Measles – Ignorance and Complacency are the Greatest Dangers

Listening to the news reports surrounding the current measles epidemic in South Wales this week, it has struck me afresh how much our nation is in need of a refresher course on the nature of this age-old infection. While it has been one of the resounding successes of modern medicine that this potentially devastating disease is so rare in the developed world in the 21st century, this inevitably means that we have lost a great deal of the collective knowledge and understanding that was such a valuable resource when measles was commonplace. The contrast with chicken pox is clear – we still know this illness and understand it. Parents usually diagnose it themselves and manage it without needing any medical advice, only turning to a doctor when there seem to be problems. For measles, most of us know it involves a fever and a rash, and can be serious, but not much more.

The result of this is that we are left collectively stunned by the death of a man of 25 with measles. How can that happen? Isn’t a young man of that age supposed to be in the prime of his life, having escaped the frailties of childhood but well before the vulnerability of old age? And yet the risk of death as a complication from measles in this age group is the same as that for the under 5’s. In fact the age group that is most at risk of the major complication of measles – death, encephalitis (infection of the brain), hospitalisation and pneumonia – are the over 30’s. Young children are more at risk only for diarrhoea and ear infections.

It is no surprise, therefore, that a woman being interviewed on the radio recently had made the assumption that measles was only really a problem for the under 5’s. Why would she think differently? This is the case for other infections, after all. Whooping cough, for instance, will give you a nasty cough for 3 months as an adult, but it is infants whose life could be in danger. Haemophilus B, part of the vaccination programme for babies, can cause meningitis in the under 2’s, but not in older children. Yet if we assume measles is not a problem for older children and adults, then the greatest risk to a successful catch-up programme for the MMR vaccine is not those ideologically opposed to vaccination, but ignorance and complacency among those with a more moderate view, but who were caught up in the confusion surrounding MMR in the late 1990’s.

It is easy to see why measles is so associated with childhood in our collective unconscious. The disease is so infectious that, before vaccination, it was rare to get to the age of 5 without having succumbed to it – and so our image of the infected patient is usually one of a child. The vaccination programme is delivered in two doses, at around 1 year of age and again pre-school – so we have no reason to associate it with any other age range. The fact that 10-18 year-olds are the primary age group affected by the outbreak in Wales, however, is a stark reminder of the naivety of these assumptions, as it is clear that this infection is no respecter of age, and anyone who lacks immunity is vulnerable.

The post-mortem of the young man who died has been described as inconclusive – there is no doubt that he had measles, but at the moment it cannot be said with certainty that this was the cause of his death. Well, it seems to me that it stretches to incredulity the idea that someone who dies with measles has not died from measles. I suspect we are making another false assumption about his death, however. The fact that he was found dead in his flat could easily make us draw the conclusion that if only he had sought medical advice, he might still be alive now. In truth it is unlikely that a hospital would have been able to do anything. We have better supportive measures these days than in the past, but there is still no treatment at all for measles encephalitis – it always has been, and remains, a lottery – the risks are low (1 in 1000 cases overall, 3 in 1000 for the over 30’s), but the stakes are devastatingly high.

Public Health England are absolutely right to launch a vaccination catch-up campaign across the country rather than just in South Wales. It would be tragic indeed if we waited for an epidemic to break out locally before anything was done, and there are many areas in the country where the drama of what has happened in Swansea could be re-enacted at any time. There is no reason to wait to hear from someone about this either – if you or your child are not fully protected (by either a clear history of having had measles, or two MMR vaccinations) then you can go to your GP this week and ask to be vaccinated. There is no upper age limit. There is also the interesting phenomenon that the children who may have missed out on MMR when they were younger are getting to an age where they can, and should, express their own views and may wish to contact their GP for advice themselves.

A final word about the situation for younger babies, which is a little more complicated. Under 6 months the MMR vaccine is not licensed, and should not be given. These babies also have a great deal of residual immunity from their mothers and so are not at great risk. Over 6 months the vaccine could be given if there was felt to be a significant risk – for instance if someone was planning to visit South Wales. This would be based on parental preference, and is not a clear recommendation. The problem with vaccinating earlier than the usual schedule is that the maternal immunity can neutralise the effects of the vaccine, and so any MMR given early does not ‘count’ towards the schedule and 2 further doses will still be required. For the most part it is best to wait and undergo the usual vaccination programme schedule.

Whooping Cough Vaccination for Pregnant Women: Neat Idea, Missed Opportunity

New medical advice is transmitted at such lightning speed these days that GPs and their patients often have to work their way through it in tandem. This was illustrated to me quite starkly on Friday morning with the announcement of a new, temporary vaccination programme in the UK for pregnant women to protect their children from whopping cough. The first I heard about the proposal was on the radio over breakfast, by mid-morning I learnt that all GPs had been sent an e-mail with the new instructions, and before lunch I was trying my best to advise one of my pregnant patients on the issue. Funny how you can feel reasonably up-to-date on Thursday evening, and behind the times only 12 hours later!

Having had the luxury of the weekend to actually read the information from the Department of Health I feel a little more prepared to advise women in the coming week – and this is what is required of a GP these days. It is not sufficient simply to adhere to the Government line on these matters; patients expect, and deserve, a doctor who will consider medical advice carefully and be willing to give thoughtful guidance. And my conclusions? In a nutshell, it’s a great idea, but why, oh why, oh why are the Department of Health not conducting a proper clinical trial?

The proposal is to vaccinate all pregnant women between 28 and 38 weeks gestation against Pertussis (whooping cough) as a temporary programme in response to the significant rise in infection rates in the last 2 years. And whatever else we think, it is certainly a neat idea. We do have a problem with Pertussis at the moment, both in the UK and worldwide. The number of confirmed cases so far in the UK in 2012 is nearly 5000, compared with around 1000 for the whole of 2011. There is no doubt that this is in part due to greater awareness of Pertussis at the moment on the part of doctors (myself included) and so increased diagnosis of cases in adults that would previously have been missed. However, this seems to be more than just an artefact, since there has been a sharp rise in the number of cases in infants under the age of 3 months, many of whom become very unwell and in whom diagnosis will always have been much more accurate. It is the very young who are the concern with Pertussis, since they will not yet have immunity from the vaccination programme, and their small lungs are especially vulnerable. So far in 2012 there have been 9 deaths in babies in the UK, and many more will have been seriously unwell.

How best to protect these babies? Well if everyone was immunised then there would be no-one to transmit the infection to them (the protection afforded by herd immunity), but this is extremely difficult with Pertussis since the protection afforded by vaccination wanes within a few years. Unlike the recent measles epidemics where poor uptake of MMR is clearly to blame, most cases of Pertussis in older children and adults occur in people who have been fully vaccinated. A programme where everyone was immunised every 5-10 years would work, but the cost of this would be enormous.

The beauty of vaccinating pregnant women is that we know the woman will make antibodies against the disease, and that these can cross the placenta in late pregnancy, be taken up by the baby and could afford protection in those crucial early weeks until the childhood vaccinations have kicked in. A single vaccine therefore protects exactly the at risk individual, and there is no need to depend on herd immunity. When a mother chooses to accept the vaccine she is choosing to protect her own child – the personal potential benefit is very clear.

We have good reason to think the vaccine is safe. It is a killed vaccine, which means it cannot possibly cause active infection, and these vaccines have reliably been shown to be safe in pregnancy. The vaccine also contains diphtheria, Tetanus and Polio vaccination (there is no single Pertussis vaccine so the combination has to be used) and the first two of these have often been used in pregnant women without difficulty. While there is not much data for this exact vaccine it seems extremely unlikely that there are any risks other than local reactions in the arm and very rare allergic reactions, and only vaccine conspiracy theorists are likely to argue against this.

It is also likely to work. I agree with the conclusions of the expert committee that:

…it is reasonable to assume that this approach would provide young infants with some important, although possibly not complete, protection against pertussis, and it is likely to be the most effective immunisation strategy to provide protection to young infants.

The report also state, however, that

the effectiveness of prenatal immunisation against pertussis to protect young infants is uncertain.

There are reasons to think it might not work. Will the maternal antibodies be sufficient to truly protect? Is there any risk that the antibodies might actually interfere with the response to the infant vaccination programme, and lead to reduced immunity later in childhood? So what should a scientist do when he or she has a good hypothesis which is uncertain: Test the hypothesis with a trial. There is such an opportunity here to answer this question for both the current and future generations – we need to conduct a Government funded, blinded, randomised clinical trial. Instead of rolling out this temporary programme as a knee jerk reaction, pregnant women could be offered the chance to be in the trial. They would receive either the vaccine or a placebo injection, meaning adverse reactions in the pregnancy could be compared, as could infection rates and outcomes in the babies.

Within a year we would start to get a real answer to this question. If it works then this could become a permanent and valuable addition to our fight against this serious disease. If it is shown to be ineffective then we could stop wasting time and money, go back to the drawing board and look for a better solution. What is more, the vaccine itself would be protected against unfounded claims of harm. Sadly the background rate of stillbirth is sufficiently high so that the Daily Mail headline “Whooping Cough Vaccine Killed my Baby” might as well have already been written, and without the robust clinical evidence available from a randomised trial these inevitable anecdotal stories will be much harder to evaluate. Granted, the trial would need to be large and the cost would not be insignificant, but the long-term gain of truly knowing how to protect babies from this infection must surely be worth it.

So how should I advise my patients in the lack of proper trial data – well it is a shame we shall never know for sure, but the issue is important enough to take action, and the balance of risk has to be in favour of the vaccine.

The Binscombe Express rides again! The Triumph of Common Sense and the Power of Twitter

When the Infection Control lead for Surrey PCT advised me that the wooden train set in my consulting room would be deemed an unacceptable infection risk by the Care Quality Commission (CQC), I responded like most of us do when faced with a powerful figure in authority. That is to say: I muttered about it, sulked a bit, complained loudly to my family, and then assumed that nothing could be done. After a few days I thought I would write a blog on the subject – after all, then I could mutter, sulk and complain for a bit longer, and to a few more people – but I still assumed that nothing could be done, and duly complied with the order from above.

It was when I shared the blog on Twitter that things started to get interesting. It stimulated a moderate response at first, but an encouraging one. One or two people commented and added their complaint to mine, there was the odd retweet and I at least felt listened to. Then, on Sunday night I came across a tweet concerning a piece of research that demonstrated how unlikely it was to transmit infection via inanimate objects – like toilet seats and library books. Emboldened by the previous support I had received, and empowered by this piece of evidence, I posted a link to the blog again, and asked if anyone was aware of any research on the subject of toys in GP surgeries, stating that I might try to contest the instructions we had received.

They say that timing is vital on social media sites, and (by accident rather than design) the timing on this one was just right – it was about half an hour after Andy Murray’s heart-breaking defeat in the final of Wimbledon and the Twitter world, which had been in a peculiar slumber during four tense sets of tennis, had suddenly woken up. Maybe it was a lingering desire to support the cause of the under-dog, or perhaps the idea of bureaucrats taking a child’s toys away really struck a chord, but within minutes GPs and patients alike were tweeting and retweeting faster than I could keep up.

The cause came to the attention of Margaret McCartney, a GP in Glasgow who knows how to fight for a just cause (her blog is well worth a look, as is her book The Patient Paradox). She immediately involved the CQC in the conversation (I had not even thought they might be on Twitter!) and resolved to get a response from them the next day. Before I had finished my morning surgery there was a clear statement from the CQC (see comments on my previous blog) that they had no problem whatsoever with toys, wooden or otherwise, and that Infection Control teams were being over zealous in their advice. By mid-afternoon Surrey PCT had backed off somewhat, issuing a media statement to that effect, and I was being interviewed by The Telegraph!

I am delighted that Binscombe children will now be able to play trains in my room for years to come, and my faith has been restored in the CQC. I’m just as encouraged by the media attention this has received – there was an article in The Telegraph yesterday, the story was also picked up by the GP magazine Pulse, and the Radio 4 programme Inside Health. When I talk to other GPs I find that many are under the same pressure from their Infection Control teams as I was, and we need to get the right message out there.

One of the remarkable features of Social Media is the way it connects people from different disciplines – like GPs, patients and health journalists – and gets them talking together. Even two years ago it was unfeasible that most ordinary GPs would communicate directly with health journalists, and now it can happen on an almost daily basis. Whatever else we think about this internet age there is no doubt that there has never been more opportunity for ordinary people to have an impact – whether it is a GP from Godalming scoring a minor success like this, or something more dramatic like a 14 year-old girl changing the editing policy of a major teen magazine, there is a vehicle for your voice to be heard if you have something interesting enough to say, and the passion to shout about it.

And as for the Binscombe Express? Well the discerning eye will have noticed from the photograph that it is in need of a little attention – sadly, the original 6 carriages I started with 10 years ago have dwindled down to only 3 – the result of some toddlers appreciating its appeal a little too much. Like any responsible Railway Proprietor, however, I intend to invest for the future and replace the missing carriages – well, at least I plan to raid the children’s old Brio set that’s stored away in the loft and see what I can find. Let’s hope they won’t notice!

The Wrong Kind of Virus on the Line – the Demise of the Binscombe Express

I’m delighted to say that this post needs to be amended. As you will be able to see from the helpful comment from the CQC below, they do not have a problem with wooden toys. The advice we received from the Surrey PCT infection control lead that we had to remove wooden toys in order to be CQC compliant was misguided, and the Binscombe Express can stay! I will be blogging again soon on how this came about, and have left the blog in its original form below, but am very grateful for the swift clarification and common sense approach of the CQC.

Here is the original post:

This week saw the Binscombe Express roll out from the station for the final time, pushed reluctantly into an early and unwanted retirement. It might never have rivaled the glamour of the Great Western, or the notoriety of the Orient Express, but in certain circles among the toddlers of Godalming it has ranked right up there in importance with Thomas the Tank Engine. I’m talking, of course, about the Brio train set in my consulting room. Lovingly home-made in a simple figure of 8, it has been the undisputed domain of my younger patients f or the last ten years. A room otherwise associated with illness, strange metal implements and painful injections has been given a friendly, familiar face by its presence, and I am desperately sad to see it go.

And the cause of its demise? Not, for once, austerity and the bankers, or even Michael Gove declaring it to be too educationally liberal – it is the edict of the Care Quality Commission (CQC) that has banished my train set, declaring it to be too hygienically hazardous to be allowed to stay.

The CQC has turned its attention on GP practices this year, with the intention to improve health and safety, and in particular, infection control. This is not a bad thing – to have rigorous procedures for the sterilisation of invasive medical instruments, for instance, is clearly a very good thing indeed; nor should GP practices aim for anything other than a high standard of cleanliness, but is a wooden train set really that hazardous?

The CQC website states that the guidance it applies is based on the Health and Social Care Act 2008, which has a great deal to say about infection control, but does not actually mention toys in GP surgeries. Despite this, it has become de rigeur for infection control teams to target these hazardous objects in our rooms, and in particular to condemn wooden toys. I have not been told what evidence this is based upon although I suspect it is on the basis of swab results growing numerous bacteria on their surfaces, which is odd as the vast majority of infections that children might pass to one another via my Brio would be viruses. Plastic toys are deemed acceptable as long as they are swabbed with an alcowipe at the end of the day – which is also odd since viruses won’t survive the night outside of their host.

I have no doubt that some parents will be glad to see the train go, and I am sorry for any concern it might have caused, but it is important to remember that this is not a long-stay hospital ward where people with poor immune systems and open wounds run the gauntlet of super-bug infection, but a GP surgery where children bring the same germs that they merrily carry with them to schools, playgroups and nurseries. And without the child-friendly toys in my room, it would be naive to think that children won’t try to play with something – the options they are likely to head towards now will be the clinical waste bin, the hydraulic mechanism of my examination couch, or the old favourite of opening and closing various finger-trapping drawers. Is this an improvement?

What concerns me most about this dictat from the CQC is the way it focuses on the potential health risks associated with toys, but is entirely blind to any health benefits. What value should we place on a child being at ease when they visit the doctor? Many adults are fearful of seeing their GP, and I suspect that much of this stems from negative childhood experiences which set a lifelong pattern of health-seeking behaviour. Can a train set make the difference? Well, I can’t answer that, but I have seen the eyes of many anxious children light up when they come into my room. And for more immediate benefits you would just have to compare the quality of the conversation between adults when a child is happily and safely occupied than when they are bored, fearful or frustrated – it is hard enough to remember what the doctor has said at the best of times.

There is a worrying underlying trend here which pervades so many Government directives these days – which is where that which is easily measurable and defined trumps that which is less easy to describe, regardless of any relative merit. We see this in education, where SATS scores dominate how both teachers and schools are judged, and no value is placed on a teachers’ ability to inspire and develop their pupils outside the narrow viewfinder of the test. The obvious example in health is the Quality and Outcomes Framework of the GP contract, which is based entirely on what can be measured – like targets for blood pressure, cholesterol and diabetes control. These are not unimportant, but the end result is that the humanity of General Practice, like deep listening, counselling skills and patient-centred care (which cannot be measured so easily) is in danger of being squeezed out of the consultation entirely.

There seem to be no grounds for appeal to reprieve my train set, but I will continue to resist any pressure that threatens to reduce the relationship between doctor and patient to mere figures and targets, and every so often I will continue to stand up and say: “Now, hold on a moment!”

Cough for three weeks? Take a good dose of common sense when symptoms occur

My fondness for waking up to the sound of the radio was put severely to the test on Sunday morning when the words ‘should consult their GP’ drifted nonchalantly into my dreamy subconscious. The correct response, of course, since I am a husband and father on Sundays and not a GP, is to groan to myself: ‘What have they done now?’, hide under the pillow and hope it will all go away. Curiosity got the better of me, however, and shortly after I joined the ranks of other disbelieving GPs on Twitter, threatening to drown out the dawn chorus with our tweeted mutterings.

What ‘they’ (which is the Department of Health (DOH) in this case) have done is to launch a publicity campaign advising anyone with a cough for more than three weeks to see their GP, because it could be a sign of lung cancer. GPs are all for helping people with lung cancer, but no-one was saying that this was a good idea. There was a mixture of stress about a tidal wave of expectorating patients flooding our Tuesday surgeries (why does the Government have to launch these initiatives on a Bank Holiday weekend when we only have a 4 day week to mop up the fallout?), to concern about raising unnecessary anxiety, the harm of unwarranted chest x-rays and the overall cost to both patients and the health service of this newly trumpeted advice.

Anyone with a cough? Really? Taken at face value, the advice would mean that a baby with a cough for more than 3 weeks should see their doctor to exclude lung cancer – clearly this is ridiculous, but if the campaign makes no mention of age then how are the public meant to know who is too old and who is too young? And 3 weeks? Did they really mean 3 weeks? Don’t the DOH know that 35% of people with a simple viral respiratory infection will cough for 3 weeks? Of course they do – their own publicity poster on coughs and colds states that ‘Colds can last about 2 weeks and may end with a cough’ so don’t worry, and certainly don’t think about antibiotics – about 2 weeks must mean that some last 3 weeks, surely? Now this means that the public are meant to understand that a normal cough can certainly last 2 weeks or more and is nothing more than a harmless virus, but if your cough lasts 3 weeks then DON’T DELAY, IT COULD BE CANCER! Hmmm…can’t help feeling we need a large dose of common sense here!

So why have the DOH done this? Well, lung cancer is worth looking at because survival rates are currently very poor – with approximately 40% of patients being alive 1 year after diagnosis, and only 15% surviving 5 years. Earlier diagnosis could make a difference in some (but not all) lung cancers, and who would not want to achieve better survival from cancer? Lung cancers associated with cough are more likely to be in a place where they can be fully removed (and so cured) by surgery, and so cough is a better symptom to focus on than, for instance, breathlessness or chest pain (by the time you have these symptoms with lung cancer you are not very likely to be cured with treatment). They have chosen 3 weeks in part because of something called ‘slippage’ – the tendency for public health messages to be watered down. If you say ‘drink no more than 14 units of alcohol’, people are likely to assume that 21 wouldn’t be too bad, if you advise people that their cholesterol should be below 5.0 then 5.5 sounds ok, and if you say 3 weeks for a cough, then people might just go to their doctor after 4 or 6 weeks. The problem is that we are all wonderfully different when we behave as patients. Some will ‘slip’ far further then 6 weeks (or even not go at all – maybe if it could be cancer they don’t want to know) while others will now present to the doctor without fail on day 22 of any cough.

Let us assume that a person has lung cancer, and is just beginning to get symptoms from it. We could put that person into one of four categories like this:

Those in the blue sections do not need this campaign, as they will see their doctor early anyway, while those in the white quadrant will not be helped by the advertising either, as sadly their cancer will already be too advanced once it has started to give symptoms so going earlier will not change the outcome. The red quadrant, therefore, is the target group – those who have cancer which could be treated, but whose natural tendency is to see their doctor late. The questions then, are these: How large is this group? Will the campaign reach them, or are they the sort of people who don’t respond to advertising campaigns? And will the earlier pick up really lead to a better survival? On the other side of this argument also lies the potential harm of the campaign – how many people who don’t have cancer will see their doctor unnecessarily, worry needlessly and be exposed to chest x-rays that do not reveal anything of concern?

Well there has been a pilot study that answers some of these questions. In response to a similar, local advertising campaign people were nearly twice as likely to see their GP if they had a cough for more than three weeks, and the referral rate for chest x-rays went up by 20%. While this was hailed in the study as evidence that the intervention was successful, we must remember that these are not, in themselves, good things. In fact appointments with a GP and chest x-rays must be seen as costs in this programme, not benefits, and the question is – is it worth it? More positively there was an increase in the lung cancer diagnosis rate of 27% in the study period. Even this, however, is not the ultimate goal, which is better survival from lung cancer. The extra cases of lung cancer were spread across all stages of the disease from early to advanced, and so many of them would not fall into the crucial red quadrant in the above diagram. The study authors concluded that a larger study was required, but, as so often happens with pilot studies, it has been hailed as a success and a national programme rolled out.

So where does that leave us? In need of a good dose of common sense! The DOH know that a public health message has to be simple in order to hit home – and so they have reduced this to a one-liner: Cough for 3 weeks = see your GP. The GP is left to fill in the details. Well here’s my take on it:

Certainly we should be mindful of lung cancer in people who are at risk. A smoker over the age of, say, 40 with an unexplained cough for 3 weeks would do well to take the advice at face value – I would want to do a chest x-ray. If the same person coughed up blood, I’d be concerned enough to do an x-ray even if it only happened once. On the other hand, if you are young or have never smoked, but your cough is dragging on, we might decide to do an x-ray at some stage, but are far more likely to sort your cough out if we look for other causes – like asthma, allergic rhinitis or heartburn. Certainly a cough that goes on much beyond 4 weeks is worth seeing your doctor about – but in most cases this won’t be because we are worried about lung cancer, it will be because the cough is driving you and your family mad, and there might be something we can actually do about it!

Cervical Cancer Vaccine – warts and all

Warts don’t make headline news. They never have, and they never will. And so when the Government announced a change in the cervical cancer vaccine available on the NHS, to a vaccine that also protects against genital warts, it was never going to make the front page – or if it did, I certainly missed it.

I caught up with the change via the medical press, and an announcement sent to all GPs from the Department of Health, but was comforted to see that the ever-reliable Fergus Walsh managed to find space for it on the BBC News website. In case you missed it, I thought I would air it here.

The issue relates to a previous article I have written in this blog where the issues are discussed in more detail. In brief, there are two vaccines that are equally effective in their protection against cervical cancer Cervarix and Gardasil. The only real differences between them are that Gardasil is more expensive (hence not an initial favourite with our limited NHS resources) and also gives protection against the two strains of Human Papilloma Virus (HPV) that do not have any link with cancer, but cause the majority of genital warts. The Government has redone its calculations, and been advised by the Health Protection Agency that the cost saving in terms of the reduced cost of treating genital warts makes the more expensive vaccine better value for money after all. The change will happen in September 2012.

If you have read my previous article, you will know that I am quite ambivalent with regard any merit of one vaccine over the other, and the purpose of this article is to try to allay the natural fears that may arise in any young woman, or her parents, who are being told that the vaccine they received is to be replaced by a ‘better’ one. I am glad to say that if you want to protect against cervical cancer then you don’t need to worry one jot: The current vaccine is as good as anything at preventing the HPV strains that are associated with cancer. Sure, you might have liked to be protected against warts – it has a sort of Buy-One-Get-One-Free appeal to it after all – but at best this is a useful by-product of a vaccine designed for an altogether different purpose, and at worst a clever bit of marketing by Sanofi Pasteur MSD who, like any good salesperson, have managed to convince us to buy an upgrade that we didn’t know we needed.

At the end of the day, if you are concerned about genital warts your best protection is always going to be a responsible attitude towards sex, and a condom – with the real BOGOF bonus of protecting against something really important – like HIV…Hepatitis B…Herpes…unwanted pregnancy…Chlamydia…

MMR – it really is never too late

Baby clinics in the late 1990’s were a challenge for all involved. The baby check itself was fine – a well, happy baby is often light relief at the end of a busy morning surgery – but the discussion over MMR was never easy. Taking as long as the rest of the baby check put together, it was heart-breaking to see parents attacked by the twin spectres of measles and all it’s potentially devastating consequences on the one side, and the equally worrying and poorly understood condition of autism on the other. Parents were left in the unenviable position of feeling that whatever decision they made they were taking a risk with their child’s health.

As the story developed over the coming years, and the alleged association between MMR and autism was discredited, there was an almost palpable relief when I spoke to parents, as we mutually acknowledged that we didn’t have to go there anymore and could concentrate on the real worry that any parent has when they bring their child for vaccinations – how to look after them through an injection!

The MMR scare has left it’s legacy, though, and we were reminded of this in the news this morning. There has been an increase in the number of measles cases in the UK – numbering around 300 so far this year, which is as many as for the whole of last year. Parts of Europe have been worse hit, with several thousand cases in France, including incidences of measles encephalitis, where the brain itself is infected by the virus which can lead to death or brain damage. There are still many children in the UK who missed their MMR in the 1990’s and early 21st century and remain at risk. These children are fast approaching adulthood, and I worry about Rubella as the age of child-bearing comes near.

Many parents might now feel comfortable about catching up on the MMR vaccination, now the scare is over and their child is that much older. It really is never too late to have the MMR vaccine – there’s no upper age limit and it is always worth catching up. For patients at Binscombe, simply make an appointment to see the nurse if you or your child have not received two doses of MMR, and we can sort this out for you. If you are not sure what vaccinations you have received, we can easily check your record and let you know.