The MMR story is not complete 16 October 2008
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Bill Welsh,
Autism Treatment Trust, ATT Clinic, 29A Stafford Street, Edinburgh. EH3 7BJ

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Re: The MMR story is not complete.

The tone of John snyder’s response is unhelpful.The public health hierarchy has persisted over the years in promoting the MMR as safe by promulgating epidemiological studies that have variously proved to be irrelevant, inconclusive, or seriously methodologically flawed.

Approximately 35 such studies have been used in the UK to promote the MMR as safe and unconnected to the upsurge of bowel disease and autism worldwide. In referring to these studies, what is generally meant is that the authors have carried out large-scale population based studies, either by comparing cases (with autism) and controls (no autism) in terms of MMR exposure, or by comparing those exposed and unexposed to MMR in terms of autism or Autism Spectrum Disorder as an outcome. Whilst it is tempting to assume that studies of large populations are somehow ‘better’ by virtue simply of their size, this is by no means necessarily the case. Neither are they ‘safety’ studies, a fact of which John Snyder should be well aware, and if he is not, it is of serious concern.

The failure of the population based studies that are frequently cited as supporting the safety of MMR is in their total lack of reference to the original hypothesis formulated by Wakefield.(1) In a recent presentation at the International Meeting for Autism Research (IMFAR) (2) this year Dr Carol Stott produced evidence to indicate that of over 50 studies claiming to test what can be referred to as the Wakefield hypothesis, only five actually addressed it fully, and four of these supported it, at least in part. Of these four, two were clinical studies and two were ‘population’ based.

Another significant failing is that whilst population based evidence from case-control or cohort studies might indicate a possible association between two or more factors – and to some extent be used to indicate causality - it can obviously not be applied to prove that in any particular case X did not cause Y.

John Stone quite correctly quotes Dr Bernadine Healy ex head of the National Institute of Health and a member of the Institute of Medicine in the USA who has publicly stated on the issue of using epidemiology: “Populations do not test causality, they test associations. You have to go into the laboratory and you have to do designed research studies in animals”.

And on the vaccine/autism link: “Certain public health officials in the government, have been too quick to dismiss the concerns of these families without studying the population that got sick. I haven’t seen major studies that focus on 300 kids who got autistic symptoms within a period of a few weeks of the vaccine. I think that the public health officials have been too quick to dismiss the hypothesis as “irrational” without sufficient studies of causation. I think that they often have been too quick to dismiss studies in the animal laboratory, in mice, in primates, that do show some concerns with regard to certain vaccines”.

With regard to the Lipkin/Hornig study (3) it should be noted that only five children involved in this research met the criteria of the original hypothesis (normal development, MMR vaccination, bowel disease, leading to autism). Too small a sample, one would have thought, particularly in view of the criticism levelled at Dr Andrew Wakefield's team for publishing research in 1998 based on only 12 children. (In fact, an addendum to that original study revealed the assessment of a further 40 patients, 39 of whom had the novel form of bowel disease as described.) Interestingly one of the five children in the Lipkin/Hornig paper was found to have measles virus in the gut. But the simple fact is, this study does not really address whether MMR causes autism, let alone rule it out, as the authors erroneously claim. It does, however, confirm the presence of distressing and painful bowel disease in many autistic children. In fact the authors have credited Dr Andrew Wakefield with being the "first to recognize the importance of gastrointestinal disease in autism."

Some other interesting quotes from the authors may assist John Snyder in formulating a programme and protocol to assist autistic children, no matter the cause of their painful bowel disease:

“This study confirms that kids with autism often have "unrecognized and undertreated bowel complaints." Dr Ian Lipkin.

“These intestinal problems may well be linked to the developmental regression seen in about 25% of kids with autism”. Dr Mady Hornig

“Unless a treatment protocol is developed, many of these children will live with painful, undiagnosed medical conditions that will grow more serious as they become teenagers and adults.” “Many of the symptoms of autism such as self abusive behaviour including self-mutilation, head- banging, unexplained outbursts, atypical sleep patterns, disrupted sleep or night awakenings, are actually symptoms of pain that a child is not able to communicate”. Timothy Buie, (gastro-enterologist).

The evidence of parents re a link with MMR is overwhelming and compelling. I suspect this will become the most shameful episode in public health history.

Bill Welsh
Autism Treatment Trust, 29A Stafford Street, Edinburgh. EH3 7BJ

(1) Ileal Lymphoid Nodular Hyperplasia, Non-Specific Colitis and Pervasive Developmental Disorder in Children, Lancet, 28th February 1998

(2) A novel form of Inflammatory Bowel Disease (IBD) with Pervasive Developmental Disorder: A Systematic Review of the state of the evidence" Poster Presentation, IMFAR, London 2008 Stott CM.

(3) Hornig M, Briese T, Buie T, Bauman ML, Lauwers G, et al. 2008 Lack of Association between Measles Virus Vaccine and Autism with Enteropathy: A Case-Control Study. PLoS ONE 3(9): e3140 doi:10.1371/journal.pone.0003140

Competing interests: Grandfather of an autistic boy.

The MMR “debacle” as Ben Goldacre describes it is far from over. "The blame" does not lie with “hundreds of journalists” etc, it lies fairly and squarely with a highly politicised health system that discourages dissent from within its own ranks, that combined with a greed philosophy that has enveloped a once fine profession. It may be of interest to BMJ readers to learn of some of the glowing descriptive terms used at the ongoing GMC trial of Dr Wakefield et al, with regard to their scientific research: “excellent”, “robust and rigorous”, “revolutionary”, “watertight”, “clinical observation backed up by good science”, etc, etc. I could go on but when I tell you that these quotes are from prosecution witnesses you will realise how far off the mark ‘Becoming’ Ben is in his attacks on the witness of thousands of parents. And that is what the MMR debate has become, a battle between ordinary citizens whose children face 70 years of mental handicap and pain, and people like Goldacre. This is no longer about good science or bad science, the science debate was over when the editor of the Lancet, Richard Horton, recently conceded re Wakefield’s paper, and I quote: 'The essential clinical findings remain unchallenged as far as their accuracy is concerned'. Perhaps Horton can encourage Goldacre “to a deeper understanding of this complex issue”.

Competing interests: Grandfather of an autistic boy.