Here, Dr Donegan gives her views on measles. When I read it, I couldn’t resist giving my opinions on her article. I have to say, I wasn’t particularly impressed.
Unvaccinated children are being excluded from Swiss schools; private clinics are running out of single measles jabs……What are they panicking about? Heart attacks, strokes, paralysis? No, they are talking about measles – a regular childhood illness that most children sail through.
Most, but not all. It is those that don’t “sail through” measles that we need to be concerned about. The fact that the majority of children won’t die or suffer serious complications from vaccine-preventable infectious diseases is hardly comfort for those children (and adults) and their families who are less fortunate.
Yes, there are about 170 000 measles deaths per years world wide (2008 figures), but, as the World Health Organisation (WHO) states:
“The overwhelming majority (more than 95%)of measles deaths occur in countries with low per capita incomes and weak health infrastructures…Most measles deaths are caused by complications associated with the diseases” and
“Severe measles is more likely among poorly nourished young children, especially those with insufficient vitamin A, or whose immune systems have been weakened by HIV/AIDS or other diseases…. As high as 10% of measles cases result in death among populations with high levels of malnutrition and lack of adequate health care”1
Are children in Europe and the United States suffering from malnutrition?
Does your child have HIV/AIDS?
If not, why all the fuss?
The case fatality rate is higher in those who are malnourished (not to mention the issues around crowding, lack of access to medical care, and so on). But not all deaths occur in people who are malnourished, people who have immune system problems, or people who can’t easily access (for example) antibiotics to address secondary pneumonia. Some deaths do occur in otherwise healthy people, with adequate diets, living in developed countries, with access to good medical care. Donegan seems to ignore this and refer only to where the majority of deaths occur. Why the fuss? Because while the mortality rate may not be 10%, a mortality rate of, say, 1 in 5,000 is still worth worrying about – and doing something about. (Not to mention the other complications of measles.)
In England & Wales the death rate declined from over 1 100 per million population under the age of 15 years in the mid nineteenth century to a level of virtually zero by the mid 1960s.
Virtually zero? I suppose it depends on your point of view. There were 800 deaths from measles in the 1960s: HPA. The population was around 50 million.
The incidence of measles cases also declined. Great credit was given to the introduction of measles vaccine in 1968 for the lowering of measles notifications in the UK, however, the uptake was only 33% in that year. The level that did not get above 55% until 19805 when incidence was already well down.
You can take a look for yourself and see the relationship between incidence and vaccination. The above HPA link shows notifications and deaths. You can see vaccine uptake here: vaccine uptake (HPA). Eagle-eyed readers might have spotted that the level of vaccination got to 46% within a year and 51% within just two years. They might be wondering at this point why Donegan chose 55% as a cut-off point. I know I am. I’m also left wondering quite what Donegan’s argument is. She complains that credit is given to the measles vaccine for lowering measles notifications in spite of uptake only being 33% in the first year. Perhaps she thinks that a vaccination rate of 33% will have no effect at all? Well, it seems obvious to me that even relatively low vaccine uptake of 33% should reduce the number of notifications. Not quite as much as 55%, but you’d certainly expect it to have some effect. Perhaps Donegan thinks that something else was responsible for the reduction in notifications – however, she does not mention another candidate.
If you look at the 12 year period from 1968 to 1979, measles notifications averaged 150,200 a year – down from an average of 409,600 notifications in the previous 12 year period (1956-1967). From 1968 to 1979, measles uptake averaged 48.5% (again, eagle-eyed readers will have spotted that this figure is closer to the magical 55% than it is the 33% that Donegan refers to disdainfully). The reduction in notifications was (by my reckoning – feel free to check my maths) 63%. Which is pretty good. But maybe Donegan’s right. Maybe, even though she hasn’t mentioned a single alternative candidate to measles vaccination – let alone a plausible one – measles notifications would have reduced anyway. Maybe there was a trend towards lower notifications that nobody has noticed. While measles notifications were considerably lower in the 12 years following the introduction of the measles vaccine compared with the 12 years prior to its introduction, if you compare the period from 1944-55 with the period from 1956-67 you can see a relatively small increase from 392,000 to 409,600 (a 4.5% increase).
So. No alternative mechanism proposed, and no sign of a trend in reduction of notifications prior to the introduction of a vaccine. I think this graph makes it pretty clear that the credit for the reduction in notifications can be fairly given to measles vaccination.
Measles outbreaks in unimmunised people tend to be mild in those who do not have underlying medical conditions. In communities which generally do not immunise, the attack rate in infants less than one year of age is low because of protection by the superior maternal antibodies derived from natural infection compared to those derived from vaccination 6. Almost without exception, deaths occur in those with underlying medical conditions or poor nutrition or in those religious groups who refuse timely medical care when complications occur. 7
So, measles in the unimmunised tends to be mild? And maternal antibodies protect infants <12 months of age? I’m baffled by the first reference given as it doesn’t seem to be relevant (there are three reference for the first part of this paragraph and two for the last sentence). The second reference is to a report I can’t find online. The third reference is to a 1988 paper which includes an estimate that maternal antibodies from vaccinated mothers will decline by 8 months rather than the 11 months expected for naturally infected mothers. This does indicate that protection from maternal antibodies of naturally infected mothers lasts slightly longer than that from vaccinated mothers. Of course, in order to pass on these antibodies from natural infection, mothers would have to be infected with measles and risk the well-known complications of the disease. Some would not live to have children. A more recent paper estimated that maternal antibodies last for around 1 month for children of vaccinated mothers and around 2-4 months for children of naturally infected mothers: http://www.bmj.com/content/340/bmj.c1626.full. As for measles tending to be mild in the unvaccinated, well, we’ll get to that shortly.
Donegan claims that “almost without exception” deaths occur in those with underlying medical conditions or poor nutrition or those who refuse timely medical care. The mortality rate is higher in those groups. I might take issue with “almost without exception” though. Let’s take a look at one of Donegan’s own references: http://www.ncbi.nlm.nih.gov/pubmed/8483622 Of the five female deaths, three had underlying illnesses and two did not, so 40% of these deaths occurred in otherwise healthy individuals. The authors state that only one of the children who died received medical care. However, the overall mortality rate was 1.2% (far higher than the 1 in 5000 the Green Book states and the commonly cited range of 2500-5000). Even if we ignored the five deaths in those who did not receive medical care, the mortality rate would be 0.2% – 1 in 500, or ten times that Green Book figure. Donegan’s other reference for this claim is this: http://www.ncbi.nlm.nih.gov/pubmed/3124197 where the case fatality rate was even higher, at 2.2%. Donegan hasn’t demonstrated that most deaths from measles occur in those with underlying medical conditions, poor nutrition or lack of medical care (she has linked to papers that discuss measles deaths in specific communities rather than all measles deaths). She’s demonstrated that the case fatality rate is higher in those groups. She’s also, inadvertently, pointed out that unvaccinated groups are more likely to catch measles and more likely to die from it. The factors Donegan refers to at least partly explain why there is a high case fatality rate (but not the fact that there are fatalities at all) but the authors of the first paper are cautious enough to say that they appear to have contributed to that high rate – they certainly don’t claim that they are the only factors.
In order to support her claim that deaths from measles occur mostly in those with underlying conditions or poor nutrition or no medical care, Donegan has cited two papers that show high mortality rates in the unvaccinated. The first paper I mentioned was titled High attack rates and case fatality during a measles outbreak in groups with religious exemption to vaccination. Here’s a line from the paper that Donegan doesn’t mention: “Measles spread rapidly in this group, sparing few susceptible individuals.” If only there were some way to stop measles spreading rapidly and to reduce mortality from this vaccine-preventable infectious disease…
MMR vaccination started in the UK in 1988 with a second dose added in 1996. Nevertheless, in the first five months of 2011 almost 500 cases of measles have been notified.
Amazing. Despite two doses of MMR being scheduled, we had hundreds of cases of measles in just five months. I wonder if there is any possible explanation for these hundreds of cases of measles occurring in spite of vaccination. Maybe something happened that reduced uptake of the vaccine and meant there were more people unprotected against measles than might otherwise have been the case? Ah.
Donegan’s article doesn’t end there (sadly). If you want to click the link I provided at the start of this post and see for yourself if it gets any better then feel free. Here’s a taster: The infection is not your enemy but your friend. Holistic. Detoxifying. Vitamin A. A quote from a mother: “Sadly he did not get measles but I will try to find someone with it.” There are no systems for monitoring adverse events. The Department of Health and GPs don’t offer ‘advocating a healthy lifestyle’ as an alternative to vaccination. Homeopathy.