Breath Spa for Kids

NHS Choices Spreads Confusion About Allergy and Intolerance Tests

2007-10-01T18:37:00.000+01:00

Journalists and and a certain class of nutritionists frequently conflate allergy and intolerance. UK newspapers regularly carry stories about 'food allergies' where the topic is actually food intolerance and it is not unusual for IgG blood testing to be promoted as a scientifically and clinically validated test for the diagnosis of food allergies or intolerance. These misunderstandings are so common that I notice when a journalist doesn't make these mistakes.

Nonetheless, I was particularly irritated when a correspondent drew my attention to an NHS site with a section dedicated to allergies: Which allergy test? The page carries some useful information about various tests, both those which are available from the NHS and those that are direct-to-consumer. For some of the tests (e.g., the hydrogen breath test for lactose intolerance or the coeliac self-test) there is information about the specificity and sensitivity, as reflected in the number of accurate diagnoses, false positives or false negatives. Some of the descriptions even carry a warning that some tests are "[d]ismissed by allergists as unreliable and unscientific" (systematic kinesiology) or may be offered by people who "may not have relevant qualifications" (VEGA). The inclusion of such information for some tests and not for others makes it seem as if there are no comparable concerns for those tests where they are not mentioned rather than a lack of actual clinical data or research.

However, the credulous writer/s gave no such caveats about YorkTEST’s foodSCAN tests.

In this test, you send a small blood sample to YorkTest Laboratories. The lab examines your blood for IgG antibodies, which it believes cause food intolerance. Results are given in a traffic-light code: foods to avoid (red), to rotate (amber), and to eat freely (green).
Tests for: food intolerance.
Pros: the only intolerance test supported by Allergy UK. It is also supported by well-known figures such as Dr Hilary Jones and Patrick Holford.
Cons: very expensive (around £250).

However, when the well-respected clinician, Dr Glenis Scadding, Consultant Allergist at the Royal Nose, Ear and Throat Hospital gave her testimony to a House of Lords Committee that was considering allergy and allergic disease in the UK, she characterised IgG tests for food intolerance as a waste of money":

What I do dispute is that it is worth making any attempt to identify IgG antibodies. We all make IgG antibodies to food....I see no way in which this can be used to guide diet.

I don't think there's any point in spending money on IgG antibody tests. You're better off going to see a dietitian and using an exclusion diet followed by reintroduction. The IgG antibody tests are liable to leave patients on diets that are inadequate and patients often like to think they're improving. They carry on in the teeth of very little improvement and may end up malnourished.

I think [self-testing kits] should be banned.

The YorkTest foodSCAN range is available as direct to consumer tests; however, they are also frequently recommended by nutritionists who typically do not have any recognised or specific training in allergy diagnosis or management. It isn't clear why the people who put the NHS Choices Guide together did not take note of this strong criticism from an acknowledged expert when they noted allergists' criticism for other tests but chose to mention that the foodSCAN test is endorsed by well-known names without disclosing their relationship with YorkTest. Similarly, the Allergy UK Consumer Award is only based on anecdotal report and is no indication of clinical or scientific value. Allergy UK is admonished for their support of this testing in the House of Lords report.

In a comprehensive report HL 166-I (pdf from which pg numbers are given), the Committee makes a number of good recommendations and provide some useful summaries. Pages 86-88 cover the issue of direct-to-consumer tests such as the YorkTest foodSCAN IgG test for food intolerance and the YorkTest-Allergy UK MAST IgE test for allergies to food and airborne allergens, amongst others.

The House of Lords summed up their advice as follows (pg 87):

We are concerned both that the results of allergy self testing kits available to the public are being interpreted without the advice of appropriately trained healthcare personnel, and that the IgG food antibody test is being used to diagnose food intolerance in the absence of stringent scientific evidence...We urge general practitioners, pharmacists and charities not to endorse the use of these products until conclusive proof of their efficacy has been established.

It almost seems gratuitous to add that the House of Lords aligns themselves with clinical experts in their notion of who is qualified to diagnose allergies and allergic disease (hint, it is not the typical holder of a Diploma ION nor an auto-didact nor self-proclaimed expert nor celebrity nutritionists).

It is absolutely clear that the House of Lords has considered the evidence and finds that there is no adequate scientific or clinical support for the usefulness of these blood tests as a direct to consumer item; further than that, there is clear cause for concern as to the relevance of the tests. The House of Lords urges professionals in positions of responsibility and authority, whose opinions or recommendations may influence others, to refrain from endorsing this technique. NHS Choices includes cautions about other tests and techniques, it should include them about the YorkTest foodSCAN range and IgG testing for food intolerance.

People trust sources of information that come with the implicit imprimatur of the NHS. The information about the allergy tests is shoddily researched and rather confusing. NHS Choices should rethink their guide. They need to amend the text about IgG food intolerance tests and some direct to consumer allergy and intolerance tests to reflect the well-founded concerns expressed in the report from the House of Lords.

Possibly a Watershed in Responsible Medical Reporting?

2007-09-28T09:37:00.000+01:00

For some of us, the day that The Observer published some egregiously poor reporting about the incidence of autism in the UK and a series of errors about the MMR vaccine, was a landmark in shoddy medical journalism. I dubbed it St. Maximilian Kolbe and Blessed Titus Brandsma Day: once The Observer had published those notorious pieces, it guaranteed abysmal coverage of the issue for the next 100 days.

There was outrage throughout the UK blogosphere. Many people wrote to The Observer to correct these stories, not least Dr Fiona Scott whose views had been misrepresented and one apiece from Prof. Baron-Cohen and Prof. Bustin. Baron-Cohen:

[Your] article linked MMR and autism.

The research does not...

The best estimate of the prevalence of autism is the 1 per cent figure published in the Lancet in 2006.

My view is that any apparent rise is likely to be driven by better recognition, greater awareness, growth in services, a widening of the definition of autism and a shift towards viewing it as a spectrum rather than a categorical condition.

Bustin (see Fitzpatrick for a summary of Bustin's devastating testimony):

Remarkably, there is no reference in your story to the fact that on 11 June the first of 4,800 cases in autism proceedings came to trial at the United States Court of Federal Claims in Washington. These are designed to establish whether or not autism can be caused by MMR. For the first time, a succession of highly respected researchers in epidemiology, genetics, virology, molecular biology and other medical and scientific disciplines - the 'medical and scientific establishment' of the Observer article - provided detailed evidence of why, in their opinion, there is no medical or scientific basis for any claim linking the MMR vaccine with autism.

You might have thought that the interventions from these two luminaries might have made it into the subsequent Readers' Editor response to the letters and the result of his investigations into the story. The short piece was riddled with self-exoneration. The Head of News says:

'I believe it was legitimate to include the thoughts of two of the authors of the study. We didn't conflate the two issues; the issues are already conflated.

'We worked hard to give a non-incendiary, balanced view. I believe we had to give the readers all the information we had. After all, they would ask, "Could MMR be a factor?"

Sins of omission and commission abounded. They seemed unrepentant about publishing the inflammatory 1 in 58 figure but grudgingly acknowledged that perhaps they might have included the other figures that were less disturbing and more inline with current estimates (amongst many much-needed corrections, they didn't touch the issue of it being a tool that may generate a 50% rate of false positives which may be acceptable if it has good specificity). It doesn't seem to disturb them that their conclusions are at considerable variance with the contents of of a report about that screening tool (pdf) from Baron-Cohen's research centre (HT to correspondent who sent me this link). The concluding sentiment and sentence are breathtaking for their complete lack of any awareness of the issues that fuelled the strong response of so many readers plus the introduction of a novel definition of accurate.

And the central point, in my view, is that the leaked story of the apparent rise in the prevalence of autism was a perfectly legitimate and accurate story in its own right, which did not need the introduction of the MMR theory.

Oh misery me! Omnes plecum plangite! However, if the Guardian/Observer offered a completely inadequate apologia pro ephermeris sua (HT Kristina Chew) then The Independent among many other papers wasvox stulti as was Channel 4 News for repeating those figures uncritically.

Jon of Holford Watch has been indefatigable in chasing corrections and amendments to these stories. He phoned both The Guardian and The Observer on many, many occasions to explain what was wrong with those stories. Jon was instrumental in having some online corrections published in The Guardian which carried some uncritical follow-ups that reproduced 'facts' from The Observer. Even after Dr Ben Goldacre published his remarkably restrained coverage of what was so appalling about media coverage of MMR-related issues, the editor of the The Observer refused to retract the story (judging by the the sins of omission rather than actual action).

The belief in a link between MMR-vaccines-mercury-autism has cultish overtones. Most religions have an act of contrition. Several months ago, I argued that the UK media collectively needed to make an act of contrition and perform an act of reparation. My preference was that these should take the form of some informed coverage and some active retraction of those abused figures. However, it rather seems as if obduracy in this matter may lead to a sacrificial act: Madame Arcarti floats the possibility that a senior person from The Observer is going, although the precise identity is unclear.*

This is the result of news ed Kamal Ahmed getting to keep his job - the result of an investigation into the embarrassment over the MMR splash that wasn't a story of two months ago (Catch up here, on the very good bad science website). The Scott Trust got involved, editor Roger Alton had to go to before them and receive six of the best like a naughty schoolboy. [Edited to embed URL.]

Jon has been diligent in pursuing a correction to 'MMR-idiocy' and has published a vigorous response to this news:

Hopefully the rumour is accurate, and Alton will face the consequences of his actions. I think it is entirely appropriate that – if a newspaper Editor publishes something both stupid and damaging on their front page, then refuses to retract the story – their career should suffer as a consequence of this.

Whatever the rights and wrongs of this rumour, it is not enough. I would far rather that The Observer stopped the Quackometer's MMR Apology Counter and retracted those stories and errors. I would rather that they did some soul-searching and resolve to be more responsible in reporting medical stories full-stop, but particularly those with significant public interest, and those where emotion seems to trump science. If somebody has to leave, that is a dramatic action: will it put editors on notice that medical reporting has to be handled responsibly and, above all, be accurate? It will be fascinating to see how this story plays out over the next few weeks.

Update* The Independent and an anon commenter on the Madame Acarti story indicate that they sacrificial lamb's identity may be illusory as may any hope for an improvement in journalistic standards for responsible reporting in science/health.

Did Scoop Campbell Pull a Brizendine: More on Science and Journalism
Myth: Measles Is A Trivial Illness, There's No Point to Vaccination
MMR Vaccine Does Not Contain Mercury, Thiomersal, Thimerosal and It Never Has
Myth: Autism Omnibus Hearings Have Not Included Evidence About MMR
The Observer Still Doesn't Understand Corrections of Fact
Confused by 'Muddled Medical Research'? Scoop Campbell to the Rescue
Observer MMR Story Has Disappeared From the Archives: Why?
The British Medical Journal Embarrasses Itself by Reproducing That Notorious 1 in 58 Figure
Another Day of Shame for UK Media on Topic of MMR and Autism
Autism: The Truth Plus Sensitivity, Specificity and All That Is Decent to Reveal About Predictive Values
Wakefield: Another Triumph for Mainstream Journalism in the UK
Anthony Cox: How virulent were The Observer’s MMR articles?
Dr Michael Fitzpatrick on Stephen Bustin's devastating testimony and why there is nothing in the MMR-autism theory
Brian Deer for a very readable summary of The MMR-autism scare and Wakefield's role in it.
Brian Deer on Prof. John Walker-Smith and his involvement in experimentation on children with autism symptoms and his statement relating to the revelations about the Lancet paper.
Brian Deer on Prof Simon Murch and his involvement with the studies and his defence of the Wakefield research. Brian Deer has performed a thorough analysis of the differences between that statement and the claims made in the Lancet paper
Daily Telegraph on Prof Murch and his statement that there is no link between MMR and autism
Brian Deer has made available an easy-to-read format of the cross-examination of Dr. Arthur Krigsman in the Cedillo case of the Autism Omnibus.
Anthony Cox of Black Triangle: Virological evidence does not support a link between MMR vaccine and autism
Andrew Wakefield, Chronology and "Bad Science"
Patrick Holford and Dr Andrew Wakefield's Discredited Findings: Part 1 and Part 2
Wakefield's Latest Tent Mission on the Doctrine of Autism
Kevin Leitch on Andrew Wakefield and the death of the MMR debacle
Patrick Holford, MMR and What Passes for Hard Evidence
Mike Stanton on Patrick Holford and his unusual views on vaccination, MMR and autism
Ben Goldacre of Bad Science: Try Me, Sh*thead - the strange case of Carol Stott, Wakefield and the Observer
Dr Crippen of NHS Blog Doctor: Andrew Wakefield, MMR, Autism and the GMC
Tony Hatfield of Retired Ramblings: What the Observer's MMR Piece Didn't Tell You!
Tim Worstall: Crap Reporting in the Observer
Anthony Cox: New Autism Fears, A Man in Denial and MMR Memes in Newspapers
Mike Stanton: Cry Shame on Wakefield and MMR
Kristina Chew of Autism Vox: 1 in 58
Ms Clark of Autism Diva: Embattled Andy Wakefield Speaks and Wakefield and Walker-Smith: Dishonest and Irresponsible
Russell Brown of Public Address: Bad journalism, old stories
Wakefield and Why the Edith Piaf Routines is Baseless: Part 1
Patrick Holford and Andrew Wakefield

Thanks to Wellcome for use of this open access image.

House of Lords Reports on Allergy And Allergic Disease

2007-09-26T10:47:00.000+01:00

Imagine having a Ferrari that you are only ever allowed to drive in a velodrome. Imagine further, that there is a noise-limiter on the engine and that you are not allowed to exceed 12 miles an hour. The UK is in the somewhat remarkable position of having some of the most well-respected and expert clinical allergists and immunologists in the world yet employing them within a National Health Service that is infamous for its lack of adequate allergy services and the poverty of available resources.

A House of Lords Committee has been investigating allergy and allergic diseases in the UK. The House of Lords (HoL) committee has issued a comprehensive report (HL 166-1 or pdf) and made some strong recommendations that seem wholly appropriate to the scale of need within the UK.

It is breathtakingly difficult to obtain a referral to a clinical allergist in the UK. In the whole of the UK, we have the equivalent of 26.5 consultant posts: approximately 5 of those are specialists in paediatric allergy. Clinical allergists frequently express their concern that it is this lack of provision that is driving some desperate people towards inappropriately qualified advisers who may lack a full understanding of allergy, anaphylaxis, intolerance and their appropriate diagnosis and management. The lack of timely access to NHS allergy diagnosis and management pushes people who suspect that they have allergies towards the more dubious fringes of CAM or to testing laboratories that claim clinical validation and "sound science" for their product range of tests.

Both allergies and intolerances can have a dramatic and deletrious impact on quality of life. Allergy can kill. It is difficult to write about less severe forms of allergy because it is not practical to predict whether or not a mild allergy might suddenly become a life-threatening allergy.

A number of children 'grow out of' allergies but many of them don't although there is some indication that timely intervention for allergic rhinitis might mitigate the onset of asthma. Some children have allergies that are multi-systemic and this puts them at particular risk.

Allergies are typically managed, not cured. An exception to this is the laborious process of immunotherapy for some allergens which is rarely available on the NHS in the UK and is reserved for those people for whom medical management has failed. However, allergic rhinitis and hayfever respond well to immunotherapy. Immunotherapy can take a long time: people with allergies are exposed to small doses of the substance which causes a reaction in order to "desensitise" them and the exposure is increased gradually to erode the response. Immunotherapy is a well-established standard of care in other countries and known to lighten the disease burden for some allergies. Dr Lourdes de Asis has provided an excellent overview of allergen immunotherapy and reports that where it is used appropriately:

Immunotherapy is successful in up to 90-95% of patients with seasonal allergies and up to 85% of patients with year-round allergies.

Professor Hourihane gave evidence on immunotherapy to the HoL committee; he commented:

The NHS is the laughing stock of Europe for its absence of immunotherapy for allergic diseases.

The technique, which used be given in GPs' surgeries, fell into disrepute in the UK after the mid-1980s after a report from the Committee on the Safety of Medicines in 1986 found that immunotherapy had caused 26 deaths over the previous 30 years. However, Committee Chair, Baroness Finlay of Llandaff, reports that it seems that immunotherapy was being administered to "the wrong patients by the wrong people in the wrong places".

The report makes interesting reading and there are many useful recommendations that would make a dramatic difference to allergy services within the UK and a significant difference to the appropriate management of allergic disease and the quality of life of many people. One of the most striking recommendations is the unequivocal support for the re-introduction of immunotherapy as a management technique for allergy and allergic disease with appropriate caveats governing the people and conditions for whom/which this is most effective and the setting for such treatment (a specialist tertiary centre, see pg 79 pdf).

Immunotherapy is a valuable resource in the prophylactic treatment of patients with life-threatening allergies, or whose allergic disease does not respond to other medication. Although initially expensive, immunotherapy can prevent a symptomatic allergic response for many years, and may prevent the development of additional allergic conditions, so its wider use could potentially result in significant long-term savings for the NHS. We recommend that NICE should conduct a full cost-benefit analysis of the potential health, social and economic value of immunotherapy treatment. [pg 81, pdf.]

This is a comprehensive and fine report with many important recommendations that I shall explore in other posts (not least, the importance of food-labelling; the call for responsible professionals and charities to stop endorsing direct to consumer allergy and intolerance tests and an outline plan to set up a national network of specialist allergy centres).

However, one dispiriting note is that the HoL Committee can only make recommendations. The National Allergy Strategy Group (NASG) represents clinicians working in the field of allergy, and cautions that this is the fourth national report highlighting deficiencies and the Department of Health has failed to act on any of them despite increasing evidence of the marked increase in allergies in the UK. The NASG representative said:

Health Ministers must act now.

Unless health authorities and trusts are directed to develop services and funding is identified, patient care will not improve.

Investment to train more specialists in allergy and to support GP education is needed.

Failure to diagnose and treat allergy is resulting in continuing illness and cost to the NHS.

These clinicians are experts; they have a very clear view of the desperate state of allergy services on the NHS. It is long past time that the Dept. of Health should stop making these people tootle round velodromes; these clinicians deserve better and so do millions of people throughout the UK who need the provision that they recommend.

Did Scoop Campbell Pull a Brizendine? More on Science and Journalism

2007-08-06T16:20:00.000+01:00

There have been lots of tedious stories in the news about the alleged chattiness of women and the Trappist-like qualities of men. One of the major sources for this recent nonsense is Louann Brizendine.

The San Francisco Chronicle took the appearance of the new paper in Science about women's and men's chattiness as a prompt for a front-page story last Friday (July 6), and of course got some quotes from San Francisco resident and myth spreader Louann Brizendine. Quotes of astonishing disingenuousness, it turns out. Brizendine's newest story is this:
My book is really about hormones, and that one line [about women uttering three times as many words per day as men] has been taken out of context. It's fascinating, anytime you talk about sex differences, it's controversial. But the bottom line is, there are more similarities than differences between men and women.
So first she claims to be just an ordinary working endocrinologist. Then, like a politician caught on tape saying something derogatory about negroes, she plays the "I-was-taken-out-of-context" card. Next, she ruminates in wonderment at the controversiality of the whole topic (could it be the fault of the press, perhaps, pumping all this up?), and then, in a dramatic big-lie U-turn, she endorses the "more-similarities- than-differences" position that properly belongs to her critics...

[I]t's Brizendine now who is the hunter of the origins of the myth — a myth that she now implies she has almost nothing to do with!

Scoop Campbell is responsible for a new myth, that of the wretched 1 in 58 prevalence for autism among UK schoolchidren (see, e.g., this discussion about autism and MMR on WDDTY). Campbell is also responsible for significant inaccuracies about the content and safety profile of vaccines. Yet, it is Campbell who has produced a Special Report for Those Confused By Muddled Medical Research; first amongst those muddlers who are responsible for such confusion would be Scoop Campbell.

many media reports last week [detailed] new medical or scientific research on key health issues. Some involve real breakthroughs, others are more questionable.

'The public ends up very confused,' says Professor Jack Winkler, a sociologist of science at London Metropolitan University. 'Every week we are told about some new wonder ingredient in our diet that's different to the one we read about a year ago.'

A UKDietitian has responded (comment 2), arguing that:

Campbell's attempts to disguise his central role in the 'muddled world of medical research' - with regards autism last week and nutrition this week - by pointing the finger elsewhere fails miserably.

It's ironic that this article - just like his MMR article that preceded it - demonstrates beautifully the central role of the journalist (and this one in particular) of perpetuating 'muddle'.

Is this an elaborate ruse for Scoop Campbell to claim that although mistakes were made, they were not by him, it's the fault of pesky scientists and their muddled research? Not his muddled research for his journalism, nor his lack of understanding of even the basics of his subject-matter? Not his fault for failing to check his sources and materials with relevant principals?

Has Campbell pulled a Brizendine yet, or will that only be true the next time that he purports to inform the public understanding of MMR, autism or vaccinations?

How much of this can be attributed to newspapers failing to educate their readers in how to distinguish reputable sources of information and well-validated research? How much responsibility do newspapers accept for muddling health and medical news that has plausible physiological/scientific mechanisms and those that do not?

Back in 2005, Mark Liberman argued that we would raise standards in science reporting by lowering them. Liberman has a very well-worked out plan, but if Campbell is anything to go by, the mainstream media has little interest in the public understanding of science, choosing to concentrate on what science and health have to offer in the way of fodder for the gaping maw of newsrotica (an obsession with salacious news stories).

Other than scoopmania, is there a neologism that captures sloppy, sensationalised reporting of health and science?

Scienceblogs host many good discussions about science. However, too frequently, there is little discussion about the science, more the public statement of different views and the interpretation/rejection of publications in line with the respective writers' or commenters' confirmation bias. In non-specialist fora, the science discussion has a distressing tendency to favour the more attractive narrative rather than the scientific plausibility.

There is more to be said about whether journalism is changing and the issue of wisdom v. ignorance in networked crowds. Scoop Campbell is thought-provoking in some ways - it is a shame that it is more about his potential emulation of Brizendine rather than a positive contribution to the public understanding of science.

Confused by 'Muddled Medical Research'? Scoop Campbell to the Rescue

2007-08-05T10:30:00.000+01:00

Scoop Campbell was the trigger for St. Maximilian Kolbe and Blessed Titus Brandsma Day: once The Observer had published those notorious pieces, it guaranteed abysmal coverage of the issue for the next 100 days. Following Campbell's fine example, other staff from The Observer duly obliged with failed clarification upon failed clarification and no adequate apology although one of these articles has now disappeared from the archives seemingly related to legal enquiries.

Jon of Holford Watch has been remarkably diligent about following up on factual errors with The Observer's Readers' Editor but it seems that Steve Pritchard is still not ready to acknowledge that Campbell erred in points of fact, and that Pritchard's attempts to deny this are increasingly ludicrous.

Campbell was wrong. The article that was so egregious that Healthbolt has styled it as a hoax has been withdrawn.

The zombie autism/MMR thing is back. In the new BMJ, Ben Goldacre tells the appalling story of an article in the UK's Observer newspaper that claimed new research had found the prevalence of autism to be much higher than previously believed -- 1 in 58 -- and that "leading researchers" thought this might be due to the MMR vaccine. None of the above was true. Period. The article can only be described as hoax. The study found no such thing, one of the "leading researchers" had no such opinion, and the other, who is not even part of the study team, works for Andrew Wakefield, the doctor who started the whole thing with a fraudulent paper in The Lancet many years ago, which has been withdrawn. [My emphasis.]

There are still errors of fact-not interpretation, fact-in the article that is still available in the archives. These errors are serious enough to pollute the public understanding of issues that are relevant to public health, namely the composition and safety profile of vaccines.

This weekend, we have learned that there is yet another outbreak of measles among unvaccinated children. One of the reasons that some parents have declined to vaccinate their children is the sensationalist reporting of an unsubstantiated link between vaccinations and autism; reporting that has been untempered by subsequent reports that find that there is no evidence for such a link.

So, it is with spectacularly bad timing that the The Observer carries a Special Report by Campbell: Confused by health advice? Then read on. It beggars belief that somebody perceived a need for clear guidance on important matters of public health and the cry went up, "Send for Scoop Campbell; nobody does it like him!".

It kills you; no, it does you good. Hang on, here's another report that says ... Denis Campbell looks at the muddled world of medical research

Seriously, that's what it says. One has to assume that the sub-editor has a tongue-in-cheek sense of humour in such matters. It reads like an apt description of Campbell's knowledge of the matters that he is writing about in the assumed capacity of expert mediator between scientists and the public. It is not always true that medical research is muddled. Many substances and interventions have both advantages and disadvantages; it's a somewhat sophisticated argument but it should not be beyond the wit of Observer journalists to write with appropriate qualifiers and nuances.

As it is, for Campbell to be The Observer's journalist of choice seems like breathtaking incompetence or arrogance. I feel that they have let loose someone with the subtle understanding of science that invites comparisons with Margaret Cavendish, Duchess of Newcastle and her remarkable musings on What is liquid?

All that doth flow we cannot liquid name
Or else would fire and water be the same;
But that is liquid which is moist and wet
Fire that property can never get.
Then 'tis not cold that doth the fire put out
But 'tis the wet that makes it die, no doubt.

Just how much contempt does The Observer have for its readers? Well, enough to ignore what might have been an excellent opportunity to retract Campbell's completely erroneous report, that must have 'baffled' many, that there is a 1 in 58 prevalence of autism among UK schoolchildren. Le Canard Noir is not easily stirred, but he has been moved to describe this article as "barefaced cheek, hypocrisy and cowardice". Quite.

It is past time that Pritchard and Campbell paid attention to the hoardes of people who are waving correction slips at them. Is it time to pick up the virtual pitchforks and flaming torches in the form of more corrections and besiege the citadel of the Readers' Editor's office?

Update 14:00: Le Canard Noir is sufficiently irritated that he has added an Observer-MMR Non-Apology Counter to his front page.

The Observer Still Doesn't Understand Corrections of Fact

2007-08-04T17:47:00.000+01:00

To recap: on July 8, The Observer sullied its reputation as a quality newspaper by publishing two articles that were breathtakingly inaccurate. They added to their ignominy by subsequently issuing clarifications that were nothing of the sort (neither apologising nor clarifying).

Along with many other people, I wrote to The Observer to correct some inaccuracies. My email is as follows; I have yet to receive an acknowledgement and these matters are still outstanding.

From: Shinga
Date: 08-Jul-2007 12:32
Subject: Corrections to Campbell's Articles
To: Readers' Editor

Dear Sir/Madam,

I'm sure that you will receive many well-founded objections to the two companion pieces by Denis Campbell. I wish to comment on some of the many factual errors in these pieces but shall concentrate on the Wakefield interview in this post.

The factual errors are so numerous that even picking this short selection at random yields several examples:

Critics point out that the US court case is not about the MMR vaccine itself but centres on the use of a preservative called thimerosal, which contains 50 per cent mercury and until a few years ago was added to routine vaccinations given to children in the US under one. Crucially, it has never been an element of the MMR vaccine here.

The Autism Omnibus Hearings have included extensive discussion of the MMR vaccine. The various experts for both the petitioners and respondents have discussed the MMR vaccine, the claimed presence of wild or vaccine strain measles virus in biological samples, and various hypotheses that include biological mechanisms for the contribution of thiomersal/thimerosal and MMR vaccines in the aetiology of autism. Some examples follow; all quotations are from the court transcripts (pdf files):

Mr Matanoski of the legal team for the Secretary of Health and Human Services discussed MMR in his resumed opening comments on Day 6:

We want you to be sure in your own mind that MMR vaccine is not causing autism because you've had good evidence to look at and
consider on that...[pg 10 of 345]

A serious accusation has been leveled. A serious accusation has been leveled against an important part of the public health arsenal against a preventable disease. An accusation has been leveled that MMR vaccine causes autism. That accusation must be answered, and we will answer it...

This accusation goes against a vaccine that is designed to prevent a killing disease. [pg 11 of 345]

...we are going to put on the evidence this morning and throughout this week that will allow you to effectively deal with that and to show you that MMR vaccine is indeed safe. [pg 16 of 345]

You heard from Dr. Hepner [one of the petitioners' expert witnesses: Day 3], and frankly, I think the PSC [Petitioners' Steering Committee] may have cringed at one part of her testimony, that is, when she said that MMR vaccine causing autism is an unproven hypothesis. [pg 18 of 345]

Similarly, on Day 12, Mr Powers, for the Petitioners Steering Committee (PSC), said:

You have a case here [the Cedillo case] that is a test case for the theory, the general theory that a combination of exposure to thimerosal-containing vaccines with a significant dose of ethyl mercury early in a child's life, combined then with MMR, can result in a complex system response that present symptoms that can get diagnosed as autism.

And in particular a suppressed immune system from the thimerosal in the vaccines, the introduction of the attenuated live measles virus then persists, and the persistence of that virus leading to a complex biological process of disease...
[pg 19 of 49 or 2887]

From the same transcript of Day 12, Mr Matanoski:

You need to find whether Michelle Cedillo's autism occurred before her vaccine. You need to find whether the PSC has proven that autistic spectrum disorders can be caused by MMR.

Whether or not there's inflammation in Michelle's Cedillo bowel or intestines, you need to find whether or not MMR can cause autistic spectrum disorder. [pg 30 of 49 or 2898]

Prof. Bustin's testimony is entirely concerned with the discussion of whether or not the findings of measles virus in the biological samples (a foundation stone of the work of Wakefield and those who claim to have replicated his findings) can be relied upon. In brief, he discusses his investigations and the expert report that he had prepared for the UK MMR litigation; he reports that the Unigenetics findings are unsound.

It is unusual for a misunderstanding to be so widely propagated that an government agency has to issue a clarification that a substance has never been part of a vaccination, but the FDA has done that for thimerosal and MMR.

MMR is a live vaccine, it would be unwise to add the thimerosal preservative to it because it would inactivate it and render it useless. Thiomersal/thimerosal any similar mercury compounds have never been a component of MMR anywhere.

Amidst the many complaints that you may receive about these articles, it would be helpful to correct these errors.

-------
I know that other people (notably Jon of Holford Watch) have contacted Readers' Editor Steve Pritchard of The Observer with similar concerns and they have received unsatisfactory replies. I may well discuss some of these responses tomorrow if The Observer continues to fail to correct/retract those pieces. However, for now, I will remark that the only proper response to Pritchard's latest response is to be scornful. For a hint as to the tenor of the response, assume that the Readers' Editor requires us to believe that the informed reading public has misinterpreted Scoop Campbell's writings, rather than that Campbell made a mistake or that Pritchard erred in supporting him. Pritchard seems to have overlooked that if Jon's interpretation erred, and mine erred, then so did David Batty's (who reproduced some of those facts in a piece for The Guardian, a piece that has now been edited to remove those claims).

It defies belief that a credible Readers' Editor for a quality broadsheet can have a writing style that makes Scoop Campbell's look subtle and sophisticated coupled with New York Governor Eliot Spitzer's instinct for framing a sincere apology (albeit Pritchard seems to believe that the mistake lies with the readers/correspondents, not the staff). Pritchard's attitude is the more incomprehensible when one considers that one of these infamous articles has already been withdrawn for unspecified reasons that may be related to possible legal investigations.

I find this issue particularly irritating in the context of a recent, thoughtful article in Seed Magazine the outlines the difficulties faced by science journalists in developing countries:

Science and technology writers in the developing world are taking on issues that have profound implications for the countries and emerging economies in which they report. One need think only of the African AIDS crisis, climate change, prescription-drug access, agricultural biotechnology, bird flu, and many other specific science issues that have huge importance for the developing world. Perhaps the most crucial issue in places like Africa and South Asia is health policy, which is inextricably intertwined with social progress--more-productive nations tend to be those whose citizens are healthier and live longer. Philip Hilts, a former science and medical reporter for both the New York Times and the Washington Post who has spent many years working in developing countries, observed that as health improves, wealth follows. By informing governments, NGOs, and the international community about their countries' health policies, science writers in the developing world are performing a job that's fundamental to international development.

Yet despite having such a critical role to play, in many cases science journalists from the developing world face a series of hurdles that I, comfortably ensconced in Washington, D.C., simply never encounter. For some of these writers, basic research resources like cheap and reliable telephone service, libraries, and even dictionaries can be scarce. And while the physical act of researching and writing can present dramatic logistical challenges, science correspondents in some parts of the world are also faced with the worry that offending despotic or corrupt governments will result in retribution...

The specific challenges faced by the science journalist—getting access to scientists, getting them to talk about their work, the work of their peers, or recent studies and their implications—are also more difficult to overcome.

I have not complained about matters of interpretation in the above email but about facts that are easily checked and verified. Campbell, Pritchard and their support staff on The Observer are awash with resources. MMR, the safety of the vaccination programme, autism, and children's health are all significant areas for public concern and journalism in these areas has a particular significance and responsibility. As Fiona Fox explained, they could have had access to all the scientific expertise that they wanted to check facts both big and small, and to talk through the likely implications of those articles. If they were to compare their resources to those of their colleagues in other countries, then that is an additional cause for shame.

Where's Molly and the Rest of That Generation?

2007-08-02T08:19:00.000+01:00

Autism Diva has a thought-provoking post with many poignant links about the issues raised by Where's Molly? Where are the others?

One day in 1957, when Jeff Daly was 6 years old, his little sister Molly, disappeared.

Every night at dinner, he would ask his parents the same question, "Where's Molly?"

Every night, he says, he received the same answer: "Stop asking about Molly."

Decades later, Daly learned that his parents had sent Molly to a state institution nine days before her third birthday. Nearly 50 years later, Daly found his sister and made a documentary about his search.

"Since the movie, literally hundreds of people have come up to us and said, 'I had a [relative] that I remember my family talking about that was sent away. Do you know how we can find out about that person?'" says Daly...

There's a timeline that explains that in 1967 about 195,000 people, half of whom were children were institutionalized for being disabled, many of them would have been diagnosable as autistic by today's standards. Many of the were treated brutally and died in those institutions of the actions of drugs and of neglect and disease.

Reading the remainder of Autism Diva's post, I'm reminded how strange it is when I hear people ask, "If there is no epidemic of autistic spectrum disorders, where are all the older ASDs?". My mother's family was the lynchpin for many others. My grandmother held a 'come all ye' that was open to all friends, relatives and neighbours every Friday evening. My mother recalled that every weekend, although most people returned home after the evening, they had around 25 people staying over with them; the children would top-and-tail in the beds and others would sleep wherever they could fashion a sleeping space. The come all ye was primarily a social event but it also provided food and regular respite for relatives who were caring for those who needed 'special care and attention' (as it was known).

It sounds rather Gormenghast but my mother's childhood home had a large and comfortable basement level. An assortment of friends and relatives lived in the basement at various times. By report, they included people who had fallen on hard times (but social delicacy forbade discussion of this) along with those who didn't like noise, being surrounded by others, or busy visual scenes. They ate with the family as they chose, or took their meals down with them. Some of them had particular aptitudes and roles for which they were accepted and praised for their contribution to the household. One of the young men took over all of the endless mangling of the laundry and helped out with the extensive vegetable preparation that took place before every family meal (he would prepare the vegetables in the basement kitchen or would occasionally do it upstairs if my grandmother would promise not to sing, and my gregarious great-grandfather were not present). Another was known to be a dab hand at keeping the machinery running in the local dockyards.

When I was a child, most extended families had a couple of relatives who needed 'special care and attention' from other family members. Families who were separated from their extended families sometimes had children who 'disappeared' (this seemed to happen in new build estates that were created to meet the post-war housing shortage). Depending on their age, some of these children may have been to Children's Homes. Older children tended to disappear to Borstal (if male) or a 'home for wayward boys and girls'; others went to residential schools when they became too large or heavy to be managed at home by their mother.

A few years ago, I met someone who was horrified to discover that her husband had a sister whom he hadn't seen since he was a very young child. Somewhere in the early 60s, the sister had regressed when she was around two-years old. She spent hours at a time, running around the perimeter of the garden. She was terrified if people laughed, either in the same room or on the television. One day, the family took her to a residential home and thereafter, although the parents visited twice a year, her brother found it to be too upsetting and stopped seeing her. After the new bride found out about the sister, she started to visit her. Her husband accompanied her but would wait in the car during the visit; he was still unable to see his sister.

Autism Diva has provided a poignant example of Roy Grinker's argument in Unstrange Minds that there is no epidemic of autism. Kristina Chew presents a good overview of Grinker's findings. Both Chew and Grinker wrote an essay that is well worth reading: If There’s No Autism Epidemic, Where are all the Adults with Autism?

Just where might those 1 in 150 adults with autism be?

As surprising as it may seem, they are living and working among us.

Some live at home with their aging parents or siblings. Some live in group homes, or in institutions. Some have jobs and live independently. Many have the diagnoses given to them when they were children, such as mental retardation, seizure disorder, or schizophrenia. Recently, one of us met a severely autistic 60 year old woman in eastern Tennessee, who we’ll call Donna. Donna’s internist diagnosed her with autism ten years ago, when she was 50. Her mother said that Donna’s first label, in 1950, was “mentally retarded with emotional block and obsessive compulsive traits.” Today, for the purposes of public assistance, she is classified as mentally retarded.

There is no record anywhere to suggest that Donna is “autistic.”

Like Autism Diva, I wonder how many people like Molly there are in the UK. I wonder how many people are puzzled as to the identity of young children in photo albums.

Edited: August 4. Kristina Chew has told us about JP and other invisible or disappeared children.

Liberman Proposes a New Commandment About Odds Ratios

2007-07-30T15:04:00.000+01:00

Mark Liberman is on a mission to improve the rhetoric and logic of science journalism. He has written some excellent pieces on the topic and his latest is: Thou shalt not report odds ratios.

No, let's make it a commandment: Thou Shalt Not Report Odds Ratios. In fact, I'd like to suggest that any journalist who reports an odds ratio as if it were a relative risk should be fired sent back to school.

Many of you probably don't know what I'm talking about -- that's why dozens of science journalists disobey this commandment every week. But the basic concepts are simple, and nothing more than simple arithmetic is required to understand them.

Liberman puts up a thoroughly readable explanation of one of my recent pet peeves and takes readers through a shocking headline report to show how an arithmetical blunder led to the dissemination of a shocking 60% attention-grabber that should have been reported (more accurately) as the less startling 93.5%.

Liberman includes further discussion and provides some very informative links to allow for further exploration and understanding.

If you have ever wanted to learn about accurate reporting and odds ratios, grab this opportunity, and estimate for yourself just how pleased you were that you did.

Myth: Autism Omnibus Hearings Have Not Included Evidence About MMR

2007-07-30T14:48:00.000+01:00

Recently, there have been several comments, news-stories and posts that disseminate the misunderstanding that the Autism Omnibus Hearings have not included rigorous discussion of the MMR vaccine. A number of the experts testify about their involvement in the UK MMR class action legal case and have included some of that research in this case. It should be noted that the UK legal case was solely concerned with the MMR vaccine; the Autism Omnibus Hearings and the UK case involve many of the same experts as witnesses.

Dr Kinsbourne makes this pertinent comment during his cross examination (pdf) (albeit he is corrected by the Special Master who states that it was the Petitioners Steering Committee who chose to apportion the causation issues into the three categories):

The Special Master designated three questions for us at the beginning of the proceedings. Number one was about the relationship between thimerosal and immune function. The second was the relationship between the measles or MMR vaccination and autism. The third one was about collaboration as it were between thimerosal and the MMR in the causation of autism.

I see myself as addressing number two, the relationship between MMR and autism.
[pg. 150 of 191 or 1172: Day 5]

Many of the experts explictly included discussion of MMR, the presence of measles vaccine virus in the gut and the confidence in the integrity of laboratory findings of measles virus in gut and CSF samples. Mr Matanoski of the legal team for the Secretary of Health and Human Services made MMR part of the second part of his opening comments on Day 6 (pdf):

We want you to be sure in your own mind that MMR vaccine is not causing autism because you've had good evidence to look at and consider on that...[pg 10 of 345]

A serious accusation has been leveled. A serious accusation has been leveled against an important part of the public health arsenal against a preventable disease. An accusation has been leveled that MMR vaccine causes autism. That accusation must be answered, and we will answer it...

This accusation goes against a vaccine that is designed to prevent a killing disease. [pg 11 of 345]

...we are going to put on the evidence this morning and throughout this week that will allow you to effectively deal with that and tto show you that MMR vaccine is indeed safe. [pg 16 of 345]

You heard from Dr. Hepner [one of the petitioners' expert witnesses: Day 3], and frankly, I think the PSC [Petitioners' Steering Committee] may have cringed at one part of her testimony, that is, when she said that MMR vaccine causing autism is an unproven hypothesis. [pg 18 of 345]

Mr Powers, for the Petitioners Steering Committee (PSC), said the following as part of his closing statement on Day 12 (pdf):

You have a case here [the Cedillo case] that is a test case for the theory, the general theory that a combination of exposure to thimerosal-containing vaccines with a significant dose of ethyl mercury early in a child's life, combined then with MMR, can result in a complex system response that prsent symptoms that can get diagnosed as autism.

And in particular a suppressed immune system from the thimerosal in the vaccines, the introduction of the attenuated live measles virus then persists, and the persistence of that virus leading to a complex biological process of disease...
[pg 19 of 49 or 2887]

From the same transcript of Day 12, the following remarks are drawn from the Respondents' legal representative, Mr Matanoski:

You need to find whether Michelle Cedillo's autism occurred before her vaccine. You need to find whether the PSC has proven that autistic spectrum disorders can be caused by MMR.

Whether or not there's inflammation in Michelle's Cedillo bowel or intestines, you need to find whether or not MMR can cause autistic spectrum disorder.
[pg 30 of 49 or 2898]

The following remarks are taken from the same transcript of Day 12 but from wrap-up statement of Special Master Hastings:

the parties for both sides have presented evidence not just about the particulars of Michelle's case, but also about the general causation theory, the first general causation theory of the Petitioners Steering Committee. That is, the general theory that MMR vaccines and thimerosal-containing vaccines can combine to cause autism.
[pg 47 of 49 or 2915]

The following references are all to pdf files. I have included those transcripts that explictly include discussion of: MMR; the impact of the wild measles virus on the brain; the presence of measles vaccine virus in the gut; and the confidence in the integrity of laboratory findings of measles virus in gut and CSF samples.

Day 2: Dr Krigsman

Day 3: Drs Hepner and Kennedy

Day 4: Dr Byers

Day 5: Dr Kinsbourne

Day 6: Matanoski Esq.'s Opening; Drs Fombonne and Cook

Day 7: Dr Witnitzer

Day 8: Drs Ward and Bustin

Day 9: Drs Hanauer and McCusker

Day 10: Drs Chadwick and Brent

Day 11: Drs Fombonne and Griffin

Day 12: Mrs Cedillo and closing statements by Powers Esq. for Petitioners Steering Committee and Matanoski Esq. for Respondents

Paediatric Grand Rounds 2:8 Is Up

2007-07-30T10:07:00.000+01:00

Paediatric Grand Rounds 2:8 is up, courtesy of Walter of Highlight Health.

The theme is a creative and delightful use of Deathly Hallows. A mixture of the intriguing, the odd, the humourous, the contentious and the interesting about paediatric healthcare. I commend PGR to you.

Dr. Clark Bartram is looking for hosts for future PGRs. You can consult both the hosting schedule and earlier editions in the Paediatric Grand Rounds archive. Please sign up for hosting.

Prof. Mawson on Andrew Wakefield: Why Do His Views Need Consideration?

2007-07-27T11:38:00.000+01:00

Dr Crippen has posted a Letter from America. However, it is not a gentle insightful reprint of a favourite Alistair Cooke but a letter from a US epidemiologist, Prof. Anthony R. Mawson. Mawson writes to offer his opinion on Prof. Trisha Greenhalgh's critical analysis of the Wakefield et al. study that was published in The Lancet in 1998. [I shall address these criticisms in another post although I suspect that the comments will deal with these matters in some detail.]

Mawson is a staunch supporter of Dr Andrew Wakefield. Although we may disagree on the quality of Wakefield's research and its significance, I do think it is admirable that Mawson has not only written this supportive letter to the most widely-read medical blog in the UK, but he may also have signed the Nigel Thomas petition that has gained the reputation as being in support of Wakefield and his research. I have emailed Mawson to ask him to confirm that he is currently signatory 2054 and maybe even 3529 (the numbers may be subject to change). If he confirms one or other of those signatures, then I shall discuss the supportive comments that he left there in another post.

Dr. Crippen tells us that:

Professor Mawson’s views need consideration.

He doesn't tell us why he thinks this, although he does then offer a potted summary of Mawson's current positions. However, it is not clear to me why Dr Crippen believes that any of these are more relevant than the opinion of most other commentators. There seems to be some potential for confusion about Mawson's qualifications. Dr RJ makes a robust comment that explores Mawson's reproof to Prof Greehalgh. In passing, he remarks:

Perhaps Professor Mawson hasn't kept up with his continuing medical education?

Having consulted Mawson's CV and various other sources, it's my understanding that he is not an MD or medical doctor. The CV lists an MPH or Masters in Public Health. His alma mater for this offers a 45-credit hour curriculum for this course although I don't know if the requirements were different when he took it. The MPH programme focuses on the

application of management concepts in the public health sector to protect and improve the health of the community. The MPH program consists of a 45-credit hour curriculum, which focus on management at the operating level.

The DrPH seems to be a Doctor of Public Health but it is clear that this is not a PhD programme: in UK terms this seems to resemble an MPhil. Mawson does not list a PhD in any subject. His CV states:

Dr. Mawson obtained his bachelor’s degree in sociology and psychology from McGill University, Canada, his MA degree in sociology from the University of Essex, UK, and both MPH and DrPH degrees in epidemiology from Tulane University’s School of Public Health and Tropical Medicine, New Orleans. He was also a post-graduate student at the London School of Economics and Political Science.

[Edited: 14:00] As several commenters to that letter have pointed out, but Dr RJ summarises:

Prof Mawson is an epidemiologist. He is not a medical doctor, not a virologist, not a pathologist, not an immunologist, not a gastroenterologist and not an autism researcher. There is nothing in Professor Mawsons CV that makes me think that he is qualified to hold an opinion on this paper any more than, say, a nuclear physicist with an interest in the topic.

I fail to understand what added value an epidemiologist without a record of research into autism, MMR, or the prevalence/incidence of paediatric gut-issues brings to a discussion of the appropriate design study for a case-series of 12 children, selected according to criteria that were mostly related to participation in a legal case.

Dr Crippen is notoriously scathing towards the value of PhDs and other higher degrees when nurses comment that they have them. What would his attitude be to those BAs and MAs in sociology and psychology, or the MPH or DrPH if a nurse were to report that s/he had them and was using them as a basis to claim academic credibility or excellence for Wakefield's work? Just why are Mawson's qualifications more relevant and why do they make his opinions more deserving of consideration?

Food for the Brain Promotes an Autism-Gut Seminar

2007-07-24T23:08:00.000+01:00

Understandably enough, Food for the Brain updated its homepage to coincide with the broadcast of an update of its project with Chineham Park Primary School on Tonight with Trevor Macdonald, July 13.

Fair enough. It was a little odd, however, that they chose to use that update to promote a seminar, AUTISM AND DEPRESSION - A GUT PROBLEM? with these troubling words:

Dr Andrew Wakefield suggested a link between gut immunity and autism. Was he right? This September we offer a seminar 'The Gut Brain Link in Autism, Depression and Mental Health' for health professionals. For more details and booking a place click here.

Well, that is not quite all that Andrew Wakefield suggested in the aftermath of that discredited Lancet paper and it is a little disingenuous to cherry-pick out one aspect of that work (see related reading). However, I followed the link for more information and learned that the leader of this rigorous investigation into whether Wakefield was right is Michael Ash.

Michael Ash, BSc.DO.ND.Dip ION, is an experienced osteopath, naturopath and nutritionist who specialises in mucosal immunology and its relationship to systemic health problems including neuro-development and psychological health. Anyone interested in the relationship between the Gut, the Brain and Mental Health should attend what will be a fascinating three hour seminar.

A Dip. ION, what were the odds? However, maybe Michael Ash will lead a rigorous examination into Wakefield's work, exploring Prof. Bustin's devastating expert report and testimony to the Autism Omnibus Hearings alongside Dr Chadwick's extraordinary revelations that Wakefield knew that there was no confirmed finding of measles virus in any of the samples at the time of the Lancet publication (more in related reading).

However, I have my misgivings if this is the same Michael Ash who signed the Nigel Thomas petition which has been characterised as supporting Wakefield (currently, signatory 9164) and left this comment:

Dr Wakefields work in the immunological disturbaces in the GIT of individuals with Autism, needs encouragement not derision. This eminent clinician,should be funded to explore this area further. The golden goose in medicine of vaccination is not without risk.

It does seem very much of a piece with one of the articles (pdf) by the Michael Ash who will be running the FFTB seminar. Ash relies heavily upon Wakefield's findings and reports of ileal-lymphoid-nodular-hyperplasia, inflammation and identification of autistic enterocolitis as a novel disorder. However, those findings have been discredited and called into question by many experts with considerable standing in relevant disciplines (see related reading) and have been retracted by the majority of Wakefield's co-authors on that Lancet paper.

I don't know. Maybe Michael Ash will use this seminar as an opportunity to inform concerned health professionals about why Wakefield's work on autistic enterocolitis and related issues can not be relied upon. Perhaps he is announcing a major re-think of some of his own treatment offerings and theories but there is no information about such a significant theoretical overhaul on his own website and it is the sort of thing that anxious parents need to know.

I can't help wondering if Sir Trevor Macdonald knows that FFTB is offering this event or if he is at all concerned that FFTB has strong links with people who are opposed to the recommended vaccination schedule?

The Independent on the Motivation of Criticism of the Infamous Campbell Articles

2007-07-24T21:01:00.000+01:00

Stephen Glover of The Independent somewhat magnificently misses the point of Dr Ben Goldacre's criticisms of Denis Campbell's infamous MMR-autism article for The Observer:

It is not often you read an attack in one newspaper on another such as appeared in The Guardian last Wednesday. The oddity here is that the venom of the article's author, Ben Goldacre, was directed at The Guardian's sister paper, The Observer. Mr Goldacre was angry about a front-page piece in The Observer suggesting a possible link between the MMR jab and autism. According to Mr Goldacre, The Observer had wilfully misrepresented research at Cambridge University. His piece was quite persuasive, though I dare say The Observer's case is stronger than he made out. Some may say it is grown-up for one newspaper to be able to attack another in the same group. No doubt it is. Yet, one cannot help wondering whether the publication of this piece in unexpurgated form did not reflect irritation on the part of The Guardian's editor, Alan Rusbridger, at The Observer's distinct populist identity. [My emphasis.]

Oh, I think that one can quite easily avoid that line of thought, if one comprehends the full horror of just why that article and the one that accompanied it are so spectacularly horrible that they will probably end up in textbooks as an Awful Warning to Journalists Who Get Out of Their Depth and Write About Matters that They Don't Understand While Behaving in an Irresponsible and Indefensible Way - and to the Editors Who Back Them.

According to Ginger Yellow, this matter was mentioned in The Guardian's media podcast but, again, missed the point by a country mile.

Tim Radford’s comments about this debacle on the Guardian’s media podcast. He basically took the line that you shouldn’t have scientists or people trained in science in newspapers because only lay journalists would know the questions that readers would want asked, and that we should rely on scientists to give the right answers. But isn’t it the job of an editor to make sure the right questions have been asked? And besides the Observer story had nothing to do with asking the right questions (as far as we can tell they didn’t ask any) and everything to do with basic misunderstandings of science and pushing an anti-scientific agenda. [My emphasis.]

Eh - wasn't one of the most significant points here that Denis Campbell signally failed to contact any of the principal scientists who could have set him straight about his astonishing story? Or was he too busy practising his new signature as Scoop (don't call me Denis) Campbell?

And, frankly, it may be the fact that he knew nothing about the subject, and couldn't assess his sources that led him to repeat the canard by implication that MMR in the US contains thimerosal (UK thiomersal, a mercury-containing preservative) which it does not and never has (he makes this mistake in his interview with Andrew Wakefield* that accompanied the autism scoop article, but he was obviously dazzled judging by the breathless fanfic prose). It may also have led to his inability to understand some of the terminology used and his lack of awareness that it is unwise to report the results of a tool that yield a known false positive rate of 50% without appropriate caveats and qualifications alongside. Those are just a few of the many flaws in Denis Campbell's piece that has now disappeared from The Observer's archive**.

Golf fans would not sit still for reporting by a journalist who didn't know one end of a club from another and flaunted ignorance of the history of the game. Why would anyone think that the public needs science interpreted for them by people whose understanding is worse than their own? Goldacre has described the responsibilities of journalists, acknowledging that the public is expected to rely upon journalists of various media to read and understand studies that are of general interest and to report upon them accurately. However, as Goldacre expresses it, although

newspapers like to fantasise that they are mediators between specialist tricky knowledge and the wider public...I wouldn’t be so flattering.

Scoop Campbell's debacle is a horrible example of this and, yes, An Awful Warning to Others. It is particularly galling that the consequences of correcting his misinformation will not have to be faced by him and The Observer. GPs and health workers in the UK and other countries will face yet more conversations with parents who are alarmed by Campbell's claims and have not heard that there is no foundation to them. Health insurers or the NHS will have to pay for that time. Who knows what the final bill will be if parents are so alarmed by these groundless statistics and claims that they refuse to vaccinate their children against preventable childhood illnesses?

The excellent Language Log posted a thoughtful piece on the Sí se puede surrounding a contretemps that involves language classes and some remarkably simplistic solutions that were offered by people who may not have known better but should have been aware of the appropriate resources that they might have consulted. They quote John Moore and Ana Celia Zentella with approval:

Rarely do politicians think to consult language researchers when dealing with linguistic problems. The governor seems to think that his recollection of his own experience with learning English is enough evidence to know how to deal with complex issues of second-language acquisition and literacy among poor immigrants under very different circumstances. However, we still harbor hope that research and facts might occasionally trump a facile appeal to personal anecdotes, so often invoked in political discourse.

That seems remarkably sensible. If you have an announcement to make that might influence public understanding and even lead to some friction, then it might be worth talking to some experts on the subject. The Science Media Trust comes to mind for Denis Campbell, editors, Correction Offices and anyone else who might regard this as a helpful tip.

*Campbell propagates the myth that the Autism Omnibus Hearings did not discuss MMR but were solely concerned with thiomersal, thimerosal and mercury preservatives
**The Guardian uncritically reproduced some of Campbell's claims in an article that claimed to give a summary background on MMR: Q&A: MMR vaccine row. This article now has the offending paragraph removed pending investigation:

A paragraph regarding concern about MMR overseas, extracted from a piece in the Observer now deleted from the website due to concerns about its accuracy, has been removed from this article until the information can be verified.

Observer MMR Story Has Disappeared From the Archives: Why?

2007-07-24T17:26:00.000+01:00

Quick update. Dr Ben Goldacre has just posted a note to say that Observer MMR Story Disappears From Archives.

For obvious reasons of propriety I have studiously avoided having an inside track on anything to do with this piece from the beginning, so I have no idea what is going on here.

Were The Observer nibbled to death by ducks in trying to find out where to start for the corrections? Has that desperate email by Dr Fiona Scott convinced them that they had this story badly wrong? Is there going to be a retraction? The Observer badly needs to retract that story albeit the damage is done and those infamous figures have been widely quoted as evidence of an autism epidemic.

Maybe there will be a retraction. Must go, I've just been told that pigs are flying and that there is to be an announcement that Patrick Holford had decided to rethink his treatment programmes that are based on Wakefield's research.

More, as the story unfolds...and there are virtual Jaffa Cakes on offer to the first person who spots a decent conspiracy theory for this disappearance. You know, like the doctors too terrified to speak against vaccines who were given an honorable mention by Halvorsen in his recent Sunday Express extravaganza that blazed, Children 'Used As Guinea Pigs for Vaccines'. Something classy along those lines, or that resembles Sherri Tenpenny's remarkable theory that the reason that Dr Byer's testimony at the Autism Omnibus hearings was so gob-smackingly awful might be more sinister than it reflected Byer's level of knowledge, competence and expertise:

Ya have to wonder if someone got to her or threatened her kids by her response. Absolutely unbelievable and I would suspect was really unexpected by the Chin-Conway team or they wouldn't have put her on the stand.

Of course, it might just be an accurate reflection of the level of actual scientific support for the case...So, something really decent along those lines, please.

Update, July 25: The Guardian's User Help Desk is responding to enquiries thus: "“The article was removed from the website for legal reasons. We are unable to provide a copy.” It is a little sad to reflect that newspapers and such are considerably more responsive to legal actions/discussion than they are to corrections of facts.

Autism Diva Gives a PoMo Sting to Wakefield Support Banners

2007-07-24T14:01:00.000+01:00

Go and see what Autism Diva has done to some of the banners of Wakefield's bank of supporters outside the GMC Hearings. It is definitely what some of those banners should have said in a disarmingly charming comment on some of the charges.

I don't know whether my favourite is:

1st photo - poster in back says "No time 4 ethics"
2nd photo - "We support Andy Wakefield and his lifestyle ££££"
Photo 3 - "Give us bad science"

The sad thing is that these banner-bites resemble so many of the comments made by his supporters that they lack the PoMo sting that should have made their irony more apparent.

Media Comment on Media Coverage of Wakefield, MMR and Related Matters

2007-07-23T19:04:00.001+01:00

It's hats off to Matthew Norman of The Independent's Media Diary who has some astute and wry comments about the schadenfreude enjoyed at the BBC's recent discomforts and ties it in to the ongoing debacle that is the general coverage of autism, MMR and Dr Andrew Wakefield.

Will this wretched appeasement of a tabloid press, whose malevolence is surpassed only by its hypocrisy, never cease?

ALSO CONSIDERING the BBC was Melanie Phillips, who fretted in the Daily Mail about declining standards of objectivity. "With an attitude that regards all challenges to its warped world view as beyond the moral pale," declares the woman who knows Jewish critics of Israeli policy towards the Palestinians as Jews For Genocide, "it follows axiomatically that the truth goes out of the window altogether." Indeed, indeed. Whether Mad Mel will apologise for propagating the dangerous nonsense about a link between MMR and autism should Dr Andrew Wakefield be disciplined by the GMC hearing, we must wait and see.

"He paints a picture of a BBC," declares Mad Mel of Anthony Jay's recent report on wicked BBC liberalism, "in which arrogance and a false sense of moral superiority combine with gross ignorance of the real world, to spread an ideology 'not based on observation and deduction but on faith and doctrine', and into which all events are wrenched to fit".

Uncanny, really, how exquisitely well she puts it.

Heh.

Of course, I would still like to see the British Medical Journal consider whether or not it would be helpful if they blogged the GMC Hearings.

Observer Gives a PoMo Clarification: Retract Already

2007-07-22T13:20:00.000+01:00

The Observer deserves sackcloth and ashes for its autism, MMR coverage. The British Medical Journal (BMJ) embarrassed itself by uncritically reproducing that 1 in 58 figure but at least it had the good grace to take a piece by Dr Ben Goldacre that criticised the media coverage of this issue.

Bloggers have offered thoughtful criticism, snarked and ridiculed this on-going story but still it continues because we don't have opinions that should be noted. Baltimore Sun offers an intriguing argument that bloggers are ruining quality mainstream journalism:

the Internet siphons audiences and revenue from the media outlets that can give citizens a voice, causing them to shrink and further impairing the media's democratic power.

Apparently, there is an argument that in a time of contracting revenues, newspapers offload science/environment/health reporters because they don't sell papers and any actual experience/knowledge is not valued.

So, as one of the more respectable representatives of the MSM, The Observer had the opportunity to do the mature, right thing and retract Denis Campbell's New health fears over big surge in autism [Edited: July 24; new URL as original story removed from Observer archive.]for:

inappropriate linkage (MMR and autism)
spectacular over-emphasis of a particular figure (the 1 in 58, ignoring the particulars of the tool etc.)
failing to contact principal parties (shoddy journalistic practice)
failing to disclose relevant information (too many examples)
plain being wrong.

Instead, they have compounded matters by issuing one of those PoMo clarifications, the sort that reads like an apology if you were offended but the fault lies with you for being offended/picky about the boring science/significance of the statistics. After all, according to Ben Goldacre, Holford Watch, Anthony Cox and Mike Stanton, they were only mostly wrong on most points.

Seriously, The Observer should stop faffing about with this story, they're just compounding the errors and the insult. At the risk of sounding all blogger and undemocratic, their clarifications are inadequate and cannot begin to address the problems with their coverage. As an american friend recently commented to me: Retract already.

Related material

Dr Eric Fombonne delivers a presentation to a conference that addresses the issue of whether there is an epidemic of autism: answer 'No'. 1 hr+ talk, slighly dodgy soundtrack and the slides are tricky to read but it is a good presentation. The site has a lousy interface: you need to load the home page, select conference online and Fombonne is Day 1: Session 2.

The Fombonne presentation is excellent if you can persevere. It discusses prevalence v. incidence; changes in case definition and how this impedes comparison with other studies; changes in the age of diagnosis and its implications for recording figures; and issues relating to statistical power.

If I really can't persuade you that you need to take the time to listen to Fombonne for an hour, Autism Speaks offers interviews with experts who say more or less the same thing in nicely edited 90s to 5min pieces. Both Drs Insel and Volkmar skilfully avoid the loaded, emotive, sensationalist questions lobbed at them by their interviewers and explain that there is no autism epidemic. They both give a good basic overview of the changes in diagnostic criteria (including the development of criteria that embrace a range of IQs); the difference between an educational label of autism (triggers desirable services) and a clinical diagnosis of autism etc.

Dr Insel does a nice job of distinguishing prevalence and incidence in The Increase in Autism Diagnosis.

Dr Volkmar gives a good overview of why there is no autism epidemic in The Increased Rate of Autism Diagnosis.

But, seriously, if you want the inside track on what is so wrong with the figures bruited about by The Observer and precisely why it behoves the researchers to be so careful in evaluating them, listen to the Fombonne presentation.

Why Can't We Have Single Jabs While There Is Uncertainty?

2007-07-20T13:05:00.000+01:00

Following recent news stories about Dr Andrew Wakefield, MMR, autism and the vaccination programme in general, I've seen a number of variations on the question:

I want to vaccinate my children but why can't we have single jabs on the NHS while there is uncertainty?

Dr Richard Halvorsen recommends single jabs or individual doses of vaccine, administered one at a time, on separate visits in his recent piece in the Daily Mail.

First and foremost, unless it is contraindicated for a individual (e.g., someone who is immunocompromised), there is no uncertainty about the safety of MMR v. the potential for harm of these preventable illnesses among Public Health Officials and the majority of scientists. The Medicines Control Agency and Dept. of Health issued a useful summary of the safety investigations: it is a clear and well-referenced rebuttal to the flawed claims about the safety record and evaluations studies of MMR that arose from a paper and comments by Drs Andrew Wakefield and Peter Fletcher.

MCA has carried out a review of the licensing of MMR vaccines and can assure the public that the licensing followed normal procedure and was based on robust studies...

Combined MMR vaccines had been extensively tried and tested in Scandinavia and the USA before they were introduced in the UK in 1988. Now MMR is successfully used in over 30 European countries as well as USA, Canada, Australia and New Zealand. In addition, a publication in 1988 lists 30 published studies where combined measles, mumps and rubella vaccines were studied and follow up extended up to ten years. The safety of the combined MMR was studied and shown to be the same as that for the component vaccines...

The Department of Health vaccination programme uses the combined MMR vaccine because it is the safest and most effective means of protecting children from these diseases. The child is put at greater risk of contracting these infectious diseases because of the gap between vaccinations. [pg 1]

More recently, Peltola and colleagues published a 14-year prospective follow-up of MMR vaccination. They reported:

an incidence of serious adverse events with possible or indeterminate causal relation with MMR vaccination of 5.3 per 100,000 vaccinees or 3.2 per 100,000 vaccine doses...Comprehensive analysis of the reported adverse reactions established that serious events causally related to MMR vaccine are rare and greatly outweighed by the risks of natural MMR diseases.

Secondly, there are well-founded concerns that administering individual doses will leave children, and the people with whom they are in contact, exposed to the dangers of preventable illnesses for longer than is necessary. Sense offers a press briefing on why Sense is opposed to single jabs with an excellent summary of the safety and success of MMR with particular emphasis on their principal concern, rubella.

The MMR vaccine was introduced in 1988. Since then, the numbers of children affected by Congenital Rubella Syndrome, and the incidence of rubella in the population at large, has dropped dramatically.

Between 1971 and 1980, 447 children were reported as born with congenital rubella syndrome. Between 1991 and 2000 only 38 cases were reported. Between 1971 and 1980, 5711 terminations were reported as a result of rubella. Between 1991 and 2000, 61 terminations were reported.

Sense provides a fuller briefing paper: MMR - the issues (pdf).

We are aware of calls for making single antigen vaccines available and, having considered the weight of evidence available, conclude that the introduction of single antigen vaccines carries the serious risk of an increased incidence of congenital rubella in addition in the increases in disabilities caused by measles and mumps infections.

Separate vaccinations would mean 6 visits to trips to the GP/Health Clinic and experience shows that a significant number of those opting for this do not attend all of the sessions. These visits would

take from 3-5 years depending on the time span left between each administration of each vaccine. The proportion of children protected at any one time against all three diseases would be reduced.

This would mean more children going uprotected, increasing the risk of infection to themselves and to other children [ref]. Such a decrease in herd immunity would lead to outbreaks of rubella, measles and mumps. [pg 6]

Separate vaccinations encourage a pick-and-mix attitude where some parents decide that, e.g., a boy derives no personal benefit from rubella vaccination and opt to omit this.

Finland has had a 2-dose MMR strategy in place since 1982 and has uptake rates of more than 98%. Finland is the first country to be documented free of indigenous measles, mumps and rubella (Mumps and rubella eliminated; Measles eliminated). In stark contrast, in 1993 Japan stopped giving the MMR and replaced it with individual vaccines for measles and rubella with an optional mumps vaccine. Between 1992-1997 there were 79 deaths related to measles in Japan; for the same period in the UK there was one death. Contrary to the expectations of people who believe in a link between MMR and autism and advocate for single jabs, the rates of autism continued to rise in Japan.

Related posts:
Myth: Measles Is A Trivial Illness, There's No Point to Vaccination
MMR Vaccine Does Not Contain Mercury, Thiomersal, Thimerosal and It Never Has

Ben Goldacre Breaks His Silence on the Media Coverage of the MMR, Autism Stories

2007-07-18T12:18:00.000+01:00

I recently complained about the standard of coverage of MMR and autism issues in the UK media alongside the ubiquitous hagiographies of Dr Andrew Wakefield.

The belief in a link between MMR-vaccines-mercury-autism has cultish overtones. Most religions have an act of contrition. UK media collectively need to make an act of contrition and perform an act of reparation. The latter, of course, should take the form of some informed coverage. I would nominate Ben Goldacre (who is uncharacteristically/ominously quiet at present) but then what would somebody who is medically qualified and known for promoting the public understanding of science (awards and everything) have to add to this discussion?

Ben Goldacre has broken his silence with an article in the BMJ: MMR: the scare stories are back (also available on Bad Science). It's a feisty piece (can men be feisty?) and quotes some robust language from an email tirade that happened long ago but is still a stone in the shoe for enraged academic.

One of the interesting nuggets that came out of the article was the background to Prof. Baron-Cohen's widely-reported concerns and consulation of Public Health Officials.

How did the Observer manage to crowbar MMR into this story? Firstly, it cranked up the anxiety. According to the Observer, Baron-Cohen “was so concerned by the one in 58 figure that last year he proposed informing public health officials in the county.”

But Professor Baron-Cohen is clear: he did no such thing and this was simply scaremongering. I put this to the Observer, which said it had an email in which Baron-Cohen did as the paper claimed. Observer staff gave me the date. I went back to the professor, who went through his emails. We believe that I too now have the email to which the Observer refers. It is one sentence long, and it is Professor Baron-Cohen asking if he can share his and the other researchers’ progress with a clinical colleague in the next door office. This dramatic smoking gun reads: “can i share this with ayla and with the committee planning services for AS [autism services] in cambridgeshire if they treat it as strictly confidential?”

Professor Baron-Cohen told me, “That’s not saying I’m concerned, or that we should notify anybody; these are just the people who run the local clinic, who I share a corridor with, who said they were interested to hear how it was going so far. They are not public health officials, and it’s not alarmist, it’s not voicing concern, it’s simply saying: ‘am I allowed to share a paper with a colleague in the next door office?’ It seems very important to me that we discuss clinical research with clinical colleagues, and I only stressed confidentiality because the paper was not yet final.” [My emphasis.]

Now, there is a saying along the lines of "Bring me a dozen words written by any man and there's enough therein to hang him" but the resulting farrago of nonsense seems to rely upon a remarkable over-interpretation of this simple one-liner. If Baron-Cohen had mentioned that he had to dash because he was working to meet a deadline on this report while munching the morning toast, would this have been trailed as a clandestine briefing at a breakfast meeting? Who leaked this email? Why didn't Denis Campbell contact Baron-Cohen to discuss the matter rather than relying upon an over-interpetation by parties who may well have had their own agenda?

The BMJ is one thing. The wider UK media have to step up and start making reparations although that 1 in 58 figure has spread so far that it seems impossible to recall (examples: blogs, here and here; the newspapers who cite this are too many to mention but include, of course, The Observer, the Daily Mail, The Daily Express and even the BMJ). Goldacre concludes, somewhat dismally although accurately:

Whatever one might think about Andrew Wakefield, he was just one man: the MMR autism scare has been driven for a decade now by a media that over-emphasises marginal views, misrepresenting and cherry picking research data to suit its cause. As the Observer scandal makes clear, there is no sign that this will stop.

The British Medical Journal Embarrasses Itself by Reproducing That Notorious 1 in 58 Figure
Another Day of Shame for UK Media on Topic of MMR and Autism
Autism: The Truth Plus Sensitivity, Specificity and All That Is Decent to Reveal About Predictive Values
Wakefield: Another Triumph for Mainstream Journalism in the UK
Anthony Cox: How virulent were The Observer’s MMR articles?

Thanks to Wellcome for use of this open access image of the removal of wounded by horse-drawn sledge by Ugo Matania.

Should the BMJ Blog the GMC Fitness to Practise Hearings?

2007-07-18T10:17:00.000+01:00

There are repeated complaints about the General Medical Council's Fitness to Practise Hearings. Many of the hearings are justifiably closed to the public because they involve close scrutiny of otherwise confidential medical records.

In the case of the current hearing that involve Profs Walker-Smith and Murch with Dr Andrew Wakefield, the medical records of most of the children in the Lancet paper are already partly in the public domain. These hearings are open to the public and will be reported upon by various media. However, so far, much of the coverage is associated with mis-information.

The BMJ has editorial blogs. Would it be interesting to have the blog perspective of relevantly qualified and experienced people on these and other relevant hearings that involve public interest? Would the BMJ be able to offer a less sensationalist view than is seen in the newspapers from time to time?

Both in the UK and various other countries, there are doctors who are known for being, e.g., Lyme Literate or willing to run tests for or treat the conditions such as environmental illness, CFS/ME, thyroid or adrenal problems or controversial diagnoses that cause much frustration for some GPs and patients. Both in the UK and elsewhere, these doctors are being investigated by their licensing bodies or equivalent. Some of the UK doctors have survived various hearings but closed their practices because it is difficult/impossible to obtain insurance to cover GMC Hearings and they couldn't afford to fund a future defence.

I recently attended a wedding where several people discussed the case of Dr. Sarah Myhill, a private GP, who is in just that position. Five years ago, she was scheduled to have a GMC Hearing but it was cancelled without further explanation. However, because of the Hearing that didn't happen, she couldn't obtain insurance against future Hearings and she is now scheduled for a GMC Hearing, later this year. She is asking her patients to help fund her defence.

The complaints against me are all from doctors who do not like my style of practice. No patient has been harmed or even put at risk. The three patients involved have all refused to have their medical records used against me, but their "anonymised" records have been taken anyway by the GMC against their desires and without their permission.

The merits or de-merits of Dr. Myhill's practice and the complaints against her were not under discussion (the charges are not formalised, I don't know the basis for the complaints etc.). There seems to be some unhappiness about the way in which the GMC gathers its evidence and runs its Hearings.

These cases and the way in which they are handled are cited by a number of the doctors who feel that it is a strong indicator that they could not consent to an non-standard test or treatment protocol without running the risk that a colleague might use it as the basis of a complaint. I have no idea whether or not they are being over-sensitive and hyper-cautious or merely prudent in a climate where they feel that their decisions are being consistently second-guessed or questioned. Some GPs are concerned that PCT and NICE dictats along with these concerns are compromising their therapeutic autonomy and not always in the best interests of the patient.

Would decent, informed blog coverage of Fitness to Practise hearings alleviate these misgivings by making them more accessible (assuming that appropriate privacy can be preserved, where necessary)? Or would exposing hearings to more scrutiny make them appear more like the witch-hunts to which they are sometimes (albeit not always appropriately) compared?

Thanks to Wellcome for use of this open access image.

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

2007-07-17T13:44:00.000+01:00

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.

Paediatric Grand Rounds 2:7 Is Up!

2007-07-17T01:14:00.000+01:00

Paediatric Grand Rounds 2:7 is up, courtesy of Dr. Bryan Vartabedian of Parenting Solved.

A mixture of the intriguing, the odd, the humourous, the contentious and the interesting about paediatric healthcare. I commend PGR to you.

Dr. Clark Bartram is looking for hosts for future PGRs. You can consult both the hosting schedule and earlier editions in the Paediatric Grand Rounds archive. Please sign up for hosting.

MMR Vaccine Does Not Contain Mercury, Thiomersal, Thimerosal and It Never Has

2007-07-16T20:24:00.000+01:00

MMR has never contained mercury in any form: MMR has never contained thiomersal (UK) thimerosal (US). There are multiple sources for this information. The FDA/CBER has a full report on Thimerosal in Vaccines. The report details the history and use of the mercury-based preservative thiomersal/thimerosal in vaccines with an overview of the reasons for its introduction and the studies on its safety.

The specific information that MMR has never contained thimerosal/thiomersal is Table 1 and Table 3.

If UK readers would prefer a UK source then please consult MMR The facts.

Adding a preservative to MMR would be like adding a preservative to live yoghurt. Some people eat live yoghurt because they want the beneficial bacteria or even specially cultivated probiotics. If you were to pasteurise that yoghurt or add anti-bacterial or anti-fungal preservatives, then you would inactivate those potentially beneficial bacteria so you wouldn't get the benefit. It's a similar story for live vaccines such as MMR and thiomersal/thimerosal.

Kevin Leitch Canards Project is an opportunity to put together a resource that answers FAQ or common concerns; please contribute questions or answers to it.

Related posts:
Measles Is a Trivial Illness and There's No Point to Vaccination: The Myth

The British Medical Journal Embarrasses Itself by Reproducing That Notorious 1 in 58 Figure

2007-07-16T10:45:00.000+01:00

The deluge of bad reporting flowing from St. Maximilian Kolbe and Blessed Titus Brandsma Day continues. The mojo of this day is so powerful that it has even influenced the British Medical Journal for the worse: GMC hearing against Wakefield and colleagues opens.

After listing some of the charges against Dr Andrew Wakefield, Profs Walker-Smith and Murch but then reporting that the full list of charges won't be announced until today, when the hearing opens, the BMJ concludes this item with a blaze of shame.

Researchers from Cambridge University's autism research centre will conclude in an as yet unpublished study that autistic spectrum disorders are almost twice as common among British schoolchildren as current estimates indicate. The lead researcher, Simon Baron-Cohen, said that this study, which examined some 12 000 primary school children in Cambridgeshire, will conclude that one in 58 children has such a disorder.

No, no, no. Prof. Baron-Cohen has written a letter to The Observer (amongst others) to correct that canard about the 1 in 58 figure.

[Your] article linked MMR and autism.

The research does not...

The best estimate of the prevalence of autism is the 1 per cent figure published in the Lancet in 2006.

My view is that any apparent rise is likely to be driven by better recognition, greater awareness, growth in services, a widening of the definition of autism and a shift towards viewing it as a spectrum rather than a categorical condition.

Once more and with feeling, the researchers used several screening tools on that population. The 1 in 58 figure is the result of the Childhood Asperger Syndrome Test (CAST). When used with a general population such as a mainstream school, the CAST generates 50% false positives but it has a reasonable specificity (the negatives are true negatives) so it might seem reasonable to evaluate its potential usefulness as a comparatively low-cost first pass screening tool for epidemiology research. All of this was quite obvious to anyone familiar with screening who just read the newspaper articles: however, it was up to the journalists to explain this to the general reading public.

If the journalists and BMJ had had any further questions, they might have actually talked with one of the professors at the Cambridge University Autism Research Centre (ARC). They might even have consulted the ARC website and looked at the current research projects where they would have read about: Screening for Asperger Syndrome in primary and secondary schools. Despite the frequent accusations that there is no research into autistic spectrum disorders (ASD), this project is exploring ways of lowering the age at which diagnosis is practical. The researchers are aware that early intervention will help those children who are affected by ASD and they hope that effective screening would "reassure the worried well" (pg 2 of following report).

Currently, AS is picked up far too late. It should be possible to identify AS in children in primary school (age 5-11). We have developed a screening instrument for this purpose, called the CAST (Childhood Asperger Screening Test) and are testing it at a population level.

The team links to some relevant reports, including The CAST (Childhood Asperger Syndrome Test): test accuracy (pdf).

If the journalists or BMJ had done any of that then they would have learned that the researchers do not support that 1 in 58 figure and report it as an artifact of using the CAST. They conclude that although CAST may be useful in epidemiology research, there is not enough evidence to support its use as a general screening tool.

The Childhood Asperger Syndrome Test (CAST) is a parental questionnaire to screen for autism spectrum conditions. In this validation study, the CAST was distributed to 1925 children aged 5-11 in mainstream Cambridgeshire schools. A sample of participants received a full diagnostic assessment, conducted blind to screen status. The sensitivity of the CAST, as a designated cut-point of 15, was 100 percent, the specificity was 97 percent and the positive predictive value was 50 percent, using the group's consensus diagnosis as the gold standard. The accuracy indices varied with the case definition used...The CAST is useful as a screening test for autism spectrum conditions in epidemiological research. There is not currently enough evidence to recommend the use of the CAST as a screening test within a public health screening programme in the general population. [My emphases.]

More relevant quotations from the report are as follows but feel free to page-down through this if you feel that the researchers have already set out their stall.

Currently there is insufficient evidence to recommend screen for autism spectrum conditions as a public health service (National Screening Committee Child Health Subgroup, 2001). One of the gaps in the evidence is the lack of a screening test that has been fully validated and shown to be effective in the general population...

An effective screening test for autism spectrum conditions would also be invaluable for epidemiological research. Due to the resource implications it would not be possible to undertake a detailed assessment of all children in a large population-based study. A screening test can be used in the first phase of an epidemiological survey to sift out the children who require further detailed assessment in a second phase of the study, and hence make large studies feasible.
[pg 2 of 24 or 46.]

Many promising screening tests are being developed, but there is currently no screening test for autism spectrum conditions which has been fully validated in the general population, which has been shown to be effective, and for which information about validation is available in the public domain. The aim in further developing the Childhood Asperger Syndrome Test (CAST) was to validate a test for use in the general population rather than clinical populations, and to develop a test that is sensitive to autism spectrum conditions, including pervasive developmental disorder not other specified (PDD-NOS), not just to typical autism.
[pg 3 of 24 or 47. It is worth noting that the authors acknowledge that the name of the test is a little mis-leading, it has been retained for continuity purposes. They emphasise that CAST is for ASD.]

The consensus diagnosis captured children with wider spectrum conditions. When using the consensus diagnosis, a cut-point of 15 appeared to be appropriate where sensitivity (100 percent; 95 percent CI 74-100 percent) and specificity (97 percent; 95 percent CI 93-99 percent) were high. At higher cut-points, the sensitivity dropped. The positive predictive value was low at a cut-point of 15, at 50 percent (95 percent CI 28-72 percent). Using the assesment diagnosis, a higher cut-point may be more appropriate, such as 18 where sensitivity was 100 percent (95 percent CI 63-100 percent) and specificity 99 percent (95 percent CI 96-100 percent).
[pg 13-15 of 24 or 57-59 (intervening pp of tables).]

The drawback of the CAST is the low positive predictive value, which is a function of low prevalence of the condition in the general population (O'Toole, 2000). There are major resource implications of assessing a large number of children who are false positives. There could be much anxiety associated with false positive screen results, as has been demonstrated with other screening tests (Marshall, 1996). A positive screen results brings uncertainty about health status (Marteau, 1994), in the case regarding the presence of a developmental disorder, until further assessment is under-taken. It should be noted, however, that a child who is a false positive for an autism spectrum condition may have another developmental problem which may be clinically important...
[pg 16 of 24 or 60.]

There is no absolute gold standard test for a developmental disorder...
[pg 18 of 24 or 62.]

If there had been complete response to the screening test, proportionally more respondents with low scores would have been expected and lower prevalence estimates, compariable to those in other studies (e.g. Scott et al., 2002b), could be expected.
[Researchers discuss the type of family that was most likely to have filled out and returned the questionnaire. They missed some known children with ASD because the parents of those with confirmed diagnoses were less likely to participate in the study: to that extent, the prevalence rates might have been higher. However, the rate of participation in the study means that in general, there should probably have been a much greater proportion of low scores, so the prevalence rates were more in line with those reported elsewhere.]

The CAST is demonstrating good sensitivity and specificity but low positive predictive value...As the aim is to develop a screen for the general population, however, a more pragmatic method of increasing the positive predictive value [is needed]. It might be possible to introduce an additional phase prior to using the CAST, such as asking if the parent has concerns over the child's development. The CAST could then be used in a higher-risk population, and the positive predictive value may be considerably increased (O'Toole, 2000).

The CAST can be recommended as a screening test for autism spectrum conditions in epidemiological studies, as the low positive predictive value and subsequent false positives are unlikely to cause anxiety because a range of children from low to high scorers would be invited for further assessment...It is not appropriate, however, to recommend the use of the CAST as a general population screening test in a public health or educational setting...
[pg 19 of 24 or 63.]
[My emphases.]

[Edited: July 18] Simongates commented:

I think I read somewhere that the sample size was actually 116 i.e. there were 2 autistic spectrum children. If this is right the 95% confidence interval around the estimate of 1.7% would be 0.5% to 6.0%, which includes pretty much every value that has ever been claimed. So claiming an autism epidemic (let alone one caused by MMR) from these sorts of figures would be misleading even if the numbers were correct.

As a general point, in the absence of open access journals we rely upon journalists of various media to read and understand studies that are of general interest and to report upon them accurately. However, as Goldacre expresses it, although

newspapers like to fantasise that they are mediators between specialist tricky knowledge and the wider public...I wouldn’t be so flattering. In fact, if you have access to the original journals, you can see just how rubbish things can get.

In this case, the actual report is freely available but the journalists concerned, and those who were subsequently involved in supporting their actions, do not seem to have read it. It's almost as if the source of this figure is of no relevance to the heat and light that can be generated by the mis-reporting.

It was bad enough that this canard of the 1 in 58 prevalence spread like wildfire in the newspapers; it is a new nadir that the BMJ reported it so uncritically.

More when the feeling of sadness goes away.

Update: 15:00 Dr Fiona Scott was one of the implied sources for the MMR-autism connection in the original story that broke the 1 in 58 prevalence figure. A Dr Scott (identity unconfirmed but claimed) has posted this response to The Observer Readers' Editor response. Comment July 16, 2007 11:31 AM.

I feel, given that I was one of the two 'leaders in the field' (flattering, but rather an exaggeration) reported as linking MMR to the rise in autism, that I should quite clearly and firmly point out that I was never contacted by and had no communication whatsoever with the reporter who wrote the infamous Observer article. It is somewhat amazing that my 'private beliefs' can be presented without actually asking me what they are. What appeared in the article was a flagrant misrepresentation of my opinions - unsurprising given that they were published without my being spoken to.

It is outrageous that the article states that I link rising prevalence figures to use of the MMR. I have never held this opinion. I do not think the MMR jab 'might be partly to blame'. As for it being a factor in 'a small number of children', had the journalist checked with me it would have been clear that my view is in line with Vivienne Parry of the JCVI. The 'small number' was misrepresented by being linked inappropriately and inaccurately with 'rise in prevalence', leading readers to arguably infer that it is in fact NOT a small number!

I wholeheartedly agree with Prof Baron-Cohen, and many of the posts and responses received to date, that the article was irresponsible and misleading. Furthermore I reiterate that it was inappropriate in including views and comments attributed to me and presented as if I had input into the article when I had not (and still have not)ever been contacted by the journalist in question. I am taking the matter under advisement.

How many more times will Dr Scott and Prof Baron-Cohen have to issue clarifications?

Update: Denis Campbell's article, New health fears over big surge in autism has been removed from the Observer archive so I have linked to a new URL.

Myth: Measles Is A Trivial Illness, There's No Point to Vaccination

2007-07-15T14:18:00.000+01:00

I tried to leave this story alone but this horrible reporting of MMR and autism is like some weird vortex that is drawing me in.

Even with the marvellous work of the successful Measles Initiative vaccination programme there were still 345,000 deaths from measles worldwide in 2005. Even in the UK, with comparatively adequate nutrition and abundant medical services, and a baseline of healthier people, the BBC cited some alarming statistics from the medical newspaper Pulse related to measles:

lowering levels of immunity meant as many as 12% of children and 20% of adults could be hospitalised if infected by measles.

Does a hospitalisation rate of 12% of children and 20% of adults sound like what Patrick Holford characterises as "mild and temporary illness"? Does it even vaguely resemble the Peter Hitchen version of measles:

In very rare instances, measles can lead to disastrous complications. In poor countries, where children are hungry and there is no clean water, it can easily be fatal. But in advanced civilisations such as ours, where hunger is extremely rare and clean sanitation universal, it isn't actually a big threat.

Yet the MMR lobby pretend that it is.

If you want to learn about measles from the sort of world authority that I would hope that journalists would quote on the topic if they were seeking to inform rather than polarise then you need to read Dr Diane Griffin's testimony at the recent Autism Ominibus Hearings. Dr Griffin is the editor of the definitive Field's Virology and her status is such that she has contributed the chapter on measles for the last 3 editions.

For a good summary of the testimony, see Autism Diva's Omnibus hearing: Griffin.

[I]f you'd like to know about what happens to children who catch the wild-type measles and do just fine for 7 to 10 years when they
develope subacute sclerosingpanencephalitis or SSPE and then die a horrible death because the measles that had gone into a kind of remission and suddenly reaches a point of replication in their brains that destroys their brains literally eating it up (2785-2790). It's rare among kids who get the wild measles, but not found in kids who have been vaccinated for measles. Autism Diva's typical kid got wild-type measles at age 15 months or so. It was a pretty mild case. That kid was vaccinated on schedule with the MMR a few weeks later. It's frightening to think that kids who get the wild-type measles can end up dead from it 10 years later. That's one of the best arguments Autism Diva has ever seen for vaccinating.

Measles can kill quickly, too, but usually the death comes from a secondary infection. Measles seems to tie up all the immune resources or something and that allows whatever germs are around to come in and run amok and kill the child. So measles can cause a death by pneumonia, for instance, with the pneumonia germ sort of cooperating with the measles to kill the person (2799). Germs can be very scary things. Measles itself can kill people who have advanced AIDS or other severe immune dysfunction. Babies who are infected with the AIDS viruse are vaccinated with measles to take advantage of their still working immune system, after the person's immune system is badly damaged by AIDS they don't vaccinate for measles (2794). Measles is more contagious than many other viruses (2750).

Prof. Bustin wrote to The Observer in response to last week's MMR and autism story: he mentioned his own expert testimony and that of people like Griffin. And The Observer doesn't respond. Other papers hint that public health officials are shroud-waving when they talk about the dangers of a measles epidemic.

Judge this for yourself. Take a look at the records of HPA mortality figures for measles 1940-2006. Look at the figures; follow the trends for the introduction of measles vaccination in the UK and the introduction of the MMR in 1988. Note the downward drift from:

high six figure notifications down to low four figure numbers
mortality rates in 3 figures to 2 and then single digits.

Who would you place your confidence in? People of the ilk of Bustin and Griffin or the journalists who are shaming their profession and the reputation of the UK media?

Related posts:

MMR Vaccine Does Not Contain Mercury, Thiomersal, Thimerosal and It Never Has

Another Preventable Tragedy

Another Day of Shame for UK Media on Topic of MMR and Autism

2007-07-15T08:52:00.000+01:00

It's St. Swithin's Day. According to folklore in the UK, if it rains today then it will rain for the next 40 days. It is a little known fact (in fact, known nowhere outside the confines of my imagination) that last Sunday was St. Maximilian Kolbe and Blessed Titus Brandsma Day: once The Observer had published those notorious pieces, it guaranteed abysmal coverage of the issue for the next 100 days.

The Observer publishes some of the many letters that they received, including one apiece from Prof. Baron-Cohen and Prof. Bustin. Baron-Cohen:

[Your] article linked MMR and autism.

The research does not...

The best estimate of the prevalence of autism is the 1 per cent figure published in the Lancet in 2006.

My view is that any apparent rise is likely to be driven by better recognition, greater awareness, growth in services, a widening of the definition of autism and a shift towards viewing it as a spectrum rather than a categorical condition.

Bustin (see Fitzpatrick for a summary of Bustin's devastating testimony):

Remarkably, there is no reference in your story to the fact that on 11 June the first of 4,800 cases in autism proceedings came to trial at the United States Court of Federal Claims in Washington. These are designed to establish whether or not autism can be caused by MMR. For the first time, a succession of highly respected researchers in epidemiology, genetics, virology, molecular biology and other medical and scientific disciplines - the 'medical and scientific establishment' of the Observer article - provided detailed evidence of why, in their opinion, there is no medical or scientific basis for any claim linking the MMR vaccine with autism.

You might have thought that the interventions from these two luminaries might have made it into the Readers' Editor response to the letters and the result of his investigations into the story. The short piece is riddled with self-exoneration. The Head of News says:

'I believe it was legitimate to include the thoughts of two of the authors of the study. We didn't conflate the two issues; the issues are already conflated.

'We worked hard to give a non-incendiary, balanced view. I believe we had to give the readers all the information we had. After all, they would ask, "Could MMR be a factor?"

Sins of omission and commission abound. They seem unrepentant about publishing the inflammatory 1 in 58 figure but grudgingly acknowledge that perhaps they might have included the other figures that were less disturbing and more inline with current estimates (I know, amongst many much-needed corrections, they didn't touch the issue of it being a tool that may generate a 50% rate of false positives which may be acceptable if it has good specificity). It doesn't seem to disturb them that their conclusions are at considerable variance with the contents of of a report about that screening tool (pdf) from Baron-Cohen's research centre (HT to correspondent who sent me this link). The concluding sentiment and sentence are breathtaking for their complete lack of any awareness of the issues that fuelled the strong response of so many readers plus the introduction of a novel definition of accurate.

And the central point, in my view, is that the leaked story of the apparent rise in the prevalence of autism was a perfectly legitimate and accurate story in its own right, which did not need the introduction of the MMR theory.

Oh misery me! Omnes plecum plangite! However, if the Guardian/Observer offered a completely inadequate apologia pro ephermeris sua (HT Kristina Chew) then The Independent is just vox stulti. They offer yet more publicity for the Fletcher family who are caught up in an MMR action against the UK Government (also recently featured in the Daily Mail) and are stalwart supporters of Dr Andrew Wakefield. That is probably understandable and gives the sort of dramatic colour that newspapers favour. It is the coverage of the 'factual information' that is peculiarly irritating.

"There is now overwhelming evidence that MMR does not cause autism," says the DoH in its official guidance and almost every medic and scientist in the country agrees, at least in public. Tomorrow, the one doctor who has been prepared to challenge this universal wisdom will appear before a disciplinary hearing which may lead to his being struck off.

It is nine years since Dr Andrew Wakefield raised doubts about MMR, suggesting it may be linked to bowel disease and – by extension – autism. His paper in The Lancet medical journal – and the media firestorm that followed – triggered one of the great public-health scares of modern times. Who should parents believe? The experts and officials who insisted Dr Wakefield was scaremongering? Or the lone doctor who said the needle might destroy their baby's chance of a healthy life?

The sympathies of the writer seem to surface in the juxtaposition of the acknowledgement that MMR uptake declined with some claims that don't make sense as written (could be bad editing):

Alarmed health experts have warned many times that a deadly measles epidemic may follow. It never has and relentless government information campaigns have slowly regained the trust of some parents. And questions have been asked about Dr Wakefield's methods and his motives. Critics say he is a peddler of bad medicine and hope that the fears he has raised will now be killed off once and for all.

It look like the writer claims that health experts indulged in shroud waving but they have the money to fund information campaigns so some parents trust them because their opinion has been bought; there is no possibility that the parents have been reassured by some decent science arguments? The "peddler of bad medicine" is not a useful way of describing all of the issues involved and I haven't seen any criticisms expressed in that way. By the by, from the paucity of information about Profs Walker-Smith and Murch, either they are keeping a strategically low profile or they lack the money to hire Wakefield's remarkably effective PR team.

Just in case there hasn't been enough dis-information based on the leaked report and that infamous 1 in 58 estimate, The Independent thinks that we need to see it being inappropriately quoted yet again.

The number of autistic children is far higher than previously thought, it emerged last week. One child in 58 may have a related condition, believe researchers at Cambridge University. The previously accepted figure was one in 100. Professor Simon Baron Cohen of the Autism Research Centre, whose team discovered the high rate, does not believe it is due to the jab. "Evidence does not support the idea that the MMR causes autism," he says. The causes are a mystery, but many believe the neurological condition is genetic and the rise in cases is a result of better and wider diagnosis.

No, no, no. The 1 in 58 does not supplant the 1 in 100 estimate but Baron-Cohen doesn't get to rebut that in situ here which just makes this coverage even worse. It looks as if his reference to "the rise in cases" is tacitly accepting the 1 in 58.

The remainder of the piece is just as irritating.

"If Wakefield is struck off," says John Fletcher, "it will discourage any doctor from asking questions about the safety of vaccines and it will leave the policy making to the government and the pharmaceutical industry. Parents who complain will be disregarded, and the research on better treatment for these children will stop. That is unthinkable."

Unlikely. Wakefield, Walker-Smith and Murch are not embroiled in GMC Hearings because they questioned vaccine safety but because of assorted charges relating to serious ethical irregularities and dishonesty. There are many research projects on the topic of improving education and quality of life for children with autistic spectrum disorders.

Government arguments for MMR have always been based on civic responsibility: the jab is the best way to protect society. Yes, there is a "very, very small risk" of some kind of reaction, as one expert put it last week, but that is the case with all vaccines. However, parents act primarily on behalf of their child, not society. For those who visualise a doctor hovering over their baby with a needle, the words "very, very small" can sound like a whisper, and the word "risk" like a warning shout.

MMR: The Facts does make a hidden reference to civic responsibility but it is 1 point in a list of 10 that does include benefits for the individual child (albeit this could be a better list). The fact that we are all given to irrational fears is not a terribly good reason for acting in accordance with them. I think that it is a tad disingenuous of The Independent to affect ignorance that they and other MSM have disseminated so much information that it feeds this irrationality. A few months ago, Orac was discussing Wakefield's financial benefits from involvement in the MMR litigation in the UK. There is a remarkable comment from a parent in the UK:

...deciding to go with MMR, and taking my son to be vaccinated was still one of the most terrifying things I have ever done. I think there is little that is more horrifying to a parent than the idea that your own actions could directly and irreperably harm your child. I am a rational individual, and a strong proponent of the scientific method, and all that I had read on this subject could still not completely eradicate that fear.

The preponderance of coverage of vaccination issues has resulted in some parents feeling that a routine medical procedure is "terrifying" and the MSM (amongst others) shares responsibility for that.

I'll mention the Mail on Sunday farrago of pseudoscience, pseudoepidemiology and, well, generally, pseuds but I refuse to discuss its version of The truth about MMR because I will lose my will to live. I do recommend: Dr Michael Fitzpatrick MMR and Autism: what parents need to know; Arthur Allen Vaccine; Dr Paul Offit The Cutter Incident: How America's First Polio Vaccine Led to the Growing Vaccine Crisis; for an easy web reference, I like the Science Museum's straightforward coverage in the MMR Files although it could stand some updating.

The belief in a link between MMR-vaccines-mercury-autism has cultish overtones. Most religions have an act of contrition. UK media collectively need to make an act of contrition and perform an act of reparation. The latter, of course, should take the form of some informed coverage. I would nominate Ben Goldacre (who is uncharacteristically/ominously quiet at present) but then what would somebody who is medically qualified and known for promoting the public understanding of science (awards and everything) have to add to this discussion? In the absence of such reparations, I would be grateful for suggestions for penances that are rather more colourful and a touch mediaeval. After all, we needn't be superstitious about events on St. Maximilian Kolbe and Blessed Titus Brandsma Day.

Thanks to Wellcome for use of this open access image.

Autism: The Truth Plus Sensitivity, Specificity and All That Is Decent to Reveal About Predictive Values

2007-07-12T05:26:00.000+01:00

The Times is tremendously pleased with itself: Autism: the truth. In rather a classy way, they manage to include all of the flaws in the Observer's recent coverage of a leaked, unpublished report from the Autism Research Centre; they do all of this while refraining from criticism of either its rival or the benighted journalist responsible for the story. Nonetheless, they land some telling blows:

Baron-Cohen says the news story is alarmist and wrong. He does not believe that MMR has anything to do with autism. “We are gobsmacked, really, at how this draft report has got out,” Baron-Cohen says. “It was only in the hands of the authors – about half a dozen people. There are three professors listed, including me, and none of us was contacted. It was also seen by two PhD students for whom I have the utmost respect because they are very careful scientists...

The draft report was leaked a week ahead of [the] GMC appearance [of Dr Andrew Wakefield and Profs Walker-Smith and Murch]. Baron-Cohen puts it like this: “We think it [the report] has been used. They’ve picked out the one figure that looks most alarmist.”

Autism Diva and Kevin Leitch have both expressed their thoughts on this article.

New health fears over big surge in autism was the original source for the 1 in 58 figure. Edited: July 24 as original story removed from Observer archive.

I did note that:

It is possible that the one-in-58 figure comes from ARC’s use of the Childhood Asperger’s Syndrome Test (CAST), a questionnaire that parents can use to assess whether their child may have autism. The ARC team has used it on Cambridgeshire children in mainstream schools. However, it does not provide a diagnosis and is known to result in a high number of false positives. Around half the children flagged up by CAST as possibly having autism turn out not to.

It is obvious that a test that flags that number of false positives is of limited utility for specific purposes such as diagnosis but may (possibly) have some value if you are trawling for children who might benefit from follow-up screening and more sophisticated evaluation techniques.

Some time later today, I may expand this post to include an explanation of testing and the importance of two (or maybe more) of sensitivity, specificity, the positive predictive value and the negative predictive value. I will only do this if somebody else doesn't come up with a better explanation (virtual chocolate biscuits are on offer; Jaffa Cakes are not out of the question). For anyone who wants an explanation without my dubious intervention, the BMJ offers Understanding sensitivity and specificity with the right side of the brain. Beware, there are several errors in the text and some misleading sub-editing: however, some people find the diagrams helpful (less so if you are red-green colour-blind).

I should state upfront that a diagnosis of autism involves input from many people and several specialist assessments; I'm not aware of anybody that would suggest that a questionnaire might be the primary contribution to the diagnosis of a complex condition. Typically, there are parental, school and specialist assessments, and the behaviours should be present in more than one environment (not just home or school) alongside a slew of other factors. From the little that we know of the ARC report, it seems as if CAST is one of 6 assessment methods that were used. If the false positive rate is reported correctly then that would be in-line with other estimations of around 1 in 116 for children on the autistic spectrum (although this crude arithmetic overlooks the possibility of false negatives).

The word spectrum is also a flag that the researchers were not looking at a simple diagnostic test where the results of an investigation can classify the children into two clear-cut groups on the basis of the presence or absence of symptoms, test scores or behaviours.

True positive is someone who has ASD and tests positive by a test or instrument.

True negative is someone who is non-ASD (for the purposes of this example) and tests negative by a test or instrument.

False positive is someone who tests as positive but who is actually negative.

False negative is someone who tests as negative but who is actually positive.

Sensitivity is the proportion of true positives that are correctly identified by a test or instrument.

Specificity is the proportion of true negatives that are correctly identified by the test or instrument.

Without knowing anything more about the test, its results and the specific population on which it was used there are several possibilities. The test may seem over-sensitive and to flag up too many children as needing further, more sophisticated testing to confirm or rule-out a possible diagnosis of ASD. Conversely, however, it may be that although it flags up many children who are later determined to be false positives, it may have a very high-rate of specificity and be a very good first-pass instrument for ruling-out true negatives from further consideration and it might have very few false negatives.

Sensitivity and specificity are both proportions so it is practical for researchers to calculate confidence intervals for them which quantify their diagnostic range. For any test or instrument however, that is rarely sufficient; in order for a result to be truly useful, the researchers need to know how accurate the test/instrument is at predicting a true abnormality. What is the predictive value of the test?

Positive predictive value is the proportion of children with positive test/instrument results who are correctly identified as ASD.

Negative predictive value is the proportion of children with negative test results who are correctly identified as non-ASD.

The predictive value of the test/instrument will vary according to the population on which it is run, they are not universal. E.g., the predictive value may vary according to the likelihood of the tested condition being present in that population. So, in a cohort of children with identified but not otherwise classified emotional and behavioral disorders, one might expect a high prevalence of some positive test results. However, in a mainstream school, one might expect this prevalence to be lower, in which case, the more unusual it is to expect a positive result, the more certain a researcher can be that a negative test is a true negative and the less sure a researcher can be that a positive result really indicates an true positive.

If the facts are as reported in the Times, then it seems as if the CAST was run in a mainstream school, in which case one might have some confidence that the negatives are true negatives, but less confidence that the positives are true positives. Prof. Baron-Cohen seems to indicate that this may the case.

I may return to the topic of test/instrument results in a separate post. I will only return to the topic when I have fortified myself with the chocolate biscuits that were on offer to anyone who was willing to offer an earlier explanation.

Related reading:

Orac has, of course, posted an excellent discussion of test sensitivity and its impact on diagnosis and assessing whether or not a finding is clinically relevant. Early detection of cancer, part 1: More complex than you think
Superb discussion of screening, its role in early diagnosis and its distortion of results that report efficacy of treatment. Early detection of cancer, part 2: Breast cancer and the never-ending confusion over screening
HIV testing example deals nicely with the changing value of a test, depending on whether you are running it in a general population or a population where you expect the result to be positive or negative. Sensitivity, Specificity and Positive Predictive Value
This example of an infection in different clinical populations is also a good demonstration of the changing sensitivity and specificity and their impact on predictive value

Diet, Lung Capacity and Asthma Links and Stories

2007-07-11T15:42:00.000+01:00

Children who eat an inadequate diet may be at risk for respiratory conditions This is an interesting paper but it is difficult to draw any firm conclusions about the results. The researchers report that teenagers with a low intake of some micronutrients tend to have a slightly reduced lung function that has little impact on them but may have consequences in the future. In addition, some of those teenagers may be more prone to respiratory symptoms, including chronic bronchitis, wheezing and asthma.

However, the researchers acknowledge that it is difficult to know if the teenagers present diet is less relevant than their diet in early life. I was startled to learn that teenagers rely so much upon fortified drinks for their vitamin C. They further mention that teen smoking in combination with low vitamin C status is particularly associated with respiratory symptoms.

The take-home message is that a healthy diet with plenty of fruits, vegetables, and fish should supply needed micronutrients. I am not wholly in line with the claim that vitamin supplements may make up for some bad food habits particularly if early life diet is important. Yes, it may be the realpolitik but I object to it because I think that it does foster the notion that what you eat is irrelevant if you can supplement away all of the deficiencies. I did like the authors acknowledgement that a cross-sectioanl study cannot establish causality or claim to:

establish the temporal relationship between diet and respiratory outcomes. It may be that the critical period for diet's effect on the respiratory system is during early childhood when there is rapid differentiation and growth.

You're eating the WRONG fruit and veg! Oddly enough, a back story from the People's Medical Journal came to my attention albeit the dramatic headline did not bear much relationship to the topic or opening paragraph.

We've known for some time that eating five portions of fruit and vegetables a day can help protect you against cancer, but now research suggests that if we're not eating the right sort, it could be a waste of time and money.

Now, I may be wrong, but that is not how I read the information that was given. However, I haven't seen the paper and the Quackometer has his own take on the matter based on the salvestrols story with the same cast of characters from last year. There is some interesting discussion in the comments. I know nothing about it, but I do admit to being intrigued by the claims about the application of fungicides preventing the development of a plant's own defences, and thus reducing the salvestrol content. It's a superfically plausible and attractive story but the claims should be readily amenable to testing in the right lab. But, then again, how much lab time should be given over to researching stories that knowledgeable scientists recognise as wrong (if that is the case)?

Breathing lessons and eating healthily to mitigate asthma symptoms I will return to the breathing interventions at some point but I'm concentrating on the diet in this post.

There is evidence to suggest that asthmatics may benefit from antioxidants such as vitamins E and C, as well as the mineral selenium, which can be found in foods such as brazil nuts, cereals, dairy products, fish and meat. Antioxidants help combat free radicals, which are thought to damage the airways.

But Dr Seif Shaheen, a senior lecturer in epidemiology at Imperial College and senior research fellow for Asthma UK who works in the area of asthma and diet, says: "In our selenium trial, a lot of the asthma sufferers had quite good selenium levels - so extra selenium wouldn't be expected to have any benefit, but it still might have an impact for people with really low selenium. However, the test relied on people taking supplements rather than changing their diets, which might also have an effect on the results. To derive maximum benefit from antioxidants, they may need to be consumed in food rather than as pills, although trying to change people's diets is notoriously difficult."

Dr Shaheen is investigating whether diet early in life, including nutrition when a mother is pregnant, might influence whether children develop asthma and whether beneficial effects of antioxidants might depend on a person's genetic make-up.

In the meantime, it might be worth eating more apples, which are a rich source of antioxidants. Research by Dr Shaheen suggests that adults who eat two or more apples a week are almost a third less likely to have asthma than those who eat them less than once a month.

There have been dispiriting recent reports about the impact of long-term selenium supplementation. In a recent study, selenium supplementation was linked to an increased risk for Type 2 diabetes. The caveat with such studies is that the results may only hold for this group of people who were studies; however, it does raise the issue that:

long-term selenium supplementation should not be viewed as harmless and a possibly healthy way to prevent illness.

I wish the issue of diet, asthma and respiratory function were more straightforward but it isn't. The one take-home message is that mostly everybody recommends a healthy, balanced diet.

Dr Crippen on the Human Drama of the Wakefield Story Is Overemphasised to the Detriment of the Science

2007-07-10T16:43:00.000+01:00

Dr Crippen posted about Andrew Wakefield, MMR, Autism and the GMC. There have been some interesting remarks in the discussion but it seemed inappropriate to address them all in situ because it would take up too much space. I thought it might be better to reply over here.

Dr Crippen wrote:

Let as look at the options.

1. Maybe he is "mad". I mean that in the vernacular sense, not psychiatric. For example, I think that David Irving is "mad" in this sense and that is why he is largely ignored in this country, though not abroad.

2. Maybe he is evil, and is on a vendetta to harm children, to deliberately deprive them of protection against life threatening illnesses. The way some of the press vilifies him, you would think that he is evil in this way. I do not believe that, either.

3. Maybe he is just a crook on the make, a flogger of patent medicine, a spiv, a con man. We can all give examples of people like that - I have one in particular in mind but will not name him or I will be in trouble. I don't believe that of Wakefield either.

I beseech you gentlemen, in the bowels of Christ, conceive it possible that you may be mistaken.
I think that there are more options than these which include the possibility that Wakefield is mistaken but finds it impossible to encompass the notion. In the UK, we have a number of examples where well-motivated, knowledgeable people were mistaken. Dr Crippen will know the ins, outs and fallout of the Wilson research far better than I do. Dr Fitzpatrick has written a good account of the whooping-cough debacle.
Lord Justice Stuart-Smith subjected the case against whooping cough vaccine to the most rigorous scrutiny...
The judgment was highly critical of Dr Wilson (he was 'so completely committed to the view that the vaccine could cause brain damage that he was reluctant to re-examine evidence') and of other expert witnesses supporting the plaintiff's case against the vaccine.
I have looked for press accounts where Wakefield has been vilified as evil; I haven't found any but I will say that I am limited to searching on Google rather than dedicated newspaper services.

Brian Deer has been critical of Wakefield but has not accused him of evil actions or intent. I did run a Google site: search for as many variations on evil as I could think of, but the only returns were not for Wakfield stories. Nonetheless, I may have missed some references. I did look through 60 of the 183 returns for site:briandeer.com+wakefield but didn't anything that was stronger than discredited, flawed or dishonest.

If anything the majority of the press coverage that I have seen tends to be tremendously respectful and even sympathetic to the point of lionising him: e.g., the Observer interview; the Daily Mail.

My reading of him is that he is a hugely intelligent, caring man who has lost his way. Who presented some shoddy research (that should never have been accepted by the Lancet in the first place) in which he honestly believes. He is now on his mission and, yes, is making a living out of it. If he is right, as he believes he is, why should he not make a living. And if he is right, why should he not cut a few corners. Sir Richard Branson cut a few legal corners in his early days.

I do not think he is right. But I been in medicine long enough to have had some Galileo like experiences in terms of changes in medical advice:

When I qualified, if I had put someone in heart failure on beta blockers, I would have been struck off. Now I might be struck off if I don't.

And then there is HRT...and many other things.

We defeat Wakefield by using scientific evidence not by media lynching.

Maybe I've over-interpreting the hyperbole, but I've not seen any media lynching. The Brian Deer investigations asked questions that needed to be answered. To me, it looks as if was very clever to respond to this with a legal action that was abandoned only a few months ago. The legal action seems to have been funded by the Medical Protection Society rather than from Wakefield's own resources, so it may have cost Wakefield much heartache but has not beggared him as it would many people. The libel action also seems to have kept the focus on the human drama and the "he said, she said" rather than obtaining any response to the substance of the programme which was about research irregularities and flawed science.

Yes, I know that there are all sorts of questions about finances and consents and fudges but, believe me, it is a rare edition of the Lancet that does not have papers in it written by doctors who have supped extensively and surreptitiously at the Big Pharma table, who have had "honoraria" paid in brown envelopes under that same table. That does not make Wakefield right, or excuse him, but he is not alone. He was, if you like, unlucky that his bit of shoddy research was put under the microscope because of its effect on MMR uptake.

Have you ever seen Prof Tyer's short article in the BMJ about how Big Pharma got all the psychiatrists onto the SSRI bandwagon? Do you REALLY think these drugs are more effective than amitriptylline? Examples are legion. Wakefield merely got caught doing what everyone else does

With my hand on my heart, I have never thought nor said that SSRIs are more effective than the tricyclics.

I have written a few pieces on the distressing quality of research. Nonetheless, I strenuously object to the implication that every researcher does what Wakefield did.

Below the belt vilification - for example, publishing pictures of his expensive house in Kew as Brian Deer does - will not help to prove him wrong. On the contrary, it will allow him to claim, with justification, that he is being persecuted for his scientific beliefs.

Agreed. However, I have no idea how much of that was Brian Deer and how much was the editors who wanted "some art" and were seduced by the human drama rather than the science; sadly, the latter doesn't sell newspapers or the ideas for TV programmes. On balance, I think that Brian Deer might also lay claim to the notion that he has been persecuted, albeit many people might shrug that off on his behalf as being the cost of doing business.

The Cutter laboratories Salk vaccine tragedy still lives in peoples' minds and will not be eradicated by you and me talking of herd immunity and the good of the many.

We have to accept that many people are nervous about immunisations. They should not be, but they are.

The way to deal with Wakefield is to show that his theories are wrong.

Agreed and agreed. I have written about vaccinations on a number of occasions and I would hope that I have mostly discussed the science. I think that it would be very helpful if the mainstream media were more amenable to concentrating on the science. But there isn't any human interest hook to capture a significant audience.

More generally, a number of bloggers have discussed and criticised the science (an obvious recent example is Orac's very fine explanation of PCR technology). However, bloggers are not setting the media agenda here. The Observer interview was set up with a journalist who usually covers sports and social issues; there have been previous interviews were it was (allegedly) stipulated that the interviewers who would be accepted were not those with any knowledge of medicine or MMR (see the postscript). It does look like the PR company are opting to emphasise the man, rather than the science, despite the bravura comment from Wakefield in a BBC profile from 2004.
Dr Wakefield is still adamant that the scientific results of his 1998 study are still valid.

In a statement, he said: "The clinical and pathological findings in these children stand as reported."

He has welcomed moves by the General Medical Council to examine how he carried out his research.

"I not only welcome this, I insist on it," he said.
As far as I can tell, there are no interviews that address the science, the revelations made by Bustin, Chadwick etc.

I think it is very difficult for journalists who are interested in the science to place those stories. As Ben Goldacre wrote, the silence concerning the D' Souza paper was almost universal: one might almost imagine that the MSM had no interest in a story that rebutted one of the major tenets of anti-vax beliefs. So, if there is no interest in science stories, it is possible for the players in this drama to influence the media coverage so that it does emphasise the human drama, e.g., the Galileo gambit, the martyrdom, Pasteur etc. The only simile that seems to be missing is Barry Marshall. That is pretty telling because Marshall won over the people who rejected his work by the quality of his science.

Private Eye published a standalone supplement about the MMR issues in 2002 (concentrating more on the anti-vax stance). However, I doubt that any newspaper would publish a supplement that is dedicated to an analysis of the science rather than the human drama. It is unlikely that any publication is going to publish something comparable that would rebut the myths about MMR and the poverty of the science that is put forward as the intellectual and theoretical underpinning of the case for MMR-vaccination-maybe-mercury-is-the-villain-autism link.

Orac recently posted: Robert F. Kennedy, Jr. has declared a crank-off!. In the comments, TBell posed an interesting question:
Here's a question to ask yourself, no matter which side of the debate you are on....

What evidence would convince you to change your mind?

If the answer is effectively 'there is no such evidence' or 'there can be no such evidence', then you are demonstrating a serious lack of committment to reason and science.
It generated some interesting responses. It did demonstrate, yet again, that you cannot debate some issues with people who are unwilling to consider evidence/information that does not confirm their point of view.

In conclusion, I'm happy to concentrate on the science; however, I know from past experience that you can disagree with somebody on one topic (No - MMR has never contained thiomersal) and then they move straight on to "Well, I'm convinced that MMR is linked to Crohn's Disease, asthma and allergies" and that immunisation is linked to the development of type 1 diabetes. I've had previous comments from people who argue that Shaken Baby Syndrome is a misdiagnosis for vaccine-induced scurvy, and they have the science to prove it. Where does arguing with the 'science' stop?

Thanks to Wellcome for use of this open access image.

Paediatric Grand Rounds Wants Your Post, Please

2007-07-10T00:42:00.000+01:00

Yes, it is out with the begging bowl, as I shamelessly rattle the post collection bag and ask you for your contributions to Paediatric Grand Rounds. As you can see from the magazine cover, we are open to conventional and more off-beat topics.

The next edition of the PGR will be hosted by Dr. Vartabedian from Parenting Solved. Please send your submissions to colic1 AT mac DOT com ASAP but at least by Saturday

Clark Bartram is looking for hosts for future PGRs. You can consult both the hosting schedule and earlier editions in the Paediatric Grand Rounds archive.

For more information about the image used in the illustration (from Tedsblog), click on it or visit the detail on Flickr.

Update on Google, Where Anti-Immunisation Pseudoscience Reigns

2007-07-09T16:10:00.000+01:00

At the beginning of 2007, Medgagdget ran some interesting vaccination searches on Google. The results of their investigations were dispiriting. At the time, there were some suggestions that the medical/healthcare blogging communities might take some concerted action to change these search results and various ideas were floated. So, a little more than 6 months on, and in the light of a resurgence of news about Andrew Wakefield in the UK and the Autism Omnibus Hearings in the US, has anything changed?

I repeated Medgadget's searches, using their search terms, on Google.com. Medgadget originally reported:

To see what's going on, one does not have to go far. Goggle's [sic] search for 'vaccination' returns 10 results on its first page. Of them, two are from the CDC (Centers for Disease Control and Prevention). One result from Wikipedia that has some questionable statements , such as "...the overall effect might, in theory, be to cause more deaths than before the vaccination was introduced." The remaining seven results are from vaccination-haters and moonbats that accuse governments, pharmaceutical companies, the medical lobby, you name it, of untold millions of dead children. The second page of the vaccination search is even worse.

If you wish to refine your 'vaccination' search to see results from the medical authorities, you get whopping 54 results. Alternative medicine search returns 942 results. Strong medicine by peasants for peasants, as we say around here.

Do we need to tell you about 'vaccination risks' search? The results (from the CDC, NIH, and the FDA) are all comfortably on the bottom. The top of the Google page is occupied by such luminaries as Vaccine Risk Awareness Network, a member of the Committee Against Compulsory Vaccination; whale.to, a URL that says "the primary cause of encephalitis...... is the childhood vaccination program..."); and The Healing Center On-Line, a place that does not have to be quoted.

Results for 9 July, 17:00-18:00

vaccination returns are as follows:

Wikipedia, although this entry has been edited recently and seems better than it was; the reality of Wikipedia is that it is difficult to know for how long this will be true
CDC Travelers' Health which is concerned (perhaps understandably following the recent TB story) with travelers' health rather than childhood vaccination issues. Searchers would need to select More results before they would find items about childhood vaccination and they are not the top entries
whale.to makes its appearance at no. 3 and the remainder of the top 10 are kith and kin to Medgadget's previous findings, except for a brave showing by the New York Times at no. 7

Thereafter, the results are mixed with some familiar moonbats and some medical resources. One of the difficulties is that so many of the whale.to rant-alike sites use the terms honest, reliable and unbiased (e.g., vaccination news that is sponsoring an online conference that will explore whether shaken baby syndrome is a misdiagnosis for vaccine injury (see Orac on this)) that it is effectively code for anti-vax sites, so it is a tad unfortunate that their presence meant that I almost missed the seemingly sensible lists of members that contribute to vaccine.org.

Results 9 July 19:00

vaccination results from the medical authorities returns 46 results which is a drop of around 15%. CDC Travelers' Health is no. 1 again, but, this time, there are no more results available. The drop in numbers wouldn't matter if the results were more relevant or targeted to the general reader but they're not.

The numbers for the vaccination + alternative medicine search have crept up to 1,000 results. Perhaps understandably, 9 of the 10 top results feature homeopathic alternatives; the holdout on this first page is Quackwatch item at no. 7. So, perhaps, given the nature of homeopathic dilution, the results indicate less emphasis on "Strong medicine by peasants for peasants" than Medgadget's previous results.

The results for vaccination risks were interesting. Overall, it looks like this may be worse. They were dispiriting, because the first site that looked reasonable is at no. 5 but it turned out to be concerned with pet vaccination. The list is dominated by those who argue for the point of view that vaccination is an instrument for genocide, health care professionals are all pharma shills or conspiracists and other such run of the mill fodder before they reach for the hyperbole.

Vaccine Risk Awareness Network, of course it is
whale.to keeps up its strong showing in such matters
Worldwide Health Center was new to me. But let's just say that it includes Drs Gallo (the spread of Aids and the vaccination programme are linked) and Kalokerinos (vaccination-induced scurvy and death) amongst others.

The FDA shows up at no. 6. The remainder of the entries are a mixed bag; the more conventional offerings are, again, not particularly relevant or readable. The CDC doesn't make it to the front page with childhood vaccination, it's sole entry is concerned, again, with travel vaccinations. The CDC entry on vaccine safety does appear until no. 27 (and involves a re-direct). All in all, there is a very poor showing from governmental or medical institutions; they do not seem to provide adequate material on the web for parents who may be investigating this matter and who may well be searching by using such terms.

Medgadget's other searches are still dominated by anti-vax entries although vaccine + side + effects seems to have improved because CDC makes it to no. 1 albeit, this is another re-direct.

Regrettably, immunization + risks is still dominated by anti-vax sites with another pole position for VRAN. There are some medical or governmental sites on the top page and beyond, but, again, they may not be well-targeted.

Recently, Kevin, M.D. chronicled: The Google Health Advisory Council: Outrage. While we are on the topic, how strong is this advisory group on the subject of paediatric healthcare and the topic of vaccination?

Would it be both herding cats and inappropriate to engage in any action that might alter these rankings? A recent enquirer asked questions at Autism Diva.

Asking these questions does not mean that I am claiming that MMR causes autism or that I am supporting Wakefield. Especially after I specifically acknowledged that MMR apparently does not. Not all people with questions are antagonists, but when treated as such, find it difficult not to be antagonistic in kind.

It can be difficult to distinguish between faux-naif commenters and those who are sincere enquirers and have some real concerns based on what they have heard from other sources. Would presenting a fuller picture of the non-anti-vax stance on immunisation on Google be of any help to this sort of enquirer?

Image information: 1. Mass Vaccination Ouch!, 2. Double ouch, double vaccination, 3. Polio outbreak campaign, 4. 065 Norwich Historic Plaque (Green)

Created with fd's Flickr Toys Mosaic.

Asthma, Allergies, Paediatrics: Links and Stories

2007-07-09T14:19:00.000+01:00

Use children as medicine guinea pigs No, this is not yet another bizarre version of recent MMR-vaccine-autism reporting but a rather sensationalist take on a perfectly sensible call by Prof. John Warner for the inclusion of children in medical trials. Children are not small adults. This is one of the reasons that Clark Bartram initiated Paediatric Grand Rounds. This stark fact is a headache for pharmaceutical companies who are frequently criticised for their lack of drugs that are specifically formulated for children and tested on them. Understandably, however, it is difficult to obtain ethical approval for drug trials (or any therapeutic trials) that involve children. There has been a lot of adverse publicity about the effect of anti-depressants on children. There is increasing controversy about the effectiveness of current asthma treatments for children.

Professor Warner, who is Chair in Paediatrics and Head of the Department of Paediatrics at Imperial College and consultant paediatrician at St Mary's Hospital, explained that researchers need to design therapies specifically for children and their problems, rather than the present situation that relies upon scaling-down treatments as if children are small adults. In some significant ways, children differs from adults: they have different metabolisms; their organs are not as mature as adults'; and both diseases and drugs can behave differently in children's bodies. Warner said:

To create the best therapies for children we need to include them in our research. A lot of paediatricians' work doesn't have much of a scientific evidence base and we prescribe drugs by extrapolating from what we know about adult bodies. We have a desperate need to understand precisely how children's bodies work so that we can custom-design therapies for them and their problems.

A Review of Psychogenic Cough and Its Diagnosis and Misdiagnosis in AsthmaAsthma takes so many forms that some researchers have said that it is long past time to abandon the idea of asthma as a single disease concept. Until such time as that happens, we will all continue to refer to cough-variant asthma in which chronic cough is the sole presenting manifestation of bronchial asthma in all age groups. The review authors report that recent findings indicate that most children with persistent cough but without other respiratory symptoms do not have asthma. They argue that cough should not be used as a single or major determinant to diagnose and treat asthma; it should be taken as a major clue if trials with medication fail to alleviate symptoms. The reviewers argue that when medical staff consider the range of illnesses that might cause cough, no single management guideline can be universally effective.

Briffa discusses food allergies and intolerance in children with allergic rhinitis or asthma Briffa comments on a recent paper where the authors indicated that:

rhinitis is generally not due to food allergy, and that treatment for rhinitis due to food allergy is therefore rarely indicated.

Briffa disagrees and argues that his clinical experience indicates otherwise. All of which is fair enough but Briffa indulges in truthiness and referenciness to such an extent that this story deserves its own post. I'm waiting to hear back from the authors of a paper that he discussed. In case I don't get round to doing this, note that the elimination studies to which Briffa refers are in infants rather than children and he omits some significant findings from those papers such as the incidence of asthma in those children at follow-up.

Flickr details: 1. Guardian of the Gadgets, 2. Lettuce

Wakefield and Why The Edith Piaf Routine Is Baseless: Part 2

2007-07-09T04:15:00.001+01:00

Over on Scienceblogs, the brothers Hoofnagle write an extraordinary and thought-provoking blog: Denialism. They caution that we should never mistake denialism for debate:

Denialism is the employment of rhetorical tactics to give the appearance of argument or legitimate debate, when in actuality there is none. These false arguments are used when one has few or no facts to support one's viewpoint against a scientific consensus or against overwhelming evidence to the contrary. They are effective in distracting from actual useful debate using emotionally appealing, but ultimately empty and illogical assertions...

5 general tactics are used by denialists to sow confusion. They are conspiracy, selectivity (cherry-picking), fake experts, impossible expectations (also known as moving goalposts), and general fallacies of logic.

Denialism is a useful way of looking at Wakefield's latest foray into public awareness that was so over-faciliatated by the Observer.

My concern is that it’s biologically plausible that the MMR vaccine causes or contributes to the disease in many children, and that nothing in the science so far dissuades me from the continued need to pursue that question’, Wakefield said. ‘The trend in autism has gone up sharply in many countries. It’s interesting that that increase coincides in many places with the introduction of the MMR vaccine. That doesn’t make it the cause. But it’s an observation that needs to be explained, because there was clearly some environmental change at that time that led to growing numbers of children becoming autistic. It’s a legitimate question if MMR is one of those factors. I fear that it may be.’

Whatever Wakefield professes to fear, it should not be that he discovered a plausible biological link between MMR and autism. Reputable scientists in reputable labs with functioning equipment and good routines in place for running standard controls have not replicated his work. Anthony Cox provides an elegant summary of why Virological evidence does not support a link between MMR vaccine and autism. Wakefield would know this from the reputable literature, unless, of course, he is cherry-picking and relying upon other literature; the sort of literature that doesn't appear in indexed journals or wasn't published after peer-review or with sufficient detail to allow adequate assessment. There is no reputable support for Wakefield's claims of an MMR-vaccine-autism link.

Those trends might sound as if they are plausible enough that someone should investigate them. A number of very well qualified people have carried out these investigations. I will defer to the learned testimony of Dr. Fombonne during the recent Autism Omnibus Hearings. There is no trend of the sort that Wakefield describes. Wakefield is aware of a relevant finding in Japan. Japan abandoned the MMR individual vaccines instead - which is what some campaigners have called for in the UK - yet the rate of diagnosis for autism continues to rise in Japan. Why didn't Campbell ask him about this? Did he not know about Fombonne's testimony (although it is readily available and very readable)? Did he not know about the research that Fombonne had published: Pervasive developmental disorders in Montreal, Quebec, Canada: prevalence and links with immunizations?

The findings ruled out an association between pervasive developmental disorder and either high levels of ethylmercury exposure comparable with those experienced in the United States in the 1990s or 1- or 2-dose measles-mumps-rubella vaccinations.

Or closer at home in the UK, in Stafford? Did Campbell not consult Entrez Pubmed for some of the relevant epidemiological studies?

It's obvious that we have some aspects of denialism, but what about the others? I may address some of the others in later posts. For now, I will touch (lightly) on the topic of conspiracy theories because I came across an excellent comment. It seems that Wakefield's friends:

say that he views the GMC hearing as part of a long-running 'Stalinist' campaign to ruin his reputation.

Over on Autism Diva, Matt provides the drollest comment that I've seen on this matter:

the similarities to Stalinist justice are striking. Let's say Wakefield had raised a public health scare in Stalinist USSR. Let's say he had concealed data, and that people had died of preventable diseases.

You could count on the Stalinist courts waiting 10 years, giving him time to mount a defence. You could count on Stalinist judges being limited to removing his right to practice medicine in the USSR. In the end, his punishment would have been the same--banishment to the US where he would be forced to set up a clinic and accept a large salary.

Yep, the similarities are striking.

Wakefield is certainly living La vie en rose if he thinks that the GMC's actions are stalinist. Maybe Wakefield should consider touring with his Edith Piaf, "I have no regrets" routine; it obviously knocked Campbell senseless. Luckily, the Press Complaints Commission has a handy guide to making a complaint. To paraphrase a characteristially astute remark by Anthony Cox about the Japan study:

The BBC and other mainstream media wouldn’t give the time of day to flat earthers, or Holocaust deniers. With the weight of evidence we have now on MMR, it’s time that they stopped giving a platform to the cult of MMR-vaccines-maybe-mercury-autism.

Blog reactions:
Ben Goldacre of Bad Science: Try Me, Sh*thead - the strange case of Carol Stott, Wakefield and the Observer
Dr Crippen of NHS Blog Doctor: Andrew Wakefield, MMR, Autism and the GMC
Tony Hatfield of Retired Ramblings: What the Observer's MMR Piece Didn't Tell You!
Tim Worstall: Crap Reporting in the Observer
Anthony Cox: New Autism Fears, A Man in Denial and MMR Memes in Newspapers
Mike Stanton: Cry Shame on Wakefield and MMR
Kristina Chew of Autism Vox: 1 in 58
Ms Clark of Autism Diva: Embattled Andy Wakefield Speaks and Wakefield and Walker-Smith: Dishonest and Irresponsible
Russell Brown of Public Address: Bad journalism, old stories
Wakefield and Why the Edith Piaf Routines is Baseless: Part 1
Patrick Holford and Andrew Wakefield

Wakefield and Why The Edith Piaf Routine Is Baseless: Part 1

2007-07-09T01:41:00.001+01:00

When Andrew Wakefield went through his deeply-affecting Edith Piaf routine for Denis Campbell of the Observer, did his voice suddenly take on husky gallic overtones in contrast to "the deep green polo shirt, chinos and outdoor jacket" that seem to have so impressed Campbell and made him come over all descriptive? Edit update, July 9: Wakefield has a history of insisting that he should be interviewed by journalists who know little about MMR or medicine (Brian Deer postcript).

It seems as if moral probity oozed from Wakefield as he recounted his touching story of the prophet who is without honour in his own country. The story was obviously so affecting that Campbell neglected to research some basics.

Journalists asked about the authors' main claim to have discovered, in a study of 12 children, a new form of inflammatory bowel disease, which they linked to the MMR vaccine. The doctors outlined their theory that in some children the combination vaccine damaged the immune system because they could not cope with simultaneously receiving a tiny dose of three separate diseases, leaving them susceptible to illness.

Campbell could have consulted many sources on this issue or gone straight to Brian Deer for the inside story (no pun intended) on the gut issue. He might have looked at the official investigation in the immune question: Addressing Parents’ Concerns: Do Multiple Vaccines Overwhelm or Weaken the Infant’s Immune System?. He could have done that and then he would never have written as if these issues were still worthy of further consideration.

What about that scary-sounding ileal-lymphoid-nodular hyperplasia that so impresses and intimidated these hardened journalists? Wasn't this a new, terrifying, malign finding that must mean something? Well, no. It turns out that the swelling of the glands, near the end of the small intestine and close to the appendix is a generally benign finding in children that has been known about for some time. It has nothing to do with inflammatory bowel disease and is not, of itself, an inflammatory bowel disease.

But what about the autistic enterocolitis? Patrick Holford (amongst others) is concerned about the chronic inflammation that scourged the large and small intestines of the children in Wakefield's studies. He still refers to autistic enterocolitis in his books and articles; especially those promoting the need for a restrictive diet that should be supervised by one of his nutritional therapists who will also recommend a gut-healing programme and extensive supplementation. He also emphasises that the children have inflammation arising from infection because he is a staunch advocate of anti-fungal medications for children with these compromised guts.

Patrick Holford and others who recommend elimination diets (amongst other modalities) for children with autism cleave to their belief in this chronic inflammation despite the fact that Wakefield's colleagues have withdrawn their support for his research and retracted the publication that articulated this claim. Patrick Holford still promotes this idea although one of Wakefield's collaborators and co-authors, Walker-Smith, has admitted that most of the children did not show signs of inflammation and that there were no unusual findings in the children's colons.

If you're not queasy about that sort of thing, do go and look at the illustrations and photographic plates on Brian Deer's site; you will learn a lot about the appearance of normal and inflamed bowel tissue.

You will also learn enough to be confident that the researchers had not discovered a "new inflammatory bowel disease" or anything else that could be linked to the MMR vaccine.

Whatever various characters in this drama claim to have thought then, there have been several investigations into the claim that vaccines overwhelm the immune system of young children. One notable report is: Addressing Parents’ Concerns: Do Multiple Vaccines Overwhelm or Weaken the Infant’s Immune System?. In summary, we learn that matters are not quite as those researchers (mainly Wakefied) thought at that time:

Newborns commonly encounter a host of challenges to their immune system at the same time
Newborns are capable of generating protective immune responses to bacteria and viruses, as well as vaccines, from the moment of birth. This capability is necessary for them to meet the tremendous number of environmental challenges they will encounter in the first few hours and days of life.

One of the authors, Dr Paul Offit explained some findings about the remarkable robustness of newborns:

Babies emerge from the relatively sterile environment of the womb into a world teeming with bacteria, viruses and other microorganisms, and their immune systems are designed to stand up to these challenges from the start. Newborns have billions of immunologic cells that are capable of responding to millions of different microorganisms. By quickly making an immune response to bacteria that live on the surface of their intestines, for example, babies are able to keep those bacteria from invading their bloodstream and causing serious disease.

He went on to further explain that research indicates that young infants are fully capable of generating protective immune responses to multiple vaccines given simultaneously.

Our analysis shows that infants have the theoretical capacity to respond to about 10,000 vaccines at once. Currently, the most vaccines that children receive at one time is five. Using this estimate, we could predict that even if all 11 of the routinely recommended vaccinations were given to infants at one time, only about .01 percent of the immune system would be used.

Offit also reveals that improvements in vaccine development mean that today's infants receive fewer substances in vaccines that stimulate an immune response than they did 40 or 100 years ago. The nett effect of this is that although there has been a substantial increase in the number of routine
childhood vaccines over the past several decades, children receive fewer antigens.

Parents who are concerned about the growing number of vaccinations recommended for their children may take comfort in knowing that children are actually exposed to fewer antigens-- proteins that stimulate an immune response -- in the vaccines they receive today than in the past. Vaccine formulations have been refined and simplified over the years. Although we currently give children more vaccines than in the past, the actual number of antigens they receive has declined significantly. Whereas previously one vaccine, smallpox, contained about 200 antigens, now the 11 routinely recommended childhood vaccines
contain fewer than 130 antigens combined.

Now, granted those issues, is it unfair to expect researchers to keep quiet if they suspect flaws in matters that affect safety? No-of course it isn't. But it does behove those researchers to be absolutely sure of their ground. And, at the time of the Lancet publication, Wakefield knew that people in his own lab. had serious misgivings about some of the claims in the paper.

Dr Nick Chadwick started to work as a graduate student in Dr Wakefield's lab in the Royal Free Hospital in 1994. The lab started to focus on testing samples and tissue from autistic patients in 1996. Chadwick was responsible for processing the materials and looking for measles RNA. He reported that there were never any confirmed findings of measles RNA. The only positives that were obtained were rapidly shown to be false positives and he reported this to Wakefield.

Chadwick's testimony to the Autism Omnibus hearings (pdf) was devastating.

pg 10
Q [Y]ou personally tested while you were in Dr. Wakefield's lab gut biopsy material, CFS, PBMCs?

A Yes, that's right.

Q And all the results were either negative, or if they were positive it always turned out that they were false positives?

A Yes, that's correct.

Q Did you inform Dr. Wakefield of the negative results?

A Yes. Yes.

Chadwick further reported that Wakefield had decided that it would be useful to send samples to Dr Kawashima's lab because he was also working on the detection of measles virus using another methodology. Chadwick discovered that there were serious and significant reporting errors from Kawashima's lab and that, yet again, the only positive results were subsequently shown to be false positives. He had concerns about contamination. He informed Wakefield of the problem with the Kawashima results. Chadwick's results also returned negative results, with every positive being subsequently shown to be a false positive.

pg 12
Q [D]uring your time on your Ph.D. research in Dr. Wakefield's lab you only obtained nine positive PCR results for measles. Every time you did that you sequenced them.

A That's correct, yes. We sent it off to a sequencing lab to be sequenced, and the data that came back showed that they were all false positive results.

Q Every positive result you got was a false positive?

A Yes...

[pg 12 cont. to pg 14]
Q [Y]ou state that you had reservations about the immunohistochemistry done to detect measles virus, specifically the use of an antibody from Porton Down?

A Yes, that's right. The antibody seemed to cross-react.
Experiments we did in the lab seemed to show that the antibody cross-reacted with bacterial proteins, which I think is an artifact of how the antibody was made, and that led us or led me to think that it may have been cross-reacting with bacteria in the gut of patients rather than measles virus.

Q Now, that would lead to contamination?

A Well, it would lead to a false positive result. Say for instance if the antibody was binding to something in the guts of these patients, it may well have been a bacteria rather than the measles virus.

Q Okay. Producing the false positives in those?

A Yes, that's correct.

Q You also state in your affidavit that you believe Dr Wakefield was aware of all your negative results when he submitted his paper "Ileal Lymphonodular Hyperplasia, Nonspecific Colitis and Pervasive Developmental Disorder," which was published in 1998 to the Lancet.

A Yes, that's correct.

Q You were working at the lab at that time, and you had actually published some articles with Dr. Wakefield on other subjects, hadn't you?

A Yes. Yes.

Q Why isn't your name on the paper I just referenced?

A Well, my name isn't on that because none of my data went into that paper.
There was a manuscript which did use some PCR data I think from Dr. Kawashima's lab, and I asked for my name to be taken off anything that was related to PCR data because I wasn't comfortable with the quality of the data.

It is a remarkably serious step to request that your name is taken off a paper and should not be used in reference to data. The significance of this would be apparent to any researcher, scientist or journalist.

So, Campbell might have done some background checking but he would then have discovered that there was no scary "new inflammatory bowel disease" and that the concerns about overwhelming the immune system of healthy infants and children were unfounded, and that Wakefield knew that there was no foundation for the "potential link between gut disorders, autism and MMR vaccination" that he had received Legal Aid money to investigate. All of this information is public domain. Why did Campbell not present it in the Wakefield as Edith Piaf piece?

Wakefield told The Observer that he has no regrets for saying what he did in 1998 nor for continuing to seek to prove his view of MMR as the likeliest explanation for the rise in cases of autism in Britain.

Brian Deer has suggested that some of these claims are worthy of an investigation by the Press Complaints Commission; I would like to think that the PCC would treat this matter seriously. I would also like them to give a stern talking-to to whomever was responsible for signing-off on these pieces from the Observer and whoever told Denis Campbell that his science/medical material was accurate.

Blog reactions:
Ben Goldacre of Bad Science: Try Me, Sh*thead - the strange case of Carol Stott, Wakefield and the Observer
Dr Crippen of NHS Blog Doctor: Andrew Wakefield, MMR, Autism and the GMC
Tony Hatfield of Retired Ramblings: What the Observer's MMR Piece Didn't Tell You!
Tim Worstall: Crap Reporting in the Observer
Anthony Cox: New Autism Fears, A Man in Denial and MMR Memes in Newspapers
Mike Stanton: Cry Shame on Wakefield and MMR
Kristina Chew of Autism Vox: 1 in 58
Ms Clark of Autism Diva: Embattled Andy Wakefield Speaks and Wakefield and Walker-Smith: Dishonest and Irresponsible
Russell Brown of Public Address: Bad journalism, old stories
Patrick Holford and Andrew Wakefield

Wakefield: Another Triumph for Mainstream Journalism in the UK

2007-07-08T12:39:00.000+01:00

Mr Matanoski, a lawyer for the US Govt. Health and Human Services Dept., recently made this remarkable comment in his concluding statements for the first part of the Autism Omnibus hearings (pdf) in the US. The MMR-autism case has no plausible or verifiable science to support it.

It's at best speculation, idle speculation. Now, at worst--at worst--it's a contrivance. It's a contrivance that's been developed and articulated and promoted by its chief proponent, and that's Andrew Wakefield. He promoted it for financial gain. Either way it's not science.
pgs 28-9: Day 12 Transcript of Cedillo v. Secretary of Health and Human Services (pdf)

Denizens of mainstream media frequently criticise bloggers; either we are ill-educated, close-minded and so unskilled at writing that we are a carbuncle on the internet and the intellect of those who read us or we will be the downfall of civilization. Bloggers such as Autism Diva and Kevin Leitch have played close attention to the proceedings and blogged them faithfully.

But, it seem that the mainstream media don't see fit to research recent developments in the Wakefield autism debacle just because they are writing about it.

Whatever.

You may recall a recent blogging uptick in stories about coverage of the Autism Omnibus hearings and what they have revealed about the shoddy science and laboratory practice behind Dr Andrew Wakefield and those notorious MMR-autism-gut findings. This is particularly relevant in the light of the upcoming General Medical Council hearings that will investigate Dr Andrew Wakefield, Professor Walker-Smith and Professor Murch.

So, what has mainstream media done for us today? I'm too angry to comment now; I shall update this as the day progresses.

I told the truth all along, says doctor at heart of autism row

In his only interview before he appears in front of the General Medical Council to face serious charges of malpractice, the campaigner against the MMR vaccine tells Denis Campbell that he has no regrets.

I am hanging my head in shame for the Observer. Among the many, many problems with the story, I just drag out this paragraph at random.

Critics point out that the US court case is not about the MMR vaccine itself but centres on the use of a preservative called thimerosal, which contains 50 per cent mercury and until a few years ago was added to routine vaccinations given to children in the US under one. Crucially, it has never been an element of the MMR vaccine here.

Give me strength. Thiomersal has never been a component of MMR anywhere because MMR is a live vaccine. How does this muck get through a scientific sub-editor?!? (See MMR the Facts for the UK and the CDC for the US (no. 7) plus the ever-reliable Orac.) Sunday is not the sort of day to take you through the structure of thiomersal (but I can't resist saying that Autism Diva gives a diagram of thiomersal/thimerosal in the Byers' link, and that mercury is one atom among the 23 in a thiomersal molecule so the issue is molecular not actual weight) or the issue of mercury v. ethyl mercury (but start thinking of ethanol v. methanol or regular alcohol v. wood alcohol) but, if you have the stamina, look at Dr Byers' ludicrous testimony in the Autism Omnibus on this topic.

New health fears over big surge in autism [Edited: July 24; new URL as original story removed from Observer archive.] Let's not go into the whole epidemic issue right now. The article is about an upcoming paper that says the prevalence/incidence of autism is higher than suspected.

Two of the academics, leaders in their field, privately believe that the surprisingly high figure may be linked to the use of the controversial MMR vaccine. That view is rejected by the rest of the team, including its leader, the renowned autism expert, Professor Simon Baron-Cohen.

One of the two people who thinks this is Dr Carol Stott. That's right, Dr Carol Stott who harassed Brian Deer by email and is a collaborator at Thoughtful House with Andrew Wakefield? Dr Fiona Scott used to be in business with Dr Carol Stott. They used to provide assessments for use in the failed MMR vaccine litigation.

This is a brilliant move. It's impossible to comment on an upublished study or one that is 'in publication'. So, for now, I will defer to the learned testimony of Dr. Fombonne during the recent Autism Omnibus Hearings. Edit update: 23:00 Ben Goldacre of Bad Science has emailed both Scott and Stott (the two experts). Scott has responded by quoting a press release:

The Cambridge University Autism Research Centre have not yet released the findings from their prevalence study, as the study is not yet complete. The Cambridge researchers are surprised that an unpublished report of their work was described out of context by the Observer. They are investigating how this report was made available to the Observer. They are equally surprised that the Observer fabricated comments attributed to their team.

Edit: 23:00 One useful thing I learned, this is obviously a prevalence study.

Do Observer journalists do any basic websearches before emoting in ink? Edit: 23:00 - in light of the above edit, who knows what to think but the substantive point still stands...

MMR Scare Pair Acted Dishonestly and Irresponsibly Despite the promising title, this places undue emphasis on the controversy: there is no controversy, the preponderance of evidence is with the truly world-class experts who testified for the defendants at the recent Autism Omnibus hearings. It also mentions that the Nigel Thomas petition in support of Wakefield, Walker-Smith and Murch has 7000+ signatures without mentioning that approximately 50% of the signatories are anonymous or are the duplicates of those who have signed between 2-5 times.

The indefatigable Kevin Leitch is all over the comments, of course. Edit: He has posted an excellent response to the Observer piece.

In the comments there is a dispiriting Private Eye story that looks like it was based on a JABS PR release.

Professor Trisha Greenhalgh wrote a very readable critical review of the Lancet paper.

In conclusion, the Wakefield study was scientifically flawed on numerous counts. I am surprised that neither the editor nor the reviewers spotted these flaws when the paper was submitted. Had they done so, the public would have been saved the confusion and anxiety caused by false credibility conveyed by publication of the study in this prestigious journal.

Had Denis Campbell read it, then we might have been spared yet another airing of this mis-information. But, then again, Wakefield's PR company has a history of insisting that he should be interviewed by journalists who know little about MMR or medicine (Brian Deer postcript).

More when the red mist has left my eyes.

Blog reactions:
Ben Goldacre of Bad Science: Try Me, Sh*thead - the strange case of Carol Stott, Wakefield and the Observer
Dr Crippen of NHS Blog Doctor: Andrew Wakefield, MMR, Autism and the GMC
Tony Hatfield of Retired Ramblings: What the Observer's MMR Piece Didn't Tell You!
Tim Worstall: Crap Reporting in the Observer
Anthony Cox: New Autism Fears, A Man in Denial, MMR Memes in Newspapers and How virulent were The Observer’s MMR articles?
Mike Stanton: Cry Shame on Wakefield and MMR
Kristina Chew of Autism Vox: 1 in 58
Ms Clark of Autism Diva: Embattled Andy Wakefield Speaks and Wakefield and Walker-Smith: Dishonest and Irresponsible
Russell Brown of Public Address: Bad journalism, old stories
Patrick Holford and Andrew Wakefield

Asthma, Allergies: Links and Stories

2007-07-06T13:39:00.000+01:00

Gene Variation, Childhood Asthma Risks and Dubious Press Coverage British researchers made an announcement about some exciting advances in childhood asthma:

We are confident that we have discovered something new and exciting about childhood asthma.... These novel findings do not explain completely how asthma is caused, but they do provide a further part of the gene-environment jigsaw that makes up the disease. We and our colleagues are currently preparing even bigger studies to find other genes of smaller effect, and to relate these to environmental factors that protect against asthma.

Wired gives an excellent overview of the press coverage, some of which was notable for its unwarranted hyperbole. The Daily Telegraph is commended as one of the few papers that gave sensible coverage: Gene May Diagnose Childhood Asthma Early.

... there have been many false dawns in the quest for better treatments. When scientists first began to locate the genetic traits for asthma more than a decade ago, commentators suggested that their work would lead to a cure for asthma within five years, a prediction that proved optimistic.

Encouraging Results for Atopy Patch Test for Children with Food-Allergy-Related Gastro-intestinal Symptoms This has great potential. It can be heart-breaking for clinicians to attempt to administer a skin-prick test (SPT) to unco-operative or frightened young children; it is wretched for parents to watch while this happens. The researchers evaluated the diagnostic accuracy of food challenge, SPT, serum-specific IgE determination, and an atopy patch test (APT) using fresh food and commercial food extracts in parallel in children referred for suspected food allergy-related gastrointestinal symptoms. There are also known concerns about the accuracy of SPT in indicating food allergies. The different methodology with APT seems to by-pass some of these problems.

Atopy patch test is a useful tool in the diagnostic work up of children with food-allergy-related gastrointestinal symptoms. The diagnostic accuracy of ATP was higher with fresh food than with commercial food extracts.

Facial Thermography for Assessing Food Challenge Outcomes Another one of those fascinating ideas that prompt the "Why didn't anyone think of that before?" reaction. You might recall the Radio 4 deeply distressing account of William and the oral food challenge test that went horribly awry, partly because of the time-lag between the subtle onset of symptoms to the point where they become flagrant.

Oral challenge is widely used for diagnosing food allergy but variable interpretation of subjective symptoms may cause error...Facial thermography consistently detects a significant early rise in nasal temperature during positive compared with negative food challenges, which is evident before objective symptoms occur. Thermography may therefore provide a sensitive method to determine outcome of food challenges and investigate the pathophysiology of food allergic reactions.

Techniques like this have great potential for detecting earlier onset of symptoms during challenge tests and making the procedure much safer.

Skeptics' Circle 64 Is Up at The Skeptical Alchemist

2007-07-05T17:10:00.000+01:00

The Skeptics' Circle 64 is up at The Skeptical Alchemist. Learn about The New Truth University and their amazing offerings that bear an uncanny resemblance to something that was covered recently on Holford Watch:

New Truth University. At NTU, we think for you. Open yourself to an alternative view of truth - the one we give you.

At NTU, we combine alternative academic dogmas with the absolute flexibility that allows you to create your own degree. At NTU, we’re all about life-changing experiences. Our admission requirements vary widely because each program of study is different. However, if you are completely unable to have your own opinion, and even if you do you simply cannot justify it logically, you're guaranteed admission to almost all of our programs, plus a space in residence, and priority course access. When you are admitted to NTU, you'll be ready to make your dreams a reality.

64th Skeptics' Circle is a thoroughly educational read.

Warner Despairs That Allergy Is Still a Cinderella Subject

2007-07-04T18:02:00.000+01:00

Prof. John Warner is Professor of Paediatrics at Imperial College London and has contributed to several jeremiads about the state of allergy services in the NHS. Warner is particularly concerned about the parlous state of paediatric allergy and has written a strong editorial in the latest edition of Pediatric Allergy and Immunology: Allergy – still a Cinderella subject.

There are frequent newspaper articles about the scale of need for allergy services in the UK; they range from the sensible to the ludicrous but they do highlight the level of concern that there is. There is increasing coverage of the profound quality of life issues that children with allergies face on a daily basis.

I admire allergy specialists in the UK for their continued restraint in the face of many rebuffs for their repeated and well-reasoned argument that the NHS desperately needs to improve its provision of allergy services. In his editorial, Warner claims that:

the incredibly high prevalence of allergic disease...dwarfs that of any other chronic condition.

Ironically, despite the paucity of allergy provision in the UK, we have researchers who are acknowledged as world experts; nonetheless, their expert advice is routinely ignored by the Dept. of Health which claims that decisions about allergy services should be made at a local level rather than be part of a national framework.

It is all the more frustrating because researchers are confident that they have a good, comprehensive understanding of the basic mechanisms that contribute to allergies and allergic disorders in children. Researchers and clinicians have developed a number of new treatments that are designed to target the specific mechanisms involved. There is a catch, however. Some of these targeted treatments are comparatively expensive and they should only be used after diagnosis by appropriately trained allergists and under their supervision.

UK Health Trusts have a dilemma. They can refuse to fund the treatments at all, which may make them unpopular but is the simplest option for a cash-strapped health service, particularly if they have been asked to find unplanned savings. If a Health Trust agrees to fund a treatment, then they may have to pay not only for that treatment, but also for an 'out of area' referral to a specialist service for which they need to pay a premium price. If a Health Trust is trying to plan for the future, then they may realise that agreeing to provide a novel medical treatment will involve further costs because that treatment necessitates an increase in training and consultant posts to make the best and most cost-effective use of these highly effective new treatments.

I have occasionally wondered what the history is that would account for the poor status of allergy services in the UK. As a partial explanation, Warner gives an interesting overview of how allergy emerged as a medical discipline in several countries in his editorial.

The problem has arisen because as the scientific basis of medicine has become ever more sophisticated, there has been a progressively increasing focus on specialization. In most countries this has evolved system by system. Thus tertiary specialization has carved up the holistic approach to medicine into organs. Allergy being a discipline which covers many systems and considerable co-morbidity, requiring a holistic approach, has been left behind as the remit of the generalist. As the scientific basis of allergy has advanced the generalist has unfortunately not kept pace with new knowledge leaving sufferers without any recourse to expert advice.

In the UK, this means that too many GPs are left to manage allergies without appropriate support or adequate resources, such as the option to refer to allergy or immunology consultants in secondary or tertiary levels of care. Unfortunately, this can have significant impacts for the most profoundly affected patients, especially those who are unfortunate enough to have multi-systemic allergies that affect more than one system, such as the skin, the respiratory system or the gut. I have met too many parents who feel betrayed by NHS provision for their atopic children. Even parents who are financially-strapped feel the need to purchase private diagnosis and medical management for their children in order to ease their children's sufferings (e.g., chronic urticaria or unstable asthma) and their own concerns.

Warner gives an overview of the origins of allergy services in different countries and discusses their relative merits. He presents the options of developing either "a cadre of mono-specialists in adult and paediatric allergy" or a network of allergy clinics that act as a one-stop shop for appropriately-qualified respiratory specialists, dermatologists, otorhinolaryngologists, etc..

Warner emphasises that allergy services in the USA and France are linked to aggressive programmes of allergen immunotherapy-a treatment modality that is rarely available in the UK. Such a system is clearly effective in those countries but it is not clear that such a model is wholly appropriate in the UK which lacks that history. Warner acknowledges that the UK needs a good immunology service to back up allergy clinics, but highlights the issue that clinical immunology covers a very much wider area including immunodeficiency, rheumatology and in some circumstances infectious disease. It would be too easy for allergy services to be subsumed into immunological services despite the tremendous level of need.

Warner speculates that medical trends over the last 100 years indicate that:

the discipline of allergy will be progressively split and we will have experts exclusively focusing on food allergy, respiratory allergy, dermatological allergy, etc. However, this will be at the expense of the patient with concurrent allergic problems in several systems which are all too frequent.

Warner sounds a salutary warning note as to the disadvantages of such specialisation:

I am referred ever larger numbers of children who have already been seen by a range of specialists and prescribed treatment relevant to the individual system problem. The cumulative effect of the drugs and particularly topical steroids is having a significant adverse influence on growth and development. I believe the future lies in ensuring that the discipline of paediatric allergy retains its integrity as a holistic discipline working harmoniously alongside systems specialists and clinical immunologists.

This is yet another well-reasoned plea for an improvement to paediatric allergy services in the UK along with a summary of what a reasonable clinical service would look like. There is a verifiable need for better allergy provision on the NHS. For how much longer will the Dept. of Health ignore these specialists? For how much longer will they ignore parents such as Claire who left this comment on a previous post:

The patient charities Allergy UK and The Anaphylaxis Campaign and many doctors and patients have made this point until they're blue in the face (no pun intended). Donna Covey of Asthma UK stated recently that an astonishing proportion of people contacting them don't know know if they have a diagnosis of allergic or non-allergic asthma. But very little seems to change and I recall HoC health comittee report warned that the situation might even deteriorate, as some of the small number of clinical allergists near retirement. Appeals for central funding and direction to boost provision to the levels recommended in the 2003 RCP report ('Allergy: the unment need") continue to fall on deaf ears, as evidenced most recently in the BBC Radio 4 'Allergic Reactions' broadcast, where Minister Andy Burnham simply passed the buck back to the PCTs, even though Dr Ewan had explained why this is not working and why allergy could be considered as a special case (historic cinderella status in NHS, now faced with rising numbers of affected patients, increasing incidence of severe and/or complex disease).

Clutching at straws, I fear, but, given that there is now an overall surplus in NHS funds, perhaps Gordon Brown could mark his accession to power by earmarking some of this to kick start the process of building up NHS allergy provision? I know lots of people who would respond to such a move with undying gratitude.

I've described my concerns about CAM and allergy [elsewhere], particularly my theory that the overstated and inaccurate claims made by some of these practitioners is actually reinforcing the scepticism people can encounter when they raise concerns about allergies with their doctors. On a more personal note, one of the burdens a parent of an allergic child has to bear is the constant torrent of unsolicited advice about CAM 'cures' from friends and family, mostly based on something they have come across in the media. Often, this is accompanied by uninformed opinions about the dangers of conventional medications. I realise this is well meant but it drives me mad: parents doing their best to work with their doctors to deal with these difficult conditions don't need to be undermined by suggestions that they are harming their children. I have taken to telling people who offer me unsolicited advice on ear candling, homeopathy, kinesiology, fad diets etc that what would really help me would be easier access to a clinical allergy service, and if they really want to help, please would they kindly write to their MPs about this.

Click on the image or visit Flickr for further information about the images. 1. IMG_2441, 2. IMG_2446

Asthma, Allergy, Immunology, The Menace of Cats, Links and Stories

2007-07-03T12:05:00.000+01:00

Cats Are a Ubiquitous Source of Irritation for People with Allergies I have previously made my position on cats very clear: You're Not Free of Cats Just Because You Don't Own One. I will grudgingly admit that the report needs to be verified but it merely confirms me in my prejudice that cats are a force for evil, irritation, anti-histamine and air-freshener sales. It seems that allergen avoidance advice that has concentrated on avoiding house dust mite might have neglected the ubiquitous nature of cat allergens which may be a more relevant trigger, even in the absence of an apparent allergy. Cats may trigger an asthmatic airway response even in people who are not specifically allergic to cat dander.

Cat allergen exposure at moderate levels may be harmful to all atopic adults...The clinical implication is that it is insufficient to test patients with asthma for cat sensitization. [A]dvice should be against cat ownership in those showing sensitization to any allergen.

Not that that can protect you, oh no. Cats and their ghastly allergens get everywhere. No one is safe. Except at the North Pole. Maybe. If you are not visited by anyone wearing clothes anywhere that a cat has been at some point.

Allergy to Electromagnetic Emissions People report adverse reactions to electromagnetic emissions (EME) emitted from power lines, etc. The editor for the American Academy of Allergy, Asthma and Immunology dryly comments:

I do not know what to make of this story. Some individuals have attributed a variety of their medical problems to emissions from nearby power lines. The term "allergy to EME" may prompt some individuals to seek testing for such an "allergy." This situation may be analogous to the "multiple chemical sensitivity" complaints. which were postulated by some patients and "alternative" practitioners in recent years to cause a variety of ill-defined symptoms without definitive proof.

Whole Grains in Diet Prevent Inflammatory Diseases Or do they? I enjoyed the editor's comment about this epidemiologic study and its observations about the anti-oxidants in wholegrains and putative impact on inflammatory disorders:

I am not sure that one can draw definitive conclusions from these large "guilt by association" epidemiologic studies. Although anti-oxidants in dietary whole grains may be protective against inflammation, I think that a prospective controlled intervention study is needed to get more definitive evidence.

For more information about the image click on it to see the detail about the contributor on Flickr.

Paediatric Grand Rounds 2:6

2007-07-01T10:48:00.000+01:00

What with the floods, the bombing attempts in my local area, and the shrill warnings that the UK is on critical alert for terrorist events, a number of households are probably taking the time to go through emergency planning dilemmas and review contingency plans with their children. Matthew Baldwin of Defective Yeti is a menace to tidy desktops: he too often causes the rapid nasal dumping of whatever I'm drinking over a keyboard, monitor and surrounding area. He turns the everyday into, well, Photo Finish.

Squiggle's daycare was creating emergency kits for each child. One of the things they asked the parents to supply was pictures of themselves. That way, if there was a natural disaster, and the child was separated from his caregivers, he could at least find comfort in seeing them in a photograph.

I'd like a headcount of those of you who think that your children would find this comforting in the event of such a contingency. The importance of having proper emergency provisions is highlighted by Orac who reproduces a battery advertisement that tells the story of how fumbling about during a blackout almost led to a situation where: I poured a death potion for my sick baby!

We might be tempted towards DIY diagnosis under emergency conditions. Find out why Judy of Tiggers don't Jump says I hope they were just waiting for the pediatrician's office to open. On the topic of unsettling search terms and the information that you might expect to receive from Dr Google, Kevin, M.D. chronicles: The Google Health Advisory Council: Outrage. While we are on the topic, how strong is this advisory group on the subject of paediatric healthcare?

Parents wanting to comfort and help their children and advocate for them during medical visits is a strong theme for this PGR. Jen is one of the alpha-girls of Unique But Not Alone. I think that we are all familiar with the situation where a child just trips on air and, in no uncertain terms, lets you know, "It hurts so bad." It is just so much more fraught when both parent and child are veterans of many procedures.

I kept thinking, “I know it hurts. Let me help you kid!” My frustration with the situation and not really being able to make it feel better, made me a lot less patient and my tone was at best witchy. I reminded myself to keep it together, though.

Catherine of Charming BB was a little apprehensive when she met up with a new paediatrician for her son. There were a few reservations and a little awkardness on both sides. Find out why mutual respect and good manners really do oil the wheels of many potentially fraught situations: So, How's It Going?

He didn't say: "You are a crazy pain in the ass parent." And I didn't say: "Wish you guys had caught this disease earlier."

Girl MD of girl MD gives a lyrical and poignant account of Ondine's curse; a condition that had taken some time to diagnose.

before this night, i did not know the extent of their journey together, this young boy and his mother. as it became clear that he would sleep soundly, the tension drained from her face.

Stacy of The Preemie Experiment is a staunch advocate for her daughter, Paige. However, Stacy was taken aback when Paige, who has mild CP, announced: Mommy, I need a wheelchair. When the parental/medical impression of "She looks good to me" contrasts with a child protesting that she is in pain:

Being honest here... I don't know what to do when Paige utters this statement.

Neonatal Doc was watching a professional fishing tournament in which the fish were returned to the water when it triggered a train of thought. Given the complexity of caring for current premature babies, he considers that medical research has so far not developed an artificial placenta and wonders if it represents a natural physical and ethical Barrier.

Sometimes we wish we could throw a tiny baby back into the uterus to grow some more, but it obviously doesn't work that way with humans.

Dr Clark Bartram of Unintelligent Design gives a fascinating account of the dramatic medical progress of diabetic mothers and Willy Wonka Wombs.

The abnormally low, and potentially quite dangerous, blood sugar arises from spending roughly 9 months in the Willy Wonka womb of an uncontrolled diabetic mother...

Prior to 1922, when cow insulin was first given to a human with diabetes, there was no hope for young diabetics. They rarely lived long enough to bear children and diabetic women with child were counseled to terminate their pregnancies. Insulin, and more importantly the ability to make a lot of it, was irrefutably one of the biggest advancements in modern medicine...

Walter of Highlight Health reports more common in utero exposures: Second-hand Smoke Exposure Linked to Psychological Problems in Children.

Researchers found that children whose mothers had been exposed to tobacco smoke either by smoking or exposure to second-hand smoke when they were pregnant had more symptoms of ADHD and conduct disorder than children whose mothers did not experience smoke exposure.

Christian Bachmann of Med Journal Watch summarises the debate about whether it is in utero or social influences that have an impact on intelligence scores: What the birth order IQ study tells us. I enjoyed his conflict of interest:

I am a firstborn of seven siblings which may influence my view of this study.

I wonder if the impact of social order could be overcome by appropriate branding. Dr Bryan Vartabedian of Parenting Solved has a remarkable account of contemporary childhood in The Wall St Journal and Baby Branding.

Of course, this is the sort of post that I typically associate with GI specialist Dr Vartabedian. A Really Close Look at a Dirty Diaper, or, to be more accurate, a year's worth. Be careful about when you look at it, but there is an interesting discussion of a paper that reports fascinating material about GI tract colonisation and the role of microbiota in extracting nutrients from food.

By applying sophisticated genetic analysis to samples of a year's worth baby poop...researchers have now developed a detailed picture of how these bacteria come and go in the intestinal tract during a child's first year of life.

Moving on to older children, Medgadget has taken a robust attitude on a controversial topic: Video Game Addiction: We Don't Care.

Why? Because it's pretty clear there are those who spend way more time interacting with screens and virtual worlds than is healthy, and apparently have a hard time doing otherwise. However, getting on board with the addiction classification opens up a scary scenario where parents of loner overweight kids can sue Capcom for the results of their bad parenting.

How many "loner overweight" kids are stressed? Treatment Online covers recent discussions: Stress Effects Children's Social Skill, Academic Success. I doubt that anyone is surprised by this but I wish that there were an obvious and practical remedy.

[R]esearchers found that children who have elevated amounts of stress tend to demonstrate lower social skills than classmates without as much stress. They also found that active participation by parents in their child’s academic life results in positive performance in both the long and short term.

They also discuss The Alleged Risks of Psychotherapies; this is not directly about child psychotherapies but it did raise questions for me as to the extent of the evidence-base that exists for them.

Sandy Szwarc of Junk Food Science gives us her usual commonsense take on the topic of diet and related issues in children. She reports that Fitnessgrams (fit report cards) are being implemented in increasing numbers of school systems in the U.S. They claim that academic performance is dependent upon fitness -- Sandy takes a look at those claims and the evidence in: Take home message from school: Kids, spend as little time reading as possible. Sandy also takes a cool-headed look at yet another another diet claimed to be effective for children and teens that is riddled with the assumptions and errors common to most weight-loss studies. Figure Flaws — Did this diet really work?

Dr Scott of Just Practicing is familiar with both inundation, overwhelm and false promises. He has a startling announcement, he's had Enough.

The government has done NOTHING for healthcare after Katrina...Forgive me for playing the martyr, but I feel like I've been caring for the children of Waveland and Bay St Louis on my own back and on my own dime. I can't do it by myself anymore, and if no one is coming to help, it can longer be my problem.

The second part of PGR reflects events in the UK and US.

Vaccination, MMR and autism

I should explain that while you have the Autism Omnibus hearings in the US these issues are coming up for us again in the UK because the General Medical Council is holding hearings in the matter of Dr Andrew Wakfield and two of his previous colleagues, in July. The UK's self-styled leading nutritionist Patrick Holford recently asked: Was Dr. Andrew Wakefield Right About the Link Between Autism, the Gut, Allergy and the MMR Vaccine?. He purported to give an overview:

If you are not sure, then please read on to find out what we know about autism, the gut, vaccinations and what food has to do with it.

We do not know any of that: the science has been well and truly exposed. At best, Patrick Holford is outdated in his knowledge and it is past time that he updated it. Something he had ample opportunity to do before repeating these beliefs in recently published books.

Patrick Holford depends upon Wakefield's work to justify some of his entrepreneurial and charitable endeavours. He owes it to the people who rely upon him to revise his acceptance of Wakefield's science and findings. And people are guided by Patrick Holford when it comes to MMR. Petition signatory 4797 credits Patrick Holford with her daughter's decision not to vaccinate her children:

Thank God my daughter used her judgement and did not have the MMR for her children. She based her decision on extensive research, most particularly 'What Doctors Don't Tell You' and Patrick Holford.

Patrick Holford owes it to that woman to put together a better overview of the research that purports to find a link between MMR and autism: he may even owe it to her that he should strongly reconsider his position on a number of important matters.

The following posts address various aspects of Wakefield and the MMR debacle and how Wakefield's work and that of others has spawned some dubious treatment programmes for autism.
Patrick Holford and Dr Andrew Wakefield's Discredited Findings: Part 1
Kevin Leitch on Andrew Wakefield and the death of the MMR debacle
Mike Stanton on Patrick Holford and his unusual views on vaccination, MMR and autism
Patrick Holford Claims Remarkable Benefits for Homeopathic Vaccinations
Holford Watch: Holford believes Secretin is "Worth considering" as an autism treatment; however, there is no evidence that this treatment is effective and
Holford is sceptical about off-label prescribing, but thinks that secretin for autism is "Worth considering"
Patrick Holford alias Doctor Knock aka Holt Senior

Courtesy of the Autism Omnibus, there have been many fascinating posts about similar issues in US blogs. Autism Diva has done an outstanding job of blogging the Autism Omnibus Hearings and her summaries of the testimony are well worth reading. If you want to learn about measles from a world authority on the topic, however, I have to single out Omnibus hearing: Griffin.

if you have the slightest inclination to get an understanding of the natural history of measles and how the wild-type virus is so different from the vaccine strain virus, and if you'd like details on how the vaccine virus was developed and what the limitations are on culturing vaccine strain and wild-type strain in a laboratory setting, if you'd like to know about what happens to children who catch the wild-type measles and do just fine for 7 to 10 years when they develope subacute sclerosingpanencephalitis or SSPE...

Arthur Allen has provided interesting coverage of the Autism Omnibus, both on his own blog and for Slate. Fombonne was one of the experts who testified in the case of Michelle Cedillo. It was both sad and enlightening to learn of Fombonne's interpretation of the Painful home videos in the autism/vaccines trial.

It’s common that parents, especially first-time parents don’t pick up such abnormalities. And they should not blame themselves for that. But with hindsight you do see these very clear patterns.

The ever-reliable Orac has posted one of the most accessible explanations of PCR that I've seen and explains just why the expert testimony should discredit some of the widely-propagated beliefs about the claims that the MMR measles strain has been identified in gut samples. The difference between real scientists and crank scientists:

If the evidence presented in the Autism Omnibus doesn't put the final stake in the heart of the misbegotten "MMR causes autism" pseudoscience, truly there is no hope for reason and science.

Prometheus of A Photon in the Darkness was intrigued by Generation Rescue's claim that their survey shows that vaccination causes autism. Prometheus has looked at the figures and sums it up: Survey Says....Nothing!!!

Well, actually, it doesn't really show that vaccines cause autism, what it shows is that vaccines cause "neurological disorders", loosely defined as autism (or autistic spectrum disorder) and/or ADD/ADHD.

Except that it really doesn't show that, either.

Kevin Leitch addresses the issue, What will change? It seems that the answer is, very little. People who thought that there was little science to support the MMR-mercury-autism hypothesis have probably just been strengthened in that by the array of world-class experts and their commentaries. People who believed in the link already have refreshed their crop of conspiracy theories. Kevin concludes with an allusion to Swift:

You cannot reason someone out of a belief they did not reason themselves into.

Dr Bryan Vartabedian of Parenting Solved is our next PGR host for Sunday July 15.

Clark Bartram is looking for hosts for future PGRs. You can consult both the hosting schedule and earlier editions in the Paediatric Grand Rounds archive. Please sign-up. Pretty please...PGR

Andrew Wakefield, Chronology and "Bad Science"

2007-06-29T18:49:00.000+01:00

It's at best speculation, idle speculation. Now, at worst--at worst--it's a contrivance. It's a contrivance that's been developed and articulated and promoted by its chief proponent, and that's Andrew Wakefield. He promoted it for financial gain. Either way it's not science.
pgs 28-9: Day 12 Transcript of Cedillo v. Secretary of Health and Human Services (pdf)

As part of his closing, he presented this unsettling chronology of events. (For a more detailed summary of events, see Brian Deer and the MMR-autism scare.)

I've mentioned several times in the course of these proceedings Andrew Wakefield and his theory, and there's a reason for that. That's because all the strands through these cases come back to him. He presented bad science.

I'm going to run through the chronology again because it's important, the chronology of how this arose and how it was promoted. In 1996, Alexander Harris, a firm of solicitors in Great Britain, approached Andrew Wakefield and asked him to consult with them in cases involving MMR, allegations of MMR causing autism. Andrew Wakefield was paid 55,000 pounds for his efforts at that point.

Andrew Wakefield in 1997 took out a patent for a monovalent measles vaccine. In 1998, he published the paper that caused the stir that we've now seen reinterpreted, rearticulated a number of times until more than 10 years later we have it in our courtroom today.

He did not reveal at the time that he published that paper that he had this financial interest. He did not reveal that several of his patients in that paper were in fact litigants in the MMR litigation.

In 1998, Andrew Wakefield approached John O'Leary and consulted with him. John O'Leary went on to set up Unigenetics, a company of which he was the director and shareholder. Unigenetics' purpose was to test samples for the U.K. MMR litigation.

Now, you've heard testimony about the reliability of that testing. You've seen the papers that have come out of that lab. In fact, the Uhlmann paper that was discussed here at length and relied on so heavily by the Petitioners, the patients, some of the patients at least, some of the patients in that case study were MMR litigants. There's a direct connection between that litigation and our litigation here. That litigation folded. Unigenetics went away, but we have it back here now in this case. It folded in 2004 after the whistle was blown on Andrew Wakefield and it was revealed his substantial financial connection with ongoing litigation.
pgs 30-2: Day 12 Transcript of Cedillo v. Secretary of Health and Human Services (pdf)

According to Brian Deer, the £55,000 was a payment for clinical and scientific tests on the children of clients: Wakefield had been retained by a solicitor involved in anti-MMR action since Feb. 1996. Brian Deer put in a Freedom of Information Act request to the Legal Services Commission and in December 2006 they provided a spreadsheet of fees to paid witnesses in the MMR lawsuit. According to that payment schedule, Wakefield had been paid £435,643 [about $780,000], plus expenses, for his expert participation in the legal case against MMR. Brian Deer reports that these sums do not include the fees for work on individual children's records.

A substantial number of the signatories to the Nigel Thomas petition believe the claim that:

The threat that faces Dr Andrew Wakefield, Professor John Walker Smith and Professor Simon Murch is that they may be struck-off the medical register for daring to investigate why these children are so ill, which no-one else has been prepared to do.

On just one page of signatories, people write of Wakefield as a hero, as a prisoner (who is awaiting crucifixion and will be retrospectively vindicated) and in terms of Pasteur and Galileo. There is no final word on the charges but the GMC is not convening a hearing because these researchers investigated these children, nor, as Patrick Holford would have us believe, for "challenging the status quo".

Related posts
Patrick Holford and Dr Andrew Wakefield's Discredited Findings: Part 1
Patrick Holford and Dr Andrew Wakefield's Discredited Findings: Part 2
Kevin Leitch on Andrew Wakefield and the death of the MMR debacle and Justice for Katie
Mike Stanton on Patrick Holford and his unusual views on vaccination, MMR and autism
Patrick Holford Claims Remarkable Benefits for Homeopathic Vaccinations
Holford Watch: Holford believes Secretin is "Worth considering" as an autism treatment; however, there is no evidence that this treatment is effective and
Holford is sceptical about off-label prescribing, but thinks that secretin for autism is "Worth considering"
Patrick Holford alias Doctor Knock aka Holt Senior

Image detail on Flickr

Patrick Holford and Dr Andrew Wakefield's Discredited Findings: Part 2

2007-06-28T11:59:00.001+01:00

Patrick Holford is a staunch supporter of Dr Andrew Wakefield and recently set out his case as to why we should likewise support him. Patrick Holford claims to have remarkable insight into the causation of autism and how to "bring them back" when children are on the autistic spectrum. He suggests that there is hard evidence that links MMR and autism.

Wakefield's claims about the inflamed and diseased guts of the children in his original Lancet study have been shown to be unfounded.

But what about those measles antibodies in the cerebro-spinal fluid and the gut tissue of the children Wakefield examined? Whatever significant problems there may be with the rest of his work, surely this is the crux of the matter.

Yes, the findings concerning the measles antibodies are significant, albeit, not in a way that most people would admire. And here we pass to one of the most alarming and distressing aspects of this whole affair; something that has been known for some time but about which Patrick Holford is silent. Those antibodies were never there.

The account of those (now) infamous PCR samples that 'proved' the existence and persistence of the measles antibodies in the children's samples, along with the issues discussed below and in part 1 is why a lawyer for the US Govt. Health and Human Services Dept. recently made this remarkable comment in his concluding statements for the first part of the Autism Omnibus hearings in the US. The MMR-autism case has no plausible or verifiable science to support it.

It's at best speculation, idle speculation. Now, at worst--at worst--it's a contrivance. It's a contrivance that's been developed and articulated and promoted by its chief proponent, and that's Andrew Wakefield. He promoted it for financial gain. Either way it's not science.
pgs 28-9: Day 12 Transcript of Cedillo v. Secretary of Health and Human Services (pdf)

What about those samples, the ones with the measles RNA?

Orac has written an excellent account of the difference between real scientists and crank scientists. By liberal referral to the leading PCR authority, Dr Bustin, we learn precisely why we can have no confidence at all in the Unigenetics lab that reported many of these findings.

Now, here's where Dr. Bustin was so devastating to the claim that MMR causes autism. Andrew Wakefield and Arthur Krigsman, who claimed to have replicated Wakefield's work and found measles virus RNA in the guts of autistic children, both used Professor John O'Leary's Unigenetics Laboratory in Ireland, and it was the Unigenetics lab whose results led to a paper by Uhlman et al and an as yet unpublished poster presentation by Walker et al, both claiming to find measles virus in the guts of autistic children.

The irregularities were extraordinary and the whole of Dr. Bustin's testimony (pdf) is worth reading as a primer into how PCR can go horribly wrong.

I don't know why Patrick Holford still finds this an area of controversy and debate rather than acknowledging that there has been some bad science that has been roundly and repeatedly exposed. He mentions none of this in the theory of autism aetiology that he promotes in his books or websites. He promotes the existence of the measles antibodies in the gut and CSF as fact despite the overwhelming evidence to the contrary. The theoretical underpinning for his heavily promoted treatment programme relies upon the existence and persistence of these measles antibodies.

So, the Unigenetics lab returned suspect results and can not be relied upon but surely the original PCR results from the Royal Free Hospital are above reproach? No.

Dr Nick Chadwick started to work as a graduate student in Dr Wakefield's lab in the Royal Free Hospital in 1994. The lab started to focus on testing samples and tissue from autistic patients in 1996. Chadwick was responsible for processing the materials and looking for measles RNA. He reported that there were never any confirmed findings of measles RNA. The only positives that were obtained were rapidly shown to be false positives and he reported this. Chadwick's account has been known for some time; more than enough time for Patrick Holford to have addressed this issue. At the very least he should have referred to it when purporting to give his email list an overview of Wakefield's work and why we might consider signing that petition.

Chadwick's testimony to the Autism Omnibus hearings (pdf) was devastating.

pg 10
Q [Y]ou personally tested while you were in Dr. Wakefield's lab gut biopsy material, CFS, PBMCs?

A Yes, that's right.

Q And all the results were either negative, or if they were positive it always turned out that they were false positives?

A Yes, that's correct.

Q Did you inform Dr. Wakefield of the negative results?

A Yes. Yes.

pg 12
Q [D]uring your time on your Ph.D. research in Dr. Wakefield's lab you only obtained nine positive PCR results for measles. Every time you did that you sequenced them.

A That's correct, yes. We sent it off to a sequencing lab to be sequenced, and the data that came back showed that they were all false positive results.

Q Every positive result you got was a false positive?

A Yes...

[pg 12 cont. to pg 14]
Q [Y]ou state that you had reservations about the immunohistochemistry done to detect measles virus, specifically the use of an antibody from Porton Down?

A Yes, that's right. The antibody seemed to cross-react.
Experiments we did in the lab seemed to show that the antibody cross-reacted with bacterial proteins, which I think is an artifact of how the antibody was made, and that led us or led me to think that it may have been cross-reacting with bacteria in the gut of patients rather than measles virus.

Q Now, that would lead to contamination?

A Well, it would lead to a false positive result. Say for instance if the antibody was binding to something in the guts of these patients, it may well have been a bacteria rather than the measles virus.

Q Okay. Producing the false positives in those?

A Yes, that's correct.

Q You also state in your affidavit that you believe Dr Wakefield was aware of all your negative results when he submitted his paper "Ileal Lymphonodular Hyperplasia, Nonspecific Colitis and Pervasive Developmental Disorder," which was published in 1998 to the Lancet.

A Yes, that's correct.

Q You were working at the lab at that time, and you had actually published some articles with Dr. Wakefield on other subjects, hadn't you?

A Yes. Yes.

Q Why isn't your name on the paper I just referenced?

A Well, my name isn't on that because none of my data went into that paper.
There was a manuscript which did use some PCR data I think from Dr. Kawashima's lab, and I asked for my name to be taken off anything that was related to PCR data because I wasn't comfortable with the quality of the data.

It is a remarkably serious step to request that your name is taken off a paper and should not be used in reference to data. The significance of this would be apparent to any researcher or scientist. Except, of course, to Patrick Holford, who does not mention any of this when instructing his readers in the role of MMR in the development of autism. Nor does he mention it when discussing the scientific rationale for his treatment programme for children on the autistic spectrum.

Patrick Holford has not included any of this material when updating his publications or websites nor when writing his recent books. If he were to, perhaps he would have to acknowledge that there is no scientific foundation to his treatment programme which relies upon the findings of Wakefield.

Patrick Holford recently asked: Was Dr. Andrew Wakefield Right About the Link Between Autism, the Gut, Allergy and the MMR Vaccine?. He purported to give an overview:

If you are not sure, then please read on to find out what we know about autism, the gut, vaccinations and what food has to do with it.

Thank God my daughter used her judgement and did not have the MMR for her children. She based her decision on extensive research, most particularly 'What Doctors Don't Tell You' and Patrick Holford.

Patrick Holford owes it to that woman to put together a better overview of the research that purports to find a link between MMR and autism: he may even owe it to her that he should strongly reconsider his position on a number of important matters.

Related posts
Patrick Holford and Dr Andrew Wakefield's Discredited Findings: Part 1
Kevin Leitch on Andrew Wakefield and the death of the MMR debacle and Justice for Katie
Mike Stanton on Patrick Holford and his unusual views on vaccination, MMR and autism
Patrick Holford Claims Remarkable Benefits for Homeopathic Vaccinations
Dr Crippen on the remarkable cost-savings that Patrick Holford could offer the NHS: Pay £6.99 to say "no" to cancer
Holford Watch: Holford believes Secretin is "Worth considering" as an autism treatment; however, there is no evidence that this treatment is effective and
Holford is sceptical about off-label prescribing, but thinks that secretin for autism is "Worth considering"
Patrick Holford alias Doctor Knock aka Holt Senior
Flickr credits for the images. 1. question, 2. Questions?

Patrick Holford and Dr Andrew Wakefield's Discredited Findings: Part 1

2007-06-27T19:56:00.000+01:00

Patrick Holford sent round an email last week in which he asked people to sign a petition in support of Dr Andrew Wakefield for his upcoming hearing before the General Medical Council in the UK. Patrick Holford hadn't signed the petition the last time that I looked (yesterday evening), nor is the petition solely about Wakefield. Nonetheless, Patrick Holford seized this opportunity to reproduce swathes of text from his own books where his claims and recommendations stand and fall with the reliability and accuracy of Wakefield's work: Was Dr. Andrew Wakefield Right About the Link Between Autism, the Gut, Allergy and the MMR Vaccine?. [Update Jan 2008: Patrick Holford's Concerns About the MMR Vaccine] He undertakes the task of providing a salient overview:

If you are not sure, then please read on to find out what we know about autism, the gut, vaccinations and what food has to do with it.

You will notice that Patrick Holford emphasises food allergies because he routinely recommends food allergy and intolerance tests, tests for nutritional deficiencies, hair mineral analysis, restrictive diets and mega-supplementation. However, he does rely upon Wakefield for the scientific underpinning of many of these entrepreneurial opportunities.

Dr Andrew Wakefield, in a now controversial study, published in the Lancet in February 1998, of 60 autistic children with gastrointestinal symptoms, found much greater incidences of intestinal lesions than in non-autistic children with similar digestive problems. Over 90 per cent of autistic children showed clinical evidence of chronic inflammation of the small and large intestine as a result of infection, at levels greater than six times that found in non-autistic children with inflammatory bowel disease [5].

Despite a concerted effort to discredit Wakefield's research, recent studies are confirming the link between autism, digestive problems, immune system abnormalities and the MMR vaccine. Wakefield's own research has shown that, in a group of 15 autistic children versus healthy children, there is clear evidence of immune dysfunction [6]. Three studies have shown measles antibodies in the central nervous system, with the potential to damage both brain and gut. [7;8;9]

Now, I know that there are times when Patrick Holford relies upon news reports rather than troubling to read the scientific papers so I recommend Brian Deer for a very readable summary of The MMR-autism scare and Wakefield's role in it.

Keen-eyed readers will have noticed that Patrick Holford refers to 60 children in the Feb. 1998 Lancet paper when there were 12 but he repeatedly has problems with reporting numbers accurately (and here) so we should overlook that. What we should not overlook is that this paper has been so discredited that it should be left to moulder in a quiet grave and referred to in hushed tones as an example of what can go horribly wrong in research and publication.

The Patients and Methods section of the Lancet paper claims:

12 children, consecutively referred to the department of paediatric gastroenterology with a history of a pervasive developmental disorder with loss of acquired skills and intestinal symptoms (diarrhoea, abdominal pain, bloating and food intolerance), were investigated.

However, most of these children were (through their parents) potential parties in a law-suit against vaccine manufacturers (by the publication of the paper 10 had Legal Aid to sue which meant that public funds were meeting their legal costs). Nor had Wakefield disclosed his conflict of interest arising from the substantial fees he would collect as an expert witness in the litigation that would rely upon his research findings (around £500,000); further, he did not disclose that he had patents for potentially competitive products.

Partly because of Wakefield and this paper, the rules of disclosure are very different now, in most journals. The money and the law-suit may seem murky, but what about the science?

Brian Deer's summary is an excellent guide to the goal-post shifting. Wakefield had claimed that 8 out of 12 [66.6%] of the children had received MMR within 14 days of symptoms and that the onset of symptoms was rapid and dramatic. However, expert witnesses who were recruited to confirm the MMR-autism link reported that the median time to the onset of symptoms among the children in the law-suit was 1.1 years, while Wakefield had claimed a median time of only 6.3 days.

So, the argument had to change. The emergence of autistic disorders after MMR wasn't rapid and dramatic, but delayed and insidious.

What about that scary-sounding ileal-lymphoid-nodular hyperplasia that so impresses Patrick Holford? Wasn't this a new, terrifying, malign finding that must mean something? Well, no. It turns out that the swelling of the glands, near the end of the small intestine and close to the appendix is a generally benign finding in children that has been known about for some time. It has nothing to do with inflammatory bowel disease.

But what about the autistic enterocolitis? Patrick Holford is concerned about the chronic inflammation that scourged the large and small intestines of the children in Wakefield's studies. He still refers to autistic enterocolitis in his books and articles; especially those promoting the need for a restrictive diet that should be supervised by one of his nutritional therapists who will also recommend a gut-healing programme and extensive supplementation. He also emphasises that the children have inflammation arising from infection because he is a staunch advocate of anti-fungal medications for children with these compromised guts.

Patrick Holford cleaves to his belief in this chronic inflammation despite the fact that Wakefield's colleagues have withdrawn their support for his research and retracted the publication on which Patrick Holford relies. Patrick Holford still promotes this idea although one of Wakefield's collaborators and co-authors, Walker-Smith, has admitted that most of the children did not show signs of inflammation and that there were no unusual findings in the children's colons.

So Patrick Holford still relies upon Wakefield's work although it has been known for some time that he was wrong about the rapid emergence of behavioural symptoms after MMR; wrong about the significance of ileal-nymphoid-nodular hyperplasia; and wrong about the autistic enterocolitis. Of course, many of Patrick Holford's recommendations for the treatment of autistic children and his remarkable claims that he can "bring them back" like so many latter-day Lazarus depends upon the validity of Wakefield's research.

But what about those measles antibodies in the cerebro-spinal fluid and the gut tissue of the children Wakefield examined? Whatever significant problems there may be with the rest of his work, surely this is the crux of the matter. That is Part 2.

But, for now, it may be worth pondering the idea of just what would make Patrick Holford give up his belief in the 'science' that underpins so much of his own treatment recommendations. What would make him update his many books and websites to at least acknowledge that this has gone far beyond "he says, she says" and it is now acknowledged that this science is discredited? So discredited that a lawyer for the US Govt. Health and Human Services Dept. recently made this remarkable comment in his concluding statements for the first part of the Autism Omnibus hearings in the US. The MMR-autism case has no plausible or verifiable science to support it.

It's at best speculation, idle speculation. Now, at worst--at worst--it's a contrivance. It's a contrivance that's been developed and articulated and promoted by its chief proponent, and that's Andrew Wakefield. He promoted it for financial gain. Either way it's not science.
pgs 28-9: Day 12 Transcript of Cedillo v. Secretary of Health and Human Services (pdf)

Mike Stanton of Action for Autism has some remarkably robust view on Patrick Holford and his opinions on vaccination, MMR, autism and treatments.

Related posts
Patrick Holford and Dr Andrew Wakefield's Discredited Findings: Part 2
Kevin Leitch on Andrew Wakefield and the death of the MMR debacle and Justice for Katie
Mike Stanton on Patrick Holford and his unusual views on vaccination, MMR and autism
Patrick Holford Claims Remarkable Benefits for Homeopathic Vaccinations
Dr Crippen on the remarkable cost-savings that Patrick Holford could offer the NHS: Pay £6.99 to say "no" to cancer
Holford Watch: Holford believes Secretin is "Worth considering" as an autism treatment; however, there is no evidence that this treatment is effective and
Holford is sceptical about off-label prescribing, but thinks that secretin for autism is "Worth considering"
Patrick Holford alias Doctor Knock aka Holt Senior

Image information: 1. Mass Vaccination Ouch!, 2. Double ouch, double vaccination, 3. Polio outbreak campaign, 4. 065 Norwich Historic Plaque (Green)

Created with fd's Flickr Toys Mosaic.

Eczema, Asthma, Allergy Links and News

2007-06-26T15:52:00.000+01:00

Gotham thugs and a forgotten benefit of vaccination Similar historical oddities may be found in speech as well as comics. I have elderly relatives who still say, "Harder to get rid of than the measles" or "It follows you around like the measles". P.G. Wodehouse has several quotations about measles:

Boyhood, like measles, is one of those complaints which a man should catch young and have done with, for when it comes in middle life it is apt to be serious.

Interactions between breast-feeding, parental atopy, and sex on development of asthma and atopy An intriguing paper that I havered about mentioning but the results are too thought-provoking to ignore. There is an extensive observation and research history which reports both that breast-feeding protects against allergy and asthma and that it increases the risk. This study looked at 1037 children from a 1972–1973 New Zealand birth cohort: the authors report that whether breast-feeding carries an increased risk for atopy and asthma for a child depends on their gender and the family history of the disease.

Breast-fed boys had a 63% increased risk of atopy by age 13 years, and those with atopic mothers had a 95% increased risk but neither of these reached a recognised significance value.

Breast-fed boys with atopic fathers had a significantly increased risk for atopy of 639% when compared with those who were not breast-fed. However, breast-feeding did not increase the risk for atopy among boys with atopic mothers.

For girls, the risk of atopy at age 13 years was not affected by breastfeeding, maternal atopy, or paternal atopy alone. However, breast-fed girls with atopic mothers had a 213% increased risk when compared with those who were not breast-fed. Breast-feeding did not have a reportable effect in girls with atopic fathers.

The authors report that the findings need to be replicated in larger cohorts. They comment that the findings have implications for how other researchers design and report trials of asthma and atopy epidemiology. the findings may also indicate some useful questions for clinicians although it is difficult to assess their practical significance at present.

For clinicians, it may be important to inquire about the history of breast-feeding in the context of assessing risk factors for the development of asthma and allergy.

However… breast-feeding is to be encouraged for its numerous other benefits.

The authors suggest that it is possible that the mechanism of action is the level of oestrogen in the mother's milk; however, like their other findings, this awaits further work and confirmation by others.

Eczema gene may predict asthma medication needs in children and young adults Asthma frequently co-exists with dermatitis or eczema. Previous research has suggested that it is possible that filaggrin (FLG) mutations can impair the formation of skin barriers and strongly predispose to childhood skin complaints such as eczema and atopic dermatitis. Mukhopoadhyay and fellow researchers report that this FLG status might identify asthma patients with severe disease who frequently need to use reliever medication.

Filaggrin (FLG) status influences controller and reliever medication requirements in children and young adults with asthma...

If skin barriers play a key role in preventing sensitization in asthma, a greater entry of allergens through a poorly formed epidermal barrier may speed up or intensify the activation of the immunologic changes of asthma.

The team evaluated the role of two FLG null alleles in asthma by assaying 874 patients in Scotland. They discovered that more of the patients with these markers were treated in accordance with the BTS recommendations for greater asthma severity (steps 3 and 4). 40% of those with the FLG null carriers were receiving treatment that implies greater asthma severity as compared with 23% of those who had wild-type FLG status.

The authors conclude:

An understanding of the possible relationships between filaggrin gene defects, a TH2-dominant cytokine response, and asthma could begin to test the exciting hypothesis that primary prevention strategies for asthma and allergy may be more cost-effective for genotype-stratified populations.

It would be interesting to know how much more development is needed before this becomes a recognised and affordable test at (say) secondary care levels. Nonetheless, it is interesting research and is further weight towards the argument that it is past time to abandon the idea of asthma as a single disease concept.

Paediatric Grand Rounds Wants Your Post, Please

2007-06-26T12:04:00.000+01:00

Yes, it is out with the begging bowl, as I shamelessly rattle the post collection bag and ask you for your contributions to Paediatric Grand Rounds. As you can see from the magazine cover, we are open to conventional and more off-beat topics.

The next edition of the PGR will be hosted right here at Breath Spa. Please send along your contributions (a little note as to why it appealed to you would be helpful):

breathDOTspaATgooglemailDOTcom

And please do this by Saturday June 30, allowing for the fact that I am in a much earlier timezone than people in the US.

Clark Bartram is looking for hosts for future PGRs. You can consult both the hosting schedule and earlier editions in the Paediatric Grand Rounds archive.

For more information about the image used in the illustration (from Tedsblog), click on it or visit the detail on Flickr.

Echinacea and Selenium Lack Efficacy for Colds and Asthma

2007-06-25T09:22:00.000+01:00

Echinacea promoted as cold preventer and treatment. Stories about the new Lancet review of echinacea are abundant in the general media; e.g., the Daily Mail trumpets that Scientists confirm echinacea halves the risk of catching winter sniffles. It is a little dispiriting that the Daily Mail coverage is more informative than the BBC's; the former is explicit that this isn't a new study but a review of previous studies.

A review shows that taking supplements of the plant, also known as purple coneflower, can cut the chances of catching a cold by more than half.

When used as a treatment it reduces the length of a cold by one and a-half days on average...

The review, which combines the results of 14 previous studies, should finally give the seal of approval to the remedy.

I have to say that I thought the recent negative studies and reviews of echinacea guaranteed it a quiet grave but it is now the echinacea zombie. There is a Cochrane Systematic Review of echinacea for preventing and treating the common cold.

Echinacea preparations tested in clinical trials differ greatly. There is some evidence that preparations based on the aerial parts of Echinacea purpurea might be effective for the early treatment of colds in adults but results are not fully consistent. Beneficial effects of other Echinacea preparations, and for preventative purposes might exist but have not been shown in independently replicated, rigorous randomized trials.

The Lancet provides an analysis of 1,600 patients pooled from 14 previously published studies but the criteria for their inclusion differ from those used by the Cochrane review: as ever, if there are questions about the methodologies of those studies then it can invalidate the meaningfulness of the pooled results.

The authors acknowledge that the analysis indicates that echinacea is less effective against rhinovirus than other cold viruses which would limits its usefulness because rhinovirus is the most common cold virus. They further acknowledge that there is no standardisation of the echinacea used in the studies that they include; beyond that, the studies included people who were taking Vitamin C, rosemary, thyme and other combinations.

It is difficult to understand why this new review is promoted as if it has completely reversed the Cochrane conclusions and those of previous reviews but it has afforded an opportunity for several asinine remarks on breakfast television and possibly makes some of the faithful feel smug that they stood by their nostrum even when science said that it was useless but now science has vindicated it. I don't have a strong feeling on the matter; I just wish that if the story has to be covered, it is presented with an appropriate amount of detail. E.g., there are some theoretical concerns about the safey of echinacea pollen for people with pollen and ragwort allergies and the use of echinacea (unspecified type) with paracetamol. Just because preparations are available over the counter or in a healthfood shop doesn't mean that they don't have known contraindications.

Selenium supplements are not helpful in asthma: however, there is no coverage so far in british media which seems to prefer a good news flow about supplements. People with asthma are reported to have lower-than-normal blood and dietary levels of a number of minerals, including selenium. The authors conducted a randomised, double blind, placebo-controlled trial of selenium supplementation; the participants were 197 adults with asthma, the majority of whom (75%) reported inhaled steroid use at baseline. The study ran for 24 weeks. There was a 48% increase in plasma selenium between baseline and end of trial for those people in the active treatment group but no change in the placebo group. However, there were no clinical effects associated with selenium supplementation for this group. The take-away message is that selenium supplementation is not likely to be a useful public health strategy for mitigating mild-to-moderate asthma in adults.

Plasma selenium levels in pregnant women and neonates relates to wheeze but not asthma in young children. Reduced dietary selenium intake has been linked to the development of asthma. In another UK study involving selenium:

[t]he selenium status of mothers during early pregnancy, and neonates is associated with early childhood wheezing but not asthma or atopic sensitization, furthermore, this association is absent by the age of 5 years.

There may be many contributory factors involved in the development of asthma; however it doesn't seem as if low levels of plasma/dietary selenium, independent of other factors, is a significant one.

Asthma, Misunderstood and Misdiagnosed: Interesting Initial Study Results

2007-06-21T17:04:00.000+01:00

An estimated 1 in 6 New Zealanders has a diagnosis of asthma. For some time there have been concerns that asthma is misdiagnosed and over-diagnosed: Asthma: A Multi-Headed Hydra or Misunderstood Genus. So, in research terms, it seemed sensible to use hospitals in New Zealand as a testing-ground for a study to evaluate new tests that promise a more accurate assessment of the patient than was previously practical.

Investigators needed to explore how well patients tolerate the tests and whether or not the tests were both specific and sensitive enough to provide reliable information that would guide a clinician as to whether a diagnosis of asthma was appropriate or not; and whether they were under-treating or over-treating the patient. Initial results on the first 50 patients have been reported at a professional meeting and suggest that misdiagnosis for another condition that mimics asthma is common (the study has yet to be completed, written-up and submitted for peer-review).

A Lancet editorial forms the bulk of the hydra discussion.

[P]erhaps, asthma as a symptom is really only the clinical manifestation of several distinct diseases. As Martinez explains, until the 19th century fever was regarded as a disease and maybe in 20, 30, or 50 years' time we will look back at asthma in the same way.

Other researchers speculate that the simplest explanation for the different phenotypes of asthma is that they are different time points in the progression of a single pathology, that of airway inflammation. People's progress along the timeline reflects their genetic predisposition and vulnerability to various triggers.

Leading asthma researchers, Professors Robin Taylor (University of Otago, New Zealand), Peter Gibson (John Hunter Hospital, Australia) and Ian Pavord (University of Leicester, England) have designed and validated this series of new tests that may provide useful data for considering those issues. They are running several tests:they check for allergies; run a sputum analysis; measure exhaled Nitric Oxide (a measure of inflammation); and perform a lung and airways scan. In the March Thorax australasian meeting, they reported preliminary findings that 50% of the adults to date have a condition that mimics asthma, rather than asthma.

TV New Zealand covers the story and offers a short, interesting video of one woman's experience with the tests.

Lynette Kingsbury has used inhalers for 10 years. She says she has had a lot of similar symptoms to asthma, such as wheezing and shortness of breath.

However the tests have cleared up years of doubt.

Kingsbury's tests showed she had been suffering from allergies and her inhalers had been a waste of time.

Damage to the lower airways during childhood or adolescence when they are more vulnerable to damage may lead to symptoms which may mimic asthma. It seems possible that a significant proportion of people are who being treated for asthma because of a chronic cough, wheeze or chest tightness, may have other inflammatory conditions which respond better to more appropriate medications. In some people, it seems as if they have long-standing, chronic infections that are the cause of their symptoms but these are amenable to the appropriate antibiotics rather than asthma medications that have a very different mechanism of action.

It looks as if well-targeted, specific tests such as expired nitric oxide measurement, sputum analysis and CT scans can differentiate between asthma, chronic infections and damaged airways. A more accurate diagnosis allows for better treatment with more appropriate medication and contribute to a better quality of life.

Dr Jeff Garrett, the local branch president of the Thoracic Society, has been quoted in a number of interviews about the study.

Half of the patients who've been labelled as asthmatic who've come along to the clinic and have been enrolled in the study to date, have had other conditions which have mimicked asthma.

Based on these findings it may well be that as many as half the people who've been labelled as having asthma may well have another sort of inflammatory airways disorder.

The challenge for the Thoracic Society will be to evaluate ways of transferring the results of tests undertaken in the laboratory into the clinical work place. The results of the studies currently being conducted in our leading hospitals in New Zealand will hopefully give us more direction.

It is fascinating research that promises to have a substantial impact on the diagnosis and management of asthma and chronic airways disease: it is important that this is written-up as quickly as practical. The financial considerations are significant for the health systems of many countries. There are potentially significant improvements for the quality of life of many children and adults. Most of all, it promises to add some important data for considering the question of whether asthma is misunderstood, misdiagnosed and sometimes mis-treated.

For more information about the images used in the illustration, click on it or visit the detail on Flickr.

Patrick Holford Claims Remarkable Benefits for Homeopathic Vaccinations

2007-06-20T13:08:00.000+01:00

Bowel-whisperer Patrick Holford has some disturbing ideas about vaccination. If you pay a subscription to him, you can consult his special online reports on a number of topics. One of these reports is about vaccination. I'm accustomed to anti-vax denialism and general crankery but reading this report was like allowing my eyes to turn into two fists and pummel my brain.

I was slightly worried by Holford's introduction:

The orthodox view is that vaccinations are essential, save lives, have few down-sides and are responsible for the decrease in deaths from many infectious diseases.

These views are, however, highly questionable. One of the best reviews of the facts about immunisation is by Lynne McTaggart in the book, What Doctors Don't Tell You in which she explodes the myths surrounding vaccinations...

The content did nothing to alleviate my concerns and I have addressed a number of them previously, when discussing improvements in childhood mortality and morbidity because of vaccinations. Ignoring those issues for now, the concluding section was the one that disturbed me most.

Alternatives to vaccination
The alternatives to vaccination are to ensure that you or your child has a fighting fit immune system. There is no better way to confer immunity to an infant than breast feeding and, once weaned, ensuring an optimal intake of immune-boosting nutrients. Vitamin A, for example, offers protection against measles and probably polio.

In underdeveloped countries deaths from measles are virtually eliminated by ensuring an adequate intake of vitamin A. It is highly likely, although not yet proven, that a good all-round intake of immune-boosting vitamins, minerals, amino acids and essential fats can turn a potentially life-threatening virus into a mild and temporary illness...

Although less well researched, you may wish to investigate homoeopathic immunisations. In one study 18,000 children were successfully protected against meningitis with a homoeopathic remedy, without a single side-effect.

I've previously blogged about the issue of vaccination v. faith in vitamins as a prophylactic for preventable childhood illnesses. You will notice that there is no reference for the "highly likely although not yet proven" thought about the benefit of supplementation in the "underdeveloped countries" and that this assertion has not been tempered even in the light of the successful Measles Initiative vaccination programme in some of those same "underdeveloped countries".

Even in the UK, with comparatively adequate nutrition and abundant medical services, the BBC cited some alarming statistics from the medical newspaper Pulse related to measles:

lowering levels of immunity meant as many as 12% of children and 20% of adults could be hospitalised if infected by measles.

Does a hospitalisation rate of 12% of children and 20% of adults sound like a "mild and temporary illness"?

Holford is a firm believer (without supporting evidence) in the value of an immune boosting diet as a prophylactic or staunch defence against childhood illnesses. A hat-tip to Orac for giving me a polite response for the next time somebody tells me that a product/diet 'supports the immune system'. Orac scrutinises the advertising claims for a herbal remedy that used to claim that it prevented colds until advertising regulations downgraded that claim to 'helps to support the immune system'. Orac hazards a guess that the people who make these products:

don't know an antibody from a T-lymphocyte, but now they're pushing a "boost the immune system" claim. What specific aspect of the immune system are they boosting? Cell-mediated immunity? What cell type? Neutrophils, T-lymphocytes, B-lymphocytes, natural killer cells?

Despite charging for access to this report, Holford does not detail the aspects of the immune system that he believes to be 'boosted' by supplements and diet or why they would be adequate.

As for Holford's claim about homeopathic vaccinations, I have searched everywhere for that study but I can't find it. It would even have helped if he had been more specific about the specific meningitis organism. If you can identify this study, I would be very grateful. Although Holford is not a homeopath, he might be interested to learn that leading homeopath, Dr Peter Fisher, recently argued that homeopaths approve of childhood vaccinations. Fisher even said that Hahnemann would have approved of the vaccination programme (albeit in a very convoluted fashion).

Other issues aside, that subscription is looking like even worse value than I thought. Holford recites the tired anti-vax rhetoric that does not become any more true for the number of times it is cited. You would need very good evidence to argue otherwise, as Holford attempts, but that evidence isn't there. Please discuss vaccination with your paediatrican, Health Visitor, GP and other trusted sources. As a bowel-whisperer Holford may have a touching faith in the "highly likely although not yet proven" and "less well researched" value of an 'immune-boosting' supplementation programme and homeopathic vaccines but the consensus of medical and scientific evidence is in favour of the vaccination programme for children for whom they are not contra-indicated.

Click on the image to read the details on Flickr.

Eczema and Allergy Links and News

2007-06-20T08:58:00.000+01:00

When I attended the Allergy Show last week I picked up an information leaflet about allergies in small children that is starting to be distributed in pharmacies and similar places. The slogans that aroused an Amen Corner response were:

Allergy care starts with early diagnosis

Early testing prevent allergy symptoms becoming severe

The irritating thing was that there is no follow-up relevant website. The leaflet was supported by an educational grant from Pharmacia Diagnostics. It is not surprising that the leaflet contained the summary advice:

Find out to what your child is allergic!

Only a doctor can confirm the diagnosis of allergies, using skin testing or appropriate blood tests.

Go and visit your doctor for an allergy test!

Your child will be tested to identify the substances (allergens) causing the allergy.

The appropriate treatment (eviction, immunotherapy, medication...) can begin to help your child feel much better!

I have no idea what eviction is in this context. I would also say that the leaflet places too much reliance on the value of tests: there is no substitute for a good clinical history taken by an appropriately qualified and experienced clinician. Tests are valuable for confirming a diagnosis, they are rarely sufficient by themselves. So, early diagnosis and appropriate management are good things but parents should be wary of the over-stated clinical significance of some tests. If you're concerned about your child, you might contact one of the allergy charities to ask for details of your best NHS referral that you can discuss with your GP.

Action Against Allergy Parent Workshops These workshops are for the parents of allergic children: the venue is St Thomas' Hospital in central London. The workshops will be led by consultants, dietitians and nurses from the deservedly-renowned Children's Allergy Service at the Evelina Children's Hospital based at St Thomas'. The sessions are scheduled for 2 hours and will take place in the afternoon or evening. The anticipated cost is £10 per participant. The first 3 workshops are planned for autumn 2007: they focus on eczema, asthma and food allergy. Register at their website to be kept up-to-date with developments. These sound very promising; I hope that they fulfil their potential and meet the needs of parents.

Do lifestyle choices such as frequent washing, harsh soap and biological washing powders contribute to eczema and allergies? Specialists from Great Ormond St Hospital argue that too much washing with strong soaps, the use of exfoliants and other such skin care products, and even biological washing powders (as promoted for low-temperature, energy-saving laundry) may be stripping away the skin's outer protective layer, resulting in allergic responses to allergens in susceptible individuals. There was a nicely specialist argument in the original paper about the role of Langerhans cells that raises some interesting questions about the widely-accepted hygiene-hypothesis. However, the take-home message for parents is that you might be well advised to avoid using harsh soaps or exfoliating products with your children and switch to less abrasive emollients. I would also add that you may have to give up low-temperature laundry and use gentler washing-aids. Take advice from suitable sources such as the National Eczema Society and GP.

Apply corticosteroid creams only once daily for atopic eczema Atopic eczema affects many adults and up to 20% of children; the health costs are comparable to diabetes and asthma. Corticosteroid creams are a mainstay of treament: usually applied twice or more a day, recent studies indicate that once a day is adequate.

Children's Health, Asthma, Eczema and Allergy Links and News

2007-06-19T15:26:00.000+01:00

Blossom - Stop Allergies Spoiling Childhood A campaign to reduce the social exclusion of children with allergies. The members promise reliable and regularly updated information, advice resources and support. The site is a little light on content at present but it will be interesting to see how this site and campaign mature.

Food allergies reported to have increased 12-fold in australian children since 1995 It's a gallimaufrey of numbers and it is hard to avoid the speculation that some of the increase reflects increasing awareness of the symptoms of allergies and a greater readiness by parents to request allergy testing for their children. Nonetheless, it is worth looking at the paediatric trends in food allergy in a community-based allergy practice.

Omegas 3 and 6 exposure from early life do not influence asthma, eczema or atopy levels at age 5 Last year, there was some surprise when the Childhood Asthma Prevention Study failed to show any protective benefits for omega-3 fatty acid supplementation and restriction of dietary omega-6 fatty acids in children. The interventions did not prevent asthma, eczema, or atopy at age 5 years. This related observational analysis of the cohort, adds further weight to the negative findings of the randomised controlled trial. Both the study and trial report that modifying or supplementing dietary polyunsaturated fatty acids in early childhood does not protect against atopy and asthma in children.

Wales has one allergy specialist to deal with an estimated one million people with allergies This is an interesting story made ridiculous by the implication that the excellent Dr Paul William, a clinical immunologist at Cardiff University, is solely responsible for the secondary/tertiary care of these people and yet he has only an 8 month waiting-list. The rest of the article is pretty run-of-the-mill except for some gratuitous and inappropriate advice at the end about garlic, lavender, chamomile, eucalyptus, royal jelly and honey.

Backlash against bipolar diagnoses in children After recent enthusiasm for this diagnosis, it was inevitable that it would fall into disfavour once people considered the wisdom/experienced the reality of prescribing antipsychotic medication to very young children. The article offers a recent overview of the issues and mentions that Biederman's insight was correct as it is now acknowledged that bipolar disorder can strike before puberty. However, the 2001 guidelines also state the difficulties in validating a diagnosis in children is challenging because normal children are prone to be irritable, aggressive, or giddy. It does contain some details of the death of a child who may have been over-medicated by her parents in an attempt to wrest control of her behaviour.

Paediatric Grand Rounds 2:5 Is Up!

2007-06-17T08:13:00.001+01:00

Paediatric Grand Rounds 2:5 is up, courtesy of Christian Bachmann of Med Journal Watch. Bachmann has 30 years of experience as a science and medical writer and editor and it shows in the elegant way that he has put the PGR together, assembling the posts into appropriate sections and commenting on them thoughtfully.

PGR is back into the usual swing of controversial ethical issues and childhood concerns like handing out icecream. Neonatal Doc considers the ethics of resuscitation for the very premature and for babies with Downs Syndrome. New to me, the Black Breastfeeding Blog reports that there are racial/ethnic disparities in the breastfeeding advice given to african-american and white women.

One of the unexpected consequences of sucessful treatment for previously fatal childhood illnesses is that they age out of the paediatric domain where they have got best care, but sometimes there isn't the transitioning care available for them in adult healthcare.

Sandy is always an educational read. For this PGR she offers a post how public health messages may be pushing young girls towards anorexia.

The Autism Omnibus hearings have extensive coverage in several blogs. We also hear about recent awareness and fund-raising campaigns for primary immunodeficiency and neurofibromatosis.

All this and more for some of the odd and interesting about paediatric healthcare. I commend PGR to you.

Dr. Clark Bartram is looking for hosts for future PGRs. You can consult both the hosting schedule and earlier editions in the Paediatric Grand Rounds archive.

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