Black Triangle

Recently the BBC reported on a concern about the use of single vaccines:

UK researchers have raised concerns over the monitoring of the safety of single measles and rubella vaccines.

It comes after an unexpectedly high number of cases of anaphylactic shock after single vaccines given at private clinics in south west England.

Although the figures are likely to be an anomaly, poor data on vaccines given at private clinics is preventing proper scrutiny, they warn.

I am a supporter of the use of the combined measles, mumps and rubella (MMR) vaccine. I support its use for two reasons, neither of which involve concerns about the safety of single vaccines.

1. The use of single vaccines leads to gaps in the vaccination schedule, exposes the child to more discomfort, and potentially can lead to a failure to vaccinate at all. It should be remembered that before MMR thousands of children suffered measles.

2. Providing single vaccines against the scientific evidence would be exploited as a tacit admission that there was a risk of autism attached to MMR vaccine by UK anti-vaccinators. It would undermine confidence in MMR vaccine, and the media would publish extremely confusing news stories about MMR vaccine. Wakefield’s hypothesis never explained why single vaccines might be “safer” in this regard.  Anti-vaccinators would then move on to attacking single vaccines, winning by increments.

The latter point is a perhaps less of a concern. Despite some calls from politicians for the provision of single vaccines in the past, the autism-MMR vaccine hypothesis is now so discredited that I don’t think there is any possibility of caving in to the demands of a few isolated cranks. In addition, a rising awareness of the damage done to herd immunity in the UK, and outbreaks of measles, make the public health case for the combined vaccine even more compelling. So why don’t I admit a loud Whoopee about this news? MMR vaccine has less chance of causing anaphylaxis. Or does it?

The authors of the new study, which the BBC report is based upon, cite a UK national incidence of anaphylaxis for MMR vaccine as 1.4 cases per 100,000 doses from a paper by Peng et al in Arch Intern Med from 2004 [PDF]. That study is a GPRD (General Practice Research Database) study, which uses medical data from a large number of GPs (currently 450) and their patients (currently 13 million). While the GPRD has a good reputation, in terms of quality of data, even Peng et al state that “we cannot rule out the possibility that some cases of anaphylaxis may not have been recorded in the GP computer record, particularly those that occurred in hospital.” Anaphylaxis in the community may not have been recorded in patient’s notes in all cases. If a child suffered anaphylaxis in a surgery acute treatment of the child would have been a priority; the child later being admitted to a hospital where the coding would happen in a totally different system. In addition, the average of 1.4 cases per 100,000 is based on 2 cases of anaphylaxis after 143,000 administered doses of MMR vaccine. Only a small amount of cases which avoided coding would move the average up considerably.

The paper by Erlewyn-Lajueunesse et al that the BBC report is based upon used what appear to have been 4 spontaneous reports of anaphylaxis submitted to the authors in their locality, with data obtained from the MHRA on the number of imported MMR vaccine obtained nationally during the period. They argue that the incidence of anaphylaxis they found (18.9 cases per 100,000 for measles and 22.4 per 100,000 for rubella) was probably an under-estimate, since presumably more cases of anaphylaxis occurred elsewhere they were unaware of. This is probably a fair assumption. However, there are perhaps other biases at work. Perhaps the reporters were also the suppliers of the single vaccines, and are partly motivated by what they perceive as a danger of MMR vaccine. If so, they may have been more keen to report reactions to other vaccines. Alternatively, the reporters could have been those treating the anaphylaxis and may have felt strongly that side effects to the unlicensed single vaccines should be reported. So reporting rates in both studies may have been totally different in nature. It is hard to make any firm decisions on the limited data we have.

It is therefore not sensible to compare the two incidences, and to come to the conclusion that single vaccines are more prone to anaphylaxis. To be fair the authors make this point themselves at the BBC:

“We can’t think of any reason why it [anaphylaxis] would be higher for single vaccines and it’s probably an anomaly.

“The issue is that people go for these vaccines because they are uncertain about how safe the MMR is but we know how safe the MMR is because we have lots of data.”

He added that the Healthcare Commission should insist private clinics are subject to the same standards of vaccine data reporting as is expected of the NHS.

“They are more than likely safe but the issue it raises is about how that is monitored.”

Seeking to scare parents into using the combined jab on the basis of the evidence about anaphylaxis isn’t quite as dubious as the Wakefield-inspired scare story over MMR vaccine, but it is in the same ball park. David Elliman’s comments are also sensible:

Immunisation expert Dr David Elliman, a community paediatrician at Great Ormond Street Hospital also said there was “no logical reason” why the rates of anaphylaxis should be so high with the single vaccines.

“The important message is not about the rate but the fact that it does occur and this idea that the single vaccines for some magical reason are safer is nonsense.”

The Daily Mail influenza vaccine kills people story has an interesting background. Looking at Hansard, it is apparent that the data the story is based on came from a written answer to a question posed by Sandra Gidley MP (Liberal Democrat). The question and answer by Dawn Primarolo are here:

To ask the Secretary of State for Health (1) how many people died in each trust as a result of receiving an influenza vaccine in each of the last five years;

(2) how many people were admitted to hospital in each trust as a result of receiving an influenza vaccine in each of the last five years.

Sandra Gidley is known to me professionally, since we are both pharmacists and have an interest in the future of our professional body. We have met on several occasions at professional meetings, and I have found her an intelligent, interesting, and sensible individual. She also runs a blog called Romsey Redhead, which appears in my sidebar. I have emailed her to ask about her concerns about influenza vaccine, and her reaction to The Daily Mail scare story.

After being told of a death after the use of influenza vaccine, she decided to find out the facts on and figures on reported deaths and other serious reaction to influenza vaccines. She suspected that far more people would have died of flu had they not been vaccinated but wondered if there was merit in examining the deaths to see if the advice about giving the vaccine needs to be refined in any way.

The Daily Mail obviously picked up on the question and spent some time talking to Sandra, who made the point that the deaths “had to be set in the context of how many flu deaths may have been prevented”. She also suggested to the journalist that given the age of the recipients a number of deaths could have been pure coincidence. However, it was fairly clear what sort of story they wanted to write. It is because Sandra Gidley was too sensible and avoided sensationalism that the The Daily Mail decided not to include any comments from the person who made the very information request they were reporting on, and certainly didn’t raise her name. You can imagine their disappointment.

So, let’s make it clear. The Daily Mail trawls for bad news stories about vaccines, and then will willfully ignores the comments from the person who raised the concern in the first place.

As regulators become more transparent and provide information, can the media be trusted not to misuse the data? Not if it gets in the way of a nice juicy anti-vaccine story.

A Chinese woman has reportedly had a mole grafted on to her face to avoid being mistaken for her twin sister.

Xiao Ai, of Xiamen city, Fujian province, had the mole removed from her leg and transplanted on to her face.

She was sick of being mistaken for her twin Xiao Ping, reports the Southeastern Morning News.

Both sisters are married but still live with their parents.

Xiao Ai said: “One day when I got home after work, my brother-in-law came up and wanted to kiss me. I was so scared.”

From then on, the sisters would mark their faces each day so their husbands could tell them apart but they wanted a more permanent solution.

Xiao Ai added: “I came up with the idea of transplanting a small mole from my leg onto my face. And the idea was well-received by the whole family.”

Mumbai Mirror.

Some of the readers of this blog may use a proctoscope in their professional practice. Here’s an interesting product recall.

Jagged imperfections may be present on the leading edge of some proctoscopes, adjacent to the obturator , which could injure the patient.

120 years ago, pharmacist John Pemberton concocted the blend of water, sugar, coca leaves and kola nuts into a sweet syrup called Coca-Cola.

It went on sale in Jacob’s Pharmacy in Atlanta on 8 May, 1886.

Take the BBC’s Coke test. [Hat-tip: PB]

I can juggle three balls for quite a while, and can even perform the occasional, and sometimes successful, under the leg throw. I can also juggle three clubs for a short time. My luminous balls in the dark are legendary.

However, my brother-in-law can juggle three balls on a uni-cycle pretty well, and I’m sure he once did five balls.

However, even he can’t juggle this well, and he most certainly can’t juggle this well. (via Pootergeek)

Some of you may have been watching the BBC’s Balderdash and Piffle. If so, and assuming you like science fiction, then you may enjoy the OED’s Science Fiction Citations page.

Amazingly, it appears Gotham City predated Batman by 132 years. (Via Rullsenberg Rules)

In the September 2005 edition of the Israeli Medical Association Journal there is a paper dedicated to “Rabbi Dr. David Applebaum Rabbi, Physician, Teacher and Friend, murdered together with his daughter Naavah in a terrorist attack, Jerusalem, 9 September 2003 on the eve of her wedding.”. It’s a fascinating account of the life of Moses Maimonides [PDF] (1138-1204) who ended up being court physician in Egypt in the time of Saladin, as it’s in PDF format here is a snippet:

Maimonides was born in 1138 in Cordoba, Spain, to a celebrated rabbinic family. His mother died in childbirth. His father Maimon, a rabbinic scholar and judge in Cordoba, gave his son a broad Jewish and general education that included mathematics, astronomy and philosophy. In 1148, Cordoba was conquered by the Almohads, a fanatical Muslim sect that forced Jews to convert to Islam. Maimonides’ family fled Cordoba, spent time in Spain and probably also in Provence, and in 1160 settled in North Africa in the city of Fez. Maimonides continued his studies during this period and began his literary work. [...]. In Fez, Maimonides studied under Rabbi Judah Ha-Kohen ibn Susan and acquired medical training from prominent Muslim physicians. But the continuing persecution forced the family to flee Fez (1165) and they made their way to the Holy Land, arriving at the port of Acre.

Finding that the local Jewish community was living in a state of desperate poverty and political oppression at the hands of the Christian Crusaders, the family moved on to Egypt, finally settling in Fostat, the Old City of Cairo. Maimonides’ father Maimon died soon after their arrival (1166). Supported by his younger brother David, a merchant who dealt in precious stones, Maimonides was able to pursue his studies free of financial care. His brother drowned several years later (1178) in the Indian Ocean while on a business trip; Maimonides was shattered by this tragedy and remained depressed for a long time, as seen in his letter to Rabbi Yephet. For reasons of principle Maimonides refused to take money for his rabbinic services, turning to the medical profession for his livelihood.

Maimonides was appointed official leader (naggid) of Egyptian Jewry (1177) and court physician to Vizir Al-Fadhil, Regent of Egypt during the absence of Sultan Saladin the Great, who was off fighting the Crusaders (1185).

Giant snake attacks large two-metre alligator.

Who do you think won?

Now find out the shocking truth!

[via Hak Mao]