Stossel, Department of Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, USA
Email: tstossel{at}partners.org
Kirby Lee, Assistant Professor of Clinical Pharmacy, University of California, San Francisco, USA
Email: leek{at}pharmacy.ucsf.edu

(3) Could half bottles of wine help cut alcohol-related harm?
(Personal View: Half bottle or half cut?)
http://www.bmj.com/cgi/content/short/336/7642/507

Reducing wine portions could help cut alcohol consumption and related harm, suggests a doctor in this week's BMJ.

Banning supersize meal portions may help to cut obesity rates. But where's the debate on supersize portions of wine, asks Dr Trish Groves, Deputy Editor at the BMJ? Why does wine have to come in 75cl bottles?

I like a glass of good wine with my supper, she says. But, once two of us have had a glass each, it’s all too tempting to finish the bottle there and then. Coupled with the news that wine is getting stronger, it’s no wonder Britain's middle aged middle classes are getting wasted.

A recent report from Liverpool John Moores University showed that wealthy towns top the league table for hazardous drinking in the UK. The BMA's new report Alcohol misuse: tackling the UK epidemic also confirms that men and women who are higher earners are more likely than the lower paid to have drunk alcohol at all, and to have drunk on five or more days a week.

And, while beer remains Britain's favourite drink, wine consumption rose from 10% of all alcohol in 1970 to 28.8 % in 2005.

Wouldn't reducing wine portions reduce some of this consumption and harm, asks Groves?

Easier said than done. She points out that her local upmarket supermarket offers only three wines in half bottles and bumps up the prices prohibitively. Online UK retailers are no better, and it's no easier to find a decent half bottle in a UK restaurant.

Maybe this is a peculiarly British problem, she suggests. For example, restaurants and cafes in France offer drinkable wines by the carafe, pichet (small jug), and half bottle, and mini markets have a good range at 37.5cl at fair prices. Most French wine websites also have a tab for searching by bottle size, and plenty of half bottles to choose from.

There are some technical and economic downsides to producing wine in half bottles, she says, but some of the best French Grand Cru houses produce half bottles. And none of the disadvantages should rule out the production and sale of youngish, drinkable, everyday wines in half bottles.

She concludes: Banning supersize meals won't stop people from buying two regular burgers, and selling half bottles won't stop some drinkers from simply having two. But there must be at least one supermarket chain willing to give the half bottle market a proper go with a decent range and fair pricing, and to trump their competitors' hands for responsible, healthy retailing.

An editorial, also published in this week's journal, supports higher alcohol taxes and restricting availability, while a clinical review discusses the diagnosis and management of alcohol use disorders.

Contact:
Trish Groves, Deputy Editor, BMJ, London, UK
Email: tgroves{at}bmj.com

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