David Oliver: Vaccination sceptics are immune to debate
BMJ 2019; 365 doi: https://doi.org/10.1136/bmj.l2244 (Published 22 May 2019) Cite this as: BMJ 2019;365:l2244
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David Oliver needs to recognise that the ultimate problem is not that vaccine critics are sentimental about disease but if policy can only be maintained by heaping scorn and loathing on those people then there is something amiss. How, in such a culture, could safety be more than notional? The witnesses are disparaged, the symptoms are dismissed.
Being predisposed to disparage what the patient is telling you is not normally considered a medical virtue. I recall as a child the dentist told me to raise my hand if it hurt too much - and indeed when I raised my hand she pushed it down and told me not to be so silly. Oh dear!
Competing interests: No competing interests
Whether or not I qualify for David Oliver’s “vaccine sceptic” label, I can assure him that “ vaccine positivists “ (to extend his terminology to embrace those who seem happy with the status quo) may be no better at communicating in debate, than are those “sceptics” he finds fault with.
Oliver may be aware that in the past eighteen months about 100 copies of three well referenced books on vaccination science and controversies were sent to senior doctors, legislators, and other vaccine cognoscenti, in an attempt to stimulate debate. Four or five were acknowledged. (1)
The questions posed by Oliver in his follow up response (2) seem to require answers “ ... from those campaigning against vaccination...“. Oliver’s choice of words rules out most contributors to this on line discussion, who are concerned to encourage an informed debate on the safety and effectiveness of vaccines, not to eliminate their use.
Oliver raised some similar points last year, (3) and I attempted straightforward replies, (4).
He did not comment.
He and like minded colleagues have regular access to the BMJ print edition. Others, who raise uncertainties about vaccination, are sometimes labelled as ‘anti vaxx’ in those pages, where we are not granted space to justify our unease. We remain grateful to the BMJ for on line access.
The essential medic-legal issue is surely the need for every patient or parent in the UK to be provided with sufficient information on the effectiveness, safety and possible side effects of vaccines, so that they can give fully informed consent.
I make no excuse for repeating, yet again, this necessary professional duty, which is part of UK law. (5)
Has Oliver, or have any of his like minded colleagues, acknowledged that they are aware of the necessity of gaining fully informed consent, in these post Montgomery times, and of the consequences of not doing so ?
The Patient information Leaflets (PILs) for vaccines describe possible rare, serious side effects. eg. The Guillain-Barre syndrome. (6) If these are not discussed, and the child is affected by such an alleged adverse event, the courts have demonstrated that neglecting the Montgomery decision in clinical situations will be punished - to the tune of £4.4million damages - in a case last year. (7)
I am not aware of any comment on this case, from the JCVI, the RCGP, nor PHE, whose ‘Green Book’ on immunisation in primary care continues to quote the Bolam case, and not the Montgomery decision, in its chapter on liability. (6)
It is four years out of date.
Similarly, I am not aware of comments on the seeming conflicting interests of the chairperson of the JCVI I raised in a rapid response. (8)
Are such conflicting interests consistent with the impartial role of the JCVI ?
In view of Oliver’s professed trust in such expert bodies, he may wish to comment ?
How many parents are given the PILs to read carefully, as the PIL heading requests ? How many doctors are cognisant of the rare but real risks of adverse effects, and how many are knowledgeable enough to put the risks in context ?
How many doctors explain to parents, the practice’s financial interest in achieving high vaccination rates ?
If we cannot give confident positive answers on these points, the tendency of Oliver, his colleagues, and the WHO to concentrate attention on “vaccine hesitancy" seems very strange, when such central concerns go unaddressed.
My concern is to make our profession more aware of the need for informed consent, post -Montgomery, and of the need for us to be well informed on all aspects of vaccine use.
At the BMJ, informed consent for vaccination seems to arouse little interest.
The BMJ recently left unreported the 30 year failure by the USA HHS, to perform its statutory governance role regarding the vaccine industry. (9)
Very relevant to the UK, is it not ?
Attempting to debate the role of vaccination in the northern hemisphere is more difficult because many serious students of vaccination seem unaware of the research of Thomas McKeown, later confirmed by others, showing that the morbidity and mortality from common infectious diseases had fallen almost to zero before the widespread use of antibiotics and vaccines. (10)
1. https://www.bmj.com/content/363/bmj.k4953/rr-2
2. https://www.bmj.com/content/365/bmj.l2244/rr-9
3. https://www.bmj.com/content/362/bmj.k3596/rr-17
4. https://www.bmj.com/content/362/bmj.k3596/rr-22
5. https://www.supremecourt.uk/cases/docs/uksc-2013-0136-judgment.pdf
6. https://www.bmj.com/content/364/bmj.l739/rr-1
7. http://www.bailii.org/ew/cases/EWHC/QB/2018/164.html
8 https://www.bmj.com/content/360/bmj.k1378/rr-3
9 https://www.bmj.com/content/362/bmj.k3244/rr
10 Thomas McKeown. The Role of Medicine. Nuffield Provincial Hospitals Trust. 1976.
Competing interests: No competing interests
David Oliver, you say “My starting point in looking into any medical field investigation or treatment not in my own field of expertise and practise would be to go for systematic reviews, expert guidelines, professional bodies and acknowledged content expertise.”[1]
I cited a Cochrane systematic review of MMR vaccination in my letter questioning the Australian government’s requirement that children be vaccinated with two doses of the MMR vaccine to access financial benefits, i.e. challenging the second dose. My letter was addressed to then Australian Federal Health Minister Tanya Plibersek, and was forwarded in June 2012.
In my letter to then Health Minister Tanya Plibersek, I note that the Cochrane systematic review of MMR vaccination reports that “based on the available evidence, one MMR vaccine dose is at least 95% effective in preventing clinical measles and 92% effective in preventing secondary cases among household contacts”. The Cochrane review also notes that: “The design and reporting of safety outcomes in MMR vaccine studies, both pre- and post-marketing, are largely inadequate.”[2]
FYI, a copy of my letter to then Health Minister Tanya Plibersek can be accessed via this link:
http://users.on.net/~peter.hart/Letter_to_Minister_Plibersek_re_MMR_vacc...
(My letter to Tanya Plibersek is fully referenced. The letter also includes hyperlinks, but some of these might now be broken, or hyperlinked documents might have been modified/updated, given the passage of time since 2012, but the references are there for back-up.)
References:
1. David Oliver’s response to Elizabeth Hart (27 May 2019) on David Oliver: Vaccination sceptics are immune to debate:
https://www.bmj.com/content/365/bmj.l2244/rr-15
2. Demicheli V, Rivetti A, Debalini MG, Di Pietrantonj C. Vaccine for measles, mumps and rubella in children. Cochrane Database of Systematic Reviews 2012, Issue 2. Art. No.: CD004407. DOI: 10. 1002/14651858. CD004407.pub3.
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004407.pub3/...
Competing interests: No competing interests
VACCINE SCEPTICS, MANDATES AND RANDOMIZED TRIALS
Nick Mann correctly observes that MMR uptake dropped in the UK following Wakefield’s 1998 report in The Lancet (from over 90% before Wakefield to 83.8% by July 2002--Horton, “Vaccine Myths” in Health Wars, 2003), but does not ascribe recent drops in vaccination rates to “the Wakefield effect.” (BMJ rr 5/25/19) There were serious vaccine safety concerns before Wakefield, and some commentators had the view that the media furore following his report was prompted more by those prior concerns than by the report itself. In the last 20 years a number of additional vaccine safety concerns have emerged, unrelated to MMR or autism, but they have received short shrift while the media continue a misleading focus on Wakefield, MMR and autism. One recent example is the Dengvaxia scandal in the Philippines, which accelerated a decline in vaccine uptake and led to their current measles outbreak.
David Oliver asks, “Where does the balance of personal choice vs. population benefit lie?” (BMJ rr 5/25/19) The answer depends on the target disease. Measles is a bad and a highly contagious disease; the herd immunity threshold typically quoted for measles is 92-95%, although a recent meta-analysis suggests that it may be substantially lower in some circumstances. (Guerra et al, Lancet Inf Dis 2017;e420) The HITs for diphtheria, pertussis and polio are 85%, 93% and 83%, respectively. (Fine, Epidem Rev 1993;15:265) These also are bad contagious diseases for which we should maintain herd immunity. The same cannot be said for other diseases on the immunization schedule, and we should certainly not infringe upon parental/child autonomy for the sake of these other vaccines.
I am glad that Dr. Oliver and Dr. Mann are against compulsory vaccination, even though they are vaccine advocates, and I appreciate their civil discourse.
Dr. Oliver asks, “How much evidence and expert consensus do we need to prove that vaccination programs are effective?” Once again, the answer depends on the particular vaccine, including what we truly know about adverse effects. He is correct when he asserts that, “clinical trials (are) hard to achieve for well-established vaccination programmes.” However, the reality is that vaccination programs have been established with quite limited information about long-term effectiveness and safety. Furthermore, this has not stopped many vaccine authorities from declaring a “Catch-22”, that such trials are now unethical!
Dr. Oliver says, “…our focus should be constructive engagement with the vaccine-hesitant to understand their fears.” I believe we already understand the fears of honestly vaccine-hesitant individuals; their fears are based on concrete examples of vaccine adverse effects and on awareness that the sum of our knowledge is incomplete. By the way, among the “vaccine-hesitant” are some doctors, nurses, epidemiologists, and vaccine experts.
I recently re-read Richard Horton’s book MMR. Science & Fiction. Exploring the vaccine crisis, 2004. It is a detailed, heartfelt narrative of the Wakefield episode. Dr. Horton managed, barely, to keep his job as Lancet editor, where he continues to this day. I also re-read “Vaccine Myths”, which he concludes by saying, “Vaccines have been one of the great success stories of human scientific ingenuity—and one of the most degrading examples of man’s selfishness and greed.” (2003) I don’t know what he would say today.
We don’t need more PR campaigns or vaccine education programs. In the US, at least, we need to quit bullying parents about every vaccine on the immunization schedule. We need better and more transparent vaccine science, including honest surveillance of adverse effects, instead of the “window-dressing” represented by VAERS. We need more effective influenza, pertussis, and mumps vaccines. Finally, we need unbiased, randomized trials of vaccine schedules as a whole, so that we can know the true balance between risks and benefits.
ALLAN S. CUNNINGHAM 27 May 2019
Competing interests: No competing interests
Editor
Elizabeth Hart is quite right to assert in the title of her response that I am not qualified to answer detailed questions about vaccination. As i was quite clear about this in my original response my admitting it again should be no surprise
I didn't use the term "mere layperson". I think anyone with relevant scientific training and some expertise in systematic literature review, epidemiology, phases of drug development, medical statistics and critical appraisal of research is capable of appraising studies.
However, i think it takes someone who is steeped in a particular field very conversant with the literature and the full range of literature is best able and qualified to comment. And bodies which have within them a whole range of such expertise are better qualified still.
My starting point in looking into any medical investigation or treatment not in my own field of expertise and practise would be to go for systematic reviews, expert guidelines, professional bodies and acknowledged content expertise .
That's a plan I'll stick with
As for other people who do consider themselves experts, and are recognised as such,, whether or not to reply to BMJ rapid responses is their perogative. But there may be more direct ways to ask them
David Oliver
Competing interests: No competing interests
David Oliver admits he is not qualified[1] to consider or respond to my questions about MMR vaccine products, i.e. about shorter term maternally derived antibodies via vaccinated mothers, or why parents and others are not offered the option of antibody titre testing after the first dose of MMR vaccine[2].
In regard to my questions he says “...I don’t ‘think anything’ about them because despite being a medical qualified and research trained doctor I have no relevant content expertise and am not prone to wading into areas of data science I don’t have the experience, content expertise, training or un-earned overconfidence to do”.
Does David Oliver presume that a mere layperson cannot have anything of value to say about vaccination, that citizens are not entitled to ask questions relevant to vaccination policy?
Does David Oliver suggest that my questions are not worthy of response from those accountable for vaccination policy and practice?
I ask again, is there someone with responsibility for vaccination policy and practice, and with knowledge of the MMR vaccine products, able to respond to the questions outlined in my previous rapid response on this article? See: Vaccination, the medical establishment, and immunity from accountability:
https://www.bmj.com/content/365/bmj.l2244/rr-3
References:
1. David Oliver’s response to Elizabeth Hart on David Oliver: Vaccination sceptics are immune to debate: https://www.bmj.com/content/365/bmj.l2244/rr-1
2. Elizabeth Hart. BMJ rapid response: Vaccination, the medical establishment, and immunity from accountability: https://www.bmj.com/content/365/bmj.l2244/rr-3
Competing interests: No competing interests
Editor
I thank Nick Mann for his measured and thoughtful comments and as a GP i realise he must have considerable experience of delivering and co-ordinating vaccinations and doubtless encountering some parents or patients who were hesitant if not completely opposed to vaccines.
I have personally never argued for mandatory vaccination enforceable by law and i can't see myself doing so.
As i said in my column, citing others who have made the same argument, i think we need to work with those who are vaccine hesitant, understand their fears and concerns and work to overcome them with information and reassurance.
My other remarks were aimed at activists and campaigners and in some cases propagandists who wish to discredit or undermine mass vaccination programmes and for whom, the WHOs claim that even between 2010 to 2015 an estimated 10 million deaths were prevented by vaccination would be disputed, challenged or minimised at every turn
My view is that arguments with such groups cannot easily be won with consensus expert opinion, or big epidemiological data or systematic reviews of the evidence because the tactics and lines of arguments they tend to deploy make it a near futile quest
David Oliver
Competing interests: No competing interests
For several years of my working life, I immunised babies and toddlers in Child Health Clinics, until that task was diverted to GP surgeries by financial incentives. I was not sorry! Nevertheless it was still part of my job to encourage vaccinations, since enquiring is part of a full paediatric history.
My impression was that many parents who had strong anti-vaxx views were more interested in converting me to their opinions than in listening to anything I could say. Some people seemed to believe that nothing free could be of any value, in comparison with cranial osteopathy (which can cure allegedly, everything from depression to dyslexia, growth hormone deficiency, as well as, more believably , the three-month colic in only three months), homeopathy, Chinese herbal medicines (with no English language labels, let alone a patient information leaflet).
In the case of autistic spectrum disorders, sometimes there are subtle signs apparent to developmental paediatricians before the child was immunised, and hints of sub clinical traits in parents.
Like ADHD, which only came to notice once all children had to go to school, ASDs belong, even more, to an age of prosperity and the expectation that our offspring probably won’t die in childhood.
And if the last remaining smallpox virus samples escape from their confinement in US labs, or are used as biological weapons, I’ll have to hope my immunity has lasted as long as the scar on my upper arm all bus pass holders bear.
Competing interests: No competing interests
Some interesting and thought-provoking responses below. The problem with trying to parse contentious debates is you end up getting flak from both sides.
My issue with this debate is that the imperative for 'action' in the form of mandatory vaccination comes at an odd time, and with menacing overtones. I know how strong the industrial lobby is in medical research and Govt, and how that affects Health policy and decision-making, particularly where whole-population coverage of a product may be envisaged.
My reading of the trend data is that lapses in MMR coverage in UK were almost entirely due to the Wakefield effect. The data show that that effect is no longer relevant in our coverage rates, which exceed those in France, Italy and USA.
Perhaps England's recent slight drop in MMR coverage has been more affected by national fragmentation of immunisations contracts and administration away from GPs to Local Authorities, schools and children's centres, private companies etc, than by increasing numbers of anti-vaxxers.
Whatever the reason, the overall trend is very encouraging: with improved nutritional standards and measles vaccination since the 1960's, I would expect the existing trend to see the end of significant numbers of UK measles cases in perhaps 20yrs or so, perhaps sooner with better education and the passing of the Wakefield effect.
The case for urgent implementation of mandatory vaccination is based on short term spikes in measles cases, 2017-18, but this is misleading because there are natural peaks in measles incidence every two or three years, and this is measured from a trough year. However, amplitude of spikes overall are also decreasing concomitant with trend, so I think it would be premature to determine that we are risking an epidemic without mandatory vaccination from one off-trend spike.
Mandatory vaccination can be seen as a matter of enforcing individual socialist responsibility, which I think is philosphically oxymoronic; or from the opposite pole of a hostile authoritarian state, removing an aspect of fundamental autonomy. With enforcement, the anti-vaxx movement would inevitably grow to include human rights activists, liberals, anti-establishment groups, as well as those with unfounded fears.
Mandatory vaccination would be self-defeating, risking deeper entrenchment of anti-medic and anti-establishment conflict. The Wakefield effect - which resulted in a 15-percentage point drop in MMR in one year - was a lesson in prioritising open and credible information as quickly as possible, not a recipe for enforcement. My firstborn had MMR in that very year, but I had to read and think about it carefully for six months first.
Competing interests: No competing interests
Vaccination guidelines and the ever-increasing 'vaccine load' - a response to David Oliver
David Oliver, as well as systematic reviews, you suggest to me that "...expert guidelines, professional bodies and acknowledged content expertise" are useful to go to for medical field investigations: https://www.bmj.com/content/365/bmj.l2244/rr-15
In my investigation of vaccination policy and practice over the past ten years or so I have been influenced by vaccination guidelines issued by the World Small Animal Veterinary Association.[1] These are guidelines for the vaccination of dogs and cats, but I suggest they contain information which is also relevant to consider for human vaccination.*
The WSAVA guidelines for the vaccination of dogs and cats were originally formulated to address the problem of over-use of vaccine products in companion animals. For example it was, and often still is, common practice to vaccinate dogs every year with modified live virus (MLV) vaccines for parvovirus, distemper virus and adenovirus (the equivalent would be people having a live MMR every year). Other vaccines were/are also given every year, e.g. aluminium-adjuvanted vaccines for bordetella bronchiseptica (often called 'kennel cough').
The current WSAVA guidelines state "we should aim to reduce the 'vaccine load' on individual animals in order to minimise the potential for adverse reactions to vaccine products and reduce the time and financial burden on clients and veterinarians of unjustified veterinary medical procedures".
It's interesting that while vaccination guidelines for dogs and cats are recommending "we should aim to reduce the 'vaccine load' on individual animals in order to minimise the potential for adverse reactions to vaccine products...", vaccination of humans is going through the roof, with an ever-increasing 'vaccine load' being imposed. A startling number of vaccine products and revaccinations are given to children now, see for example:
- NHS vaccination schedule: https://www.nhs.uk/conditions/vaccinations/childhood-vaccines-timeline/
- Australian National Immunisation Program Schedule: https://beta.health.gov.au/health-topics/immunisation/immunisation-throu...
Who exactly is influencing the ever-increasing vaccination schedules, i.e. the increasing 'vaccine load? As Allan Cunningham suggests in his recent rapid response, is the "Vaccine Industrial Complex" in charge?[2]
Do we have any objective and independent specialists in the area of infectious diseases and immunology considering the current and long-term impact of this increasing vaccine load?
Returning to the WSAVA dog and cat vaccination guidelines again, the authors of these guidelines also recognise "there is gross under-reporting of vaccine-associated adverse events, because of the passive nature of reporting schemes, which impedes knowledge of the ongoing safety of these products". The situation is the same in human vaccination. For example, the Therapeutic Goods Administration, the regulator of medical products in Australia, acknowledges that "adverse event reports from consumers and health professionals to the TGA are voluntary, so there is under-reporting by these groups of adverse events related to therapeutic goods in Australia. This is the same around the world".[3]
David Oliver, there is much that is unknown about vaccination and immunisation, this is a global experiment underway.
Currently we are awash with an army of shrill 'experts' in the medical establishment and the media who appear to be determined to defend 'vaccination' at all costs, and stifle dissent. This is wrong. Serious problems are emerging with the use of vaccine products, e.g. early waning of maternally derived measles antibodies in babies born to vaccinated mothers, as I have tried to raise previously in rapid responses on your article, see: https://www.bmj.com/content/365/bmj.l2244/rr-3
The early waning of measles MDA is a huge red flag, is anybody in 'authority' thinking about the implications, including for other vaccine products?
*Caveat: The WSAVA dog and cat vaccination guidelines are sponsored by a vaccine manufacturer (originally Intervet Schering Plough, more recently MSD Animal Health). Guidelines sponsored by industry are compromised, and in my opinion the WSAVA guidelines still contain ambiguous information in regards to dog and cat vaccination. However, they remain useful for this discussion.
References:
1. Guidelines for the Vaccination of Dogs and Cats, compiled by the Vaccination Guidelines Group (VGG) of the World Small Animal Veterinary Association (WSAVA). Journal of Small Animal Practice. Vol. 57. January 2016: https://www.wsava.org/WSAVA/media/Documents/Guidelines/WSAVA-Vaccination... These guidelines were first published in 2007. The Journal of Small Animal Practice is the journal of the British Small Animal Veterinary Association and also the scientific journal of the World Small Animal Veterinary Association.
2. Standard media outlets are dominated by vaccine officialdom: https://www.bmj.com/content/365/bmj.l2351/rr-3
3. About the DAEN - Medicines: https://www.tga.gov.au/about-daen-medicines
Competing interests: No competing interests