Measles: neither gone nor forgotten

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

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

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.

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.