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The Pharmaceutical Journal Vol 268 No 7191 465-468
6 April 2002

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Childhood vaccination

MMR vaccine is safe and effective

From Dr J. Smith, FRPharmS

Not surprisingly, concern about safety of MMR vaccine and criticism of the Government’s stance on this issue has spread from the news media to The Journal’s letters pages. Pharmacists, with their science knowledge base, and as one of the most readily accessible health professionals at the heart of most communities, are well placed to provide advice and explanation to parents. However, if they are to discharge this important public health role, it is vital that pharmacists fully understand the issues.

Criticism of the MMR programme has been inaccurate and misleading, and has unnecessarily alarmed parents. The findings of a limited number of small observational and immunological studies claiming to show a link with autism and bowel disease, mostly with flawed methodology, have been misinterpreted and given undue prominence. And the evidence from many large-scale epidemiological studies and world-wide clinical experience has been consistently ignored or undervalued by critics. Pharmacists are in a position to help correct this. I will not rehearse the extensive evidence to support the safety of MMR vaccine; the facts are set out in detail on
the Department of Health website www.doh.gov.uk/publich.htm). Pharmacists should study this to familiarise themselves with the evidence. They should in particular be aware that:

The MMR programme has been hugely successful in reducing the incidence of measles and its serious complications, and has virtually eliminated congenital rubella. These gains are seriously at risk if parents lose confidence in MMR.
All the safety evidence has been considered independently and exhaustively by the Joint Committee on Vaccination and Immunisation (JCVI) and the Committee on Safety of Medicines (CSM). On all the evidence available, the JCVI and the CSM have agreed that there is no link between MMR and autism. This view is supported by the World Health Organization, by the All Party Parliamentary Group on Primary Care and Public Health, and by all the major UK health organisations, including the Royal Pharmaceutical Society.
There is no evidence whatsoever to support the efficacy or safety of giving MMR as three separate vaccines, but there is evidence that this may reduce uptake and increase the prevalence of measles. No country in the world recommends this approach. MMR vaccine is used in more than 30 European countries, and in the United States, Canada, Australia and New Zealand. In total, over 90 countries around the world use MMR, and more than 500 million doses of MMR have been given since the mid-1970s.

I know from my own experience during the pertussis scare in the 1970s just how difficult these decisions are for parents. But irrational concerns about the safety of pertussis vaccine led to many children being left unprotected and a resurgence of the illness. The arguments for single vaccines instead of MMR are equally irrational. We all want to do what we judge to be best for our children, and that is parents’ responsibility. But it is the Government’s responsibility to ensure that the care and treatment it makes available is the best possible. The evidence shows that MMR remains the safest way to protect children against these three potentially serious diseases and that separate vaccines would put children’s health and lives at greater risk.

Pharmacists have played a valuable part in supporting immunisation campaigns for many years. Community pharmacists’ role in providing wider public health advice and services has grown rapidly. The Government has signalled its intention to build on these achievements in “Pharmacy in the future” and, more recently, in its response to the House of Commons Health Select Committee’s second report on public health. I would therefore urge pharmacists to respond to current anxieties by drawing on the solid evidence base to provide accurate, well-informed advice to parents on the safety and effectiveness of MMR vaccine

Jim Smith
Chief Pharmaceutical Officer, Department of Health

Need for independent clinical research

From Mrs J. Loch, MRPharmS

nthony Cox states that “infants have the ability to deal with up to 10,000 antigens at a time” (PJ, 23 March, p398). I assume he is referring to the supposition put forward by Paul Offit and colleagues earlier this year.1 It has also been supposed that in a susceptible group of children, persistent measles infection in the bowel can lead to immune dysregulation and damage to the bowel, allowing neurotoxic agents to enter the brain leading to permanent developmental and cognitive defects. It has also been supposed that in combination, vaccines may interact, or have synergistic effects on each other, leading to unexpected events in the body. Interestingly, it is becoming apparent that the average time for developing subacute sclerosing panencephalitis following vaccination is significantly shorter than following infection with wild measles.
It is dangerous to assume that suppositions are correct because we wish them to be, or to assume that they are not correct because we feel uncomfortable. Mr Cox also states that “pharmacists should therefore feel able to reassure patients of the overwhelming body of evidence supporting the safety of MMR”.
I am sure that the vaccine is safe for the majority of children. But what of the group that Professor Walker-Smith refers to: “A highly selected group of children with developmental disorder (many with regressive autism) exists, who have an unusual gastrointestinal abnormality.”2
Mr Cox seems extremely impressed by the epidemiological studies that have been carried out in recent years. In fact, when studied carefully, these reflect the confusion about the MMR issue. By the author’s own admission, the most recent study was flawed, because the data used were incomplete.
The only sensible way forward is for the Department of Health to commission independent clinical research into the children who have developed regressive autism and/or bowel disease following vaccination with MMR. We need to establish exactly why they have reacted in this way, whether their illnesses are amenable to treatment, and if so what can be done for them to improve their long-term prognoses.
Most professionals (myself included) are in favour of safe vaccination. It is possible that in the course of these investigations, an alternative factor may be revealed as the cause of the illnesses. If not, we need urgently to identify an “at risk” group of children for whom MMR is not safe. The devastation suffered by the families concerned is immeasurable and the financial cost to the state is rising alarmingly day by day.

Julie Loch
Cardiff

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