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Rapid response to:

Views & Reviews Review of the Week

Becoming Ben

BMJ 2008; 337 doi: (Published 01 October 2008) Cite this as: BMJ 2008;337:a1856

Rapid Response:

In response to Peter Flegg's use of data.

Dear Sir,

Peter Flegg says that there would have to be an average of 750 MMR
deaths a year, to tip the balance in favour of not vaccinating with MMR.

During the rationing of the second world war, in 1943, measles death
rate in UK was 773 (1), and it never approached that rate again.

In the fifteen years before the measles vaccine was licensed in the
UK death rates never went above 200; in the ten years before the vaccine
was introduced, the death rate never went above 150. After 1953, deaths
rates were never of the order of 1 per 2,000.

The measles vaccine was licenced 24 years later in 1967, and did not
reach significant levels of uptake for quite some years after that. In
fact in 1980, there were 139,487 cases of measles with 26 deaths. Even
that isn't 1 per 2,000 cases. And presumably those deaths also included
late-onset deaths as well.

Therefore, Peter Flegg’s basis for 750 deaths per year would indicate
that this analysis came from Thomas Kuhn’s Sabre Toothed Tiger syllabus.

The reality of the years between 1952 to 1970, and afterwards, prove
that Dr Flegg’s mathematical equations are about as relevant as saying
that the measles death rate in Africa, is comparable to the Measles death
rate in UK.

In reply to Peter Flegg’s expansion of my question to him: no, it did
not occur to me that Peter Flegg would decide to include the third world
when the BMJ was discussing a topic based in UK.

But since Peter Flegg wishes to compare apples with army jeeps, let's
discuss his concept of that as well. Flegg states that, "in 1999 there
were estimated to be 873 thousand deaths from measles, reducing to 530
thousand in 2003."

Last year, WHO (2) stated that measles mortality in Africa had
slashed the death rate from measles by 91% since 2000. This 91% is an
artifact figure, because before 2000, measles in Africa was "estimated",
while after 2000, notifications were only accepted after being laboratory
proven. In 2000, WHO implemented a system of laboratories (3) specifically
to diagnose measles, and provide the laboratory confirmed cases which are
now the basis of WHO data.

Look at pages 2, and 14. On page 14, 14,185 cases were reported in
2006, but after blood testing, 9,764 were "discarded". That's an immediate
69% drop in cases, because they are no longer relying on doctor's eyes.

On page 2, of 14,185 cases, 3,257 were accepted, leaving a balance of
10,928 discarded measles cases which equals 77% which were NOT measles
after being blood tested, but which would have been accepted on the pre-
2000 measles notification system. Comparing data from laboratory-confirmed
blood tests after 2000, with pre-2000 guessing, and then claiming a 91%
decline, is not a valid scientific comparison.

Which raises an obvious issue. Peter Flegg says that clinicians
caring for measles cases " would have had no doubt. Acute measles is a
relatively easy clinical and laboratory diagnosis." Did (and can) UK
doctors do any better than those who guessed measles in Africa before
2000, or even New Zealand for that matter? That depends on who you listen

An old UK newspaper article, unfortunately undated, received on 17th
April 1997, reads: London (Europe Today). – "97.5% of the times that
British doctors diagnose measles they are wrong", says a publication of
the Public Health Laboratory service. The mistake being made by National
health GP's was found when the services tested the saliva of more than
12,000 children who had been diagnosed as having measles. Roger Buttery,
an adviser on transmissible diseases at the Cambridge and Huntingdon
Health Department, said that the majority of doctors "say they can
recognize measles a mile off, but we now know that this illness occurs
only in 2.5% of the cases." Buttery says that doctors classify as measles,
many other viruses that also cause spots. He found eight different viruses
during the survey in East Anglia. One of them, parvovirus, gives symptoms
similar to German measles. The reason for the high rate of error puzzled
Buttery. "Doctors are neither vague nor careless," he said. The solution
is to defer the diagnosis until more detailed information can be got.
There are 5,000 to 6,000 cases of measles registered each year in the
United Kingdom, but these findings now call most of them into doubt."

A later report by the same laboratory (4) showed that the most common
viruses causing "morbilliform rash" in the UK are "parvovirus B19; group A
streptococcus; human herpesvirus type 6; enterovirus; adenovirus, and
group C streptococcus."

An editorial in an Australian medical journal (5) pointed out that:

• In Sydney, in 1990-1995 only 49% of 58 notified cases were
serologically confirmed.

• In Victoria, in 1997-1998 only 8% of 248 notified cases were
serologically confirmed, and for the whole of Australia in 1997 – 1998,
only 45% were serologically confirmed.

• In 1994 in UK and Finland, only 1% of notified cases were
serologically confirmed.

So now, doctors check for BOTH IgM (immediate antibody) IgG (evidence
of past infection). If there is both IgM and IgG an enzyme immunoassay or
a reverse transcriptase polymerase chain reaction is required to type the
virus to figure out whether it's wild, vaccine, or whatever (6). In my
files is an MMR information sheet to parents which states that neither
rubella nor measles can be correctly diagnosed without a blood test. (In
UK they use a saliva test.)

Therefore, according to medical literature, and information provided
to parents, I would dispute Flegg’s assertion about the ability of all
doctors to easily or accurately diagnose measles or rubella, without the
assistance of technology. For the same reason, I also dispute the validity
of comparing any historical data from 1850 with any data after laboratory
data conformation was required.

However, since Flegg is presumably calculating his risk benefit
analysis on potentially invalid data, I have no choice but to do the same.
If the UK historical data for measles deaths is inaccurate because it too
contains more “viruses” than just measles, that makes Peter Flegg’s
calculations in the first paragraph, even more extravagant.

In countries like UK the decades of pre-vaccine death decline is
obviously due to factors unconnected with the use of any vaccine. For the
same reason, the WHO media release claiming that the measles vaccine has
reduced the measles death rates in Africa by 91% between 2000 – 2007,
defies logic, analysis and reason for anyone who knows the facts. I note
that Peter Flegg has stopped short of repeating that spectacular
assertion. Perhaps it's because even he can see the ludicrousness of such
a claim.

If that is the case, the Peter Flegg fails to mention that
comparative data in the UK, uses the same "mistake". Total numbers without
any laboratory confirmation before 1994, cannot be validly compared with
laboratory-confirmed cases only. To do so is not legitimate "science".

Peter Flegg states that, "during the last 10 years the case fatality
for acute measles in the UK has been in the order of 1 in 2000".

In UK, from 1998 to 2007 (as of 24th November), there were 28,364
cases of measles.

Out of the 12 deaths from 1998 - 2007, one is known not to be
measles, one is provisional, 2 were immunodeficient children within the
age where vaccines are administered, and the other 8 were older deaths
resulting from infections contracted prior to 1967. From the years of 1998
– 2007, the risk of any unimmunized child dying from ACUTE measles was as

immunodeficient children = one per 14,182 cases of measles; healthy
normal children = 0 out of 28,364.

Any suggestion that in 2008, the risk of any child dying of acute
measles is 1 in 2,000 is another fictional statistical manipulation, in
the same vein as: “in order for the risk/benefit equation to be tipped in
favour of leaving children unvaccinated against MMR, there would need to
have been more than 7500 deaths from MMR in the last 10 years.”

Peter Flegg says, "The only reason more children do not die of
measles in the UK is that herd immunity is still sufficiently high to
protect those who cannot or have not been fully immunised."

That is not entirely correct in my opinion.

A site called Measles Initiative says that(7), "Measles is a leading
killer of children in many developing countries for several reasons.
Children are already compromised with poor living conditions, they are
infected at very young ages when their immune systems are not strong,
malnutrition is rampant in many homes, and many families do not have
access to medical care to treat measles and its complications. Measles,
itself, does not kill children. Instead, complications from measles attack
the child's already weak immune system. Measles attacks the body, inside
and out. It is similar to HIV in the sense that when it knocks down the
immune system, the child becomes susceptible to the myriad of diseases
that fester in poor living conditions."

Do children in the United Kingdom have the same living conditions as
children in Africa?

Peter Flegg also says, "I have no doubt that another vulnerable group
(infants too young to be vaccinated) will see deaths within its ranks
before too long."

Before the measles vaccine was used, it was exceedingly rare for any
infant younger than 18 months to acquire measles because of the strong
maternally transferred immunity and, if a mother breastfed, through the
many immunological components within breast milk.

Those women in UK who now have naturally acquired measles in the last
decade, will transfer solid immunity to their babies, and their babies
will be unlikely to experience measles before 18 months. On the other
hand, those vaccinated mothers who have not had natural measles, will not
transfer that sort of immunity to their babies, and their babies might be
at risk. That being the case, to blame unvaccinated children for a
relatively new problem created by the use of a vaccine in the first place,
is more fact juggling.

A better initiative to reduce all risks to any child from any cause
whatsoever, would be to employ a certain young British chef to help start
nationwide "Vitamin D, Victory gardens, exercise and cooking course"
initiatives for parents and the unemployed, as well as someone else to
teach "breastfeeding, home nursing and nutrition during infection". More
than any vaccine, parents who provide their children with correct
nutrition, enough vitamin D, sleep, exercise, and decent home nursing, can
vastly decrease the annual expenditure of NHS with regard to a long list
of conditions, (including potential complications and deaths from any

These are conditions African parents would give their eye teeth for.
If they were able to achieve even half of what the UK achieved after World
War II, even without a measles vaccine, African children would have far
less to fear from measles infections.

Hilary Butler.

(2) Measles deaths in Africa plunge by 91%

(3) WHO, 2006 "Afro Measles Surveillance Feedback Bulletin" January

(4) Ramsay, M. et al. 2002. "Causes of morbilliform rash in a highly
immunised English population." Arch Dis Child. Sep;87(3):202-6. PMID

(5) McIntyre, P.B. et al. 2000. "Measles in an era of measles
control." Med J Aust. Feb 7;172(3):103-4. PMID: 10735018.

(6) Durrheim, D. M. et al. 2007. "Remaining measles challenges in
Australia." Med J Aust. Aug 6;187(3):181-4. Review. PMID: 17680748.

(7) Measles Initiative – The Problem

Competing interests:
None declared

Competing interests: No competing interests

29 November 2008
Hilary Butler
freelance journalist
home 2121, New Zealand.