Special report: MMR - Case notes

It has been the most highly-charged, emotive health issue of recent years: is the triple vaccine for measles, mumps and rubella (MMR) safe or is it responsible for autism and bowel disorders? The controversy that captured headlines four years ago has been reignited by the appearance before the General Medical Council of Dr Andrew Wakefield and two colleagues who claimed there was a link between the MMR vaccine and these conditions.

Dr Wakefield and Professors John Walker-Smith and Simon Murch have denied charges of serious misconduct over their research into MMR. Dr Wakefield has been accused of taking blood samples from children at a birthday party and offering them money, of being paid for advising solicitors on legal action by parents over the MMR jab and of ordering medical investigations 'without the requisite paediatric qualifications'.

Their paper, published in The Lancet in 1998, incurred the wrath of the medical establishment, caused a political furore and led to a fall in vaccination levels from 90 per cent to around 79 per cent in the UK. The World Health Organisation (WHO) insists that 95 per cent immunisation is needed to achieve what it calls 'herd immunity' to prevent serious outbreaks of infectious diseases.

The controversy's political dimension was amplified when then Prime Minister Tony Blair refused to say whether his son Leo had been given the vaccination - a refusal interpreted in sections of the media as sowing doubt about its safety. However, then Chancellor of the Exchequer Gordon Brown revealed that his son, John, was vaccinated, while London mayor Ken Livingstone declared, in 2002, that his child would not be given the triple vaccine.

For parents who feel that their children were damaged by the vaccine, Dr Wakefield and colleagues are 'martyrs' and victims of a witchhunt, and the real culprits are the politicians, the medical establishment and pharmaceutical companies that have ganged up to smother the truth about MMR.

No evidence of link

But for Dr David Elliman, consultant in community child health at Islington Primary Care Trust, the scientific evidence is 'in favour of there being no link'. He says, 'Even a highly critical review two years ago came to the conclusion that there was no credible evidence of involvement of MMR in autism or Crohn's disease (a disease of the bowel).'

He says that uptake has risen to around 85 per cent nationally, but that it ranges from 63 to 90 per cent across boroughs of London where immunisation levels generally vary because of 'a highly mobile' and often disadvantaged population.

Dr Mary Ramsay, consultant epidemiologist for the Health Protection Agency (HPA), says, 'It is encouraging that vaccine uptake is rising but we still need higher levels of coverage. It takes time to rebuild parental confidence. The media focus has been on supposed health implications of the vaccine rather than on the disease it is preventing.'

Dr Elliman points out that the GMC hearing is 'looking at the ethics and financial aspects of the research, not at whether its conclusions were right'. He adds, 'People confuse the two and may think that if the GMC finds Andrew Wakefield not guilty that means there is a link between MMR and autism.'

If Dr Wakefield is struck off, it will not allay the concerns of parents who believe that their child has been damaged by the vaccine or who fear that their child could be harmed if they are immunised.

Damage payments

Jackie Fletcher is convinced that her son, Robert, now 15 and severely handicapped, was a victim of the MMR vaccine. Shortly after he was injected, he suffered a series of major seizures which cause neurological damage.

Mrs Fletcher runs JABS - Justice Awareness and Basic Support - which campaigns on behalf of vaccine-damaged children and their families. She says that while the Government insists that there is no link between MMR and a range of conditions in many children - some of whom have died after immunisation - it has still awarded vaccine damage payments to families.

She says, 'We are not anti-vaccine, we are anti-damage. We want a recognition from the Government that these children have been severely damaged and a care package in place to help families support their children throughout their lives.'

The cost of these care packages should be borne not by the taxpayer, but by the pharmaceutical industry which, she feels, is making money both out of vaccines and medication, such as anti-convulsants and anti-inflammatories, prescribed to cope with its after-effects.

The medical establishment is concerned that a renewed focus on the issue during the GMC hearing, scheduled to last until October, may raise concerns and affect uptake. A short joint statement, signed by all the main medical bodies and released to coincide with the start of the GMC hearing, insisted that 'the MMR triple vaccine protects the health of children'.

Measles epidemic

Signatories to the statement include the Community Practitioners and Health Visitors' Association, now part of Unite - the merged 'super' union encompassing the former transport union and Amicus.

Cheryll Adams, lead professional officer of Unite, says that health visitors support the MMR vaccine and adds, 'The last time there was a measles epidemic in Britain in 1988, there were 86,000 reported cases, resulting in 16 deaths. We must avoid a repetition of this scale of outbreak. Vaccination is the best defence.'

Dr Wakefield and other doctors, including some GPs who shared his concerns about the MMR vaccine, suggested that children could be vaccinated for each of these diseases separately. However, Dr Elliman says that there is no evidence of the safety of the single vaccines, that administering them was more complicated and that more children were likely to slip through the net and not be immunised properly.

Cheryll Adams agrees, 'There is a risk that parents would not bring their children for all the single dose injections. The delay between single dose injections would give a longer period of time when children would be unprotected.'

During a measles outbreak in 2002, a south London nursery found itself thrust into the limelight over MMR. Two children at the Abacus day nursery in Streatham contracted measles during the Christmas holidays, not at the childcare facility. But remarks by a parent brought the press to the nursery, wrongly claiming it was the source of the outbreak.

The nursery's current manager Paris Petgrave, who was not there in 2002, says that while no one wants the spread of infectious diseases, least of all a nursery, the choice about vaccination rests with parents. She is concerned that pregnant women are shielded from cases of rubella (German measles) as it can have serious effects on unborn babies.

Dr Ramsay thinks nurseries should promote MMR and encourage parents to report rash fever illness to them. She says, 'They should try to document the children's vaccine history so that if there is a suspected case they know who is at risk.' She says that measles is not a treatable infection and can be fatal or have long-lasting health implications, including the risk of a child contracting a form of encephalitis, an inflammation of the brain.

Whatever the outcome of the GMC hearing, the next figures for the uptake of the MMR vaccine will show what impact its deliberations have had on public opinion.

CASE STUDY: CHILDREN'S CENTRES PROMOTING VACCINATION

Ros Polding, assistant director of child and family health at the Halton and St Helens PCT in Lancashire, believes that children's centres and other early years settings can help spread awareness about the need for the MMR vaccination.

At the height of the controversy, MMR uptake in one ward in St Helens sunk to 58 per cent. Ms Polding launched a campaign under the heading, Dispelling the Myths about MMR, which involved vaccination parties in nurseries and children's centres, promotional boards in supermarkets, visits to playgroups and the spread of information to non-clinical Sure Start staff.

She says, 'Uptake increased to 72 per cent before it started to go up nationally. Immunisation needs to be done more opportunistically by clinicians. We are often not child-friendly enough.'

Ms Polding carried out research into why parents did not get their children vaccinated and concluded that it was not just concerns over MMR but was connected to levels of deprivation.

Parents felt undermined by the attitude of medical professionals and uneasy about the environment where vaccinations take place.