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.

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…

The Cervical Cancer Vaccine – Good Value for Money or Wasted Opportunity?

As the new school term is nearly upon us, spare a thought for the lines of year 8 girls who are soon to line up outside the nurse’s office for their first of three vaccinations against cervical cancer. For a disease which is almost entirely sexually transmitted it seems patently unfair that the boys get off scot-free from any social responsibility in combatting this dreadful disease, but I guess that is health economics for you.

It was the health economics of the cervical cancer programme that hit the news at the beginning of August, being reported in The Guardian. The article quotes a new study which questions the vaccine used by the NHS as being poor value for money compared with its main rival – an indisputable fact when you view the analysis in the trial, but the important question is this: Value for money for what?

The difference between the vaccines relates to the strains of Human Papilloma Virus (HPV) that the different vaccines protect against. HPV is a sexually transmitted virus that causes both genital warts and cervical cancer. It exists in over 100 different types, and the important factor is that only some of these cause genital warts, and even fewer cause cervical cancer. HPV types 6 and 11 cause over 90% of the warts – but have no link with cancer – while types 16 and 18 are linked to over 70% of cases of cervical cancer. The current UK vaccine, Cervarix, covers types 16 and 18 only, while its rival, Gardasil, is effective against all four of these. This means that the two vaccines are as good as each other in preventing cervical cancer, but that Gardasil is also very effective at preventing genital warts.

The argument in the analysis reported by The Guardian is that the Government have missed a trick by not getting this extra protection against warts – apparently they cost the NHS around £17 million each year, which is not a small amount of money in these cash-strapped times. What is important to point out, however, is that the rival is only good value for money if we want a genital wart vaccine. Maybe we do, but I can’t believe it’s high up on anyone’s list of health priorities, or something that parents would encourage their teenage girls to queue up for.

Warts are, after all, merely embarrassing,  unpleasant and annoying, but hardly life-threatening in a cancer-like way. And would an absence of genital warts really save all that money? If there is one thing I have learnt about health economics it is that it is not straight forward. To take just one hypothetical example, there must be countless cases where a young woman is driven to attend the Genito-Urinary Medicine clinic by her horror at finding herself afflicted by warts, only for the clinic to also find and treat her silent Chlamydia infection. Untreated, Chlamydia could have gone on to cause Pelvic Inflammatory Disease and subsequent infertility – I wonder how many warts you can treat for the cost to the NHS of countless infertility investigations and subsequent treatment? I suspect it is quite a few – and I am sure it wasn’t included in the financial analysis comparing the vaccines. Oh, and there’s the personal cost to a couple who can’t have children…

So, if you are the parents of a girl who has survived the challenges of year 7 and is about to enjoy the delights of no longer being the youngest year in the school – or a year 8 girl yourself – be confident that we really do have an effective vaccine to offer her against this most unpleasant of diseases. We can leave the politicians to argue about the value for money on this one.

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.