The needle and the damage done

THE hours after her one-year-old son Victor was injected with the MMR vaccination were among the longest of Iustina Del Veneziano’s life.

After an agonising decision process before deciding to go ahead with the jag, the Edinburgh mum was watching for any small indication that she might have made the wrong move. She didn’t have to wait long.

"Victor didn’t react well," she says. "He’s a very lively baby normally and he wasn’t well. Fortunately he soon got better - I think it was probably a virus or he was teething. I suppose I was just waiting for the signs that something was wrong. But you do worry, especially when it’s a first baby."

Today, five months later, Victor is a happy toddler who knows his own mind and isn’t afraid to make his feelings known. What’s more, he’s been safely protected against three potentially devastating diseases: measles, mumps and rubella. Doctors and public health experts wish that all children had that shield against disease that vaccination can provide.

But confidence in the triple jag was destroyed by claims, based on a 1998 paper in the respected journal the Lancet, that it could be linked to autism and bowel disease. Uptake of the vaccine plummeted as confused and frightened parents desperately tried to decide what was best for their children.

Last week, when 10 of the 13 authors of the original research paper linking MMR with autism distanced themselves from that crucial interpretation, Del Veneziano and thousands of other parents had every right to feel conned. Whether they had reluctantly opted for MMR or taken matters into their own hands to go private and buy the three vaccines separately, scarcely any parent has taken the decision lightly in the six years since the report was published.

Indeed, many will still be confused by the controversy, and lead researcher Dr Andrew Wakefield is standing by the research. While logic suggests confidence should now be restored in the vaccine, there are still many who have their doubts - and a few conspiracy theorists who believe even the latest move is part of an establishment cover-up.

In fact, the MMR debate has always been surrounded by much that simply isn’t rational. The enormous weight of evidence is that MMR is entirely safe and that there is no link between the vaccine and autism or bowel disease. But that’s something GPs have found hard to explain to their patients, particularly as the whole issue is confounded by Mammon - parents know that GPs lose money if they do not meet targets on immunisation uptake.

As one GP, who firmly believes in MMR and has had his own children vaccinated, says, ‘anti’ parents have accused him of being in with the establishment and refusing to act on principle because he backed the jag. "It’s as if you can only be principled if you agree with their principles," he says.

Yes, the scientific evidence is compelling. But then, so is the experience of parents who believe their previously happy, healthy child descended into autism after the MMR jag. Nobody can deny that autism is a devastating, under-researched and under-resourced condition. Nor that more children appear to be developing it.

This is a conundrum which GPs have been coping with on a weekly basis ever since that fateful Lancet paper was published. On the one hand, they don’t want to dismiss their patients’ fears. On the other, the vast majority believe that MMR is the best, safest and most effective way to protect children.

So perhaps we can forgive family doctors for sounding a bit smug in the wake of last week’s retraction.

Dr John Garner, an Edinburgh GP who is chairman of the British Medical Association Scottish Council, says: "I feel vindicated, certainly. I’ve always believed that MMR is the way forward and now that the other authors have distanced themselves from the research, I hope that we begin to see an end to the controversy."

Garner knows how worried parents felt - he had a few bad moments himself when the Lancet paper first came to light. "I thought, ‘Oh my God, what have I been doing? My goodness, this could be awful if this is true and I’ve been giving a treatment that might feasibly cause autism in a few susceptible children.’ I was filled with dread and fear.

"Then I read the detail and I saw how thin the evidence was and learned that there were already papers published which didn’t support the idea of a link."

Garner won’t feel smug, he says, until the latest revelations are translated into a rise in uptake. There were no immediate signs of a sudden rise in demand for MMR jags in the wake of this week’s developments, but nonetheless the signs are that his wish is about to be answered.

According to Dr Claire Bramley, an epidemiologist in immunisation with the Scottish Centre for Infection and Environmental Health, there are indications that things are already looking up. "The latest published figures for two-year-olds show that 86.4% have been immunised," she says. "But preliminary figures for younger children are encouraging, so we hope the next figures to come out will show an increase."

These figures are due out a week tomorrow. They are likely to confirm that Scotland still has much better MMR uptake than other parts of the UK - around 8% higher than most parts of England and Wales. There are variations around Scotland, with uptake in Glasgow running at 85.8% compared with 88.8% in Lothian, for example. Issues like deprivation and rurality are known to have an effect on whether parents have their children immunised.

Dr Charles Saunders, consultant in public health medicine with NHS Fife, also believes the tide was already turning in favour of MMR even before last week’s events. "I think people are realising that there’s little evidence, almost none, to suggest a link between MMR and autism.

"When it comes to parents who have gone for single vaccines, the likelihood is that they’ve wasted their money and they’ve also left their child at risk of disease for longer than if they had gone for MMR."

His concern is for the future. "There’s a cohort of children who have not been properly immunised and that could cause real problems when they’re older. For example, they might pick up one of these diseases, perhaps if they go on holiday to somewhere where they are still prevalent. If women, in particular, get infected with rubella when they are pregnant, that could be disastrous for the unborn child."

Josie Saunders, who works in public relations in Glasgow, doesn’t believe that she wasted the near 1,000 she spent sending her son Marius to France for single vaccines. For her, the issue is still muddy. Even last week’s retraction doesn’t convince her that MMR is safe. "Just because research has been discredited, that doesn’t mean it’s not good research," she says. "The real problem is that nobody is funding decent, independent research which would reassure parents."

Del Veneziano, a waitress who lives in Edinburgh, had the additional worry that Victor had been born more than two months prematurely and, she thought, he seemed just too tiny to have three different viruses injected into him at once. "We thought about it a lot and looked at the internet to get as much information as possible. They don’t really give you much information at the GP surgery, just a leaflet.

"We were scared, really, because of what we read about the connection with autism. Then a relation in Italy who used to be a nurse warned us to be careful. There had been an MMR scandal in Italy a while before that and they don’t think much of the British NHS in Italy in any case."

Del Veneziano was sufficiently worried to investigate the possibility of single vaccines and contacted GP Plus, the private GP service in Edinburgh. "They gave us some information and we really thought about it. But we spoke to our GP, to other parents and to doctors at the hospital. Everyone said it was safe, so eventually we went ahead." On the day she saw the GP, Del Veneziano was still swithering. "But he said his own children had had it and that it was perfectly safe. So we went ahead."

Dr Peter Copp, the medical director of GP Plus, said he believed about 80% of the population believed that MMR was safe - and he himself thinks it is effective for most children. However, he defended the rights of the minority who still have concerns and revealed his service, one of the few to offer single jags, had immunised a total of 4,000 children in the last four years.

He told Scotland on Sunday: "There are some parents who simply would not have their children immunised unless they could have the single vaccines. As a doctor and a father, I believe we have to be pragmatic about that and the important thing is to make sure people are immunised."

Copp added that inquiries about single jags had doubled at GP Plus following last week’s U-turn by the 10 scientists who now believe there is no MMR-autism link. He said: "I think there could be several reasons for this. Some parents, and others, are already so cynical about what the authorities say that they see it as a stitch-up. They think it’s a McCarthyite vendetta against Dr Wakefield."

Garner believes that the Lancet made a mistake in running the original article but that it was published in good faith. "There’s a balance. In the scientific world there’s real pressure to publish what could be the start of a profound and exciting development, but there’s a risk that you start rabbits running."

And, indeed, those "rabbits" seem to be multiplying. We’ve had so many scares about the contraceptive pill, for example, that it’s easy to lose sight of why we use it in the first place. Hormone replacement therapy, already implicated in a slightly increased risk of some types of breast cancer, has now been fingered for strokes as well. And not to forget the other vaccine scares, including the ongoing controversy about inoculations containing mercury. Even if MMR is comprehensively cleared, a near impossibility in a world where everything has a level of risk, another health scare will doubtless be along soon.

But what of the condition at the centre of the MMR furore? Just ahead of the Lancet authors’ statement last week, the Scottish Executive announced almost 2m funding for autism, a small proportion of which will be spent on research. This simply isn’t enough for campaigners. Bill Welsh, spokesman for Action Against Autism believes that the furore surrounding the Wakefield paper has put a stop to research into a vital area - the possibility that children with autism have a serious bowel disorder.

"Although any investment is welcome, they’re simply investing in the status quo. We have an epidemic of autism. We need to have the courage to investigate that, no matter if that means the vaccine programme is implicated."

As for Del Veneziano, the clarification from the report authors helps her believe she made the right choice. But she’s not thrilled about it. "I think if I had another baby, I would go for MMR again. I don’t know what I think about the doctors saying that there isn’t a link now. I suppose I’m angry that so much worry has been caused."

How other countries deal with vaccination

THE MMR vaccine is endorsed by the World Health Organisation, which recommends an uptake target of 95% to provide ‘herd immunity’ to protect society from mumps, measles and rubella.

Some countries have already achieved that, notably Finland, where the vaccine was introduced in the 1980s.

MMR was introduced in the US in 1975. Children in Britain started receiving the vaccine in 1988 and it is also used in some 30 European countries, as well as in Canada, Australia and New Zealand.

Elsewhere the experience has been less happy. Japan withdrew its version of the triple vaccine 11 years ago, not because of fears of autism but because of unusually high rates of mumps meningitis following the injection.

Instead, Japan now immunises children with single measles and rubella vaccines given at the same time.

While Britain has taken a strident line against single vaccines, other countries, notably France, have taken a more pragmatic view. Although MMR is compulsory, around 15% of pre-school children do not receive it, so a separate measles vaccine can be given to at-risk nursery children, while rubella can be given to pregnant women.

France has, however, clamped down on UK health tourists who previously travelled across the Channel to buy single vaccines for their children.