After Wakefield: Undoing a decade of damaging debate

From flickr user debsilver
It's said that you can't unring a bell

This article was co-written by Scott Gavura, Pharmacist. Cross-posted at his blog, Science-Based Pharmacy.

Immunization has transformed our lives. This single invention has prevented more Canadian deaths in the past 50 years than any other health intervention. Our parents and grandparents accepted illness and death from diseases like smallpox, diptheria, and polio as a fact of life. Mass vaccination completely eradicated smallpox, which had been killing one in seven children. Public health campaigns have also eliminated diptheria, and reduced the incidence of pertussis, tetanus, measles, rubella and mumps to near zero.

The sickest and most vulnerable in society rely on the immunization of others to protect them from vaccine-preventable disease. When immunization rates are high, it’s much less likely a virus or bacterium will be carried and transmitted from person to person. But when vaccination rates drop, diseases can reemerge in the population again. Measles is currently endemic in the United Kingdom, after vaccination rates dropped below 80%. When diptheria immunization dropped in Russia and Ukraine in the early 1990’s, there were over 100,000 cases with 1,200 deaths. In Nigeria in 2001, unfounded fears of the polio vaccine led to a drop in vaccinations, an re-emergence of infection, and the spread of polio to ten other countries.

There are many reasons cited for refusing vaccination, ranging from fears of needles right through to bizarre conspiracy theories. But one reason that has experienced a dramatic upsurge over the past decade or so has been the fear that vaccines cause autism.

The connection between autism and vaccines, in particular the measles, mumps, rubella (MMR) vaccine, has its roots in a paper published by Andrew Wakefield in 1998 in the medical journal The Lancet. This link has already been completely and thoroughly debunked – there is no evidence to substantiate this connection. But over the past two weeks, the full extent of the deception propagated by Wakefield was revealed. The British Medical Journal has a series of articles from journalist Brian Deer (part 1, part 2), who spent years digging into the facts behind Wakefield, his research, and the Lancet paper:

Today, the BMJ calls the fraud over medicine’s missing link: the research linking MMR with autism. Published in a five-page Lancet paper in February 1998, it triggered media campaigns which sent vaccination rates plummeting, and caused the most intractable health alarm in a generation.

Wakefield’s original paper (now retracted) attempted to link gastrointestinal symptoms and regressive autism in 12 children to the administration of the MMR vaccine. Last year Wakefield was stripped of his medical license for unethical behaviour, including undeclared conflicts of interest. The most recent revelations demonstrate that it wasn’t just sloppy research – it was fraud. Unbelievably, some groups still hold Wakefield up as some sort of martyr, but now we have the facts:

  • Three of the 9 children said to have autism didn’t have autism at all.
  • The paper claimed all 12 children were normal, before administration of the vaccine. In fact, 5 had developmental delays that were detected prior to the administration of the vaccine.
  • Behavioural symptoms in some children were claimed in the paper as being closely related to the vaccine administration, but documentation showed otherwise.
  • What were initially determined to be “unremarkable” colon pathology reports were changed to “non-specific colitis” after a secondary review.
  • Parents were recruited for the “study” by anti-vaccinationists.
  • The study was designed and funded to support future litigation.

The accompanying editorial pulls no punches:

Who perpetrated this fraud? There is no doubt that it was Wakefield. Is it possible that he was wrong, but not dishonest: that he was so incompetent that he was unable to fairly describe the project, or to report even one of the 12 children’s cases accurately? No.

However, the public health implications of Wakefield’s actions continue to reverberate:

Meanwhile the damage to public health continues, fuelled by unbalanced media reporting and an ineffective response from government, researchers, journals, and the medical profession. Although vaccination rates in the United Kingdom have recovered slightly from their 80% low in 2003-4,19 they are still below the 95% level recommended by the World Health Organization to ensure herd immunity. In 2008, for the first time in 14 years, measles was declared endemic in England and Wales. Hundreds of thousands of children in the UK are currently unprotected as a result of the scare, and the battle to restore parents’ trust in the vaccine is ongoing.

The Impact in Canada

Damage wasn’t limited to the United Kingdom. It seems to have measurably affected Canadian perceptions of the safety of the MMR vaccine. An interesting paper by Neil Seeman and Mary Seeman recently appeared in the Journal of Participatory Medicine (JPM): Autism and the Measles, Mumps, and Rubella Vaccine: Need to Communicate a Health Study Retraction to Patients. The paper gives a depressing snapshot of public perceptions of MMR vaccine safety. They randomly polled over 5000 internet users from Canada:

Participants were asked to respond to the question, “Do you think the measles, mumps and rubella vaccine causes autism in healthy young children?” The response options were limited to: “yes”, “no”, “don’t know/unsure” and “skip”. Respondents were asked their age (under 18, 18-30, 31-50, 51-65, over 65) and their sex.

The results are not positive.

Figure One
Click to enlarge

Despite Wakefield’s study being retracted shortly before the survey was conducted, 65% of women and 72% of men surveyed were unsure whether MMR causes autism. Astonishingly, all age groups of men and women gave more “yes” than “no” replies, with the sole exception of women between ages 18 and 50. While samples of Canadians don’t show uptake to be as poor as the survey might suggest, uptake appears to be below optimal levels – so the results are concerning.

The authors put the responsibility on health professionals (i.e., physicians) to clarify the facts about the safety, particularly in light of the retraction of the Wakefield paper. From our perspective that doesn’t nearly go far enough. After all, most physicians do recommend vaccination already, yet many Canadians seem unconvinced. For example, Canadian data demonstrates that consultation with a family physician is strongly associated with annual flu shots.

Much of the public’s understanding has been shaped by a persistent habit of “false balance” in the popular press, who for more that a decade have messaged that there is a scientific controversy about the vaccine’s safety. Presenting what was felt to be a balanced perspective on what is understood to be a “debate” instead resulted in a manufactroversy.

Consider the timeline:

  • 1998 – Wakefield paper published
  • 1998 – UK Medical Research Council say no evidence of link
  • 1999 – Two new papers in The Lancet identify no relationship between MMR vaccine and autism
  • 2002-2004 – More data published finding no evidence of link
  • 2004 – Brian Deer’s research documents Wakefield had not disclosed conflicts of interest in his paper
  • 2004 – The Lancet announces a partial retraction of the Wakefield paper due to undisclosed conflicts of interest
  • 2005 – More data from Japan and the UK – no link show
  • 2010 – Wakefield paper fully retracted by The Lancet
  • 2010 – Andrew Wakefield loses medical license in the UK, determined to have shown “callous disregard” for suffering of children
  • 2011 – Extent of fraud perpetuated by Wakefield exposed in the BMJ

After exhaustive evaluation from multiple, independent groups, the MMR vaccine has consistently been show to be safe and effective, with no evidence it is associated with autism. Yet even as the BMJ articles receive extensive media coverage, the false balance continues. For example, CBC’s national radio news followed a story about the BMJ papers with a statement from a Canadian naturopath, linking asthma with vaccination (the data say otherwise).

The key messages? Spread them far and wide:

  • The original link between the MMR vaccine and autism was based on fraudulent research. Subsequent investigation has repeatedly shown no relationship.
  • From a scientific perspective, there is no controversy about the safety of the MMR vaccine.
  • There has never been any credible evidence that the MMR vaccine, or any vaccine, causes autism.

As Dr. Paul Offit has been quoted as saying, you can’t unring a bell. So what’s going to stop this bell from ringing? Perhaps an awareness of its fraudulent basis will do more to change perceptions than a decade of scientific investigation has been able to achieve. For the sake of population health, we hope so.

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