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Measles: Europe sees record number of cases and 37 deaths so far this year

BMJ 2018; 362 doi: https://doi.org/10.1136/bmj.k3596 (Published 20 August 2018) Cite this as: BMJ 2018;362:k3596

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Re: Measles: Europe sees record number of cases and 37 deaths so far this year

Editor

I thank John Stone for both his considered responses. I should start by saying that those of us working in adult medical specialties (and I am sure, in primary care too) are seeing an increasing number of people who have lived to mid life or well beyond with ASD and/or learning disabilities who present for care of acute medical illness or long term physical conditions. I would be the first to say that they often get a poor deal in mainstream health services because staff may not have the necessary knowledge or skills or specialist support to do the best job working with them or their families and there have been a number of recent examples of poor care to illustrate just this. It is also crucial for us to listen to those who know the person best, work with them and ensure we see the person behind any "label" - to the same extent we would for any other patient. Discriminatory services are unacceptable for whatever reason even if they come from lack of training or knowledge or from the person being in the wrong setting for their needs.

With regard to the reported rise in ASD and to what extent this is down to better recognition and better recording or whether the rise is far too big to be explained in this way, I will defer to the superior knowledge of those like John Stone, who know the field.

However, it is important to emphasise that for conditions such as Poliomyelitis, Pertussis and Measles there is a very considerable weight of epidemioligical evidence supported by reports from organisations such as the WHO, UN or Centre for Communicable Disease Control that mass vaccination programmes have been crucial in drastically reducing prevalence, incidence and harms including deaths. It is important not to present the two sides of the argument in terms of evidential equivalence when the overwhelming weight of evidence lies on the side of mass vaccination.

I completely agree that we all need to accept accounts of harms or reactions in good faith and not as vexatious or manufactured and take them seriously. And that we need to invest proportionately in researching harms as well as benefits of vaccination.

However, the concerns about harms of vaccination (including potentially their being a principal cause of a rise in ASD diagnoses) do raise a wider issue - which is "so what does this mean for public policy?"

For any major preventative intervention - especially when it comes to transmissible diseases, success rests on making it as universal as possible. And allowing the incidence of common infections to rise because we have scaled back our preventative interventions (and in the case of vaccines, reduced overall population immunity) could be seen as irresponsible and poor practice in prevention and public health and as setting back gains many years. Reduce vaccination uptake and a rise in disease incidence (and complications including death) is likely.

Commentators can argue till the cows come home about the balance of empirical evidence but for me the $64,000 dollar question is this. "If we accept without judgment that concerns raised about potential harms of vaccines are legitimate and have some emerging empirical data and expert opinion behind them, what do we then do in terms of public policy?"

Do we continue with mass vaccination programmes and aim for maximum population coverage, so long as we build in better surveillance on adverse effects and harms?

Do we change vaccination schedules (e.g. single vaccines instead of MMR) or timings? (But if we do so, then accept that coverage/uptake may be worse and disease incidence rise?)

Do we move away from the kind of national and international mass vaccination and eradication programmes for a range of infectious diseases that have been currency since the middle of the last century and leave decisions to individual citizens at the expense of population immunity?

If so, when it comes to children who are too young to decide for themselves on medical treatment, do we risk putting other people's children at risk for the sake of our own concerns about our own children?

What i would love to understand is what practical concrete public policy proposals those with understandable concerns about mass vaccination would like to see in place in stead of current arrangements.

Campaigning is important in many areas of public policy, but to govern is to decide. What should a Health Secretary or Chief Medical Officer or Director of Public Health England do?

David Oliver

Competing interests: No competing interests

28 August 2018
David Oliver
Consultant Physician
NHS
Berkshire