Melissa Hubscher, Veronica See, Michelle Chaung, Farah Asghar PHM142 Fall 2019 Instructor: Chesa Dojo Soeandy Coordinator: Jeffrey Henderson Autism and MMR Melissa Hubscher, Veronica See, Michelle Chaung, Farah Asghar September 24th, 2019

Agenda Introduction to Autism Spectrum Disorder and the MMR vaccine A study linking Autism Spectrum Disorder and MMR The Flaws of Andrew Wakefield’s Study Why we should be concerned about anti-vaccination

Autism Spectrum Disorder (ASD) Autism Spectrum Disorder: a developmental brain disorder that affects a person’s social interaction and communication capabilities The degree to which the disorder impacts daily functioning is variable Most commonly diagnosed within the first two years of life Symptoms include: limited eye contact, poor listening skills, repetitive behaviours, resistance to changes in routine, etc. NIMH » Autism Spectrum Disorder. (n.d.). . https://www.nimh.nih.gov/health/topics/autism-spectrum-disorders-asd/index.shtml.

What is the cause of Autism? The cause of Autism is largely unknown For some children, Autism is caused by a genetic condition Rett Syndrome is a rare genetic disorder that occurs exclusively in females It is caused by mutations on the MECP2 gene on the X chromosome What is Rett Syndrome? (n.d.). .https://www.rettsyndrome.org/about-rett-syndrome/what-is-rett-syndrome/

MMR Vaccine MMR is an attenuated live virus vaccine that allows the body to develop immunity to Measles, Mumps, and Rubella. Children should receive two doses of the vaccine One dose of the MMR vaccine is 93% effective against measles, 78% effective against mumps, and 97% effective against rubella. With a subsequent dose, the effectiveness increases. Vaccination programs have successfully eliminated all cases of rubella from the United states About Rubella (German Measles) Vaccination | CDC. 2019, June 20. https://www.cdc.gov/vaccines/vpd/rubella/index.html.

Agenda Introduction to Autism Spectrum Disorder and the MMR vaccine A study linking Autism Spectrum Disorder and MMR The Flaws of Andrew Wakefield’s Study Why we should be concerned about anti-vaccination

Who is Andrew J Wakefield? AJ Wakefield, S. Murch, M. Anthony, J. Linnell, D. Casson, and M. Malik. (n.d.). RETRACTED: Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children - The Lancet.

Article 12 children, with a history of normal development, followed by a loss of acquired skills and abdominal pain Findings: 12 had intestinal abnormalities 8/12- onset of behavioural symptoms associated with MMR vaccine 9 had autism Instead of saying the title, paraphrase it. Further investigation is needed AJ Wakefield, S. Murch, M. Anthony, J. Linnell, D. Casson, and M. Malik. (n.d.). RETRACTED: Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children - The Lancet.

Interpretation Normal Development MMR vaccine Gastrointestinal disease Possible relation Related Gastrointestinal disease Developmental regression Showed a temporal link although - although didn’t explicitly state there was a causal relationship. Eggertson, L. (n.d.). Lancet retracts 12-year-old article linking autism to MMR vaccines.

Agenda Introduction to Autism Spectrum Disorder and the MMR vaccine A study linking Autism Spectrum Disorder and MMR The Flaws in Andrew Wakefield’s Study Why we should be concerned about anti-vaccination

Design flaws Sample size of 12 No controls used Biased subject selection: Some of the parents were JABS activists and were convinced that vaccines were responsible for their children’s concerns Some were advised by JABS to contact Wakefield Parents knew each other https://bobsullivan.net/gotchas/everyday-economics/cognitive-bias/youre-not-wrong-you-just-have-a-small-sample-size-problem/ Deer, Brian. "How the case against the MMR vaccine was fixed." Bmj 342 (2011): c5347. Deer, Brian. "How the case against the MMR vaccine was fixed." Bmj 342 (2011): c5347. Image: https://bobsullivan.net/gotchas/everyday-economics/cognitive-bias/youre-not-wrong-you-just-have-a-small-sample-size-problem/

Distorting facts Example 1: study reported 9 of 12 children had regressive autism Fact: only one of 12 did; 3 didn’t have autism at all. Example 2: study reported that onset of of symptoms for that child appeared 2 weeks after receiving the MMR vaccine Fact: interview with his mother suggested that it was 6 months. Example 3: study indicated that all 12 children had been developmentally normal prior to MMR Fact: 5 out of 12 had previous developmental issues Example 4: Study reported that all children had gastrointestinal pathology Fact: None of the children had GI symptoms Deer, Brian. "How the case against the MMR vaccine was fixed." Bmj 342 (2011): c5347. Deer, Brian. "Wakefield’s “autistic enterocolitis” under the microscope." Bmj 340 (2010): c1127. Wakefield, Andrew J., et al. "RETRACTED: Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children." (1998): 637-641. Deer, Brian. "How the case against the MMR vaccine was fixed." Bmj 342 (2011): c5347. Deer, Brian. "Wakefield’s “autistic enterocolitis” under the microscope." Bmj 340 (2010): c1127. Wakefield, Andrew J., et al. "RETRACTED: Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children." (1998): 637-641.

Undisclosed Financial interests Hired by Richard Barr, who intended to launch a lawsuit against drug manufacturers making the MMR vaccine Total bill: £435643 + expenses In 1997, Wakefield filed a patent for his own “safer” single measles vaccine as he claimed that the MMR has been “instrumental in the development of Crohn’s disease”. https://www.pinterest.ca/pin/403635185349078432/ Deer, Brian. "How the case against the MMR vaccine was fixed." Bmj 342 (2011): c5347. Flaherty, Dennis K. “The Vaccine-Autism Connection: A Public Health Crisis Caused by Unethical Medical Practices and Fraudulent Science.” Annals of Pharmacotherapy, vol. 45, no. 10, Oct. 2011, pp. 1302–1304, doi:10.1345/aph.1Q318. Deer, Brian. "How the case against the MMR vaccine was fixed." Bmj 342 (2011): c5347. Flaherty, Dennis K. “The Vaccine-Autism Connection: A Public Health Crisis Caused by Unethical Medical Practices and Fraudulent Science.” Annals of Pharmacotherapy, vol. 45, no. 10, Oct. 2011, pp. 1302–1304, doi:10.1345/aph.1Q318.

Flaherty, Dennis K. “The Vaccine-Autism Connection: A Public Health Crisis Caused by Unethical Medical Practices and Fraudulent Science.” Annals of Pharmacotherapy, vol. 45, no. 10, Oct. 2011, pp. 1302–1304, doi:10.1345/aph.1Q318.

Agenda Introduction to Autism Spectrum Disorder and the MMR vaccine A study linking Autism Spectrum Disorder and MMR The Flaws in Andrew Wakefield’s Study Why we should be concerned about anti-vaccination

Results and Problems Anti-vaccination Movement Weaponization of Health Communication Herd Immunity

Anti-vaccination Movement and Credibility of Resources Brief History: Religious oppositions started back to the 18th century and then some scientific evidences started opposing vaccinations in the 1970s and 1980s Recent surge due to the MMR vaccine and Autism miscorrelation Jenny McCarthy and Oprah Winfrey Examples Correlation does not mean causation. Hussain, A., S. Ali, M. Ahmed, and S. Hussain. 2018. The Anti-vaccination Movement: A Regression in Modern Medicine. Cureus 10. Miseducation and Credibility

Results to Declining Vaccinations Online Medical Information Infamous example of measles outbreak: 2014-2015 in Disneyland, Anaheim in the United States 125 people contracted the disease Resulted in a law to be created Power of weaponizing online information People may also misconstrue information without proper guidance and online information have changed patient-physician interactions Dissemination of false information and receiving more “views” Hussain, A., S. Ali, M. Ahmed, and S. Hussain. 2018. The Anti-vaccination Movement: A Regression in Modern Medicine. Cureus 10. Online Medical Information

Herd Immunity Vaccination helps protects susceptible populations at high risk for complications of infections Herd immunity also protects people beyond the directly targeted population and the individual who received the vaccination Prevents overall circulation of infectious agents in unvaccinated susceptible populations Kim, T. H., J. Johnstone, and M. Loeb. 2011. Vaccine herd effect. Scandinavian Journal of Infectious Diseases 43:683–689.

Summary The MMR vaccine allows the body to develop immunity to Measles, Mumps, and Rubella. Andrew Wakefield published an article in the Lancet that showed a temporal link between the onset of symptoms of developmental regression and gastrointestinal symptoms to the MMR vaccination The temporal link speculated in the paper was based on poor study design, distortion of facts and undisclosed financial interests. Wakefield was found guilty of ethical, medical, and scientific misconduct; his paper was retracted and his medical license revoked by General Medical Council in Britain. Anti-vaccination movements surged after the Wakefield’s study, causing multiple outbreaks, decreasing herd immunity within the population. Online medical information causes miscorrelation and popular influential individuals miseducated the public, causing a weaponization of health communication. Herd immunity contains the spread of disease and it protects the less susceptible people in the population.

Research Citations About Rubella (German Measles) Vaccination | CDC. 2019, June 20. . https://www.cdc.gov/vaccines/vpd/rubella/index.html. AJ Wakefield, S. Murch, M. Anthony, J. Linnell, D. Casson, and M. Malik. (n.d.). RETRACTED: Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children - The Lancet. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(97)11096-0/fulltext#secd3554050e829. Deer, Brian. "How the case against the MMR vaccine was fixed." Bmj 342 (2011): c5347. Deer, Brian. "Wakefield’s “autistic enterocolitis” under the microscope." Bmj 340 (2010): c1127. Flaherty, Dennis K. “The Vaccine-Autism Connection: A Public Health Crisis Caused by Unethical Medical Practices and Fraudulent Science.” Annals of Pharmacotherapy, vol. 45, no. 10, Oct. 2011, pp. 1302–1304, doi:10.1345/aph.1Q318. Eggertson, L. (n.d.). Lancet retracts 12-year-old article linking autism to MMR vaccines. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2831678/. Hossain, M., and M. Kabir. (n.d.). Detecting Child Autism Using Classification Techniques. - PubMed - NCBI. https://www.ncbi.nlm.nih.gov/pubmed/31438174. Hussain, A., S. Ali, M. Ahmed, and S. Hussain. 2018. The Anti-vaccination Movement: A Regression in Modern Medicine. Cureus 10. Kim, T. H., J. Johnstone, and M. Loeb. 2011. Vaccine herd effect. Scandinavian Journal of Infectious Diseases 43:683–689. NIMH » Autism Spectrum Disorder. (n.d.). . https://www.nimh.nih.gov/health/topics/autism-spectrum-disorders-asd/index.shtml. What is Rett Syndrome? (n.d.). .https://www.rettsyndrome.org/about-rett-syndrome/what-is-rett-syndrome/

Image Citations Andrew-wakefield.jpg (2002×1502). (n.d.). . https://static.independent.co.uk/s3fs-public/thumbnails/image/2017/10/11/10/andrew-wakefield.jpg. CDC. 2019, September 16. Measles Cases and Outbreaks. https://www.cdc.gov/measles/cases-outbreaks.html. Hayes, P. 2019, April 23. RACGP - Good for the herd. https://www1.racgp.org.au/newsgp/clinical/good-for-the-herd. Reactivating MECP2 Consortium - Rett Syndrome Research Trust. (n.d.). . https://reverserett.org/research/consortia/reactivating-mecp2-consortium/. screen-shot-2018-02-18-at-8-12-36-am.png (1222×1240). (n.d.). . https://violentmetaphors.files.wordpress.com/2018/02/screen-shot-2018-02-18-at-8-12-36-am.png. Sample size image screen shot https://bobsullivan.net/gotchas/everyday-economics/cognitive-bias/youre-not-wrong-you-just-have-a-small-sample-size-problem/ Pounds image screenshot: https://www.pinterest.ca/pin/403635185349078432/