Archive for January 14th, 2009

Measles – spot the worrying trend (Updated)

January 14, 2009


Widely reported in the media, the latest figures show that cases of measles are up again in the UK. The BBC has the story here, including a graph:

bbcs-hpa-graph

…while blogging GP Euan the Northern Doctor offers some analysis here. The story has also been well covered in the Bad Science Blogosphere by both jdc and by Martin the Lay Scientist.

As if by some sort of serendipity, yesterday also marked the re-start of the General Medical Council’s protracted “Fitness to Practise” (misconduct) hearings into Dr Andrew Wakefield, one of the key originators of the UK anti-MMR panic. If there is anyone reading not familiar with the media ”manufactroversy” over MMR, Ben Goldacre offers an introduction here, while journalist Brian Deer gives a magisterial, if lengthy, summary of his investigations into Wakefield and his work on his blog.

One interesting aspect of the new measles figures, highlighted by the Northern Doctor, is that the rates of measles infections seem to vary for different parts of the country. Which got me to wondering why. Of course there are many, many possible reasons, but one variable might be the extent, and kind, of pro-vaccination information that people see.

So what material does the NHS put out?

Pretty anodyne stuff, is the answer.

If you go to the NHS immunisation information site, you can find the current NHS MMR vaccination poster:

nhs-measles-poster

– the big red blob with smaller blobs around it presumably represent a virus particle, or perhaps new virus particles budding from an infected cell, although you would possibly have to be a scientist (or at least have done GCSE science) to work this out.

To me, the whole poster seems… well, boring. It is a pretty enough piece of graphic design, and has the key verbal message, but it has no “What?” value. Just a bunch of words.

The only NHS vaccination poster which appears to have any kind of “Warning” element is the one for the winter ‘flu jab:

uk-flu_jab-pic

This one has a few scary saber-toothed gremlin-type thingies, presumably again representing nasty ‘flu viruses, and a finger-wag. But, again, nothing to really stop you short.

Im Vaterland schaffen wir das anders…

In contrast, a couple of months back my German friend “Sceptic Eric” sent me some pictures of two German posters promoting vaccination that had appeared where he lives:

german-pro-vax-ad-no1-crop

The caption says:

Lisa, aged 9, is blind because of Rubella

(The smaller writing on the red backgrounds says “Vaccinate Now!”)

And the second poster:

german-pro-vax-ad-no1-crop-2

Daniel, aged 12 – left mentally handicapped by Measles.

These appeared, note, on big advertising bill-boards – not hidden away on the wall of the GP’s waiting room. They seem to me to be much more shocking – and thus memorable – posters than the UK ones. Instead of vague exhortations, they focus on the tragic consequences that can follow infectious diseases which people commonly view as harmless.

Ah yes. “Harmless childhood illnesses”.

An argument one often hears, typically from parents who do not have their children vaccinated is

“Illnesses like measles and mumps were a normal part of childhood. Loads of older people we know had them, and they were fine.”

Well, the German campaign gives some context for this statement. Some children who catch diseases like measles are emphatically NOT fine. Some get very ill, but get better, like the child whose story is described here. Some get even sicker, with things like pneumonia and encephalitis. And unvaccinated adults can get measles, and the nasty consequences, too. As I said in an earlier post, Mrs Dr Aust treated a few seriously ill adult cases like this in her days in hospital acute medicine and Intensive care.

And for Rubella, children with the disease give it to other people. Possibly including pregnant women. After all, pregnant women often have children, including nursery- and school-age children. Schools and nurseries are the best places you can think of for children to catch bugs from one another. This is, I suspect, even truer in the UK than in some other countries. If Governments and schools bang on relentlessly about high levels of attendance; if both parents work, and employers frown on time off for family reasons; if kids are almost universally in nursery from the age of six months up – then it stands to reason that there will be plenty of children at school and nursery who are clearly sickening for something, if not frankly ill. The UK, you might notice, fulfils all the above conditions.

If a woman in early pregnancy catches Rubella, she has about a 20% chance of miscarrying spontaneously. And if her pregnancy goes to term her child has a significant chance – 20-50% depending on precisely when in pregnancy the mother caught Rubella – of being born with Congenital rubella syndrome, which can mean serious physical and developmental problems, like blindness, deafness and mental retardation – as the first German poster indicates.

So why, I wonder, do we not have similar ram-the-vaccination-message-home poster campaigns here in the UK?

Do we think it is too graphic?

Or do we think that, because of all the media’s credulous reporting of the anti-MMR and anti-vaccine scare, people will look at posters like this and see “scare tactics and thought control”?

Or do they say “well, you can get them things just from getting vaccinated, innit?”

[ Err… not. The reported rate of “serious reactions” to MMR is about 3 in 100,000. In contrast, acute measles hospitalizes roughly one child in ten and kills one in every two to five thousand]

The tricks of memory

The flawed argument about “harmless childhood illnesses” is easy to understand. Most people have never seen a case of serious illness following measles. Ergo, measles must be harmless. They are blinded by their own personal experiences, and cannot seem to grasp the statistics.

I can understand this to an extent. I am a child of the 60s, pre the measles vaccination, and I had measles. I was OK. Others, of course, were not. But not anyone I knew.

The problem (from the POV of anti-vaccine scares) is that my experience is more common than the other – getting really ill, or knowing someone closely who did. So people in my age group commonly tend to know people that had measles (them and all their friends) but who got better with no serious, or at least lasting, consequences. They in turn tell their children and friends this.

Of course, the memory may not even be accurate. Even if a cousin or friend was in hospital as a child for a week, would you remember this after thirty years? If it was a classmate? If you too were a child at the time?

Personally, I have only one lasting memory before the age of about seven, and that is that the cake for my fifth birthday was shaped like Thunderbird One and had a Walnut Whip covered in red icing for a nose-cone. And I probably only remember that because there is an old family photo of it somewhere.

So – memory is unreliable. With the benefit of years that wipe away the memory of how lousy you would have felt when you had measles, your bout of measles gets recalled as “I must have had measles, so did everyone I know, we were all fine” (which may, or may not, be accurate) and then translated on into “measles is a totally harmless childhood illness” (which of course is rubbish, as we have already seen).

Heroes in the struggle for reality-over-scares

There is a great article on this, and the underlying statistics, here, written by a retired CDC epidemiologist who survived a life-threatening bout of serious measles complications as a kid in the late 50s. The author blogs as “EpiWonk”. Over the last year or so he has done a great job on his blog of the same name deconstructing the inaccurate and spurious arguments of the MMR-equals-horrors nitwits, specifically when they misuse and abuse epidemiology

And talking of measles, vaccination, and Dr Aust’s patch in the North-west of England, an honourable “local hero” mention should go to Dr Peter Flegg, an Infectious Disease consultant from Blackpool who spends a fair amount of his time online patiently explaining risk-benefit (and related topics) to do with vaccination.

Of course, a lot of the people he is trying to explain it to are figuratively sat with their fingers stuck permanently in their ears while shouting “nyeeah nyeeah nee nyeeah nyeeah, I can’t hear you”. But he keeps trying.

For a fairly recent example of both of these, try the British Medical Journal thread here, where you will find him discussing the relative risks and benefits of vaccination (versus actually catching measles). As you would expect, the real numbers are overwhelmingly in favour of vaccination. Even more remarkable is that Dr Flegg, with heroic restraint, manages not to lose his rag with Jackie Fletcher of JABS and her equally crackers friends.

Yet another person who deserves a lot of kudos for his tireless exposition of the nonsense of the anti-MMR lobby (and anti-vaccine nuts generally) is Dr Anthony Cox, proprietor of the BlackTriangle blog.  Cox has often been found over the years taking on the thankless task of debunking the anti-science ravings of media Wakefield Über-fan Melanie Phillips, and of various inhabitants of that stew of ignorance and prejudice known as “the JABS forums”. For this Cox regularly gets abused in personal terms by the JABS crew, who of course insist endlessly that they “don’t do ad hominem attacks”

So what to do?

So what do we take from the rise in measles rates?  We conclude, I think, that it is worrying, though not as worrying as the prospect of a further rise if vaccination rates don’t increase again. And we conclude that more effort is needed to get the vaccination message out.  And to educate people on the real rates of complications of measles, rather than of vaccines.

Perhaps it is time we spent some of the money the Government likes to spend paying celebs to appear in health campaigns on a pro-vaccination campaign (with or without celeb). Or on some German-style posters. Or both. We certainly need to do something.

Euan the Northern Doctor tells us he has managed more than a decade of practicing medicine in hospital, and latterly as a GP, without seeing a single confirmed case of measles – thanks, of course, to mass childhood vaccination:


“I don’t recall having ever seen a case of measles and I am hopeful it will stay that way.”

I hope so too. Though I am not all that confident.

[bpsdb]

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Update:  Saturday  Feb 7th. Jeni Barnett is a mother and an ex-actress. So she knows all about vaccination. ..err…?

Since this post was written, the MMR vaccine has rocketed back into the news again in the UK (at least in the blogosphere) with the furore about actress turned rent-a-quote presenter Jeni Barnett and her spectacularly awful phone-in on vaccination. I have never, I think, seen an issue which has united the BadScience bloggers and the medical bloggers (like my e-friends Dr Crippen, Dr Grumble, the Jobbing Doctor and Euan the Northern Doctor) in such unanimous fashion. Indeed, it seems like Dr Aust is probably the only BadScience blogger NOT to have covered the issue (mainly because so far I can’t think of anything new or distinctive to say). Anyway, Holfordwatch has an excellent roll-call of the blogs which, in a predictable but gratifying “Streisand Effect”, have covered the issue.

Jeni Barnett’s astonishingly ill-informed comments, petulant on-air behaviour, and dismissive attitude to anyone – notably actual healthcare folks – that rang in to correct her demonstrate, yet again, just how idiotic – not to mention dangerously deluded -“personalities” can be when they comment on stuff they know F-All about.  Holfordwatch has links to all the transcripts if you haven’t already read them, or heard the programme.

It all reminded me oddly of  a depressing TV debate I saw, just a bit more than five years ago, that followed on from Channel 5’s airing of the notorious 2003 TV Play “Hear the Silence”, about a mother convinced her child had been damaged by the MMR vaccine. The play – Guardian TV review here – featured Juliet Stevenson as the mother, and had a ludicrously saintly version of Andrew Wakefield (glossily impersonated by actor Hugh Bonneville) as its main hero. It was a powerful and compelling piece of drama…

…except that everything in it relating to MMR was farcically inaccurate, and utterly wrong.

What got me, however, was not so much the play as the studio debate afterwards – in which Juliet Stevenson, a fine actor but with no scientific or medical knowledge or training, harangued the medical and scientific types about the (imaginary) risks of MMR vaccination. Embodying the role is one thing, but deciding you now know enough to harangue people about the science on national TV? As so often, the phrase “The Arrogance of Ignorance” springs to mind – see also Jeni Barnett, or Jenny McCarthy in the US.

You can read what the British Medical Journal’s commentators – child health experts David Elliman and Helen Bedford, and GP, author, and Channel 5 debate participant Mike Fitzpatrick – thought of Hear the Silence here and here. Sadly, you won’t be able to get to the full text versions unless you have BMA, University or Athens login privileges, though you will be unsurprised to hear that they were not impressed. However, you can read, for free, the Rapid Responses (e-Letters)  that the BMJ received about the articles. The thread following Fitzpatrick’s article is notable for some sane responses from another doctor-turned-author, Neville Goodman. You will be unsurprised that the thread following the other BMJ piece eventually ends up with anti-vaccine über-obsessive John Stone of JABS talking to himself (as usual) long after everyone else has left (as usual).

Meanwhile, more measles – and a death

Finally, just a couple of days ago, as the shit hit the fan over Jeni Barnett’s dismal programme, I got an e-Mail from my German-language correspondent Sceptic Eric, directing me here. This is a piece about a recent Swiss measles epidemic, including the death of a 12 year old girl from measles encephalitis (1).

Perhaps Jeni Barnett would care to read it before putting up any more ill-informed self-justification on her blog.

(1) Sorry, Google machine translation, so a bit incoherent, though you can get the gist. If you can read a bit of German, the original is here.

The same case (I think) is reported in the French-language Swiss press, e.g. here (a thank-you to Svetlana for pointing this out) – and English machine-translation is here.

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Postscript

While I was writing the original lengthy ramble Californian blogger Liz Ditz drew my attention to a talk given by American scientist and “skeptic” Dr. Steven Salzberg a couple of months back in the States, and now up on youtube. If anyone needs a concise video introduction to the MMR anti-vaccine scare, it is a good place to start. Prof S thinks we should all be doing more to combat the still-bubbling anti-vaccine hysteria:

“Scientists and skeptics need to act to quell the rumors and educate the public, so that vaccines, one of the greatest medical successes in history, remain an effective tool in our fight against disease.”

The talk may be a bit US-focussed for UK listeners, but it is a good introduction to the whole story. It is in five parts – if you haven’t got the patience for the whole lot, and/or are already familiar with the main bits, you could skip to parts four and five to see the kind of things that American defenders of vaccination like Dr Paul Offit are up against (more on Offit here).

Part One,  8:31 min – Intro to autism & Wakefield’s paper.

Part Two, 7:54 – Brian Deer’s revelation of Wakefield’s misdeeds and Wakefield’s responses.

Part Three 6:34– Mostly on the thimerosal (vaccine preservative) – autism scare so beloved of ex-travel writer David Kirby

Part Four 8:54– Why Is Autism Ripe for Quacks to Exploit? segueing into “What does science say about autism?”

Part Five 8:49 – Continued discussion of increased incidence of vaccine preventable disease with fall in vaccination levels, plus a discussion of “Is there an autism epidemic?” and “What is really known about the causes of autism”. Finishes with US lawyers’ attacks on vaccines and courting of public opinion by anti-vaccine groups.