As a Keralite living and working in another country in a medical field related to infections, I have closely watched the latest public outcry and controversies over the measles rubella vaccination campaign launched in October 2017 by Kerala Government as part of the national campaign, for eliminating measles and to prevent congenital rubella syndrome and rubella. At the heart of the matter is simply human nature which is conditioned to blow perceived danger out of proportion and ignore the abstract benefits. Vaccination in many ways is a victim of its own success. Devastating effects of once rampant diseases have slowly faded from public memory. This, coupled with the fact that vaccination involves administration of vaccines to apparently healthy individuals to prevent potential diseases, contributes to concerns about vaccine safety.
Hence it is only natural that public attention has, in some cases, shifted to side effects from vaccination rather than its advantages, which are mostly abstract. Common reasons why patients hesitate or refuse vaccines for themselves or their children include doubts over vaccine safety, belief that past shots and subsequent illness are connected, religious or moral opposition, the expectation that they or their children will never encounter diseases, and lack of trust in governmental or scientific authorities. This has been a problem worldwide and in some instances, unsubstantiated scares about the safety of certain vaccines > have led to decline in vaccination rates and outbreaks of disease. When reports of vaccine adverse effects (often premature and unverified) reach patients, it is natural that they worry about its safety. Healthcare professionals should respect their concerns, but at the same time they have a moral obligation to guide patients to evidence-based data to relieve misconceptions and fears about vaccination.
For instance, the hypothetical connection between MMR use and Autism Spectrum Disorders (ASDs) originated with the ‘Wakefield paper’ published in The Lancet in 1998, which studied ASD in a group of 12 British children, eight of whom manifested autism after they suffered gastrointestinal disorders that the researchers ascribed to MMR shots. Public outcry and opposition to vaccination began because of concerns of vaccine-autism link. MMR use dropped in several countries, with subsequent measles and mumps outbreaks. The study's results have never been replicated, nearly all of its authors retracted its conclusions, the paper was fully retracted from the Lancet in 2010 and Wakefield ended up being discredited and losing his General Medical Council licence to practise.
Before vaccination was introduced, there were hundreds of thousands of measles cases during the epidemic years, but the disease was effectively eradicated in the UK after the MMR vaccine was introduced, except a handful of cases in travellers. However, in 2012 there were more than 2,000 cases of measles in England and Wales - the highest figures for two decades. Similar figures continued in 2013. Most of the measles cases were in children and teenagers between the ages of 10 and 18, according to British health officials. In that age group, vaccination rates had dropped below 50 percent in some parts of England after the Wakefield paper was published, mainly the result of parents refusing to vaccinate their children after the above safety scare that was later proved to be fraudulent.
This is just one example which shows that in every major case of reduction in vaccination, there has followed a period of disease resurgence and mortality rate. Immunization rates have increased since then. While recent uptake of MMR in England has been more than 90 percent for the first dose and more than 85 percent for the preschool booster, overall coverage remains below the 95 percent World Health Organization target. In the Washington State of USA there are laws that require parents to get counseling and/or a signature from a licensed healthcare provider to receive an exemption from vaccination.
Countries like India too should consider adding parental counseling by healthcare provider as a legal requirement for obtaining exemptions to vaccination requirements. Studies show that a tougher legislative approach is needed in some instances because parents have been confused by anti-vaccine messages from powerful lobbying groups that make educational efforts increasingly difficult. To improve the immunization services, we need to keep using existing and emerging user-friendly technologies to improve the delivery and capture of information on vaccination services, continue to engage in dialogue with the media and use effective communication techniques to convey evidence based messages about vaccines to address safety concerns of the public.
Education and training of healthcare professionals is also key. In addition, as we focus on our own programme, we should not forget that we are part of a greater project encompassing the whole world. Just like smallpox has been eradicated, polio, measles, rubella and hepatitis B are all lining up for elimination and eventual eradication. Let us hope that we can learn from past successes and mistakes from around the world and work together to eradicate these preventable diseases, once and for all. We ought to keep reminding ourselves and others about the millions of lives immunization has saved and keep fighting the good fight for it.
(The author is a consultant microbiologist in the UK).
Wakefield falsified facts, ‘cherry-picked’ data
In 1998, Andrew Wakefield and 12 colleagues published a case series in the Lancet, suggesting that measles, mumps, and rubella (MMR) vaccine may predispose to behavioral regression and pervasive developmental disorder in children. Despite the small sample size, the uncontrolled design, and the speculative nature of the conclusions, the paper received wide publicity, and MMR vaccination rates dropped, triggered by parental concern about the risk of autism after vaccination. But soon epidemiological studies refuted the link between MMR vaccination and autism. The logic that MMR vaccine may trigger autism was also questioned because a temporal link between the two is almost predestined: both events, by design (MMR vaccine) or definition (autism), occur in early childhood.
The next episode in the saga was a short retraction of the interpretation of the original data by 10 of the 12 co-authors of the paper. According to the retraction, "no causal link was established between MMR vaccine and autism as the data were insufficient". This was accompanied by an admission by the Lancet that Wakefield et al had failed to disclose financial interests (Wakefield had been funded by lawyers who had been engaged by parents in lawsuits against vaccine-producing companies). However, the Lancet exonerated Wakefield and his colleagues from charges of ethical violations and scientific misconduct.
The Lancet completely retracted the Wakefield et al paper in February 2010, admitting that several elements in the paper were incorrect, contrary to the findings of the earlier investigation. Wakefield et al were held guilty of ethical violations (they had conducted invasive investigations on the children without obtaining the necessary ethical clearances) and scientific misrepresentation (they reported that their sampling was consecutive when, in fact, it was selective).
The final episode in the saga is the revelation that Wakefield et al were guilty of deliberate fraud (they picked and chose data that suited their case; they falsified facts). The British Medical Journal has published a series of articles on the exposure of the fraud, which appears to have taken place for financial gain. The exposé was a result of journalistic investigation, rather than academic vigilance followed by the institution of corrective measures. The Wakefield case was exposed by journalist Brian Deer.
(Source: The Indian Journal of Psychiatry).
