Measles: neither gone nor forgotten
BMJ 2018; 362 doi: https://doi.org/10.1136/bmj.k3976 (Published 25 September 2018) Cite this as: BMJ 2018;362:k3976
All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
I am grateful to Allan Cunningham, who makes some excellent points [1].
I think it is is evident that measles mortality will depend on the condition of the exposed population plus the good sense and skill (or otherwise) with which the disease is treated, however I suspect his projections for mortality in the United States in the 1980s is rather high. For instance, according to CDC statistics prior to the introduction of measles vaccination in the 1960s there were about 4-500 deaths annually [2] at a time when almost everyone got it, and this would be in 1 in 5,000-10,000 range (of course I do not wish to make light of any deaths at all).
Also, I do not believe anyone should be sanguine about the rise in NDDs and autism which in population terms is much more serious than measles [3] and without credible official explanation, nor do I see that it is at all inherently implausible that vaccines might cause neurological injury [4] (the big question being how often). As to Mawson et al [5], they surely only really deserve praise for going where governments and health official will not. After all, it is scarcely a secure or lucrative career move.
[1] Allan S Cunningham, 'We DO need a broad look at vaccination policies and programs' , 8 November 2018 https://www.bmj.com/content/362/bmj.k3976/rr-12
[2] https://www.cdc.gov/vaccines/pubs/pinkbook/downloads/appendices/e/report...
[3] John Stone, 'What about autism?' 21 August 2018, https://www.bmj.com/content/362/bmj.k3596/rr-0
[4] John Stone, 'Response to David Oliver II (Risks of Vaccines)' 28 August 2018, https://www.bmj.com/content/362/bmj.k3596/rr-11
[5] Anthony R Mawson, Brian D Ray, Azad R Bhuiyan, Binu Jacob 'Pilot comparative study on the health of vaccinated and unvaccinated 6- to 12- year old U.S. children', Journal of Translational Science, 24 April 2017, http://www.oatext.com/Pilot-comparative-study-on-the-health-of-vaccinate...
Competing interests: No competing interests
WE DO NEED A BROAD LOOK AT VACCINATION POLICIES AND PROGRAMS
I am old enough to have seen children with measles during my medical career. It is a bad disease: before the vaccine one or two of every 1000 measles-afflicted children in the US died; one of every 1000 developed encephalitis, often with resultant brain damage. Universal measles vaccination has been lifesaving, and well worth the risk of reduced transplacental immunity and increased vulnerability in adults….Nevertheless, Bernadette Pajer is absolutely right to criticize the medical community for failing to step back and examine the overall impact of immunization programs on public health.
Years ago, Paul Fine and Peter Smith said this: “The dramatic global decreases in frequency of most of the diseases targeted by EPI vaccines (e.g. measles, polio, pertussis, tetanus and diphtheria) are measures of success of that programme, but mean that any non-specific effects will assume greater relative importance than in the past.” They suggested that, as new vaccines are introduced into all populations, we need “…not only to evaluate the immunologic benefits, but also to evaluate possible longer term beneficial or adverse non-specific effects.” (Fine, Trop Med Int Health 2007;12:1) As immunization schedules have expanded, our ignorance of overall risks and benefits have also expanded.
Some specific points:
1) I doubt that vaccinations are a major cause of our increase in autism, but without properly controlled trials we can neither prove nor exclude causation, contrary to what we hear endlessly from vaccine authorities. A recent survey of US home-schooled children found that neurodevelopmental disorders, including autism, were 3 to 4 times as frequent in vaccinated vs. non-vaccinated children: P<0.001. Partially vaccinated children had intermediate risks. (Mawson, J Transl Sci 2017;3:1) This study is likely to be biased, but it was reasonably well designed and cannot be dismissed out of hand.
2) There are other “mystery diseases” like SIDS and Kawasaki disease that have been associated with vaccinations and dismissed by vaccine authorities, again without properly controlled trials.
3) The latest mystery disease is acute flaccid myelitis/AFM. It afflicts mainly children as they return to school in September. A role has been suggested for vaccinations via “provocation paralysis.” (Cunningham, BMJ rapid response, Jan.30, 2015) So far, public health authorities have not investigated the possibility.
4) Unlike Ms. Pajer, I do not worry about a decline in herd immunity from measles vaccination, but I suggest that this may be occurring with influenza as a result of universal vaccination against influenza during the last 10-15 years. Our influenza seasons seem to be getting worse in the face of increasing vaccination, and there are regular reports of “negative vaccine effectiveness” (i.e. increased risk of illness) against some strains of virus and in some age groups.
5) Ms.Pajer might remember news reports of a 6 year-old boy from Ferndale, Washington who died of an AFM-like illness with encephalitis. He had received several vaccinations, including a flu shot, 14 days before the onset of his fatal illness. (Aleccia, Seattle Times, November 2016)
We do need a broad look at the risks and benefits of our vaccination programs.
ALLAN S. CUNNINGHAM
Competing interests: No competing interests
Dear Editor
There is a fact rarely considered by public health officials: vaccination is not an intervention that eliminates disease exposure for individuals. Vaccination replaces wild exposure with artificial exposure, and they are not equal. We are many decades into mass vaccination campaigns, and it is alarming that instead of the medical and scientific community stepping back to examine the overall impact on public and individual health to see if current strategies should be reevaluated, the focus is on those who question or refuse vaccination.
Experts have acknowledged that the current measles vaccine cannot eradicate measles because of primary and secondary failure.[1] Studies have found that the concentration and duration of maternal antibody protection for infants with vaccinated mothers is lower and shorter than protection provided by non-vaccinated mothers [2] , and it has been found that a third dose of MMR cannot boost protection for any length of time [3] , leaving most adults unprotected. We have entered a vaccine-era of vulnerable infants and vulnerable older adults—populations that were protected when measles circulated naturally. It’s a messy conundrum, and it cannot be laid at the feet of those who opt out of vaccination. For the vast majority of healthy children who can easily handle a case of measles in childhood, vaccination provides no personal benefit and exposes them only to vaccine injury risk and vulnerability to measles in adulthood.
Since industry does not make a single measles vaccine available, that leaves just the controversial MMR that appears to not have had any clinical trials. MMR contains fragmented fetal DNA in the rubella portion, which some find morally objectionable and others medically problematic because of the potential for autoimmunity and insertional mutagenesis [4] . As well, the vaccine is highly contaminated with glyphosate from the gelatin [5] , and there are no studies showing injecting glyphosate to be safe or how it may alter the immune response to the other ingredients. Add that Merck has been accused of falsifying the efficacy of the mumps portion of their vaccine [6] and, Houston, we have a problem.
100% vaccination uptake would not alter the dilemma of vaccine failure or risk. The WHO chose a goal of global eradication before they had a safe tool able to achieve it. Rather than pushing for higher uptake, time and money would be far better spent on implementing rapid diagnosis and notification programs using new technologies to utilize good old-fashioned detection & isolation, researching best and safest measles treatments, and building the basics of healthy immunity in poor communities: clean water, proper sanitation, and adequate nutrition.
[1] Poland, Gregory A and Robert M Jacobson. “The re-emergence of measles in developed countries: time to develop the next-generation measles vaccines?” Vaccine vol. 30,2 (2012): 103-4.
[2] Waaijenborg, et al. “Waning of Maternal Antibodies Against Measles, Mumps, Rubella, and Varicella in Communities With Contrasting Vaccination Coverage.” OUP Academic, Oxford University Press, 8 May 2013, academic.oup.com/jid/article/208/1/10/796786.
[3] Fiebelkorn AP, Coleman LA, Belongia EA, et al. Measles virus neutralizing antibody response, cell-mediated immunity, and IgG antibody avidity before and after a third dose of measles-mumps-rubella vaccine in young adults. The Journal of infectious diseases. 2016;213(7):1115-1123. doi:10.1093/infdis/jiv555.
[4] Deisher, T A, et al. “Epidemiologic and Molecular Relationship Between Vaccine Manufacture and Autism Spectrum Disorder Prevalence.” Issues in Law & Medicine., U.S. National Library of Medicine, 2015, www.ncbi.nlm.nih.gov/pubmed/26103708.
[5] Honeycutt, Zen. “Glyphosate in Childhood Vaccines.” Moms Across America, www.momsacrossamerica.com/glyphosate_in_childhood_vaccines.
[6] Solomon, Lawrence. “Merck Has Some Explaining To Do Over Its MMR Vaccine Claims.” HuffPost Canada, HuffPost Canada, 27 Nov. 2014, www.huffingtonpost.ca/lawrence-solomon/merck-whistleblowers_b_5881914.html.
Competing interests: No competing interests
It is 50 years since we, the trusting public, have been led to believe that a particular medical product introduced in 1968 would eradicate measles. Twenty years on, in 1988, a new bigger and better product came along. The, then, health minister Edwina Curry announced ‘one jab – lifelong protection’. However a few years later a booster dose was introduced? No mention of lifelong protection that time round.
According to the data on the PHE site, which starts from 1940, it is very clear that a large fall in measles mortality occurred in the first decade and a half, well BEFORE any medical attempt to eradicate measles was introduced. According to McKeown (1): ‘less than a quarter of all children had been protected by the end of 1972’, and yet still the measles cases and deaths continued to fall despite the low uptake. In a DoH book (2) it states that ‘from 1968 to 1980 the uptake remained between 50-60%’, and yet still the measles cases and deaths fell despite the fact that the uptake was nowhere near the, now claimed, required figure of 95% uptake of 2 doses of MMR.
At the end of the 1950s you will find the description of measles by medical doctors very different to the doctors of today. Why would that be? It was because measles had been declining over the centuries, alongside other zymotic diseases, mostly due to social improvements, and by the late fifties was generally viewed as a straightforward childhood illness in the majority of cases. For example, regarding a measles epidemic in early 1959 the BMJ published (3): ‘the writers (the reporting GPs) agree that measles is nowadays normally a mild infection….’ If in 1959 it was referred to as ‘normally a mild infection’ why are today’s public (including a good proportion of health professionals) being presented a very different image? We are constantly being told of the threat of serious complications and deaths if herd immunity (another questionable theory) is not achieved via high MMR uptake.
Has measles evolved into a more deadly disease?
Why are parents being made to fear a ‘normally mild infection’ of the 1950s? You would think that by now it should have evolved into an extremely mild infection or almost non-existent? Perhaps Elliman has an explanation? Does he consider measles more dangerous than back in the 1950s? And if so, why?
Quoting figures regarding immunisation status, I wonder if Elliman can be more detailed in his comment. In my experience it is very difficult to obtain the status, as it is not generally recorded. Stating that in the 90% of cases where the status was known is rather vague. For example, if there were only 10 cases with known status out of hundreds of measles cases with unknown status, then that would mean you are only talking about 90% of 10.
Good that the authors admit that ‘inaccurate data collection’ occurs regarding the variations in uptake. If it can occur in this area how accurate is the collection of data on other aspects of this subject?
Measles was predominantly a childhood illness and yet a worrying trend is appearing with the age of incidence now high in the 20-39 year olds? MMR uptake has generally been reasonably high since it’s introduction and it is very likely that many of those cases in the older age group received at least one MMR and/or the MR during the campaign targeting all 5-16 year olds back in Nov 1994. Has the MMR programme shifted the age of incidence to an age where there may be more complications? As one Public Health doctor pointed out to me recently: ‘The case–fatality ratio for measles is age-related and is high in children under one year of age, lower in children aged one to nine years and rises again in teenagers and adults’ (4)
Has the MMR suppressed the individual’s system - resulting in a delay in their ability to develop measles at the appropriate age? A medical paper (5) reporting on a measles outbreak in a tertiary level hospital in Portugal states that strikingly most cases were in the 18-39 year old fully vaccinated health care workers. They indicate this may be due to waning immunity.
Given that ‘immunity’ is not understood – what does the future hold regarding number of MMR doses? Shifting a ‘normally mild infection’ into an age bracket where there is an increased chance of serious problems is not a very productive achievement in my opinion.
Right-wing political parties? Russian trolls? Associating anyone who dare mention the ‘v’ word in any critical form with particular groups or individuals is sadly a growing trend. It is an attempt to alienate the general public towards those who are asking questions. People from all walks of life have many concerns and it is much more than just a sentiment.
We all share the same goal – good health for all. Those who speak out have nothing to gain and yet they are met with hostility or are demonized. As the scientist Wallace stated back in 1898 in his book Vaccination A Delusion (6):
“Why this effort at secrecy in such a matter if there is nothing to hide? Surely it is to the public interest that official statistics should be made as correct as possible; and private persons who go to much trouble and expense in order to correct errors should be welcomed as public benefactors and assisted in every way, not treated as impertinent intruders on official privacy, as it is too frequently the case.”
The health of the recent generations concerns me. We are long overdue for an independent critical overview before health is gone and forgotten.
References:
1. The Role of Medice, McKeown T. p.106
2. Immunisation Against Infectious Disease 1990; p52
3. Measles Epidemic; BMJ; 7 Feb 1959 p354
4. Plotkin and Orenstein, 2004, Chapter 19
5. Measles outbreak in a tertiary level hospital, Porto, Portugal, 2018: challenges in the post-elimination era. Machado et al; Eurosurveillance, Vol 23, Issue 20, May 2018
6. Vaccination A Delusion (1898); Wallace A R, p.27
Competing interests: No competing interests
I agree with Dr Spitzer's comment that the cause of the poor immunisation uptake is NOT due to access problems. Vaccine access problems? This is not something I have heard about from all the parents I have come into contact with over the last 27 years. I am however experiencing more and more parents with doubts over the MMR trying to ACCESS more information on the subject. Especially since many of the research papers are being archived and hard to access.
As Dr Spitzer points out that 'Even when offered on-the-spot immunisation during a consultation the refusal rate is high.' This is a clear example that it is not about accessing the MMR.
Competing interests: No competing interests
We work as GPs (one of us (JS) for over 33 years) in a practice comprised mainly of patients belonging to the orthodox Jewish community of north London referred to in your editorial Measles:neither gone nor forgotten (BMJ 2018;362:k3976). I discuss immunisation with these patients on a daily basis and must disagree with the assertion that the cause of the poor immunisation uptake is due to access problems. This assertion is based on the paper by Letley L, Rew V, Ahmed R, et al (Vaccine 2018 Jul 25;36(31):4687-4692. doi: 10.1016/j.vaccine.2018.06.028. Epub 2018 Jun 23) which relies heavily on information obtained from questionnaires and interviews with parents.
Access to immunisations has always been good in this area, whether at GP surgeries, child health clinics and other facilities, as well as at a number of initiatives to facilitate ease of access over the years. I am aware that parents have become wary of discussing with healthcare professionals their reasons for not vaccinating, and fall back on the excuse of lack of access. This will be reflected in any research done with this community. Even when offered on-the-spot immunisation during a consultation the refusal rate is high. Refusal is for a variety of reasons, including what your editorial terms ‘antivaccination sentiments’, but is not due to lack of access.
Competing interests: No competing interests
I wonder if Helen Bedford and David Elliman [1] can assist? Daily opprobrium is heaped on things like "antivaccine sentiment" and "social media" for damaging the programme and putting children at risk, including recently the Chief Medical Officer, Dame Sally Davies, on the BBC [2]. But in fairness what is the evidence base for MMR safety (setting aside products like Pluserix and and Imravax which had to be withdrawn anyway [3])? Dame Sally says "It's a safe vaccination - we know that" [2] but she does not say how we know. Three times Cochrane told us that safety studies were "largely inadequate" [4]. We have this new found interest in publishing trial data [5], but in the case of MMR there does not seem to be any anyway. We also have serious questions being asked about the monitoring zeal of the licensing agencies into other vaccines [6,7,8].
So, if there are doubts surely it is not the public who are to blame, and blaming the public does not solve the issue. Where are the good studies and sound monitoring procedures that the public are entitled to, and how are properly informed citizens supposed to proceed in their absence?
[1] Helen Bedford and David Elliman, 'Measles: neither gone nor forgotten, 25 September 2018, https://doi.org/10.1136/bmj.k3976
[2] Philippa Roxby ''Don't be taken in by anti-vaccine myths on social media'', 1 November 2018, https://www.bbc.co.uk/news/health-45990874
[3] http://apps.who.int/iris/bitstream/handle/10665/228497/WER6741_301-302.P...
[4] John Stone, 'Response to David Oliver II (Risks of Vaccines)', 28 August 2018, https://www.bmj.com/content/362/bmj.k3596/rr-11
[5] Nigel Hawkes,' “Shocking” number of clinical trials are never reported, say MPs',
BMJ 2018; 363 doi: https://doi.org/10.1136/bmj.k4582 (Published 30 October 2018)
[6] Jørgensen L, Gøtzsche PC, Jefferson T.'The Cochrane HPV vaccine review was incomplete and ignored important evidence of bias', BMJ Evid Based Med. 2018 Oct;23(5):165-168. doi: 10.1136/bmjebm-2018-111012. Epub 2018 Jul 27
[7] Doshi P., 'Pandemrix vaccine: why was the public not told of early warning signs?', BMJ. 2018 Sep 20;362:k3948. doi: 10.1136/bmj.k3948
[8] Jørgensen L, Doshi P, Gøtzsche P, Jefferson T., 'Challenges of independent assessment of potential harms of HPV vaccines.', BMJ. 2018 Sep 24;362:k3694. doi: 10.1136/bmj.k3694. No abstract available.
Competing interests: No competing interests
This is my response to Ms Elizabeth Hart who commented on 29 October to my earlier response.
I was ignorant of the papers she refers to. Having now read those, I share Ms Hart’s fear that maternal antibodies to MEASLES acquired through vaccination may not be as long lasting as those resulting from natural infection. It is obvious that if the mother has fewer antibodies, the newborn will have received fewer antibodies through the placenta.
Could immunologists with experience please explain to us the facts known? And could they also tell us if any work is going on to increase our knowledge?
Thank you.
Competing interests: No competing interests
Herd immunity is often mentioned, as it is in this article, as if it is a precisely defined concept that must be satisfied, “ to protect vulnerable people who cannot be immunised.” The authors state that “this requires 95% uptake of two doses of MMR vaccine.”
There are numerous reports of outbreaks of measles where this level has been exceeded. (1,2).
A 1994 study indicated that as vaccination increases, measles becomes a disease of vaccinated people, “ ..in the particular case of measles,’herd immunity’ is not completely effective in preventing an outbreak of measles despite extraordinarily high immunisation rates.“ (3)
Confusion about the nature of herd immunity may reflect the fact that the term was first used when referring to populations who had acquired natural immunity to an infectious disease.
Such natural immunity is usually life long.
Immunity from vaccination is recognised to be variable in effectiveness, and tends to wane, over a few decades, or sooner.
Hence the concept of herd immunity must be used with caution where vaccinated populations are concerned, and this uncertainty must be explained to patients and parents when their fully informed consent is sought, prior to vaccination.
1 JAMA. 1990 May 9;263(18):2467-71.
Mild measles and secondary vaccine failure during a sustained outbreak in a highly vaccinated population.
2 Pediatr Infect Dis J. 1993 Apr;12(4):292-9.
Investigation of a measles outbreak in a fully vaccinated school population including serum studies before and after revaccination.
3 Gregory A Poland, and Robert Jacobson. Failure to Reach the Goal of Mealses Elimination: Apparent Paradox of Measles Infection in Immunised Persons.
Archives of Internal Medicine, August 22nd, 1994 pp1816-1818.
Competing interests: No competing interests
Universal measles vaccination - "well worth the risk of reduced transplacental immunity and increased vulnerability in adults..."?
I'm astonished by Allan S. Cunningham's comment "Universal measles vaccination has been lifesaving, and well worth the risk of reduced transplacental immunity and increased vulnerability in adults..."
I suggest reduced transplacental immunity is an extremely serious outcome of the measles vaccination intervention. We have no idea as yet what this means for future generations of children of vaccinated mothers, and the vulnerability of babies to disease at an earlier age.
In a measles outbreak in Australia in 2012 (168 notified cases) <1 year olds had the highest notification rate, with 10 cases aged <9 months. A paper discussing Australia's experience with declining measles antibodies states: "Continued close monitoring of cases occurring before 12 months of age (when MMR1 is due) will help to determine if vaccine schedule changes are required. This is particularly important in Australia as since July 2013 the second dose of MMR (given as MMR-Varicella) has been moved from 4 years to 18 months of age. As we have demonstrated that antibody levels begin to decline from 5 years of age (soon after children were due their MMR2 at 4 years), this change has the potential to lead to even lower antibody levels in young adults."[1]
The paper also states: "The clinical significance of declining anti-measles IgG antibody levels for protection against infection or disease is not clear..."
Do Allan S. Cunningham or others see anything to worry about here, including the reference to potential "vaccine schedule changes" and the ever-increasing load of vaccine products and revaccinations imposed upon babies and children?
This experience with measles vaccination also has implications for the implementation of other and new vaccine products and consequences for natural immunity. I suggest we have to think very carefully before implementing still experimental vaccine products, particularly for rare diseases such as invasive meningococcal B and others.
As I asked in my previous rapid response on this article, are any 'authorities' thinking about the big picture here?
Disclosure: I'm a 'measles survivor'. Born November 1959. Had measles around 18 months of age. Asked my mother about this event. She said doctor told her not to worry, they would just run their course (a rather more benign message than we receive nowadays...) My mother said the spots lasted about ten days and I did not seem to be too adversely affected. I had a serology test in 2012 - measles virus IgG antibody detected.
Reference:
1. Heather F. Gidding et al. Declining measles antibody in the era of elimination: Australia's experience. Vaccine 36 (2018) 507-513.
Competing interests: No competing interests