The MMRautism hypothesis gone but not forgotten

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The MMR-autism hypothesisgone but not forgotten

• Richard Roberts
• NPHS VPDP

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Acknowledgements

• Liz Miller, Natasha Crowcroft, Mary Ramsay,
  Joanna White, Emma Savage (Health Protection
  Agency )
• Simon Cottrell (NPHS VPDP)
• Daniel Thomas, Rhian Davey (NPHS)

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Aims

• Review development of the MMR-autism hypothesis
  and others
• Review unprotected cohorts
• Current policy on catch-up and follow-up
• Discussion

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Success of measles immunisation
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Healthy children dont die of measles

• Netherlands outbreak 1999/2000
• About 3250 cases reported, 97 cases in
  unvaccinated religious community children
• 20 serious complications 5 encephalitis
  (1/650)
• 3 children died
• Irish outbreak 2000
• Nearly 1500 cases notified, mainly from Dublin
  where MMR coverage was only 74
• 3 children died

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MMR allegations
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MMR allegations
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Role of the media

• Parents have been misled by balance of media
  reporting (Report from Cardiff School of
  Journalism, Media and Cultural Studies)
• Equal weight given by media to pro and anti
  arguments
• Leading parents to believe that the scientific
  community is genuinely divided

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MMR Mythbusting
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Reviews of MMR safety (reautism)

• Evidence reviewed at each meeting of JCVI and
  also by Committee on Safety of Medicines
• Review in March 98 by ad hoc MRC expert panel of
  all published and unpublished studies by the
  Royal Free IBD Group
• Further review by MRC December 2001
• Review of alleged vaccine-damaged cases by expert
  panel convened by CSM
• Conference convened by American Academy of
  Pediatrics
• Report from the MMR Expert Group convened by
  Scottish Executive
• Report from Joint Committee on Health and
  Children of the Parliament of Ireland
• BMJ commissioned independent review published in
  Clinical Evidence
• WHO commissioned review by Global Advisory
  Committee on Vaccine Safety
• US Institute of Medicine Review of vaccines and
  autism 2004

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Summary of research on postulated link between
measles and IBD

• Measles virus is not present in the gut of IBD
  cases (7 papers (finding in first Wakefield
  paper shown to be false positive)
• Perinatal measles is not a risk factor for IBD (5
  papers)
• Measles vaccine does not case IBD (4 papers)
• Conclusion no evidence at all that measles
  virus is involved in IBD

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Results of epidemiological studies on MMR/autism
(www.mmrthefacts.nhs.uk)

• No increased risk of autism after MMR
• No ecological association between autism
  prevalence and use of MMR
• No evidence of a new MMR-associated autistic
  enterocolitis syndrome

• Onset after
• MMR?
• Ecological
• association?
• New clinical
• presentation?

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The Mirror 7 Feb 2002
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2005
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Mumps EW notified and confirmed 1994-2005
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Mumps
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Mumps cases by region 2005
3050
5710
EW provisional total for first half 2005
33,531
4450
2425
3453
2528
2088
2432
3593
3727
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Key features of current mumps outbreak

• National
• Predictable
• Preventable

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Mumps
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2015?
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Measles, mumps and rubella predictions

• Control of measles and rubella good
• Increase in mumps since 1998
• Initially older school age children
• 2003 universities/military entrants/prisons
• Increase in measles since 2002 in line with
  predictions
• Increase in rubella - When?
• Outbreaks of all three diseases inevitable in
  future with current MMR coverage

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MMR uptake at 2 and 5 years

• MMR by age 2
• 1st 85.0 (73.3 - 89.9)
• MMR by age 5
• 1st 89.3
• 2nd 75.3

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MMR Task Group report 2005
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MMR catch up (and follow up)
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Wales MMR catch up 2005

• Welsh Assembly Government policy direction,
  vaccine purchase and funding
• 100,000 doses to those aged 11-25 years of age
• School age use records to target 2 doses
• 18-25 one dose if not had any or uncertain
• Coordinated NPHS support
• Local Trust, LHB and practice implementation

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New policy - MMR recording

• Accurate recording of
• Change of consent
• Reason for failure to attend (code 2 or 3)
• RATIONALE further recall affected by coding
• Early data checking
• CHDs will send HV a monthly list of all children
  who have recently missed two MMR appointments
• HV to check it, correct as necessary and return
  within a month
• RATIONALE ensure offer made

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New policy - early follow up

• Follow up at 18 months
• CHD will send the named health visitor a
  quarterly list of all children reaching 18 months
  of age who have not received MMR
• HV to ensure accuracy against other records, and
  contact the parents of unimmunised children to
  offer discussion or immunisation. Return amended
  list within 3 months
• RATIONALE Parents opportunity to review decision
• Reset the missed 2 appointment flag
• HSW and CHDs will clear flag at age 3 years
• RATIONALE if missed appointments for no reason
  but not withdrawn consent this allows
  re-invitation for MMR pre-school

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New policy - key age follow up

• Follow up at 4½ years (school entry)
• CHD need to provide the named school nurse a
  quarterly list of all children reaching 4½ years
  of age who have not received two MMRs
• SN to ensure accuracy then contact the parents of
  children who have missed MMR to offer discussion
  or immunisation. Return amended list to the CHD
  within 3 months
• Secondary school entry
• School nurse to identify those consented but
  missing MMR and write to these parents

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School leaving / teenagers

• The opportunity of giving the Tetanus/Diphtheria/
  Polio (Td/IPV) booster vaccine (teenagers) must
  be used to offer MMR to those who have not
  received two doses
• (WHC (2005) 081)

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New policy Trusts required to audit

• Audit the CHS every six months to ensure a 100
  offer rate for MMR
• Audit quarterly returns from health visitors of
  amended 18 month lists
• Audit quarterly returns from health
  visitors/school nurses of amended 4½ year lists

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Discussion

• Are you positively encouraging parents to accept
  MMR?
• Do you follow up defaulters early?
• Do you review uptake at key ages to offer MMR
  again?
• Are you aware of recent WAG policy on follow up
  of defaulters?

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Measles
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