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The MMR vaccine is intended to provide immunity to measles, mumps and rubella and it is a mixture of these three viruses in an attenuated form. The vaccine is given in two doses with the first given at 1 year of age. The second booster is given at 4 or 5 years of age, around the time a child starts school. This is another dose of the vaccine intended to induce immunity in the 5-10% of the population that do not develop immunity after the first dose. MMR was introduced in 1988 and has caused the number of confirmed cases of all these diseases to fall to an "all time low". The scientific consensus based on the evidence is that there is no link between MMR and autism. (NHS Choices, 2009)
In 1998 a report was published in the Lancet by Andrew Wakefield et al regarding bowel syndrome and developmental disorders with regards to the MMR vaccine. Since then there have been more developments and coverage in the media regarding the MMR vaccine and rates of MMR vaccine uptake has fallen. This SSU will discuss this in more detail.
1998 Lancet paper
In 1998 The Lancet published a paper written by Andrew Wakefield et al titled 'Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children'. It was a report on 12 children. The report stated that the parents or physicians of 8 of these children had behavioural problems linked with the timing of the MMR vaccine. The paper described a collection of bowel symptoms as well as biopsies and endoscopy findings (Wakefield would later dub 'autistic enterocolitis'). The paper recommended additional research into a possible link between this novel condition and MMR, stating that there was a real link between the bowel symptoms and autism. However the paper did not suggest any association between MMR and autism. (Wakefield et al, 1998)
During the press conference for the paper Wakefield suggested that he believe the use of single vaccines for MMR would be a prudent method until further research could be done and the MMR vaccine could be eliminated as an environmental trigger for the symptoms described in his report. (Press release from Royal Free Hospital, 1998)
This initial report did not generate the media attention that would be generated in 2001/2002. The Guardian and Independent newspapers mentioned the report on their front pages. The Daily Mail gave it a minor mention in the middle of the paper. In total there were only 122 articles mentioning the subject in all publications for the year of 1998 (Goldacre, 2008). However this was enough to create a reduction in the uptake of the MMR vaccine (Fig 1.1)
The media coverage resurged in 2001 and 2002 and reached its pinnacle in those years with total of 1,257 articles in 2002 (Goldacre, 2008).
Pinnacle of media coverage
In January 2001 Andrew Wakefield published a study in the journal 'Adverse drug reactions and toxicology review' claiming that the original safety checks on the MMR vaccine were conducted poorly and over an inadequate amount of time over 4 weeks. The department of health rejected these claims (BBC News, 2008).
In February 2002 Dr Wakefield and Professor John O'Leary, who was the director of pathology at Coombe Women's hospital in Dublin, published a paper in a journal named 'Molecular Pathology'. The study's aims were to discover if children with developmental disorders along with a bowel disorder also had the measles virus in their gut. The study examined 91 children with bowel disease and 70 healthy children. It found that 75 out of 91 children had the measles virus in their gut and only 5 out of 70 healthy children had the measles virus in their gut. Dr Wakefield and his colleagues did state that jumping to any conclusions about a causal link between the MMR vaccine and bowel disease or developmental disorders such as autism would be premature. He did theorise that the measles virus may act as a trigger in regards to problems with the immune system of the children (BBC News, 2008).
While Wakefield and his co-authors were fairly cautious with their statements it was enough to send the media into a flurry. Ben Goldacre describes this:
"The coverage rapidly began to deteriorate, in ways which now feel familiar and predictable. Emotive anecdotes from distressed parents were pitted against old men in corduroy with no media training. The Royal College of General Practitioners press office not only failed to speak clearly on the evidence, it also managed to dig up anti-MMR GPs for journalists who rang in asking for quotes. Newspapers and celebrities began to use the vaccine as an opportunity to attack the government and the health service, and of course it was the perfect story, with a charismatic maverick fighting against the system, a Galileo-like figure. There were elements of risk, of awful personal tragedy, and of course, the question of blame: whose fault was autism?" (Goldacre, 2008)
The content of the journalism surrounding this issue was subpar; it was mostly written by generalist reporters with no background in science or science reporting: Under 37% of reports in 2002 made mention of the evidence for the safety of the MMR vaccine. 11% mentioned that it is regarded as safe in 90 countries (Fig 1.2).
Another aspect of the coverage was regarding then Prime Minister Tony Blair's infant son Leo. Tony Blair was questioned on whether his son Leo had been given the MMR vaccine and the Prime Minister said that the vaccine was "safe enough for his son Leo". However he refused to explicitly state whether his son had been given the MMR vaccine on grounds of the privacy of his son (BBC News, 2002). While his right to privacy was not in question this refusal to reveal Leo Blair's vaccine record may well have done more harm than good. The public perception of the MMR vaccine may well have been damaged after the public saw the head of the government, the same government promoting the safety of the vaccine, refusing to clarify whether he trusted it enough to expose his own son to it. This layer of a perceived inconsistency between the message of the government and those running it will also have aided public mistrust. Leo Blair was mentioned in 32% of all coverage of the MMR story in 2002. Andrew Wakefield, the original author of the 1998 report was mentioned in 25% (Fig 1.2).
All in all the standard of reporting is best described in the following paragraph:
"While stories on GM food, or cloning, stood a good chance of being written by specialist science reporters, with stories on MMR their knowledge was deliberately sidelined, and 80% of the coverage was by generalist reporters. Suddenly we were getting comment and advice on complex matters of immunology and epidemiology from Nigella Lawson, Libby Purves, Suzanne Moore and Carol Vorderman, to name only a few. The anti-MMR lobby, meanwhile, developed a reputation for targeting generalist journalists, feeding them stories, and actively avoiding health or science correspondents."
Effect of the scare
The uptake of the MMR vaccine fell after the original 1998 Lancet article. It fell further in 2002 after the new statements and studies by Wakefield and his colleagues.
This was directly responsible for an upsurge in confirmed cases of mumps. This caused an epidemic in 2005, with over 43,000 confirmed cases of mumps in England and Wales (NHS Choices, 2009).
There was also an upsurge in confirmed cases of measles, with 1,413 in 2009 in England and Wales (compare this with 70 confirmed cases in 2001) (NHS Choices, 2010).
Role of the media in fighting back
While the media were a major component in the decline of MMR vaccine rates, parts of the media also helped fight back and restore public confidence, or at least part of it, in the vaccine.
In February 2004 an article in the Sunday Times written by Brian Deer revealed conflict of interest allegations in regard to Wakefield. It revealed that Wakefield had received funding from Legal Aid Board solicitors in the region of £55,000 (Deer, 2004). Deer raised further allegations in a BBC documentary in November 2004, stating that Wakefield had applied for a patent on a single dose vaccine that would rival MMR, and that he also knew of research from his own laboratory at the Royal Free Hospital that went against his own claims. Deer reported in the Sunday Times in 2006 that Wakefield had received £435,643 as well as expenses by trial lawyers that were working to prove that the MMR vaccine was dangerous. This funding was received from Legal Aid (Deer, 2006). In February 2009 Deer once again reported in the Sunday Times alleging that Wakefield had manipulated his data in his original 1998 paper in order to create a ink with autism (Deer, 2009). Wakefield denied this and lodged a complaint with the Press Complaints Commission which he later did not pursue.
Even if we were to pay no credence to the veracity of these claims they did damage the reputation and academic integrity of Wakefield severely. These revelations in the media were exposed to the public and altered their perception of Wakefield and as a result helped to restore public confidence in the vaccine, leading to a rise in uptake.
The GMC bought up a case investigating Wakefield citing that it was in the public interest. They investigated the affair and in January 2010 found that Wakefield had acted "dishonestly and irresponsibly" with "callous disregard" for the children participating in his study. He was found to have conducted unnecessary procedures with medical risks and he was found to not have had this approved by an Independent Ethics Committee. Andrew Wakefield was struck off the medical register (Boseley, 2010). The GMC did not rule on the scientific evidence of the link between MMR and autism, merely Andrew Wakefield's ethics and actions.
In the end I believe that it was not the scientific evidence that once again reversed public favour towards the MMR vaccine but the influence of the media. The media were to blame for the MMR scandal in the first place and were also to praise for resurgent trust. The media portrayed Wakefield as a dashing doctor trying to save our children: ""a handsome, glossy-haired charismatic hero to families of autistic children in this country and America" (Picardie, 2002). Emotional anecdotal stories where pushed in front of us over scientific evidence, the child Leo Blair was mentioned more than the author Andrew Wakefield. But then the media turned and suddenly Wakefield was demonised and shown to be pocketing money in exchange for our children's safety. To me it appears that Wakefield's fall from grace was the catalyst for a rise in vaccination rates. While I applaud this resurgence, one can't help but wonder whether I should lament the fact that the public are so easy to turn with apocryphal tales over peer reviewed, replicable evidence.
Figure 1.2 Ian Hargreaves, Justin Lewis and Tammy Spears (2002) 'Towards a better map: Science, the public and the media' Economic and Social Research Council
Fig 1.1 (Data obtained from Health Protection Agency)