AUTISM FIRST STEPS
AUTISM DAILY NEWSLETTER     
Tuesday January 15, 2002  


INDEX:
*  Autism, main story
*  
Autistic Kids Receiving Parent-Managed Intensive Interventions
*  
Enhanced Discrimination In Autism
*  
Can Checklist Sort Autism from Developmental Delays in Toddlers
*  
Parents' Perspectives on the MMR Immunisation A focus group study.
*  
Mind Blindness And The Brain In Autism.
*  
Were All Of These Children Killed By The Triple MMR Jab
*  If 26 Kids Died in the UK from MMR Vax, Did 148 Die in the US
*  Open Season on MMR How the Blairs' silence sparked a media storm
*  
UK Minister Promises Action On Autism
*
*****************************

Autism, main story


Sunday, January 06, 2002
By Kelly Bothum
Of The Patriot-News
On a mild Sunday afternoon, Dan scampers into kitchen and makes a beeline for the screen door. He can't maneuver the lock so he stands there waiting for someone to unlock it for him. Tom uses this as a chance to work on Dan's verbal skills. "I want," Tom says, pausing a few seconds between each word. Dan responds with an unintelligible mix of sounds. "I want," Tom says again. "Euh annt," Dan answers. "Outside," Tom says. "Side?" Dan replies. Tom obliges with a click of the screen lock. Dan's out the door, settling on a patch of grass just beyond the concrete patio in the spot where his inflatable pool sat until a month earlier. He plays with the mound of sand that remains, throwing tiny handfuls of it into the air and smiling as it falls around him. Sometimes he stops and stares at a patch of grass or looks up at the sky, content to be alone with his thoughts. Tom and Nancy watch from the table in their kitchen. "One of the great things that is refreshing about children like Dan is they can't pretend. They don't understand metaphorical language," Tom says. "It's just raw emotion and that's really refreshing. There's no game playing." The couple has worked hard to bring Dan out of his cocooned world. They're constantly prompting him to talk, to say what he wants to eat, where he wants to go, which video he wants to watch. He has a slew of therapists whose services are covered by medical assistance which Dan qualifies for because of his medical condition. Wrap-around services from Edgewater Psychiatric Center provide assistance for Dan at home and in school. A staff member helps him get ready for school and stays with him in class for part of the school day. Dan visits weekly with speech therapist Ted Huryn to increase his verbal communication. He also works with aquatherapist Esther Strader in an indoor pool, where the combination of motor exercises and rush of water across his body helps soothe his senses running on overdrive. "For certain, we have tried to get in his world, but by the same token, he's a very curious kid. He wants to find stuff out. He wants to seek things out. If you take him someplace, he'll remember," Tom says. "He'd know when I took him to get a haircut in downtown Mechanicsburg that there's a pet store at [routes] 114 and 11. He's like, 'Why aren't you taking me there, jerk?' At first, it's hard to figure out that sort of stuff." Three times a year, Dan's behavioral therapist, Karen Hornung, revises his behavior treatment plan, which dictates strategies to deal with his autism. It includes specific goals for Dan (better verbalization, improved social skills) and ways to achieve those goals (ignoring his one-word utterances, teaching him to take turns). At home, Dan adheres to a strict schedule with frequent reminders about what his next task is. The same is true at Middle Paxton Elementary School, where he's in an autism-support class with three other pupils, all boys. Teacher Amy Nissley and the aides involve the pupils with quick activities, none more than 15 minutes or so. The short bursts keep the children from getting frustrated or distracted. Each time Dan completes an activity, he removes an icon with the corresponding task from his daily schedule. The icons -- describing reading, computer and other activities -- are part of the Picture Exchange Communication System, which is used to communicate with autistic children. "They like to know what's coming. It's very important and it helps them stay stable in the sense they can anticipate what's coming," Karen says. "Oftentimes if something comes up and it's not what was planned, they get upset." Repetition and routine are constants in Dan's life. The challenge is trying to expose him to new things. Over the past months, Nancy and Karen have made it a priority to get Dan comfortable with going out in public. During the summer and into the fall, he and Karen took weekly trips to places like Arby's, Media Play, even Lake Tobias Wildlife Farm in Halifax. Dan's tolerance for going out has increased since the excursions began, Karen says. The people and the sounds aren't as overwhelming to his senses. And he's starting to understand how he's supposed to act in public, which is critical. "Before, we could only try to go through drive-throughs. When Nancy and I would try to sit down in a restaurant, he would get down on the floor or under the table," she says. "He'd get impatient because it was a long wait. In Dan's mind it was like, 'Why should I just sit there?'" The improvement is subtle but noticeable. On a trip to Friendly's with Karen one weekend, Dan sits patiently in the booth waiting for his plate of French fries. Once the fries arrive, he eats a couple -- his usual quota -- and waits for Karen to finish her Fribble. Only once does he duck his head under the table to sneak a peak. He likes affectionOn the weekends, everything slows down in the Richey household. Tom works long hours during the week, leaving at 4 a.m. and often driving to New York or Philadelphia for his job running construction projects and overseeing maintenance for a property management company. Sometimes he's gone for a couple of days. Nancy spends the most time with Dan during the week. She works part time from home on her recruiting business when she can, usually when he's in school. Saturday morning, Dan is their alarm clock. Around 8 or 9 a.m., he bounds into their room and onto the bed to cuddle and snuggle between his parents. Unlike some autistic children, the 8-year-old likes affection, taking in hugs and compliments like he was drinking them through a straw. He especially loves to snack on Tom's homemade bread, which he makes every couple of weeks and packs with whole wheat, fiber, protein and other nutrients. It's also one of the few things Dan eats willingly. Picky eating habits are common among those with autism and Dan is no exception. Arby's chicken fingers, white-cheese pizzas made by his father and an occasional peanut butter sandwich round out the short list of foods he'll eat without a fight. Corn chips are the closest he gets to vegetables, his mother says ruefully. To make sure Dan gets his nutrients, Nancy feeds him a vitamin cocktail prescribed by a nutritionist. The grape-flavored liquid vitamin packs all his nutritional needs except for vitamin C. It's also not cheap; the vitamin runs $50 a month and isn't covered by the family's insurance. Visions for futureWatching Dan amuse himself outside with the sand, Tom and Nancy say they have great hopes for what Dan can accomplish when he gets older. His future is something Nancy's been thinking about a lot lately since she started taking a class offered through Temple University about advocating for people with handicaps and special needs. They imagine him with friends, which he doesn't have many of right now. Nancy doesn't want to limit Dan by expecting he'll have to live in a group home as an adult. They envision him living out of their house, either independently or with a house mate. Given his love of nature and the outdoors, he might be a park ranger. Whatever it is, Tom and Nancy want to encourage him to find what he likes. "Other people may say, 'Oh, he'll be a janitor at McDonald's,' and that's what you don't want people to do," she says. "I want them to say he can be a park ranger if he wants to. Or maybe he does want to be a janitor at McDonald's. But right now, let's shoot far." They don't imagine he'll always live with them. One thing Nancy says she tries to do is think how it would be different raising Dan if he didn't have autism. Would she let him stay home forever? Probably not. "I'd say, 'No, Dan, get your own life.' So now I feel the same way," she says. "If he can live independently, but he says when he graduates from high school, 'Mom, I'd like to stay home for a couple of years,' maybe we'd do what all parents do -- give him a couple of years and then give him the boot." She finishes the sentence with a laugh. Dan pulls the screen door across and let's himself inside. "Oh yeah, Danny, we're talking about you," Nancy says, smiling. "We're talking about what you're going to do. Lots, right?" He wears a mischievous smile like he's the only one in on a good joke. Kelly Bothum may be reached at 255-8440 or kbothum@patriot-news.com.

http://www.pennlive.com/living/patriotnews/index.ssf?/xml/story.ssf/html_standard.xsl?/base/living/101015237416238105.xml

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Autistic Kids Receiving Parent-Managed Intensive Interventions


Progress and outcomes for children with autism receiving parent-managed
intensive interventions.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11768669&dopt=Abstract
Bibby P, Eikeseth S, Martin NT, Mudford OC, Reeves D.
Autism & Developmental Disorders Education Research, London, England, United Kingdom. PeterJBibby@compuserve.com

     Parent-managed behavioral interventions for young children with autism are under-researched. We analyzed data from 66 children served by 25 different early intervention consultants. After a mean of 31.6 months of intervention IQ scores had not changed (N = 22). Vineland adaptive behavior scores had increased significantly by 8.9 points (N = 21). No children aged 72 months attained normal functioning, i.e., IQ  85 and unassisted mainstream school placement (N = 42).
     Progress for 60 children across 12 months was found for mental age
(5.4 months), adaptive behavior (9.7 months), and language (5.1 months). The interventions did not reproduce results from clinic-based professionally
directed programs. The effectiveness of the parent-managed intervention
model as it has developed and the adequacy of professional services in that
model are discussed.
     PMID: 11768669 [PubMed - in process]

******************************

Enhanced Discrimination In Autism


http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_ui
ds=11765744&dopt=Abstract <- - address ends here.
O'Riordan M, Plaisted K.
Department of Experimental Psychology, University of Cambridge, UK.
mafo100@cus.cam.ac.uk

     Children with autism are superior to typically developing children at
visual search tasks (O'Riordan, Plaisted, Driver, & Baron-Cohen, in press;
Plaisted, O'Riordan, & Baron-Cohen, 1998b). This study investigates the
reasons for this phenomenon. The performance of children with autism and of
typically developing children was compared on a series of visual search
tasks to investigate two related problems. The first issue was whether the
critical determinant of search rate in children is the discriminability of
the display items, as it is in normal adults.
     The second question investigated was whether the superior performance
of individuals with autism on visual search tasks is due to an enhanced
ability to discriminate between display items. The results demonstrated that
discriminability is the rate-determining factor for children with and
without autism, replicating earlier findings with normal adults, and that
children with autism have an enhanced ability to discriminate between
display items. Thus, it seems that an enhanced ability to discriminate
between display items underlies superior visual search in autism.
     PMID: 11765744 [PubMed - in process

******************************

Can Checklist Sort Autism from Developmental Delays in Toddlers


Can the checklist for autism in toddlers differentiate young children with
autism from those with developmental delays?

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_ui
ds=11765292&dopt=Abstract <- - address ends here.
Scambler D, Rogers SJ, Wehner EA.
JFK Partners, University of Colorado Health Sciences Center, Denver 80262,
USA. doug.scambler@uchsc.edu

     OBJECTIVE: The Checklist for Autism in Toddlers (CHAT) has been
demonstrated to be sensitive to the presence of autism in otherwise normally
developing 18-month-old children. However, its ability to differentiate
autism from other significant developmental delays is unknown. This study
examined this question.
     METHOD: The CHAT was applied to a group of 44 children aged 2 and 3
years, rigorously diagnosed with autism or with other developmental
problems.
     RESULTS: By the original CHAT authors' criteria, the sensitivity and
specificity of the CHAT were 65% and 100%, respectively. Slightly altering
the criteria resulted in a sensitivity of 85% in the current group of
children with developmental disabilities while maintaining specificity of
100%.
     CONCLUSIONS: The current study is the first to demonstrate that the
CHAT successfully discriminates 2-year-old children with autism from those
with other developmental disorders. In addition, the increased sensitivity
of the Denver Criteria in children with developmental disabilities may
improve its usefulness as a screening tool for community-based
early-diagnostic teams and general practitioners.
     PMID: 11765292 [PubMed - in process]

******************************

Parents' Perspectives on the MMR Immunisation A focus group study.


http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_ui
ds=11761204&dopt=Abstract <- - address ends here.
Evans M, Stoddart H, Condon L, Freeman E, Grizzell M, Mullen R.
Division of Primary Health Care, University of Bristol.
m.a.evans@bristol.ac.uk

     BACKGROUND: The uptake of the combined measles, mumps and rubella
immunisation (MMR) in Britain has fallen since 1998, when a link was
hypothesised with the development of bowel disorders and childhood autism.
Despite reassurances about the safety of MMR, uptake levels remain lower
than optimal. We need to understand what influences parents' decisions on
whether to accept MMR or not so that health professionals can provide a
service responsive to their needs. AIM: To investigate what influences
parents' decisions on whether to accept or refuse the primary MMR
immunisation and the impact of the recent controversy over its safety.
     DESIGN: Qualitative study using focus group discussions.
     SETTING: Forty-eight parents, whose youngest child was between 14
months and three years old, attended groups at community halls in six
localities in Avon and Gloucestershire. METHODS: Purposive sampling strategy
was used to include parents from a variety of socioeconomic backgrounds.
Three groups comprised parents who had accepted MMR and three groups
comprised parents who had refused MMR. Data analysis used modified grounded
theory techniques incorporating the constant comparative method.
     RESULTS: All parents felt that the decision about MMR was difficult
and stressful, and experienced unwelcome pressure from health professionals
to comply. Parents were not convinced by Department of Health reassurances
that MMR was the safest and best option for their children and many had
accepted MMR unwillingly. Four key factors influenced parents' decisions:
     (a) beliefs about the risks and benefits of MMR compared with
contracting the diseases,
     (b) information from the media and other sources about the safety of
MMR,
     (c) confidence and trust in the advice of health professionals and
attitudes towards compliance with this advice, and
     (d) views on the importance of individual choice within Government
policy on immunisation.
     CONCLUSIONS: Parents wanted up-to-date information about the risks and
benefits of MMR to be available in advance of their immunisation
appointment. Many parents did not have confidence in the recommendations of
health professionals because they were aware that GPs needed to reach
immunisation targets. Most parents would, however, welcome more open
discussion about immunisation with health professionals.
     PMID: 11761204 [PubMed - in process]

******************************

Mind Blindness And The Brain In Autism.


http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_ui
ds=11754830&dopt=Abstract <- - address ends here.
Frith U.
UCL Institute of Cognitive Neuroscience, 17 Queen Square, WC1N 3AR, London,
United Kingdom

     Experimental evidence shows that the inability to attribute mental
states, such as desires and beliefs, to self and others (mentalizing)
explains the social and communication impairments of individuals with
autism.
     Brain imaging studies in normal volunteers highlight a circumscribed
network that is active during mentalizing and links medial prefrontal
regions with posterior superior temporal sulcus and temporal poles. The
brain abnormality that results in mentalizing failure in autism may involve
weak connections between components of this system.
     PMID: 11754830 [PubMed - in process]

******************************

Were All Of These Children Killed By The Triple MMR Jab?


     [Focus By Lucy Johnston, Sunday Express, UK.]
www.express.co.uk

     At least 26 families claim their children died as a result of the
controversial measles, mumps and rubella jab, the Sunday Express can reveal.
     In some cases the Government has awarded parents up to £100,000 under
its 1979 Vaccine Damage Payment Act. In others, post mortem reports
concluded the jab was the most likely cause of death. Despite this, the
Department of Health insists no child has ever died from MMR.
     This assertion is a key aspect of its £3 million publicity drive to
persuade parents the vaccine is entirely safe.
     It contradicts the view of the US Government, which accepts children
die from MMR and awards compensation as a result. Most children do not react
to the jab, but medical literature supports the view that MMR can
occasionally kill.
     The parents are now demanding an official inquiry into the deaths.
Julie Roberts, 40, whose daughter Stacey died, said: "The Government should
take responsibility. It has never given proper warnings of the risk and
still doesn't despite the evidence. Tony Blair can see his children at home.
I have to visit my daughter at her grave."
     Experts writing in the Journal of Pediatrics concluded that of 48
children who reacted to the measles component of the jab, eight died and the
rest had seizures or brain damage. And a recent study on 1.8 million
children by the Finnish Health Board linked neurological reactions, allergic
attacks, epilepsy and meningitis to the vaccine. Our research follows
speculation over whether Tony Blair's 19-month-old son Leo has had the MMR
jab. The Prime Minister has said he fully supports the vaccine but will not
say if Leo has had it.
     Many of the families of children who have died have taken legal
action. Richard Barr, of solicitors Alexander Harris, has details of 24
cases. He said: "It is widely acknowledged in medical literature and by the
American government that the triple vaccine can, on rare occasions, kill,
yet this Government won't accept it."
     Jackie Fletcher, of the pressure group Jabs, which is trying to
highlight the potential dangers, said: "The Government should be giving
people full and accurate information about health risks."
     But a Department of Health spokesman insisted: "Parents who received
payments after their children died following MMR would not get the money now
as science has moved on. MMR protects against death and we stand by the fact
that no child has died as a result of MMR."
     Wendy Francis's son, Robert, began behaving abnormally two years after
he had MMR in January 1990. He lost control of his movements and slept for
18 hours at a time. Within months he fell into a coma and died in December.
Robert, then seven, had developed a degenerative brain condition called SSPE
(sub-acute sclerosis pan encephalitis), linked to the measles component.
     The disease can have a long incubation period  and Mrs Francis, 40, an
auxiliary nurse and Robert's consultant think the vaccine was the only way
Robert could have developed it. The family, from Easington, north Yorkshire,
are taking legal action against the vaccine's manufacturer.
     Ashley Shipman was born in 1985 and was a healthy three-year-old when
he received the MMR vaccine. When he was nine his parents Elaine and Andrew
of Eastwood, Nottingham, noticed he was having problems with his balance and
co-ordination. He too was diagnosed with SSPE and died in June 1999, aged
14. They received £30,000 compensation.
     His father, a lorry driver, said: "We took Ashley into hospital in
October 1994 and by Christmas he was in a wheelchair. We were told by the
consultant who treated him that his condition was caused by his
vaccination."
     In 1995 the Government's vaccine damage tribunal paid £30,000
compensation to James Smith, of Gateshead, for brain damage after he was
given MMR at the age of four. James died nine years later aged 13. Biopsy
material taken from his brain and intestines will form a central plank of
the scientific evidence in support of a legal case due to be heard in
October next year. Up to 300 cases relate to this brand of vaccine -
Pluserix - which was banned by the Department of Health in 1992 after being
linked with meningitis. This was two years after an identical vaccine was
banned in Canada.
     John and Faye Smith say the jab transformed their healthy, intelligent
son into a child needing round-the-clock care. It took them six years and
four hearings, however, to persuade the vaccine damage tribunal of this.
     Faye, 59, said: "It's not about money, but truth. It's diabolical that
the Government refuses to acknowledge the risks of MMR."
     Judith Dwyer, 45, of Tongwynlaif, near Cardiff, received a payment
after her four-year-old daughter Chloe died following a "booster" jab in
1989. She too was given a version later banned because of its dangerous side
effects. Chloe developed pins and needles in her legs, then paralysis and
problems breathing. She was rushed to hospital but it was too late.
     After an eight-year fight Judith, an intensive care technician,
persuaded a tribunal the jab was the likely cause of Chloe's death. In
September 1996 it accepted this and paid out.
     Mother of two Judith said: "Health visitors called me a scare mongerer
and laughed. But we fought to  raise the profile of vaccine damage."
     Stacey Berry, of Atherton, Manchester was 13 when she had a booster
jab in November 1994. Days later she started having fits, "stopped smiling,
and stared into space."
     She was diagnosed with the brain disease SSPE and given two years to
live. She died in November 2000, aged 19. A post mortem examination
concluded the disease was a "rare complication" of the vaccine".
     Christopher Coulter was 15 when he suffered a fit and died in his
sleep 10 days after being vaccinated. He had an unblemished health record
and no history of epilepsy but no explanation has been offered other than
the statement on his death certificate - "asphyxiation due to severe
epileptic seizure". His mother Anne of Hillsborough, northern Ireland said:
"Nothing would replace Christopher, but I want answers. I want peace of mind
for my daughters should they ever have children."
     Hannah Buxton was 18 months old when she reacted to her first MMR jab.
She started having fits and died 18 months later in February 1992.
     Parents Carol and Tony of Towcester, Northants, did not know Hannah
had
been given the strain of vaccine later withdrawn after it was deemed unsafe.
In March that year a tribunal blamed the vaccine for her death.
     Nicola Gentle, 29, of Plymouth, Devon, is convinced her 15-month-old
baby Emma Jane died because of the triple vaccine she was given in September
1998.
Within six hours she was on a life-support machine. Three days later she was
brain dead but a coroner said he could not say for certain whether or not
MMR had killed her.
     Shirley Fitzgerald's son Kieren was given the MMR jab in June 1991
when he was 14 months. He reacted within days. "He stopped smiling, laughing
and crying and became frightened of his toys," said Shirley.
   Kieren also developed bowel problems - linked to MMR by some
scientists. In July 1992, he died, aged two.
     Toddler Harriet Moore died following an MMR vaccination in 1998. Six
weeks later she suffered fits and died in her parents arms. Sarah and Pat
Moore, of Peasedown St John, near Bath, took the case to tribunal.
     Jade Scrimger was vaccinated with MMR at 17 months and died from
meningitis three days later in October 1998. Her mother Sheena has since
discovered the drug used on her daughter was later banned by the Department
of Health because it caused meningitis.
     She has abandoned the idea of taking legal action against the vaccine
manufacturers, however, because lawyers say it is not worth it. In Britain
the
maximum award for a child's death is £7,500.
     Five days after Elaine Adam's 16-month-old son Stevie was given the
MMR vaccine 1991 he too developed meningitis and died.
     Elaine and her husband Robert, of East Kilbride, were convinced MMR
was to blame but their fears were dismissed by doctors. Mrs Adam has refused
to allow her second child, Terry, six, to have the jab.

******************************

If 26 Kids Died in the UK from MMR Vax, Did 148 Die in the US?


     This was the question posed to Barbara Lo Fisher of the National
Vaccine Information Center.  If 26 died from MMR in the UK, then given the
relative population size of the US, and all else being equal, about 148
fatalities would have occurred here. Is this true?  Here is Fisher's
response.
     "I am sure we have many deaths due to MMR vaccine. The problem here is
that perhaps less than 1 percent of all doctors report vaccine adverse
events - even though it has been the law since 1986 to report serious health
problems, including deaths, within 30 days of vaccination. MMR deaths within
30 days would be due to seizures and encephalopathy, which occurs at peak
incidence between 8 and 15 days following MMR. If doctors do not report,
there will be no statistics.
     "What we would like to see is an amendment to the 1986 National
Childhood Vaccine Injury Act which would attach a punishment for doctors not
reporting (the law made it clear the doctor is NOT supposed to decide at the
provider level whether there was causation involved - the duty was merely to
report) such as removal of the privilege of administering vaccines. That
would really hit them in the pocketbook."

******************************

Open Season on MMR How the Blairs' silence sparked a media storm


     In recent weeks opponents of the triple measles, mumps, and rubella
(MMR) vaccine have had rich pickings. In late November the General Medical
Council cleared former general practitioner Peter Mansfield of professional
misconduct for offering separate vaccines.
     The Daily Mail heralded this as a victory. Shortly afterwards, the
Express picked up an editorial in the British Journal of General Practice,
which argued that the Department of Health needed to respond to parental
concerns and rethink its policy on single vaccines.
     In early December Andrew Wakefield, whose research in the Lancet in
February 1998 stoked widespread alarm over possible links between MMR and
bowel disease and autism, left the Royal Free Hospital in London. He claimed
that he had been forced out for his rebel views.
   His departure was extensively covered in the Guardian and provoked
several angry letters in both the Daily and Sunday Telegraph. But it was the
Blairs' refusal to answer Conservative MPs' questions about whether their
youngest son, Leo, had had the triple vaccine that kept MMR firmly on the
media agenda.

+ Article continues at:
http://bmj.com/cgi/content/full/324/7329/120

******************************

UK Minister Promises Action On Autism


     [By Helen Rumbelow in the Times, UK.]

     The Public Health Minister promised a more concerted approach to
autism yesterday after a Commons debate in which MPs paid tribute to the
Times campaign to raise awareness of the condition. Yvette Cooper said that
the NHS, schools and social services would have to work together under the
National Service Framework for Children to stop families slipping through
the net.
     The National Autistic Society, the subject of The Times Christmas
Appeal, helps to improve the lives of those affected by autism, but lack of
resources means that many families are still not getting the help they need.
Linda Perham, Labour MP for Ilford North, organised the Commons debate to
inaugurate the first Autism Awareness Year, founded by Ivan Corea, a
constituent with an autistic boy, Charin, 5. Tony Blair pledged his support
at Question Time.

+ Article continues at:
http://www.thetimes.co.uk/article/0,,11-2002015880,00.html
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ALL INFORMATION, DATA, AND MATERIAL CONTAINED, PRESENTED, OR PROVIDED HERE IS FOR GENERAL INFORMATION PURPOSES ONLY AND IS NOT TO BE CONSTRUED AS REFLECTING THE KNOWLEDGE OR OPINIONS OF THE PUBLISHER, AND IS NOT TO BE CONSTRUED OR INTENDED AS PROVIDING MEDICAL OR LEGAL ADVICE.  THE DECISION WHETHER OR NOT TO VACCINATE IS AN IMPORTANT AND COMPLEX ISSUE AND SHOULD BE MADE BY YOU, AND YOU ALONE, IN CONSULTATION WITH YOUR HEALTH CARE PROVIDER.