The MMR-autism hypothesis …gone but not forgotten Richard Roberts NPHS VPDP

Acknowledgements Liz Miller, Natasha Crowcroft, Mary Ramsay, Joanna White, Emma Savage (Health Protection Agency ) Simon Cottrell (NPHS VPDP) Daniel Thomas, Rhian Davey (NPHS)

Aims Review development of the MMR-autism hypothesis and others Review unprotected cohorts Current policy on catch-up and follow-up Discussion

Success of measles immunisation

“Healthy children don’t die of measles” Netherlands outbreak 1999/2000 About 3250 cases reported, 97% cases in unvaccinated religious community children ~20% serious complications; 5 encephalitis (1/650) 3 children died Irish outbreak 2000 Nearly 1500 cases notified, mainly from Dublin where MMR coverage was only 74% 3 children died

MMR allegations

Role of the media Parents have been misled by balance of media reporting (Report from Cardiff School of Journalism, Media and Cultural Studies) Equal weight given by media to pro and anti arguments Leading parents to believe that the scientific community is genuinely divided

MMR Mythbusting

Reviews of MMR safety (re:autism) Evidence reviewed at each meeting of JCVI and also by Committee on Safety of Medicines Review in March 98 by ad hoc MRC expert panel of all published and unpublished studies by the Royal Free IBD Group Further review by MRC December 2001 Review of alleged vaccine-damaged cases by expert panel convened by CSM Conference convened by American Academy of Pediatrics Report from the MMR Expert Group convened by Scottish Executive Report from Joint Committee on Health and Children of the Parliament of Ireland BMJ commissioned independent review published in Clinical Evidence WHO commissioned review by Global Advisory Committee on Vaccine Safety US Institute of Medicine Review of vaccines and autism 2004

Summary of research on postulated link between measles and IBD Measles virus is not present in the gut of IBD cases (7 papers – (finding in first Wakefield paper shown to be false positive) Perinatal measles is not a risk factor for IBD (5 papers) Measles vaccine does not case IBD (4 papers) Conclusion – no evidence at all that measles virus is involved in IBD

Results of epidemiological studies on MMR/autism ( Onset after MMR? Ecological association? New clinical presentation? No increased risk of autism after MMR No ecological association between autism prevalence and use of MMR No evidence of a new MMR-associated “autistic enterocolitis” syndrome

The Mirror 7 Feb 2002

2005

Mumps E&W : notified and confirmed

Mumps

Mumps cases by region E&W provisional total for first half 2005 = 33,531

Key features of current mumps outbreak National Predictable Preventable

Mumps

2015?

Measles, mumps and rubella predictions Control of measles and rubella good Increase in mumps since 1998 Initially older school age children universities/military entrants/prisons Increase in measles since 2002 in line with predictions Increase in rubella - When? Outbreaks of all three diseases inevitable in future with current MMR coverage

MMR uptake at 2 and 5 years MMR by age 2 1 st 85.0% (73.3% %) MMR by age 5 1 st 89.3% 2 nd 75.3%

MMR Task Group report 2005

MMR catch up (and follow up)

Wales MMR catch up 2005 Welsh Assembly Government policy direction, vaccine purchase and funding 100,000 doses to those aged years of age School age: use records to target 2 doses – one dose if not had any or uncertain Coordinated NPHS support Local Trust, LHB and practice implementation

New policy - MMR recording Accurate recording of –Change of consent –Reason for failure to attend (code 2 or 3) RATIONALE: further recall affected by coding Early data checking: –CHDs will send HV a monthly list of all children who have recently missed two MMR appointments –HV to check it, correct as necessary and return within a month RATIONALE: ensure offer made

New policy - early follow up Follow up at 18 months: –CHD will send the named health visitor a quarterly list of all children reaching 18 months of age who have not received MMR –HV to ensure accuracy against other records, and contact the parents of unimmunised children to offer discussion or immunisation. Return amended list within 3 months RATIONALE: Parents opportunity to review decision Reset the ‘missed 2 appointment flag’ –HSW and CHDs will clear flag at age 3 years RATIONALE: if missed appointments for no reason but not withdrawn consent this allows re-invitation for MMR pre-school

New policy - key age follow up Follow up at 4½ years (school entry): –CHD need to provide the named school nurse a quarterly list of all children reaching 4½ years of age who have not received two MMRs –SN to ensure accuracy then contact the parents of children who have missed MMR to offer discussion or immunisation. Return amended list to the CHD within 3 months Secondary school entry: –School nurse to identify those consented but missing MMR and write to these parents

School leaving / teenagers “The opportunity of giving the Tetanus/Diphtheria/Polio (Td/IPV) booster vaccine (teenagers) must be used to offer MMR to those who have not received two doses” (WHC (2005) 081)

New policy – Trusts required to audit Audit the CHS every six months to ensure a 100% offer rate for MMR Audit quarterly returns from health visitors of amended 18 month lists Audit quarterly returns from health visitors/school nurses of amended 4½ year lists

Discussion Are you positively encouraging parents to accept MMR? Do you follow up defaulters early? Do you review uptake at key ages to offer MMR again? Are you aware of recent WAG policy on follow up of defaulters?

Measles