Measles, vaccination and homeopaths

Measles is in the news again.  Just to provide a little context, the graph above shows the number of confirmed measles cases in England and Wales since 1996^*. The impact of insufficient vaccine coverage is easy to see. This year is looking like being a good year for measles; not so good for vulnerable members of the community. According to the BBC, “The Health Protection Agency [HPA] reported 334 cases compared with 33 in the similar period last year.”  In fact, this is rapidly approaching the total of 374 cases reported for the whole of 2010.  It seems that this is related to “an epidemic in France, where 7,000 cases have been reported since January – more than in the whole of 2010.”

The HPA are advising “Whether you stay here in the UK or travel abroad, it is crucial that individuals who may be at risk are fully immunised.” Although the coverage with the MMR vaccine is improving in the UK, it is “still far from the 95% uptake rate needed to stop the spread of the disease in the community.”^** One reason for this is the damage done by the media^*** uncritically promoting the views of the disgraced Andrew Wakefield^† and other vaccine scaremongers.

Measles and MMR: the risks

It’s easy to forget just how dangerous measles is.  Those of us who grew up in times where it was more common may tend to look back on measles as an inconvenient rite of passage.  Generally, this is because we may not have had direct personal experience of the serious consequences that can arise from a measles infection.  In the years since, vaccination brought diseases like measles under control and people have, thankfully, become even less familiar with the dangers.

However, a mixture of anti-vaccine scaremongering, unfounded fears and, perhaps even complacency, has lead to this disease having something of a renaissance.  So, what are the risks of a measles infection?  The Medinfo website provides this useful table:

Complications	Risk
Diarrhoea	1 in 6
Ear infections	1 in 20
Pneumonia / bronchitis	1 in 25
Fits (convulsions)	1 in 200
Meningitis / encephalitis	1 in 1000
Death	1 in 2500 to 5000
Serious brain complications years later (Subacute sclerosing panencephalitis)	1 in 8000 (of children who have measles under 2 years)

This shows that measles is not to be taken lightly.  Risks of one in 200 for fits, one in 1000 for Meningitis / encephalitis and one in 2500 to 5000 for death are serious. It also illustrates why we may not have personal experience of how dangerous measles can be – how many of us know enough infected children to see a fatality when the death rate is between one in 2,500 to 5,000? This shows the fallibility of relying on personal experience.

But don’t vaccines have risks?  Yes, of course they do; but as the table below shows that the risks associated with MMR are very much smaller than those arising from measles alone.

Complications	Risk after first dose of MMR
Fits (convulsions)	1 in 1000
Meningitis / encephalitis	1 in 1000000
Conditions affecting the clotting of the blood	1 in 24000
Severe allergic response (anaphylaxis)	1 in 100000
Deaths	0

The Medinfo website puts it well:

“Nothing in life is without risk, but here the balance, for most people, is in favour of having the MMR Vaccine. It not only protects the patient, but also unborn babies.”

So, any responsible healthcare professional should be pointing out this favourable risk-benefit balance and encouraging vaccination.  A similar case can be made for other preventable diseases.

Homoeopaths: the risks

Given that homeopaths claim to be responsible healthcare providers, it’s upsetting to come across anti-vaccine views being promoted by professional homeopaths on their websites. Even if these are a small minority, and I sincerely hope that they are, their impact on individuals could ultimately prove fatal.

For example, Society of Homoeopaths member Noam Bar^†† has this to say on his website (frozen page, change log) about vaccination:

Vaccination

“Some parents might find it difficult to reject conventional vaccination all together. In such cases, they can still control a few factors which might minimize the damage: Start vaccinations later in life … Possible damage from vaccines will therefore decrease if the application is postponed. Even postponing vaccines so that they are taken only after the age of 6 months can be of benefit. Avoid using combination vaccines. This decreases the load on the system…. Use homeopathy to undo some of the damage …Remedies can be taken either immediately after the vaccine, or on later date, to reduce the damage caused by the vaccine…”

From the start, there is an implication that serious side effects, the kind that cause ‘damage’, are common.  As we have seen, they are not. Postponing vaccination is potentially dangerous, as it leaves the child vulnerable to infection.  Ironically they will be relying on vaccination rates being sufficiently high in their community to stop the spread of the disease.  Building this protection into communities is undermined by the sort of disinformation on this website. There is absolutely no credible evidence that vaccinating later reduces the small risk of complications.  Neither, for that matter, is there any evidence that combination vaccines are any less safe.  Talking about things for which there is no evidence: if a child is unlucky enough to suffer from a rare vaccine reaction, homoeopathy will not be able to help.

Bar elaborates further in a downloadable pdf.  It is an illuminating insight into a homeopathic view of vaccines, or at least Barr’s take on this.  Here are some worrying extracts:

“…To be sure, the paper is written from the point of view of homoeopathy which is very critical of vaccination”

Bar is clear that homoeopathy is not well-disposed to vaccination.  This is sad, because vaccination is probably one of the greatest contributions to improved human health in history: once common, and often fatal or debilitating, infections have become rare in countries with effective vaccination programmes.  Smallpox has been wiped out.  In fact, before the recent round of scaremongering, there was every prospect of eliminating measles in the US. If ‘homoeopathy’ is very critical of vaccination, then ‘homoeopathy’ is clearly very stupid.

“… vaccinations have some effectiveness, but certainly not to the extent claimed by the health authorities; they might have nasty side-effects, but sometimes this risk is lower than the threat of disease; conventional vaccines are not the only option, but if they are given some of the damage can be later reversed. The main conclusion is that, unfortunately, no-one can make the decision for parents. It is important, however, that parents have information from both pro and anti vaccination sources before they make up their minds.”

To be fair, there is an element of balance here.  But the claim that health authorities overstate vaccine effectiveness is not supported by any evidence.  Also, the risk is always, not sometimes, lower than the threat posed by the disease.  Otherwise they would not be licensed. I agree that parents need to make their own decision for their families.  However, they do not need any “anti vaccination” information.  This is generally either misleading or untrue.  To make an informed decision they need accurate information.

“… The idea that diseases should be eradicated from the world raises some worries. Disease is part of life and is, homeopaths believe, a reflection of a state of being. Trying to remove a disease from the world all together might “upset the balance of Nature in fundamental ways that we can barely imagine” …”

This is where the pre-scientific, magical, beliefs of homoeopaths are dangerous.  Disease is not an essential part of life.  It is inescapable, but sensible people know that, as a general principle, it is best avoided.  Why should anyone be worried that smallpox has been eradicated, for example?  In what way has the balance of nature been upset by its demise? Any fear of eradicating serious diseases is entirely irrational.

“… Contrary to the all-out war attitude to disease, many holistic thinkers claim that being sick in some of the childhood diseases is actually positive, as it allows the immune system to mature. Head (1999) says that after recovering from measles, for example, “there is usually a growth spurt, more energy, a clearer mind and increase in the child’s well-being” as well as better ability to deal with other viral infections. “

The view attributed to Head is very dangerous.  Any increase is a child’s ‘wellbeing’ after recovering from a disease is not a beneficial consequence of the disease, rather a result of recovery and return to health.  Growth is a function of childhood, not disease.  In fact, secondary infections are a well known complication of measles.  Rather than helping, measles hinders ‘wellbeing’. Of course, surviving viral infections often leaves an individual with antibodies that help us fight of infections in the future.  However, the purpose of vaccination is to train the immune system at a much reduced risk. This passage does make me wonder if holistic thinker is something of an oxymoron.

“… Measles Is a more serious disease, but again children that contract it recover swiftly apart from a low possibility for serious complications. Measles was a deadly disease in the 19th century and until the middle of the 20 century (it is still deadly in third world countries, where malnourishment is common). Its near-disappearance is generally attributed to the vaccination program. However, death rate from the disease was falling fast before the introduction of the vaccine or of antibiotics, and it is not normally dangerous now. Again, the vaccine is not very effective – in a recent measles epidemic in the US 40% of the sick children had been vaccinated. The vaccine has potentially serious side effects including convulsions, encephalitis, wasting and many more.”

This is a disingenuous mix of fact and fiction.  Most children do recover quickly from measles, but one in 2500 to 5000 die.  The death rate for the MMR vaccine, as far as anyone can tell, is zero. It is also true that measles was more deadly in the past and that malnourishment increases the risks.  The use of these facts is misleading; the risks mentioned earlier in this post apply in developed countries, with good health care provision. The death rate for measles may have been falling before, “the introduction of the vaccine or of antibiotics”; however, this careless thinking would condemn thousands to death.  Just because earlier interventions did some good, doesn’t mean that it’s not worth saving more lives with vaccines.

Back in the real world, measles incidence data for the US clearly shows the introduction of the vaccine reducing cases from more than 400,000 per year to less than 100,000 within five years.  Neither do the data show any decreasing trend over the twenty years before the introduction of the vaccine.

Measles cases reported in the United States, 1944-2007, represented as thousands of cases per year vs. year, with an inset 1983-2007 as cases vs. year. 1983 was chosen for the beginning of the inset graph as it represents the minimum reported cases until 1993, after the booster vaccine was added to the recommendations schedule. Data are from the US Centers for Disease Control.

This dramatic reduction in the incidence of the disease necessarily reduces the risk of all complications, including death.  For instance, Bloch et al(1985) published this assessment of the impact of measles vaccination in the US (which commenced in 1963).

“As a result of intensive efforts to vaccinate children, measles and its attendant complications of encephalitis and death have declined more than 99% from the prevaccine era. Similarly, subacute sclerosing panencephalitis has declined markedly. Measles vaccine has been demonstrated to be extremely safe, as well as extremely effective. The health and resource benefits due to vaccination against measles during the first 20 years of vaccine licensure have been enormous. In this period it is estimated that vaccination against measles has prevented 52 million cases, 5,200 deaths, and 17,400 cases of mental retardation, achieving a net savings of $5.1 billion. These substantial health and resource benefits of measles vaccination will continue to accrue in the future.”

The facts, as opposed to this homoeopathic propaganda, show that measles vaccination has been very effective.  Thousands of young lives have been saved.  Many more have been spared agonizing complications.

A quick look at deaths from measles in England and Wales shows paints a similar picture^‡. During the decade I was born (1960s) there were on average 80 deaths per year from measles.  A vaccine was introduced in 1968, and took a while to catch on.  In the 1970s average deaths per year fell to 24; during the 1980s it was 12.8 and for the 1990s it had shrunk to just less than two.

Bar’s point about the percentage of vaccinated children who contracted measles in an (unidentified) ‘epidemic’ belies a profound ignorance.  It fails to account for a vital fact: many more people are vaccinated than not. Taken with the fact that no vaccine is 100% effective, this means that a higher percentage of sick people in an outbreak may have been vaccinated.  However, at the same time, a far lower percentage of the vaccinated population will have been sick. [the maths is easy and has been rehearsed in lots of places, see here for example].

Whilst the MMR vaccine does have the potential for side effects, some serious, Bar ignores the fact that the risks from the natural disease are far, far higher.  He is also overlooking the fact the measles carries the risk of death, whilst MMR does not. Finally, Bar has clearly bought into a ridiculous holistic ‘disease is good’ worldview.  The fact is that measles is never a good idea.

“… Even homeopathic vaccinations shouldn’t be used in a routine, indiscriminate way; as discussed earlier, it is sometimes good to allow a child to go through a disease.”

He should be ashamed.  Any responsible homoeopath should be appalled.  I really hope that the ASA think this is unacceptable as well.

Some are more circumspect in their discouragement of vaccination.  Phoenixhomeopathy are based in east Sussex, and appear to be the vehicle of award-winning Society of Homeopaths member Sarah Whittaker.  Their website says this about vaccination (at the moment):

For those who choose to immunise, for adults and babies… …this clinic aims to minimise any ill-effects of immunisations by giving homeopathic remedies to support the patient before and after immunisation (while there is anecdotal evidence that homeopathic remedies can minimise ill-effects from vaccination, we cannot guarantee that these remedies will be sufficient to protect sensitive immune systems from vaccinosis – the term homeopaths give to ill-effects from vaccination).

(frozen page here, change log)

One of the problems I have with this is the implied default position of leaving babies unvaccinated.  There is no attempt to inform the reader what the actual risks are.  Instead there is the inference that vaccine damage is common (it is not) – so common that homoeopaths have their own name for it. This is bad enough, but there is also the claim that homoeopathy can treat vaccine complications; in reality, for the rare cases where this occurs there is absolutely no reason to think that homeopathy can help, and consequently no evidence that it can.

I would be interested to hear if any homoeopaths consider this disingenuous prose appropriate.  I’ve asked the ASA for their view.

Some friendly advice for responsible homoeopaths

If you are a homeopath or an advocate of homeopathy, we disagree profoundly about many things.  However, I would hope that we can agree that the public deserves accurate and truthful information on which to base informed decisions. I would also hope, given the very clear evidence that immunizing against measles is – with few exceptions – the right thing to do, that everyone involved in providing healthcare should be promoting vaccination for childhood diseases like measles, and opposing those who jeopardise public health by undermining it.

Given the current resurgence of measles, why not help your customers make properly informed decisions, protect the health of their children and the community generally, by saying something nice (and factual), in public, about vaccination in general and MMR in particular? Perhaps, instead of avoiding the issue you could put some accurate information about vaccines on your website, to help counteract the dangerous nonsense peddled by some of your colleagues?

Why not protect the community from dangerous homoeopaths?  If you see or hear them discouraging vaccination, or minimizing the dangers of preventable illnesses, like measles, why not complain directly to them homeopath to homeopath: they are undermining your profession as well as endangering public health.

If any of these dangerous homoeopaths belong to your professional association, please report them and demand strong disciplinary action.  If they will not see reason, please report them to the ASA and Trading Standards: don’t tolerate or condone their dangerous disinformation.

If you feel unable to help protect public health in this way, I would be really interested to hear why.

Useful information

I do not venture into this topic often on my blog.  I examined notions of informed consent and critiqued some of the Science Museum’s web pages on the topic .  Other bloggers are much braver.  The excellent Stuff and Nonsense blog has kept an eye on this topic. Respectful Insolence has commented on the current measles outbreak in the US.  This blog also covers vaccine issues and anti-vaccine propaganda regularly, as does Science Based Medicine.

For reliable information on measles and vaccination:

NHS Choices – Measles

NHS Choices – MMR

BBC Health – Measles

BUPA – Measles, mumps and rubella (MMR) vaccine

NHS Clinical Knowledge Summaries, Evidence on vaccines for measles

A nice summary of vaccine myths and misconceptions:

The College of Physicians of Philadelphia – Misconceptions about Vaccines

See here for the list of “Studies exonerating MMR” cited in Paul Offit’s seminal Autism’s False Prophets.

Disclaimer

I try to make sure that what I write is both accurate and fair.  If you think that I have got anything wrong please let me know.  If you are right I will happily change what I have written.

This is not medical advice.  If you need that see a properly qualified and registered doctor, not a homoeopath.

Notes

* Confirmed cases of Measles, Mumps and Rubella 1996-2010, ALL LABORATORY CONFIRMED CASES OF MEASLES,  MUMPS & RUBELLA England and Wales, 1996 – 2010, HPA

** “December 2010, 89.4% of two-year-old children in the UK had received their first dose of the MMR vaccine. For five-year-olds, the uptake rate had risen to 92.8%.”  Philippa Roxby, Measles outbreak prompts plea to vaccinate children, BBC Health 27 May 2011.

*** The role of the media in propagating the panic about the MMR vaccine has been reviewed by Ben Goldcare.

† The Wakefield debacle is well covered by a series of BMJ articles: Godlee, Smith and Marcovitch (2011) and Deer (2011a, 2011b, 2011c).

†† h/t @lecanardnoir, via twitter

‡ Measles notifications and deaths in England and Wales, 1940-2008, HPA.

References

Bloch AB, Orenstein WA, Stetler HC, Wassilak SG, Amler RW, Bart KJ, et al. Health impact of measles vaccination in the United States. Pediatrics. 1985 Oct;76(4):524–532. Available from: http://view.ncbi.nlm.nih.gov/pubmed/3931045.

Deer B. How the case against the MMR vaccine was fixed. BMJ. 2011 Jan;342. Available from: http://dx.doi.org/10.1136/bmj.c5347.

Deer B. How the vaccine crisis was meant to make money. BMJ. 2011 Jan;342. Available from: http://dx.doi.org/10.1136/bmj.c5258.

Deer B. The Lancet’s two days to bury bad news. BMJ. 2011 Jan;342. Available from: http://dx.doi.org/10.1136/bmj.c7001.

Godlee F, Smith J, Marcovitch H. Wakefield’s article linking MMR vaccine and autism was fraudulent. BMJ. 2011 Jan;342. Available from: http://dx.doi.org/10.1136/bmj.c7452.

Edits

None yet!

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