Dr Toni Hazell offers 10 top tips about how best to manage scepticism toward vaccination and improve uptake of vaccines

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Dr Toni Hazell

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Read this article to learn more about:

  • the absence of any link between the MMR vaccine and autism
  • increasing vaccination rates through effective communication
  • flu and pertussis vaccinations in pregnancy.

The urban myth of a link between the measles, mumps, rubella (MMR) vaccine and autism sadly still persists and, as doctors, it is important that we are clear about our rejection of this untruth and that we have facts at our fingertips to help us explain this to parents.

Over the years, the rise in autism diagnoses has been used by some to back up their claims that the MMR vaccine causes autism. However, there are other reasons for this increase in diagnosis. The most important is probably the introduction of the concept of the ‘autistic spectrum’, which significantly widened the diagnostic criteria. Autism, as originally described by Leo Kanner in the 1940s,1 referred to a cohort of children who would now be considered to be at the very severe end of the larger group with autism. Hans Asperger, working around the same time, described a broader spectrum,2 including children with normal intelligence and speech but who exhibited autistic behaviours, although the term Asperger’s syndrome did not come into use until 1981.3

It is this widening of the diagnostic criteria that is associated with the increased prevalence of autism, not the increased number of vaccinations given to children today compared with previous years; studies carried out in Sweden in the 1970s found that at least 0.7% of primary school children demonstrated autistic traits. The proportion of children with traits that suggest autism has remained static between the 1970s and now, it is just that in recent years we are more likely to recognise these traits as autism and make a diagnosis compared with previous decades.4

A 10-minute consultation does not allow time for a detailed debate about the issue, but is important to be able to offer a succinct counter-argument to those who still believe that the MMR vaccine causes autism. Immunisation against infectious disease, otherwise known as The Green Book, is the main reference source for vaccination information. It clarifies that studies have shown that:5

  • the number of autism diagnoses was rising before the MMR vaccine was introduced to the UK
  • Japan stopped giving the MMR vaccine in 1993, but rates of autism continue to rise
  • the cohort of children who have had the MMR vaccine do not have higher rates of autism compared with the cohort who have not had it
  • autism diagnoses do not rise and fall as rates of MMR vaccination rise and fall.

2. Andrew Wakefield was not just a scientist who ‘got it wrong’

The work of Andrew Wakefield, the former clinician most associated with the MMR–autism scare, was rejected by the Medical Research Council (MRC) soon after the publication of the notorious paper for which he was the lead author;6 his behaviour was also later found to be fraudulent.7 This is another important point to bring to parents’ attention. Wakefield’s first paper was published in 19988 and within 2 months it had been disputed by both the MRC6 and a 14-year-long retrospective Finnish study that showed no link. Within 3 years, Wakefield had resigned from the Royal Free Hospital and levels of the MMR vaccination had fallen well below the 95% needed for herd immunity. In 2010, the longest ever fitness to practise case saw Wakefield struck off after being found guilty of over 30 charges (including dishonest and irresponsible conduct and abusing his position of trust with vulnerable children).10,11 The General Medical Council (GMC) used words such as ‘dishonest’, ‘unethical’, and ‘callous’12 to describe him and it was revealed that he had an undeclared conflict of interest (a patent for single-disease vaccines to replace the combined MMR vaccine), that his study did not have ethical approval, and that he had paid children to allow him to take blood from them at his son’s birthday party.11 He was also being paid by legal teams hoping to mount a challenge to the MMR vaccine13 and received just over £435,000 in taxpayers’ money via legal aid.14

Parents who view Wakefield as someone who was possibly misguided, but ultimately had the best interests of children at heart, will sometimes change their view when the stark facts of the case are put before them.

3. Measles is not a harmless childhood infection

A tenet of the anti-vaccination movement is the idea that getting measles is a rite of passage of childhood—the idea that ‘I had measles and it never did me any harm’, and that vaccinating against it is an example of the nanny state and overmedicalisation. This point of view is dangerous and untrue. Measles is a serious infection and around 10–20% of children will suffer a complication, possibly more in developing countries.15 Some of the potential complications of measles are listed in Box 1.

Box 1: Potential complications of measles15

  • Increased sensitivity to opportunistic infection, causing increased rates of otitis media, pneumonitis, tracheobronchitis, and pneumonia for several weeks after the person has recovered from measles
    • complications can be more severe in those who are already immunocompromised, who are at particular risk of developing severe and prolonged measles and complications such as viral pneumonitis
  • Complications relating to the central nervous system:
    • convulsions (0.5%)
    • encephalitis (0.1%)
    • blindness
    • sub-acute sclerosing panencephalitis is a rare delayed complication, which occurs years after the virus (a median of 7 years later but can be up to 30 years later), is always fatal, and affects 1 in 25,000 of those with measles (but is 16 times more common in children who get measles under the age of 1 year)
  • Diarrhoea (8%), sometimes leading to dehydration
  • Pregnancy-related complications—miscarriage, stillbirth, and prematurity.

Adapted from: © NICE 2018 Measles. Available from cks.nice.org.uk/measles All rights reserved. Subject to Notice of rights
NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication.

Perhaps the most powerful description of the devastation that can be caused by measles was written by Roald Dahl in 1986; he recounts the death of his 7-year-old daughter from the virus in 1962, before a measles vaccine was available. He describes how she was apparently recovering when he noticed that while trying a craft activity, ‘her fingers and her mind were not working together’ and she told him that she felt sleepy. She was unconscious within 1 hour, and dead within 12. The full article, which includes a strong message that all parents should get their children vaccinated, is well worth reading and can be found on the Roald Dahl website.16

4. Measles is on the rise

In 2017, the UK achieved the World Health Organization (WHO) measles elimination status, based on data from 2014–2016. Yet in 2017 itself there were 284 confirmed cases in England and Wales, rising further to 991 confirmed cases in 2018.17 The trend for 2019 does not seem to be improving, with 301 confirmed cases in the April–June quartile alone.18 Population coverage for both doses of the MMR vaccine has fallen to 87.4%, well below the 95% needed for herd immunity.17 Furthermore, there were 49 deaths from measles in Europe in 2017, compared with 72 in 2018.19 As GPs, it is our responsibility to make sure that parents understand that if they choose not to vaccinate, they are risking their child’s health and indeed their life.

5. Vaccine deniers cannot be convinced, but you might convince a vaccine sceptic

The WHO defines a vaccine denier as ‘a member of a subgroup at the extreme end of the hesitancy continuum; one who has a very negative attitude towards vaccination and is not open to a change of mind no matter what the scientific evidence says’ and says that any attempt to change the mind of such a person is likely to be doomed to failure. However, the WHO suggests that it is still worth engaging with this group of parents if there is a wider audience to the debate, as that audience is likely to contain vaccine sceptics, defined as ‘a person who takes a scientific approach to the evaluation of claims and is willing to follow the facts wherever they lead’.20

With the WHO advice in mind, a conversation with a vaccine denier in the presence of another relative (perhaps the child’s other parent or a grandparent) may still be worth having in order to try and change the wider opinion in the family.

6. A child cannot be vaccinated if someone with parental responsibility refuses

Most children are brought for vaccination by just one parent, and we take it as given that the other parent agrees. However, if we are aware that someone with parental responsibility for the child does not want them vaccinated, then we cannot vaccinate with the consent of just one parent—unless there is a court order in place.21,22

7. Consider using a presumptive ask to encourage vaccination

Language is important; many studies have shown that perceived poor communication can be a significant factor in a patient’s decision to complain.23 Evidence shows that the use of a presumptive statement (e.g. ‘Sarah needs to have her MMR vaccination today’) is associated with higher vaccine take-up than a participatory statement (e.g. ‘what would you like to do about Sarah’s vaccination?’).24,25 If a presumptive statement does not result in acceptance of the vaccine then the next step is to give a strong recommendation in favour, ideally backed up by evidence and possibly personal experience (e.g. ‘my children have had this vaccination’).

It can also be useful to remind parents that, by not vaccinating, they are actively deciding to put their child at risk. This counters the often held view that if an unvaccinated child gets measles that it is just ‘one of those things’ and not the parent’s fault; whereas the reality is that if they have refused vaccination, any resulting injury could be considered the parent’s fault.

8. The current vaccine schedule does not ‘overload the immune system’

Another urban myth is that we give too many vaccinations on the same day and that this causes an overload of the immune system—this is part of the ‘logic’ for those who want to use single vaccinations instead of the MMR vaccine, but it is a fallacy with no basis in science. Children are exposed to multiple antigens in a normal day, many more than when given a vaccination. A simple ‘strep throat’ infection will expose a child to 25–50 antigens.26

All the available evidence shows that simultaneous multiple vaccines have no adverse effects on the normal childhood immune system compared with separate single vaccinations.26 In contrast, spacing out vaccinations can cause harm both in terms of delaying full vaccine coverage27 and distressing a child who will have to make more visits to the doctor for more injections.

9. Parents who want single vaccinations cannot get them privately

It used to be possible to pay privately for the three components of the MMR vaccine, but this has always been a risky option. Splitting the vaccinations like this inevitably delays a child receiving all of the components and full uptake of all six vaccinations (three primary, three boosters) is poorer for those who have single vaccines compared with those who have the MMR vaccine.27 There is some evidence that the single vaccines are less effective than the MMR vaccine27 and in any case, a single vaccination is only available for measles. There is a combined measles/rubella vaccination available privately but the only company to make a single mumps vaccination ceased manufacture of this product in 2009.28

10. Don’t forget other vaccinations, particularly in pregnancy

The MMR is the vaccine that gets the most publicity, but it is important to remember the other vaccines that we need to be giving. It is only in the last few years that we have vaccinated pregnant women (against flu and pertussis) and this has required a change in mindset of both doctors and patients. It is still the case that we try to use as few medicines as possible in pregnancy, but we are now aware that the benefits from vaccinating against flu and pertussis far outweigh any risks, so this has become routine practice. Flu in pregnancy can be very serious, with an increased risk of maternal complications, such as pneumonia, and fetal complications like prematurity, low birth weight, and stillbirth.29 Between 2009 and 2012, 36 pregnant women died from flu30 and it is estimated that more than one-half of these deaths could have been prevented by a flu immunisation.30,31

Pertussis vaccination in pregnancy began in 2012, after a national outbreak of pertussis during which 14 babies died, all aged under 3 months. In the following 3 years there were another 18 deaths. Vaccinating in pregnancy, usually done after 16 weeks, protects newborn babies via placental transfer of antibodies—this covers the time before the first newborn vaccinations, which is when newborns are at the greatest risk of complications and death from pertussis.32 A large observational study looked at a variety of pregnancy complications, including stillbirth, haemorrhage, and low birth weight and found no effect on these outcomes from having the pertussis vaccination during pregnancy.33 Those who persist in believing in a link between vaccination and autism may also be reassured to hear that a study of 82,000 babies showed no link between the pertussis vaccination and autism.34

Dr Toni Hazell
Part-time GP, Greater London

References

  1. Kanner L. Autistic disturbances of affective contact. Nervous Child 1943; 2: 217–250. Available at: mail.neurodiversity.com/library_kanner_1943.pdf
  2. Asperger H. Die „Autistischen Psychopathen” im Kindesalter. Archiv für Psychiatrie und Nervenkrankheiten 1944; 117 (1): 76–136.
  3. Pearce J. Kanner’s infantile autism and Asperger’s syndrome. J Neurol Neurosurg Psychiatry 2005; 76 (2): 205.
  4. Gillberg N. Is autism more common today than 40 years ago? gillbergcentre.gu.se/english/research/researcher-s-corner/2014/is-autism-more-common-today-than-40-years-ago–april-2014 (accessed 24 October 2019).
  5. Public Health England. Measles: the green book, chapter 21. PHE, 2019. Available at: www.gov.uk/government/publications/measles-the-green-book-chapter-21
  6. Bignall J. UK experts convinced on safety of MMR. Lancet 1998; 351 (9107): 966.
  7. Godlee F, Smith J, Marcovitch H. Wakefield’s article linking MMR vaccine and autism was fraudulent. BMJ 2011; 342: c7452.
  8. Wakefield A, Murch S, Anthony A et al. RETRACTED: Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in childrenLancet 1998; 351 (9103): 637–641.
  9. Peltola H, Patja A, Leinikki P et al. No evidence for measles, mumps, and rubella vaccine-associated inflammatory bowel disease or autism in a 14-year prospective studyLancet 1998; 351 (9112): 1327–1328.
  10. NHS. Ruling on doctor in MMR scare. www.nhs.uk/news/medical-practice/ruling-on-doctor-in-mmr-scare/ (accessed 25 October 2019).
  11. General Medical Council. Fitness to practise panel hearing—28 January 2010. NHS, 2010. Available at: www.nhs.uk/news/2010/01January/Documents/FACTS%20WWSM%20280110%20final%20complete%20corrected.pdf
  12. Cooper C. MMR doctor Andrew Wakefield struck off by GMC for misconduct. GP Online, 2010. www.gponline.com/mmr-doctor-andrew-wakefield-struck-off-gmc-misconduct/article/1005151 (accessed 24 October 2019).
  13. Deer B. MMR doctor given legal aid thousands. The Times, 2006. www.thetimes.co.uk/article/mmr-doctor-given-legal-aid-thousands-00ftl80msbs (accessed 25 October 2019).
  14. Deer B. Andrew Wakefield—the fraud investigation. briandeer.com/mmr/lancet-summary.htm (accessed 20 October 2019).
  15. NICE. Measles. NICE Clinical Knowledge Summary. NICE, 2018. Available at: cks.nice.org.uk/measles
  16. Dahl R. Death of Olivia. www.roalddahl.com/roald-dahl/timeline/1960s/november-1962 (accessed 20 October 2019).
  17. Public Health England. Measles in England. PHE, 2019. Available at: publichealthmatters.blog.gov.uk/2019/08/19/measles-in-england/ (accessed 20 October 2019).
  18. Public Health England. Laboratory confirmed cases of measles, rubella and mumps, England: April to June 2019. PHE, 2019. Available at: assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/827924/hpr3119_mmr_AA.pdf
  19. Vaccine Knowledge Project. Measles. vk.ovg.ox.ac.uk/measles (accessed 24 October 2019).
  20. World Health Organization. How to respond to vocal vaccine deniers in public. Best practice guidance. WHO, 2016. Available at: www.who.int/immunization/sage/meetings/2016/october/8_Best-practice-guidance-respond-vocal-vaccine-deniers-public.pdf
  21. Public Health England. Consent: the green book, chapter 2. PHE, 2013. Available at: www.gov.uk/government/publications/consent-the-green-book-chapter-2
  22. Medical Protection Society. Parental responsibility. www.medicalprotection.org/uk/articles/eng-parental-responsibility (accessed October 25 2019).
  23. Medical Protection Society. Improving communication, cutting risk. www.medicalprotection.org/newzealand/casebook/casebook-january-2012/improving-communication-cutting-risk (accessed 25 October 2019).
  24. MacDonald N, Desai S, Gerstein B. Working with vaccine-hesitant parents: an update. Canadian Paediatric Society, 2018. Available at: www.cps.ca/en/documents/position/working-with-vaccine-hesitant-parents
  25. Centers for Disease Control and Prevention. Talking with parents about vaccines for infants. CDC, 2018. Available at: www.cdc.gov/vaccines/hcp/conversations/talking-with-parents.html
  26. World Health Organization. Six common misconceptions about immunization. www.who.int/vaccine_safety/initiative/detection/immunization_misconceptions/en/index6.html (accessed 25 October 2019).
  27. Public Health England. Measles, mumps, rubella (MMR): use of combined vaccine instead of single vaccines. PHE, 2014. Available at: www.gov.uk/government/publications/mmr-vaccine-dispelling-myths/measles-mumps-rubella-mmr-maintaining-uptake-of-vaccine
  28. Smith R. Single mumps vaccine production stops. The Telegraph, 2019. www.telegraph.co.uk/news/health/news/6645284/Single-mumps-vaccine-production-stops.html (accessed 25 October 2019).
  29. NHS. Why are pregnant women at higher risk of flu complications? www.nhs.uk/common-health-questions/pregnancy/why-are-pregnant-women-at-higher-risk-of-flu-complications/ (accessed 24 October 2019).
  30. Vaccine Knowledge Project. Flu vaccine in pregnancy. vk.ovg.ox.ac.uk/flu-vaccine-pregnancy (accessed 24 October 2019).
  31. Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK (MBRRACE-UK). Saving lives, improving mothers’ care: lay summary 2014. University of Oxford Nuffield Department of Population Health, 2014. www.npeu.ox.ac.uk/downloads/files/mbrrace-uk/reports/Saving%20Lives%20Improving%20Mothers%20Care%20report%202014%20Lay%20Summary.pdf
  32. Vaccine Knowledge Project. Pertussis (whooping cough) vaccine in pregnancy. vk.ovg.ox.ac.uk/pertussis-vaccine-in-pregnancy (accessed 24 October 2019).
  33. Donegan K, King B, Bryan P. Safety of pertussis vaccination in pregnant women in UK: observational study. BMJ 2014; 349: g4219.
  34. Tracy A, Getahun D, Chiu V et al. Prenatal tetanus, diphtheria, acellular pertussis vaccination and autism spectrum disorder. Pediatrics 2018; 142 (3): e20180120.