Wednesday, August 22, 2012

Fraud, greed, and lies: the origin of the anti-vaccination movement

Recently, a good friend of mine had her first baby. He is now in the process of getting his first vaccinations, and so my friend has suddenly become exposed to the anti-vaccination movement. She is, understandably, worried: should she or should she not vaccinate? Is there any truth to what the anti-vaccination proponents are saying? Why are vaccines suddenly seen as the worst thing you could do to your child? How did all this start? Who is Andrew Wakefield?

Vaccination is the administration of an antigenic - antibody generating - material, that is, something that stimulates the immune system to produce antibodies against it.  These antibodies can recognize and neutralize this foreign material, marking it for destruction by other immune cells.  By using material from a killed or weakened pathogen (or sometimes even just a portion of it), the immune system can be primed to deal with this invader.  When an infection then occurs sometime in the future, the immune system is ready to deal with it quickly and efficiently, at the least reducing the severity of the symptoms or the duration of the disease, and in many cases even completely preventing it from developing.

While objections to vaccines have been around as long as vaccines themselves, the beginning of the modern anti-vaccination movement can be pinpointed with accuracy: the publication of a paper in the British medical journal Lancet in February of 1998. It was written by a laboratory researcher, Dr Andrew Wakefield, and co-authored by a dozen other doctors, reporting on the cases of 12 anonymous children with developmental disorders who were admitted to a paediatric bowel unit at the Royal Free hospital in Hampstead, north London, between July 1996 and February 1997. The publication of the paper was followed by a press release and further publicity that received huge media attention and began the concerted attack on vaccinations.

In a 20 minute video press release, later criticised as "science by press conference", Wakefield called for a suspension of the triple measles, mumps, and rubella (MMR) vaccine, suggesting it was linked to the development of autism in children.  A furore around vaccines exploded in the media and on the internet, where the anti-vaccine argument gained significant traction.  The uncritical or at times blatantly irresponsible reporting by numerous media outlets, as well as television talk shows giving vaccine opponents a platform, led to a widespread (and mostly unchallenged) spread of this idea.  As a consequence, vaccination rates - of not just MMR, but all vaccines - in the next decade have fallen, a trend that is world-wide:
  • In the UK, official figures for 2003/2004 have shown a drop in MMR vaccinations to 80%  from a peak coverage of 92% in 1995-6 (just before Wakefield's publication).
  • The American Council on Science and Health warned that childhood vaccination rates against measles, mumps, and rubella (MMR) fell nearly 3 percentage points in 2009 from the year before: almost 10 percent of American children are not vaccinated from serious diseases, which include diphtheria, tetanus, and pertussis.
  • In 2010, Medicare in Australia reports that  the number of youngsters not fully immunised in the national program has doubled over the past five years, and the number of children whose parents have registered as conscientious objectors to vaccinations also rose by 68 per cent in that time.
  • Also in 2010, Switzerland had one of the lowest immunization rates in Europe, with only 71% of children receiving the recommended two doses of the measles vaccine. 
This drop in vaccination is not without consequence.   Herd immunity is the resistance to the spread of infectious disease in a group because susceptible members are few, making transmission from an infected member unlikely.  To achieve herd immunity, 75% to 95% of people must be vaccinated.  The exact level of vaccination required depends on the disease, how contagious it is, and how it is transmitted.  In many places the level of vaccination has dropped below the herd immunity threshold, and the effects are painfully apparent: the incidence of fully preventable (and once considered vanquished!) diseases such as measles and pertussis (whooping cough) is on the rise.

California reported a whooping cough epidemic in 2010 that may have been the worst in 50 years.  Measles is on the rise in Europe, and England reported a 10-fold rise in cases in 2011.  Most recently, southern Alberta, Canada, is in the grips of an ugly whooping cough outbreak.  So is New Zealand.

These diseases are not innocuous.  Measles complications can affect one in 15 children infected, and can include bronchitis, seizures, and encephalitis (which may be fatal). Pertussis is especially risky for very young babies - newborns under two months have a 1 in 100 change of dying from the disease, and children up to 12 months have a 1 in 200 chance. Serious complications can include pneumonia, encephalopathy, seizures, and failure to thrive. Pertussis can also cause severe paroxysm-induced cerebral hypoxia and apnea (when the baby is coughing so hard it can't breathe and the brain is starved of oxygen, leading to brain damage).

So what is the science behind Wakefield's claim to stop vaccinating children?

An investigation into Wakefield's research by the journalist Brian Deer, of the Sunday Times, revealed an astounding scandal. As Wakefield was warning parents to avoid MMR, and publishing papers claiming a link between vaccines and autism, he was in fact being funded by Richard Barr, a solicitor hoping to raise a class action law suit against the company manufacturing the vaccine. After an initial payment of £55,000, Barr paid Wakefield out of the UK legal aid fund (run to give poorer people access to justice) a sum eventually totalling £435,643 (more than eight times Wakefield's reported annual salary).

The children themselves, supposedly routine patients at the Royal Free Hospital, turned out to have been recruited through MMR campaign groups, and their parents were contacts or clients of the lawyer Barr. In addition, nine months before the publication of the paper, Wakefield filed a series of patents, including one for a single - supposedly safer - measles vaccine, "which only stood any prospect of success if confidence in MMR was damaged."
None of these substantial conflicts of interest were reported in the paper, or declared to the journal Lancet.

The conflict of interest was just the beginning, as further investigation revealed worrying ethical issues as well.  Research on human subjects is strictly governed by national and international standards, including the Declaration of Helsinki which is a set of ethical principles regarding human experimentation developed for the medical community by the World Medical Association (WMA).  No reputable hospital review board would have endorsed Wakefield's proposed "fishing expedition" - which included a battery of invasive and distressing procedures like lumbar punctures and colonoscopies.  Without approval, however, no reputable medical journal would publish the findings.  So Wakefield simply lied in the paper, stating ethical approval had been obtained.

In addition, he showed further unethical behaviour by buying (for £5) blood from children at a birthday party, completely ignoring the inappropriateness of the setting. Later, he would go on to describe this event in a public forum, making a joke out of children fainting and vomiting, showing callous disregard for any distress or pain to the children.

As if the blatant conflict of interest, and the entirely unethical way this "research" was conducted wasn't enough, the actual data presented in the Lancet paper - the article that started the whole vaccination and autism debate - was in fact to a large degree manufactured by Wakefield himself.  In most of the 12 cases reported, the actual hospital and GP records differed to what was described in the Lancet.  The research paper claimed autism-like symptoms began within days of the vaccination, but in all cases but one such concerns were raised significantly before vaccination.  The majority of cases were presented in the Lancet as having an abnormal gut; hospital pathologists had previously declared them fully normal.

So, let's be clear: this supposed link between vaccines and autism was completely fabiracted by Wakefield in order to profit from the fallout. Numerous studies have tried to replicate his findings, but have always failed to find any link. A number of health authorities (including the American Academy of PediatricsCenters for Disease Control, the World Health Organization, and the Institute of Medicine of the National Academies), have reviewed all the available evidence, and every single time the conclusion is the same:

The body of epidemiological evidence does NOT support a causal relationship between the MMR vaccine and autism. 

More and more evidence piled up against the conclusions of Wakefield's paper, and slowly, the scientific record was put straight. First, in March of 2004, 10 out of the 12 authors of the original paper (one could not be contacted) published a formal retraction of the conclusions of the paper:
We wish to make it clear that in this paper no causal link was established between MMR vaccine and autism as the data were insufficient. However, the possibility of such a link was raised and consequent events have had major implications for public health. In view of this, we consider now is the appropriate time that we should together formally retract the interpretation placed upon these findings in the paper, according to precedent.
Then in February of 2010, the Lancet finally formally retracted the whole paper:
..., it has become clear that several elements of the 1998 paper by Wakefield et al. are incorrect, contrary to the findings of an earlier investigation. In particular, the claims in the original paper that children were “consecutively referred” and that investigations were “approved” by the local ethics committee have been proven to be false. Therefore we fully retract this paper from the published record.
This was in response to the results of an inquiry by the British General Medical Council, convened in July 2007. In a decision released almost three years later, the General Medical Council fitness to practice panel found Wakefield guilty of multiple instances of serious professional misconduct. The Panel states that he was dishonest and misleading, that he breached his duties, that he repeatedly breached fundamental principles of research medicine, that he failed to ensure that the factual information contained in the paper was true and accurate, that he was intentionally dishonest, irresponsible and misleading, and that his actions were contrary to the clinical interest of the patient, and an abuse of his position of trust as a medical practitioner. The Panel concluded that his conduct brought the medical profession into disrepute. Finally, on May 24th, 2010, he was struck off the UK medical register, revoking his license to practice medicine in the UK.

Every aspect of Dr Wakefield's claim has been disproven and discredited, numerous times over.  Yet the meme persists, possibly because it provides a simple explanation to a complex problem, provides and answer that so many parents desperately search for, and gives something to blame.  But the truth is: there is no link between vaccines and autism - there never was.  So vaccinate your kids!

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