Too Little, Too Late

By Jim McVeagh 03/02/2010 6


The Lancet has finally withdrawn the paper on MMR and autism that it published 12 years ago. The study: “Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children” consisted of a series of 12 children all of whom had been referred in to a paediatric gastroenterology unit with a triad of autism-like symptoms, abdominal pain and diarrhoea. Note that this study is little more than a series of linked case studies with a very strong pre-selection bias towards gastroenterology (they were referred in to the gastroenterology unit).

The study was seized upon by the anti-vaccination groups, despite its deep inadequacies, and used to promote unreasonable fear of the vaccination process. Long-time readers of this blog will know that I am not a fan of the drive to indiscriminately vaccinate children against every known disease. It seems to me that this is likely to be a counterproductive policy in the long run because each addition to the armamentarium of needle-weilding nurses meets with more and more parental resistance. After all, it is a traumatic experience having your child vaccinated. At some point (which we may have already reached) parents are just going to say “forget it” and ignore vaccination entirely. Of course articles like the above study simply reinforce this tendency.

I can’t see that the belated withdrawal of the study is really going to make any difference to this situation. At this stage, the withdrawal merely intensifies the suspicions of parents (look, they’re suppressing the truth) who increasingly tend to see the myriad of vaccines as just a ploy of vaccine manufacturers to make money. Given the combination of trauma and fear-driven conspiracy theory, it is a wonder that any parent has their child vaccinated!

I see a fair number of parents who opt out of the vaccination program. I usually try to (gently) persuade them to have the DTP, Polio and HiB courses. All of these diseases (Diphtheria, Tetanus, Pertussis, Polio and Haemophilus Influenza B) have appreciable mortality and are worthwhile having your child protected against. Thereafter, the benefit of vaccines compared to their cost becomes more and more dubious. Judging by the almost hysterical reaction of the public health department, one would have thought the recent measles “epidemic” – that did not actually happen – was an outbreak of ebola virus. Families who had not vaccinated their kids were being treated like some sort of plague factory. Measles is very unpleasant but not really a great deal more dangerous than seasonal flu, so some sense of proportion would have been helpful.

While the Lancet’s response to a poorly written article was “too little, too late”, the vaccination program could well be characterised as “too much, too soon”.

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6 Responses to “Too Little, Too Late”

  • Gosh, good recycling of anti-vaxx arguments, and sympathetic to them besides. You really are anti-vaccine, notwithstanding a couple of weak efforts at saying that some might be OK, but you’re not going to bother to persuade too much. Too much, too soon? Come on, this isn’t the US.

    The study didn’t just have a pre-selection bias, it was bought and paid for by lawyers seeking to create a link between autism and vaccines for legal action. Wakefield took home a lot of cash out of this. That’s before you get to the falsification of data and the unnecessary invasive tests. On a science blog, there should be a better standard and that is to say exactly what led to the retraction and why the link is spurious. Anti-vaccination groups should be condemned for their part in this, not talked about as if their position was understandable. It isn’t, it’s scaremongering of the worst kind.

    That is why parents are confused, it’s because anti-vaxx lobby groups are very vocal and very good at scaremongering with baseless claims and the media love a scare story while doctors and other health workers are not saying clearly enough it’s a pile of dung and here are the facts. It can’t get any worse when people buy into it that should know better. Those health professionals are the ones that do know immunology and about vaccines (or should do), not pro-disease groups who are ideologically opposed to vaccines and if the science doesn’t confirm their beliefs, they’ll lie and twist it to suit. It’s strange, if a study appears to support them they’ll follow it blindly but if it doesn’t it’s just bought by a drug company (never mind not all research is done by drug companies). The excuses I’ve seen elsewhere trying to defend this shoddy piece of research beggars belief.

    And yes, unvaccinated children are plague factories. They are susceptible to the diseases if they encounter them and bird of a feather cluster together creating a risk of an outbreak. Look at Otago last year, non-vaccinated family goes to Vietnam, come back with the measles. It’s not inconsequential, there is the risk of pneumonia, encephalitis, SSPE and death included in there. SSPE is not related to the vaccine either, they’ve only ever identified the wild type as being responsible. But yeah, 1-3 deaths/1000 is merely unpleasant and just like a mild case of flu. Thank goodness for modern medicine which can help mitigate a lot of foolishness.

  • diaz:

    It is a bit illogical to call me “anti-vaccine” when my post clearly agrees with the Lancet’s stance to remove Wakefield’s paper and I criticise them for taking so long about it. In addition, I actively promote vaccination in my practice. All except the hideous vaccine Gardasil whose benefits are exceedingly dubious (for my reasoning on this , I direct you to a the post a sexy needle).

    Unlike many of my colleagues, though, I treat parents with anti-vaccine concerns with respect and approach their difficulties with some logic rather than the usual vituperation exhibited by many pro-vaccine zealots. Consequently, my vaccination rate for basic vaccines, as outline in my post, is much better than my colleagues. My rational approach to parents fears usually sees them getting their children at least partially immunised against DTP, polio and Hib. MMR is a much harder sell as the autism scare is powerful piece of fear-mongering that is hard to counter and measles is not much more dangerous than common flu.

    Your comments about measles are classic pro-vaccine hysteria. The simple fact is that the death rate from influenza is not inconsequential either (as opposed to the common cold, which is what you really mean by a “mild case of flu”). Influenza has a mortality of around 4-6 per 10,000 cases. Measles has a mortality of around 10 per 10,000 cases (I am ignoring third world stats here because measles mortality is exacerbated by endemic malnutrition). The rate of pneumonia in measles is actually lower than than of flu. SSPE is very horrible (I have witnessed an actual case) but fortunately also very rare.

    Rationally, therefore, we should be as insistent about flu vaccines as we are about MMR.

    Oh, and I would be delighted to hear your rationale for the inclusion of the benign diseases of mumps and rubella in the MMR. I have never come up with one. (I would be recommending rubella vaccination to all seronegative girls over the age of 13 instead)

  • I didn’t say that you didn’t agree with the withdrawal of the paper, I pointed out that the post doesn’t present the serious issues with the paper and further, explain why the claimed link was spurious. It’s not just “deeply inadequate” or “poorly written” it was fraudulent. The bias wasn’t just towards gastroenterology it was towards trying to create a link between vaccines and autism. It wasn’t just seized upon by anti-vaccine groups either, they had an active role in referring potential claimants. With the Lancet issuing a partial retraction based on the fatal conflicts of interest in 2004 in additional to the current withdrawal based on new information, they’ve done better than the UK GMC which took many years before they investigated and then took two years to hear the case.

    I don’t think it helps to present another vaccine as “hideous” either if you claim that you are not anti-vaccine. With the amount of misinformation about on vaccines the information provided by health professionals should be factual and unbiased, and that word isn’t, Looking at the Gardasil post do you think that gleaning information from a vaccine data sheet which is necessarily simplified due to space constraints substitutes for looking at the data sources cited and other information such as that available on licensing in the US? Looking at other posts doesn’t give much confidence that you’ve fairly assessed the vaccine instead of covering all the bases of anti-vaccine talking points about those vaccines and looking at the data with a pre-determined conclusion in mind. It’s fairly clear that you’ll cite anti-vaccine material as a source quite readily instead of source medical literature, despite the fact it’s lacking in verifiable facts.

    The post does nothing to correct the misinformation about MMR and further adds to it by presenting vaccine policy as running amok and vaccination as being traumatic. That isn’t the case. The process is usually fairly slow and with Pneumcococcal parents of children fatally affected by it marched on parliament a few years ago to push for it’s addition. We have a public health system, where cost effectiveness is important and that tends to lead to pressure in the other direction. The statement that there is a “drive to indiscriminately vaccinate children against every known disease” is simply incorrect, there isn’t a drive to eradicate slapped cheek or other common childhood illnesses that could be genuinely described as “mild” for the sufferer, nor has chicken pox vaccine been added onto the schedule despite being available for a while.

    People should be treated with respect but not all ideas are equally worthy of respect. Are you really saying that many other doctors don’t treat those people and their fears with respect? I’m very surprised to see that, whatever happened to respect for your colleagues? They have to practice to the same standards you do and probably work just as hard to correct misconceptions in their patients whatever the source. The reality is though that misinformation is rife and people are happy to repeat it and it’s entirely possible your colleagues are heartily sick of seeing this cycle. Anti-vaccine groups are not so circumspect with their anti-science views and they are far more shrill and hysterical in presenting their case. I’m not the one that is claiming that anyone pro-vaccine is part of a big conspiracy, and you admit the scaremongering over MMR. It shouldn’t be that hard to counter given there was and is no evidence supporting a link. With anti-vaccine rhetoric though, you’ll be told at times it’s only this one or another vaccine that is the concern (up until you ask about any others) or they are OK with some but the thing is that it’s the same misinformation and same presentation of the vaccines as being far more harmful than the diseases they prevent and the same stuff about doctors and nurses and health officials either ignoring or deliberately hiding vaccine “damage” along with the lurid anecdotes. The idea is to sow fear, uncertainty and doubt and it works very well despite the great weight of evidence against what they say. But that’s fine and not criticised but presenting the known complications of measles is “pro-vaccine hysteria”. Great.

    I understand what flu is. It would be better to show that respect and enquire as to what I meant. I don’t consider the flu to be a valid comparison to measles, the morbidity and mortality tend to be clustered in the older age group, not infants. It’s actually not at all clear that to be rational we should add in flu to the childhood schedule, but for over 65’s and those with chronic illness it is rational to make that recommendation. If discussing it would be best to standardised figures for the infection rate, morbidity and mortality for the critical period of childhood that can be agreed upon. Maybe slapped cheek would be a better comparison, that is defined as mild. One of the problems I have, is that given you’ve seen a case of SSPE and other complications that it’s not considered that if measles infection rates increase, so will the complications in real terms and you’d be seeing more cases of those. This is going to happen to real people in real life, and it’s preventable with little risk of adverse effects.

    As for mumps and rubella, I’m surprised that you can’t think of any rationale at all. Agreed they are on the milder side of the scale and for rubella the intention is to protect the unborn child not the person themselves but you can prevent three childhood infectious diseases and any associated morbidity and mortality in one inexpensive vaccine. In addition while you don’t state so, the single vaccine is not available here, so the other option is not your recommendation but no rubella vaccine at all. It could also be fairly logistically complicated to take blood from every girl of that age to test for antibodies (especially if the parents are the sort to poo poo ideas like antibodies show immunity like some of the anti-vaccination ones I’ve met), and then get them back for a second needle later. With rubella, while this isn’t strictly necessary for boys widespread vaccination would tend to have an effect on herd immunity and lessen the risk of a non-immune (for whatever reason) woman being in contact with rubella at the critical time of pregnancy. While it might not have serious complications generally, mumps is nasty to have (had it as a child myself) and there would be the cost of treatment required should complications occur. So in addition, children would be spared the suffering of being ill with those particular diseases and parents too. While it’s not a biggie (if they are sick they are sick) having to nurse them through mumps and the like isn’t very pleasant for parents, who are faced with distressed children with fevers, pain and the rest. Then often there is a load on doctors, this would tend to increase case loads as parents will take children in for diagnosis and advice on treatment if they become ill. While the case isn’t strong, you could say there are benefits even though the diseases won’t severly damage or kill you.

  • Diaz:

    I’m not sure if I can do justice to your long comment so forgive me if I am a bit selective.

    The bias wasn’t just towards gastroenterology it was towards trying to create a link between vaccines and autism.
    True. But “fraudulent” would seem a bit harsh. “Biased” would be more accurate. But I may be wrong here – we will have to see what the medical council does with Wakefield. However, my point was that making out that I am anti-vaccine in this context is a little strange.

    It’s fairly clear that you’ll cite anti-vaccine material as a source quite readily instead of source medical literature,
    Of course. I am, after all, trying to start debate, not presenting a paper. I link to material on both sides of the debate in that particular post. The anti-vaccine material you are talking about BTW is a Scoop article, not a direct link to a flake site.

    The statement that there is a “drive to indiscriminately vaccinate children against every known disease” is simply incorrect
    Maybe a little hyperbolic (a failing of mine). But my problem with some of the suggestions for new vaccines is the vast “numbers needed to treat” to prevent a single case from occurring. This means that the trials using a couple of hundred people are completely insensitive for rare side effects. Rare side effects that become significant when there is a high NNTT. If you prevent only one case of , say, pneumococcal sepsis for every 100,000 doses but the rate of severe anaphylaxis is also 1:100,000, you just substitute one severe problem for another at a substantial cost.

    This is my problem with MMR too. While it does not cause autism, it is not a completely benign injection. I have seen both sepsis and anaphylaxis to it. One therefore has to question the wisdom of treating benign childhood diseases with a potentially dangerous drug (admittedly only a small potential).

    Are you really saying that many other doctors don’t treat those people and their fears with respect?
    I do not imply that my colleagues are rude to such patients, merely dismissive. This is the feedback I get from parents who do not what their children to be vaccinated. They all say that they feel that doctors and nurses normally treat them as if they are idiots. Whether this is actually true, I don’t know. It may be just their perception. I am well aware the anti-vaccine campaigners tend to use scare tactics. This is precisely why a hard-nose approach to these people does not work.

    And while you may not find vaccination traumatic, at least half of the mums I deal with tell me that it is very traumatic indeed. Perhaps you are tougher than they.

    I don’t consider the flu to be a valid comparison to measles, the morbidity and mortality tend to be clustered in the older age group, not infants
    This is a valid point and it is why I think the measles vaccine should remain on the schedule. I just find that the resistance to it cannot be overcome with reassurance. The anti-vaccine campaigners have done their work too well.
    I am using flu as an example to demonstrate the level of imperative, rather than as a direct comparison. I try to persuade the elderly and other at risk patients to have the flu vaccine each year. But no one I know uses quite the “strong-arm” tactics that the public health people did during the (non-existent) measles epidemic this year. When did you last hear a public health nurse tell a little old lady she might be ejected from her nursing home if she didn’t get the flu vaccine? Yet they were threatening mothers that their children might not be able to go to creche.

    three childhood infectious diseases and any associated morbidity and mortality in one inexpensive vaccine
    And therein lies the rub. Neither rubella nor mumps have an appreciable morbidity or mortality and the MMR vaccine is substantially more expensive than the measles vaccine alone. It is just not as expensive as three vaccines.

    It could also be fairly logistically complicated to take blood from every girl of that age to test for antibodies
    True, but then you would not be giving an unnecessary foreign substance. And “herd immunity” is utterly irrelevant for a benign disease.

    mumps is nasty to have
    Actually I had a great time after the first day or so 🙂

    Then often there is a load on doctors
    Oh, tosh. How hard is it to say “You have mumps/rubella/measles/chickenpox. Take this paracetamol”? Takes 5 minutes all up. Bread and butter stuff for GPs.

  • The Lancet retraction points to the false claims (i.e. “is fraudulent”) as does the Herald article you refer to. To quote from the retraction, the paper claims that children were “consecutively referred”, when in practice they weren’t. That completely alters the interpretation of the results as you indicated. That’s not being biased. At very least it’s inaccurate in a way the misleads the conclusions to be drawn.

    If you read the full report of the council, they point out how the paper makes no mention whatsoever of it’s original aims in the final paper, e.g.

    Because you drafted and wrote the final version of the paper, and omitted correct information about the purpose of the study or the patient population, the Panel is satisfied that your conduct was irresponsible and dishonest.

    I could give more, but deliberately misrepresenting the work equals fraud never mind the rest, wouldn’t you say?

    This isn’t dependent on we will have to see what the medical council does with Wakefield. The judgement has already been passed, what remains is effectively the “sentence”.

    Of course. I am, after all, trying to start debate, not presenting a paper. I link to material on both sides of the debate in that particular post. The anti-vaccine material you are talking about BTW is a Scoop article, not a direct link to a flake site.

    Science cannot be resolved through a media-style debate. I’ve written several times on this previously
    (see https://sciblogs.co.nz/code-for-life/2009/10/23/science-journalism—critical-analysis-not-debate/
    and links and the bottom of this article.)

    Trying to claim something is “better” or more credible because it’s in Scoop is nonsense. Scoop essentially accepts everything sent to it (with some exceptions). Anyone can send material there, including some of the most biased twits. You’d need to judge the content, not that it’s hosted at Scoop or wherever. As a simple example, Ian Wishart sends his stuff there, too 🙂

    I just find that the resistance to it cannot be overcome with reassurance. The anti-vaccine campaigners have done their work too well.

    Seems a defeatist attitude and one that presumes the conclusion before it’s been reached to me.

    Looking at the larger scene (i.e. outside the clinic), I’d look more to people explaining how the anti-vaccine campaigners play their game than reassurance (as that simply leaves people with a “who to trust”, rather than an understanding of why they’re being mislead). Most people don’t like being mislead after all.

    Neither rubella nor mumps have an appreciable morbidity or mortality

    I beg to differ.

    It is just not as expensive as three vaccines.

    Don’t forget to include the cost of more/longer GP visits to get 3 vaccines vs. 1, the extra stock monitoring, storage, transport, etc., involved. I would think that the health boards look at a bigger picture that just the cost of the vaccine itself.

    Actually I had a great time after the first day or so 🙂

    Your personal, anecdotal, experience is irrelevant.

    Oh, tosh. How hard is it to say “You have mumps/rubella/measles/chickenpox. Take this paracetamol”?

    I hope you realise how reads to others.