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AUTISM FIRST STEPS
AUTISM DAILY NEWSLETTER
Thursday December 6, 2001
INDEX:
* 'It is not about the
science. It's about belief'
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'It is not about the science. It's about belief'
Andrew Wakefield - the doctor who first linked MMR and autism - has resigned.
But does that mean he was wrong about the vaccine? Linda Steele reports
Wednesday
December 5, 2001
The Guardian
What is perhaps most surprising about Andrew Wakefield is his apparent lack of
bitterness. Wakefield resigned last week from his post as consultant
gastroenterologist at the Royal Free and University College Medical School,
claiming that he had been forced out for research unpalatable to the medical
school hierarchy. "It was inevitable," he says calmly. "The
issue is not about science. One is dealing with people's belief systems. And
that takes a great deal to change." The contending beliefs in question
belong to two factions: on the one hand, to a medical establishment united in
defence of combined measles, mumps and rubella (MMR) immunisation on the
grounds of public health; on the other hand, to a small but significant number
of scientists, including Wakefield, together with a larger number of parents
who have raised concerns about the jab's safety. Wakefield sparked the
controversy when he and colleagues published a paper in the Lancet in 1998,
raising the possibility of a link between MMR and regressive autism in a
handful of children they had seen with a chronic, possibly new form of bowel
disease. Most had been developing normally, reaching childhood milestones, but
then began to lose skills, such as speech, play and the ability to interact
with others. Parents, or their doctors, blamed MMR. Probably the move that most
angered the scientific establishment, including government public health
advisers, was Wakefield's suggestion that, instead of immunising children
between 12 and 15 months with the MMR, the three vaccines should be given
separately. It was on this point that Wakefield decisively broke ranks with
colleagues at the Royal Free; it was not a conclusion that had been drawn - nor
could be drawn, say critics - from the research published in the Lancet. The
argument, rehearsed by proponents of single jabs, is that children should have
a measles vaccine first, thus protecting them against what is the most
potentially lethal childhood disease of the three. Later vaccinations can
immunise against mumps and rubella. Innocuous that may seem, but it flies in
the face of the government's mass immunisation programme, of which MMR is a key
part. The official line is simple: over 500m doses of MMR have been used in 90
countries; the vaccine is backed by the World Health Organisation as the safest
way that parents can protect their children against these serious diseases.
Wakefield's critics, most notably at the Department of Health (DoH) and the
Public Health Laboratory Service (PHLS), have argued that no one else has
replicated his results, despite attempts, and that his critique of the
triple-jab is based more on hunch than science. Yet a small but growing number
of scientists has begun to question the wisdom of enforcing the triple-jab
programme. The current hypothesis - by no means wholly attributable to
Wakefield - is that the measles element of MMR in some way damages the
digestive function and bowel, allowing substances derived from the incomplete
breakdown of foods such as barley, rye, oats and dairy products to pass through
a leaky gut wall into the bloodstream. These pass into the brain, disrupting
normal brain development and causing autism. Nonsense, say critics. Assuming
that an immune response to MMR could cause leakage, the liver would filter out
harmful molecules before they reached the brain. Even if it didn't, toxins
would not pass the protective blood-brain barrier. Against this, supporters of
the theory argue that other substances, such as alcohol, do make it from gut to
brain. And HIV, they point out, is found in both the gut and the brain. One of
Wakefield's significant related claims was finding the measles virus where it shouldn't
be - in the gut of the autistic children he was treating. The reason why MMR is
risky, the theory runs, is that it overloads developing immune systems with
three live viruses at once. The presence of the virus in gut biopsies is what
lends weight to the hypothesis that it is the measles component of MMR that
does the bowel damage when an overburdened immune system is unable to cope.
Critics slated Wakefield's methods and the DoH dismissed his work as "bad
science". A senior official says: "Babies are exposed to millions of
immune challenges, through breathing germs in and playing on the floor. Dr
Wakefield has a real problem explaining his theory about immunological overload
given that the viruses in the vaccine don't have an effect at the same time.
The measles virus kicks in at five to 10 days, rubella in 11 to 14 days and
mumps in 16 to 21 days." PHLS head of immunisation Elizabeth Miller says
that Wakefield was "naïve" and has made "basic errors" in
his research methods. Dr Peter Mansfield, the GP who was reported to the
General Medical Council for giving children single vaccines but who was
recently cleared to carry on the practice, says that MMR "defies a
principle of nature. These viruses are systemic: when they work in the body,
they occupy the whole of it, so you're setting up a hurdle for the child."
Children almost never encounter the three or even two of the viruses
simultaneously in nature and, when they do, they don't have them injected into
their bloodstream. Furthermore, research has shown that measles can suppress
the immune system and that viruses can interfere with each other to produce
adverse effects. Vaccine manufacturers have admitted the difficulty of creating
combined jabs "due to the unpredicted immune interference and incompatibilities
on mixing of different components." Faced with a barrage of criticism,
however, including slights about the accuracy of his tests, Wakefield sent
samples of gut tissue to John O'Leary, chair of pathology at Trinity College,
Dublin. Using his own tests, O'Leary has found the virus in significantly more
autistic children than covered in Wakefield's first paper. The Department of
Health has brushed aside the implications, saying that the work cannot be
judged until it appears in a peer-reviewed journal. (Wakefield and O'Learyplan
to publish soon.) Meanwhile, a critical paper by David Elliman, a consultant in
the department of child health at St Georges hospital in London, and Helen
Bedford, of the Institute of Child Health, earlier this year claimed that the
results were "inconsistent" and would have to be "confirmed
independently". To outsiders, it may all seem like arcane wrangling, but
the scientific evidence may eventually come to be examined in court. There are
around 1,000 children in the UK employing legal aid to pursue a joint action in
the courts alleging damage by MMR against the three manufacturers of MMR -
Merck, SmithKline Beecham and Aventis Pasteur, out of around 3,000 whose
parents have contacted lawyers. Proceedings have started in the case of about
350. These parents' persistent question is why the DoH has not bothered to
examine their children or their medical records. They are angry that the
government has spent £3m on a campaign to persuade parents and health
professionals that MMR is safe. "It should be spent on helping our
children and further research," says Marion Wickens, who believes that her
10-year-old daughter Melissa's regressive autism and bowel disorder were caused
by the triple vaccine. "Before the MMR, she had a cheeky glint in her
eyes. She could speak a few words, she played happily. I watched her lose her
eye contact, stop speaking, stop pointing. She was like an empty doll,"
she says. "Now, she screams night and day, bites herself and tears at her
hands. She's in agony because of the inflammatory bowel disease. She attacks
young children. I feel so angry. She'll never have an independent life."
Despite parents' claims, Elliman and Bedford argue that research still shows
that "the evidence of the safety and efficacy of MMR vaccine is so
overwhelmingly conclusive that health professionals should have no hesitation
in recommending its use." But Richard Halvorsen, a London GP who offers
single jabs, says that he began to worry precisely when he started to read the
very scientific papers cited as proof of safety. "Most, but not all of the
published evidence used by those proclaiming that MMR is safe doesn't add to
the debate," he says. One study that took place in Finland over 14 years
relied on doctors informing the authorities when they thought a child had had a
serious, adverse reaction to MMR. The research concluded that serious
side-effects of MMR were rare and greatly outweighed by the risks of the
natural diseases. However, the use of "passive surveillance", akin to
the GPs' yellow card scheme in Britain, has been criticised for leading to
under-reporting and for potentially missing significant reactions. Moreover,
the study simply wasn't designed to look for autism. If medical staff weren't
asked to look for autism as a possible side-effect, then there was no reason
for them to re port it as a reaction to MMR. Given that other research suggests
that autism cases quadrupled in Finland over this period, says consultant
neuropsychologist Ken Aitken, "had they acknowledged autism as a possible
reaction [to MMR], they should have picked up some cases because it had
increased considerably in this population." Aitken, with eminent Canadian
epidemiologist Walter Spitzer, has looked at the medical records of 369
autistic children alleged by their parents to be MMR-damaged. Despite media
stories of dramatic, instant reactions to MMR, the reality is that most
children with regressive autism and bowel disorder suffer a slow degeneration
into the condition, he says. The average delay between vaccination and
diagnosis of autism was two and a half years. In these circumstances, few of
the safety trials went on for long enough to be valid, the two scientists
conclude. Aitken is now convinced that "in a significant number of the children
we see, there is a link between their problems and MMR," but that more
research is needed into the causes and level of incidence: "Clinically,
we're being swamped but there is no central database on autism and the rise in
new cases." He and other experts are hoping that reports from the Medical
Research Council, due next week, and from the Scottish Parliament expert
advisory group, due next February, will call for a large-scale, long-term
research project and a national database. For now, a question mark still hangs
over the safety of MMR. Faced with a choice between MMR or nothing, some
parents are choosing nothing. Vaccination rates have fallen to 87% (79% in
London) - well below the 95% coverage needed to maintain immunity and eliminate
infection in the general population. A recent editorial in the journal of the
Royal College of General Practitioners reiterated the view that MMR is safe but
suggested that parents should be given an option, arguing that: "The DoH,
as one arm of government... cannot encourage choice in some areas of public
policy and discourage it in others." The Department of Health argues
against such a move, saying that public confidence in vaccines would collapse.
The DoH can point to the success of MMR - no child has died of measles in the
UK since the vaccine's introduction in 1988 - but the fact is that confidence
is already shaken. The question for parents is whether the uncertainty
surrounding the MMR vaccine is, in fact, larger than the worry that children
might begin to die of natural disease because of the low rate of immunisation. Disputed
facts: conflicting research on MMRArguments rage over whether MMR-related
research proves the triple jab's safety. Some of key studies are: ·
"Peltola twins", in which one Finnish twin in each pair of 581 was
vaccinated with MMR and the other with a placebo. Three weeks later, the
MMR-vaccinated twins were given the placebo and vice versa. Critics say that
three weeks simply wasn't long enough. · Pre-licensing trials:
criticised by Wakefield and a colleague for lasting no longer than 28 days. ·
London doctor Brent Taylor and the PHLS looked at 498 cases of autism in the
North Thames area. The authors found that, while cases rose, there was no
sudden increase when MMR was introduced. Critics have questioned the original
records and the likelihood of finding the one child or fewer in 1,000 allegedly
damaged by MMR in a relatively small population. They also point to the fact
that there was a catch-up campaign when MMR was introduced in 1988 which swept
up most pre-school children. This, they argue, muddies the figures, which are
organised by year of birth. · In the US, the Oak Springs symposium
reviewed evidence and came down in favour of MMR, but called for further
research.
LS
http://www.guardian.co.uk/parents/story/0,3605,612118,00.html
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