Compulsory vaccination and growing measles threat
BMJ 2017; 358 doi: https://doi.org/10.1136/bmj.j3429 (Published 20 July 2017) Cite this as: BMJ 2017;358:j3429
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Prof Melegaro might like to consider that irrespective of vaccination status four deaths from measles in eight months is not necessarily a great success for the Italian medical system compared with the British (Andrew Wakefield and all). According to a British government website we have only four deaths in twenty-five years. I quote:
"Prior to 2006, the last death from acute measles was in 1992. In 2006, there was 1 measles death in a 13-year-old male who had an underlying lung condition and was taking immunosuppressive drugs. Another death in 2008 was also due to acute measles in an unvaccinated child with a congenital immunodeficiency, whose condition did not require treatment with immunoglobulin. In 2013, 1 death was reported in a 25-year-old man following acute pneumonia as a complication of measles. In 2016, one death was reported in a 10-month-old infant who suffered complications due to a secondary infection.
"All other measles deaths since 1992 shown above are in older individuals and were caused by the late effects of measles. These infections were acquired during the 1980s or earlier, when epidemics of measles occurred."
It is vastly troubling that the Italian Minister of Health, Beatrice Lorenzin, is on record as stating that 270 children died in London of measles in a recent year, " ricordi di sono di morbillo che'n Londra all'Inghilterra la scorso anno morte due cento settanta bambini" (...reminds me regarding measles that two hundred and seventy children died last year in London in England..) [2]. She was complaining about people getting false information off the internet.
[1] Public Health England, 'Measles deaths by age group: 1980 to 2016 (ONS data)', https://www.gov.uk/government/publications/measles-deaths-by-age-group-f...
[2]
https://www.youtube.com/watch?v=DLm5HIdO-U0
Competing interests: No competing interests
Detailed information on the recent Italian measles outbreak can be found in: Filia A et al. Ongoing outbreak with well over 4,000 measles cases in Italy from January to end August 2017 −what is making elimination so difficult?. Euro Surveill. 2017;22(37):pii=30614. DOI: http://dx.doi.org/10.2807/1560-7917.ES.2017.22.37.30614
In this work, published by researchers in the National Public Health Institute, details on the patients' characteristics and immune status are provided. In brief, three deaths due to respiratory insufficiency occurred among children aged 16 months, 6 years and 9 years respectively. A fourth death occurred in a 42 year old man. All were unvaccinated and one child was immunocompromised due to ongoing chemotherapy for a malignancy.
In relation to the 88% of cases that were unvaccinated, this does not necessarily mean that there was a 12% failure rate. Actually, to the best of our knowledge, the failure rate is expected to be around 5% after 1st dose administration and less than 1% after 2 doses. Indeed, the 12% only represents the fraction of vaccinated cases over the total number of cases. This means for instance that, by assuming that all the individuals in the population are either vaccinated at 99% of efficacy (ie. with failure rate of 1%) or immune as a consequence of natural infection, the number of unvaccinated susceptible is zero so that the proportion of cases among vaccinated individuals will be 100%. On the other hand, by assuming that the vaccine efficacy is 1% (ie. vaccine failure is 99%) but no individuals in the population were vaccinated the proportion of cases among vaccinated individuals will be 0%. In sum, among other factors, the fraction of unvaccinated cases during an epidemic is the result of a complex interplay between i) vaccine failure rate, ii) past vaccination coverage, iii) the fraction of immune individuals in the population at the beginning of the epidemic, and iv) the transmissibility potential characterizing the pathogen considered.
Competing interests: No competing interests
Prof Melegaro and colleagues say that this year, so far, 4656 cases and 4 deaths have been reported and 88% of cases were unvaccinated.
Q. 1. Does this mean that there was 12% failure rate for the vaccine used in Italy?
Q. 2. What were ages of the fatal cases?
Q. 3. Had the fatal cases not been vaccinated?
Q. 4. Were the fatal cases suffering, concurrently, from any debilitating illness or were they immuno-compromised?
Q. 5. Were the measles patients native? Or were they visitors, or were they migrants (asylum serkers or economic)?
Para 2 of the letter ‘ .......a considerable immunity gap among adults between 15 and 40:years....”
Q. Has the immune status (possible sub-clinical or undiagnosed infection) been serologically determined in all or a sample of this population?
I am pleased to see that the authors have no competing interests.
I presume that they are not under any pressure to conform.
Could they please also tell me how tbe little difficuty of Dr Domicelli was resolved? As I recall, he was threatened with legal action by some government officials. He was a non-conformist.
Competing interests: No competing interests
Andrea Ammon, director of the European Centre for Disease Prevention and Control (ECDC), pointed out in the article that “more needs to be done to close immunisation gaps among adolescents and adults.” This is particularly relevant for Italy, where 4656 cases and 4 deaths have been reported since the beginning of 2017 – 88% of cases were unvaccinated – with a median age at infection of around 27 years [1,2].
These numbers are in line with a recent study [3] which innovates from previous work by providing estimates on the current susceptibility and immunity profiles in nine countries, including Italy, giving insights into the suitability of current vaccination strategies across different socio-economic settings. Estimates for Italy suggest the presence of a considerable immunity gap among adults between 15 and 40 years of age, as a consequence of past suboptimum routine vaccination. In particular, 3 million people (corresponding to 5.0% of the Italian population) aged 15-40 years are estimated to be currently unprotected against measles, representing a sufficient proportion of susceptible individuals to sustain measles transmission in the next decades (https://tinyurl.com/y9evb8gm).
The introduction of measles vaccination in Italy in the early 80s has averted about one million of years lost caused by illness, disability, or early death [3]. Yet, the remaining pockets of susceptibility in adolescents and adults, and the lack of immunization campaigns targeting individuals older than 15 years, may hamper measles elimination in Italy, despite the introduction of mandatory vaccination policies [4]. In particular, vaccination of pre-school and school-age children might not ensure the protection of the Italian population against measles in the coming years, and the prevention of infection among those who choose not to vaccinate or cannot be protected through vaccination due to underlying health conditions. This picture calls for the urgent implementation of additional policies aimed at targeting unimmunized adolescents and young adults to not frustrate efforts to increase routine childhood coverage levels.
References
[1] Filia A, Bella A, Del Manso M, Baggieri M, Magurano F, Rota MC. Ongoing outbreak with well over 4,000 measles cases in Italy from January to end August 2017 −what is making elimination so difficult?. Euro Surveill. 2017;22(37):pii=30614. DOI: http://dx.doi.org/10.2807/1560-7917.ES.2017.22.37.30614
[2] National Integrated Measles-Rubella Surveillance System. Measles in Italy: weekly bulletin. 2017;22. http://www.epicentro.iss.it/ (accessed Oct 16, 2017).
[3] Trentini F, Poletti P, Merler S, Melegaro A. Measles immunity gaps and the progress towards elimination: a multi-country modeling analysis. Lancet Infect Dis. 2017, published online Aug 11. http://dx.doi.org/10.1016/S1473-3099(17)30421-8
[4] Italian Ministry of Health (MoH). Il Decreto vaccini è legge, tutte le novità. [The vaccination decree is now law, all the novelties introduced English]. Rome: MoH; [Accessed 16
Oct 2017]. Italian. Available from: http://www.salute.gov.it/portale/news/p3_2_1_1_1.jsp?lingua=italiano&men...
p=dalministero&id=3027
Competing interests: No competing interests
As the author of the article points out, the beginning of 2017 was marked by a sudden desire of politicians, generally individuals, to make vaccination compulsory in many European countries. These countries are high income countries. Sweden must be added to the list since it has rejected a motion for making vaccines compulsory on May 10. This motion was part of different vaccination motions [1].
Two questions arise from these initiatives: why and for what purpose? A third question is: are these initiatives justified on scientific and public health grounds since they restrict strongly the freedom of choice of parents? The last point is an ethical and political issue that can’t be separated from the questions above but that has larger implications than for immunization alone.
First question, why? We can’t identify any particular event that puts public health at risk in European countries which are targeted by these measures. So the question hasn’t any clear answer.
For what purpose?
The answer given by the promoters of these measures is: “in order to increase vaccine coverage and reach herd immunity and to avoid an unacceptable public health threat”.
These arguments are based on arbitrary and unproven assumptions. And it can be proven.
So, will compulsory vaccination increase vaccine coverage?
The ASSET project, funded by the European Union, says “no”. In a study it shows that vaccine coverage in Europe is not related to compulsory vaccination [2].
Are we threatened by epidemics putting at risk public health if a higher vaccination coverage is not met?
Many vaccines included in national vaccination programmes have been introduced in recent years. The diseases targeted such as invasive pneumococcal disease, meningococcal disease can be characterized as endemic but not epidemic. Other diseases targeted such as varicella, rotavirus infections are epidemic but not threatening. They can hardly be compared with cholera in the nineteenth century.
In France most infectious diseases targeted by vaccination accounted for 0 to 20 deaths in children and adolescents under 18 every year BEFORE the introduction of the most recent vaccines. Many of these deaths occur in children and adolescents with severe conditions.
In France, it was stated that there were 10 deaths in recent years from measles. But most of these deaths were in adults, not children.
It’s worth remembering that approximately 3000 infant deaths occurred in under 1 year infants every year in France during the 2000s. 99% of those deaths are not caused by vaccine preventable diseases. The figures are substantially the same in other European high income countries.
But we can also ask: in the event of high and sustained immunization coverage, would this allow herd immunity and would herd immunity reduce the public health burden significantly for all the diseases targeted by these measures?
Herd immunity means trying to protect a small proportion of unvaccinated individuals by vaccinating the majority to prevent the circulation of an infectious agent.
Herd immunity is not a panacea and requires a number of conditions to be met.
Herd immunity won’t be reached if there are reservoirs of the agent other than in humans, or if the vaccine exerts a selection pressure that mutates the infectious agent, or if there are multiple strains of an agent and then the pressure of the vaccine causes replacement of vaccine strains by others. In the last two cases, increasing vaccination coverage would be counterproductive by hastening the replacement or the mutation.
It is the case with pneumococcal vaccine. In France the introduction of the Prevenar 7 vaccine has led to an increase of the total cases of invasive pneumococcal disease of about 20% with respect to the prevaccination period. During the 9 year period from 2003 to 2011 (Prevenar 13 was introduced in 2010 in France) there were 8000 more cases of bacteraemia and 230 more cases of meningitis as compared to the prevaccination period from 1999 to 2000 [3]. Moreover 19 A serotype, a more virulent multidrug resistant serotype, has emerged in all countries that had implemented pneumococcal vaccination [4].
Another example, somewhat different, is vaccination for whooping cough caused by Bordetella pertussis and para-pertussis. After the introduction of an acellular vaccine in the 1990s the current strain was totally replaced by a pertactine negative strain under vaccine pressure in the United States [5]. Fully vaccinated individuals have an OR of 2,7 (95% CI, 1.2–6.1) for having pertactine negative bordetella pertussis infections [6].
Moreover, the notification of cases does not allow a correct estimate of the real number of cases. A study conducted at GP surgeries in Paris in 2009 recruiting patients with persistent cough allowed the incidence to be estimated as 145 per 100 000 cases of whooping cough. This figure would represent at the national level 100 000 cases [7]. Many other international studies using this methodology have shown the same results. That simply means that, despite or due to very high immunization coverage, there are still many cases of whooping cough that are being underdiagnosed and under reported.
So science and public health benefits can’t be invoked and used in such a simplistic manner to justify a restriction in patients and doctors choices and freedom.
Immunization is a complicated topic that needs more reflection and less coercion.
It’s time to realize that vaccines, like medicines, are not a mystic panacea and that they are subject to the commercial and political pressure and also to the influence of conflicts of interest.
1- https://translate.google.com/translate?depth=1&nv=1&rurl=translate.googl...
2- http://www.asset-scienceinsociety.eu/reports/page1.html
3- INVS, Données Epibac 2014, 20/11/2015, PDF.
4- https://wwwnc.cdc.gov/eid/article/19/7/12-1830_article
5- https://www.fondation-merieux.org/documents/en/conference-resources/pert...
6- https://academic.oup.com/cid/article/60/2/223/2895696/Pertactin-Negative...
7- https://www.ncbi.nlm.nih.gov/pubmed/21315055
Competing interests: No competing interests
A. MEASLES
This is a growing MEASLES threat. I know HMG says there is no alternative to MMR. True of the UK.
Q, Why don't you tell parents that in Japan, there is no MMR available through government sources?
B. MUMPS
Not so long ago - please see British National Formulary, 1985, number 10 (1985), page 385, column two, first para - " Since mumps and its complications are very rarely serious there is little indication for the routine use of mumps vaccine."
Q. Do you, the doctors and the nurses working under your direction, ROUTINELY tell the "patients" and their parents the contents of the para mentioned here above? If not, why not?
C GERMAN MEASLES
You the doctors and the nurses working under your direction do know that:
1. A male of any age is NOT at risk of suffering terribly from this infection.
2. Injecting the male with the vaccine (be it the MMR or monovalent available in some other country) is of no use to the injected person, but perhaps to the " herd".
Q, Do you or the nurses afore-mentioned ever tell the MALE injectee about the above?
If not, why not?
3. A female who contracts wild German Measles is immune for life.
Q. Do you or the nurses ever tell the girls and their parents about the above? If not,why not?
4. A female or male immunised with MMR is NOT immune for life.
Q, Do you explain this to the girls or boys and their parents ? If not ,why not?
D. The availble vaccine - MMR
Do you or the nurses working with you ever tell the injectee or the parents, that:
No one has carried out long-term studies (say twenty years or more) to see if there are deterimental late effects or possible detrimental late effects of the vaccine!?
I know it is very difficult. Or, impossible? But do you admit it? Spontaneously?
There seems to be dishonesty. I am sure you are not dishonest.
I await an honest answer from clinical doctors, PUBLIC HEALTH doctors, PUBLIC HEALTH ENGLAND.
Or, do I wait in vain?
Competing interests: No competing interests
Role of MMR II vaccine contamination with GAD65 containing chick embryo cell culture in the etiology of type 1 diabetes
https://www.researchgate.net/publication/318305895_Role_of_MMR_II_vaccin...
The tick-borne encephalitis vaccine is also contaminated with GAD65 containing chick embryo cell culture and has the same problem.
This is Pandemrix vaccine induced narcolepsy, on a bigger scale.
What happens to vaccine policy when you account for this?
When vaccines are safe, no compulsion would be needed.
Thanks,
Vinu
Competing interests: No competing interests
Re: Compulsory vaccination and growing measles threat
The responses from Professor Melegaro and John Stone indicate there have been very few recent child deaths from measles in both Italy and the UK, in spite of considerable increases in reported measles cases.
Professor Melegaro reports out of a reported 4000 measles cases, “Three deaths due to respiratory insufficiency occurred among children aged 16 months, 6 years and 9 years respectively. A fourth death occurred in a 42 year old man. All were unvaccinated and one child was immunocompromised due to ongoing chemotherapy for a malignancy.”
John Stone reports in the UK "Prior to 2006, the last death from acute measles was in 1992. In 2006, there was 1 measles death in a 13-year-old male who had an underlying lung condition and was taking immunosuppressive drugs. Another death in 2008 was also due to acute measles in an unvaccinated child with a congenital immunodeficiency, whose condition did not require treatment with immunoglobulin. In 2013, 1 death was reported in a 25-year-old man following acute pneumonia as a complication of measles. In 2016, one death was reported in a 10-month-old infant who suffered complications due to a secondary infection.”
Children who are immune compromised cannot be vaccinated, since they are vulnerable to the three live, but attenuated, viruses contained in the MMR vaccine. In newly vaccinated individuals these viruses can ‘shed’ and infect other vulnerable individuals, and it is a matter of concern that few official warnings are issued about this, since vaccine derived measles cases occur in a significant proportion of cases. Vaccination failures also account for significant numbers of measles cases and the mumps MMR component is now admitted to wear off after around 10 years, which coincides with the child reaching adulthood, when the disease is far more serious and can cause sterility.
The parents of the 16 month old Italian fatal child measles case might have been preparing to vaccinate their child, since the MMR vaccine is widely recommended for administration at 15 months plus. They should not be blamed for their child’s vaccination status. We are given no details about the 2 older children reported to have died in Italy from respiratory failure due to measles infection, but it has been reported elsewhere the large influx of immigrants, many of whom originate from countries which do not routinely vaccinate their children, have been partly responsible for the reported increases in measles cases. One of the child fatal measles cases in Italy is reported to have been immune compromised.
In both Italy and the UK, MMR child vaccination rates are reputed to have recently fallen by one or two percentage points, but vaccination rates overall still remain high. I have never understood why monovalent vaccines for measles and rubella (girls only), are no longer available in the UK. Mumps in childhood is almost always benign and confers lifelong immunity. Forcing parents, who distrust the MMR vaccine, to have their children vaccinated under the threat of huge fines or no state schooling for non-compliance, smacks of totalitarianism and ignores the hard won Nuremberg Code, which insists on informed consent not coercion.
Laboratory-confirmed cases of measles, rubella and mumps, England: July to September 2018 https://assets.publishing.service.gov.uk/government/uploads/system/uploa...
Re: Compulsory vaccination and growing measles threat - Prof Melegaro's response (John Stone)
https://www.bmj.com/content/358/bmj.j3429/rr-7
Re: Compulsory vaccination and growing measles threat - Our response to Dr JK Anand (Alessia Melegaro)
https://www.bmj.com/content/358/bmj.j3429/rr-6
Competing interests: No competing interests