The Pharmaceutical Journal
Vol 268 No 7190 p397-401
23 March 2002

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Letters to the Editor

MMR

Are we missing the point?

From Mrs M. A. Goldney, MRPharmS

I agree with comments last week regarding public concerns over the MMR vaccine made by Paul Shattock and Annette Morant (PJ, 16 March, p362). But I would like to raise another point. MMR has received a bad press and, rightly or wrongly, the public have lost confidence in its use. The attempts by the Department of Health to reassure the public are not working and nor will they. As a pharmacist, I am lucky to be able to put the reports at the root of this problem into perspective and be logical and rational about it. But as a mother of toddlers, even I am questioning whether I want to take the risk of immunising my children in this way.

My point is this: prospective studies to prove the links of the vaccine with autism and bowel problems would be extremely difficult, if not impossible; retrospective studies would, I suspect, throw up more problems than they would solve. Without further positive data supporting the vaccine, it is impossible to reassure anyone.

Surely, then, it is far better that the Department listens to public demand and supports the supply of single vaccines rather than risk, at best, increasing numbers of confused and concerned parents and, at worst, a measles epidemic.

My friends with small children ask me as a pharmacist what I would do. I cannot really reassure them. But I would be far happier to give advice if I knew they had a choice.

Melissa Goldney
Bromsgrove, Worcestershire

Overwhelming evidence for safety of MMR

From Mr A. R. Cox, MRPharmS

Compared with other pharmaceutical products, vaccines require higher standards of safety because they are usually given to healthy people to prevent disease in the individual and in society in general. However, no vaccine is completely safe and, in a society with high vaccination levels, the morbidity and mortality of the prevented diseases is often forgotten. In the mid 1970s people's anxieties about pertussis vaccine led to falling vaccination rates against whooping cough, leading to the preventable deaths of children. Casting doubt on the safety of a vaccine is easy, but overcoming doubts and fears spread by the media is more difficult.

Sadly, two recent letters further increase the doubts and fears about MMR's safety, without bringing any new information to substantiate their positions. In the first Paul Shattock implies (PJ, 16 March, p362) that the evidence demonstrating safety of the MMR vaccine is equivalent to the evidence supporting homoeopathy. He cites the work of Wakefield¹ showing the presence of some genetic material (RNA) from measles virus in the guts of a selected group of children. However, no inference can be made as to the origin of the measles virus and the prevalence of persistent measles virus infection in the guts of the general population is unknown. The editorial that accompanied Wakefield's article clearly states that it would be wrong to jump to the conclusion that MMR causes either development disorders or colitis. Even Wakefield's co-worker Professor O'Leary has acknowledged this, stating "the research did not set out to investigate the role of MMR in the development of either bowel disease or developmental disorder, and no conclusions about such a role could, or should be, drawn from our findings". John Walker-Smith, the senior clinician who worked with Dr Wakefield, still feels able to support the MMR vaccine.²

Mr Shattock asks pharmacists to study all the evidence, but ignores the epidemiological evidence that supports MMR's safety. Most recently, a population study looking at over 500 autistic children in five health districts showed no significant differences in the rates of bowel problems or autism in children who had received MMR before concern about their development compared with those who had received MMR only after concern had been expressed or who had never received MMR.³ No evidence was found for a "new variant" form of autism. Kaye et al⁴ also showed no correlation between MMR and autism, the rise in autism between 1988 and 1993 occurring with constant levels of MMR uptake. DeWilde et al⁵ hypothesised that the behavioural decline of autistic children would be reflected in increased consultations with the GP. They found autistic children had significantly higher levels of consultations than controls before MMR administration and no changes in consultation between autistic children and controls were seen after MMR. They suggest the report of an effect of MMR on the behaviour of a child who was subsequently diagnosed with autism may be the result of selection or recall bias.

In the second letter, Annette Morant (PJ, 16 March, p362) cites rises in autism in the United States, which has been using MMR for 30 years, and seeks reassurance that there is no correlation between the two. A Californian study of children born in the years 1980 to 1994 showed no correlation between MMR and a rising incidence of autism.⁶

Both correspondents also question the safety of giving three vaccines in combination, yet evidence suggests that multiple vaccines do not overwhelm young infants' immune systems. In fact, infants have the ability to deal with up to 10,000 antigens at a time and modern vaccination schedules actually expose children to fewer antigens now than they did in the 1960s.⁷

It is true that our Code of Ethics does state that pharmacists should not recommend any therapy "where they have any reason to doubt its safety or quality"; however safety is relative. It is a logical fallacy that one can prove a negative and for that reason no study will ever prove the complete safety of any vaccine or drug. The dangers of MMR are based on an unproven biological mechanism and conjecture about the dangers of multiple vaccinations, whereas measles kills between 1 in 2,500 to 1 in 5,000 children. Pharmacists should therefore feel able to reassure patients of the overwhelming body of evidence supporting the safety of MMR.

Anthony Cox
West Midlands Centre for Adverse Drug Reaction Reporting
City Hospital NHS Trust,
Birmingham

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