Fitzpatrick and Halvorsen Speak About Vaccines: Whom Do You Trust?

Dr Michael Fitzpatrick has posted his own version of the recent abysmal UK reporting: The dark art of the MMR-autism panic. What can I say, the man writes with economy and clarity.

Dr Wakefield’s scientific achievements lag far behind his successes in media manipulation: after 10 years (and the expenditure of £15 million in legal aid funding), he has yet to produce credible evidence that MMR has caused autism in a single child (2).

The Observer story contains three features common to the episodic upsurges in media interest in the MMR-autism link provoked by anti-vaccine campaigners over the past decade. These are the leak of an unpublished scientific paper ostensibly supporting the link; the endorsement of the link by some maverick scientist or doctor; the prominent report by a journalist lacking any relevant expertise or experience. By the time that the paper is revealed to be rubbish (or irrelevant), and the maverick is exposed as something less than a reliable authority or to be on the litigation pay roll (or both), the damage to confidence in MMR has been done. While the shabby scaremongering caravanserai moves on in search of its next media opportunity, parents are left with the burdens of anxiety and guilt (and children who miss out on immunisations as a result may be left with even heavier burdens of disease and disability).

Fitzpatrick provides some useful appendices that are a decent guide to the conflict of interest and reporting controversies.

Over in the People's Medical Journal (aka the Daily Mail) Dr. Richard Halvorsen asks the provocative question: Are vaccines a waste of time?

No.

If you think that I should add more, vaccines are a modern medical marvel and, as such, were a strong contender for most remarkable medical innovation in a recent BMJ poll.

Slaving at the altar of balance I should perhaps mention that when Halvorsen tells us about his epiphany, he does himself no favours. He tells us of his dismay at what he learned when he was asked to research the issue. What?!? At no time in his career as a medical student or family doctor had he thought that it might be useful to understand what he was advising people about?

I am now convinced that rather than being a silver bullet in the heart of disease, vaccine programmes could actually be causing some serious health problems, with hundreds if not thousands of children adversely affected every year.

Where did Halvorsen do this astonishing research? Browsing the pages of anti-vax websites or flicking through the books of anti-vax medics such as Dr Stephanie Cave (I don't accept the rhetoric of "I'm not anti-vax, I'm anti-the immunisation schedule)? As for his disingenuous claim for balance:

I repeatedly heard stories of parents being patronised, bullied and forced into a corner when deciding whether to vaccinate their child, so I set out to inform parents, honestly, and without bias, so that they can make their own decisions.

Halvorsen's recommendations are as follows (I've chosen to respond to these with information on the web; there are several books that cover these issues in much greater and more comprehensive detail):

• MMR: Halvorsen, "However, safety studies were woefully inadequate. To pick up rarer side effects, at least 10,000 children should have been followed up for at least a year.
  
  However, no children were actively watched for more than six weeks."
  Response: No, there is good quality information about side-effects. Granted, MMR the facts could stand to overhaul its text to improve the present rebuttal of this canard but the Health Protection Agency did a very reasonable job with an elegant and well-referenced rebuttal of Wakefield and Fletcher's claims (pdf) (I would imagine that their paper is the source of Halvorsen's assertion). Suffice it to say that there are studies that recorded data for between 1-10 years in addition to the six-week studies.
  Bandolier does a fine job of discussing the interesting case of Finland which implemented a vaccination catch-up programme in 1982 that also allowed a fascinating, long-term study of MMR and the epidemiology of vaccine-related adverse events.

  The total number of reported vaccine-associated events in 1.8 million people having 3 million vaccinations was 437. Of these, potentially serious adverse events occurred in 169 people, 79 of whom went to hospital. These 169 people were subject to serious scrutiny.
  
  The details of the potentially serious adverse events are shown in the Table. About half the reported adverse events could be ascribed to other factors (like other vaccinations given with MMR) on clinical, serological and epidemiological analyses. No event had an incidence of more than 1 case per 100,000 doses of vaccine.
  
  There were no cases of autism, and no cases of ulcerative colitis, Crohn's disease or any chronic disorder affecting the gastrointestinal tract.

• Measles vaccine: Halvorsen, "May be worth vaccinating against measles with a single vaccine despite the side-effects - on balance, the risks of the disease remain greater than those associated with the vaccine, especially in vulnerable children with chronic illnesses".
  Response: OK, we are agreed on the significant health risk associated with measles although I think that Halvorsen is understating them (for those who contract measles, an estimated 12% of children and 20% of adults are hospitalised as a consequence of measles and its sequelae of vicious secondary bacterial infections).
• Mumps: Halvorsen, "Not only unnecessary but the vaccine is making this disease worse".
  Response: What? There is not much of a vaccination programme against mumps in Egypt. I wonder if this sheds some light on Egypt's top-of-the-mortality-table rating with 312 deaths from mumps in 2004? The UK doesn't show up in the mortality table for mumps. The other countries that do are reporting very few deaths: this possibly reflects their well-organised vaccination programme. As for the claim about making the disease worse - that is why organisations track the disease strains as they evolve, so they can adapt the strain in the vaccine accordingly. The proposed solution (already adopted in UK and the US amongst others) is to recommend a second dose of the vaccine. WHO Position Paper on Mumps Vaccines, 2007 (pdf). Mumps is a paramyxovirus that has a substantial disease burden:

  Although the disease is usually mild, up to 10% of patients can develop aseptic meningitis; a less common but more serious complication is encephalitis, which can result in death or disability. Permanent deafness, orchitis, and pancreatitis are other untoward effects of mumps.

  We have different definitions of "unnecessary".
• Rubella: Halvorsen, "Not recommended for children. More effective to screen teenage girls for acquired immunity and vaccinate the few who don't have it".
  Response: Herd immunity? Reservoirs of infection for pregnant women?
• Polio: Halvorsen, "Still worth having a polio jab now the safer vaccine is available".
  Response: Pleasantly gruntled that we have a point of agreement.
• Whooping cough: Halvorsen, "One of the least useful childhood vaccines; I'd not now give it to my children".
  Response: fine, but please give it to other people's children. Brian Deer has dealt very thoroughly with most of the Halvorsen canards in Pertussis, DTP-DPT vaccines: it looks like the courts may have got this one wrong. If you are interested in the opinion of a gifted paediatrician and writer, please consult: The Cough of One Hundred Days.

  From 1997-2000, one out of every five children with Pertussis was hospitalized, including more than half of all infants under six months. Ninety percent of Pertussis deaths occurred in infants.
  
  Younger children are more likely to suffer complications from Pertussis. The most common complication is secondary bacterial infection, most often pneumonia. Most of the infants who die of such complications die of pneumonia.
  
  Infants are also more likely to suffer seizures and encephalopathy, probably due to the reduction of oxygen supply to the brain.

  Whooping cough may not be a big deal for older children or adults; it is for infants.
• Human Papilloma Virus (HPV): Halvorsen floats some 'maybes' about auto-immune diseases as a possible side-effect while fauxledging that these "could have happened by chance". However, his overall verdict is: "Wait and see".
  Response: I can't improve on Jo's Trust and their HPV Vaccines Information. HPV vaccines need to be administered before a woman becomes sexually active*.

There is a woeful dearth of accurate information about vaccines in the UK at present; the Daily Mail is not helping by allowing a promotional piece about his own book by an anti-vax doctor**.

Edited: 1 August: *Investigators have discovered non-genital reservoirs of HPV. It does not mean that they are necessarily tranmissable but it does emphasise the need for more research into the mechanism of transmission.

Edited: 18 July: **I haven't been able to verify this but I've seen a claim (Daily Express) that Halvorsen is an NHS GP who acts on his convictions and offers parents single jabs rather than the MMR or 5 in 1. If this is true, I have to assume that the practice is funding this as the NHS does not purchase individual vaccines; if Halvorsen is subsidising this then he is to be commended for acting on the courage of his convictions even if I disagree with his argument for such a practice and the potential for harm of pursuing such a programme.

Thanks to Wellcome for use of this open access image.