September 4, 2019


Why are measles so important? What is the difference between mortality and morbidity? Why does it matter?


In this series, Andrew Wakefield examines the impact of modern vaccination. Using the measles virus as an example, Wakefield considers the safety studies, risks, and effectiveness of vaccines. His conclusions are going to surprise you.


Sources directly quoted in the lecture

[3:15] "Post Antibiotic Apocalypse" - Dame Sally Davies, UK Chief Medical Officer - DailyMail, 13 October 2017

[4:55] - "Let Freedom Ring" - Dr. Heidi J. Larson, Vaccine Confidence Project - 1 Jan 2018

[6:20] - "The Age-Old Struggle against the Antivaccinationists"  - Gregory A. Poland, M.D., Mayo Clinic (ResearchGate)
"A taxonomy of reasoning flaws in the antivaccine movement" - Gregory A. Poland, M.D., Mayo Clinic (Mayo Clinic)

Sources for corroborating statements in the lecture

[2:14] Antibiotic Resistance -

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Hi, I'm Andy Wakefield, immunology and vaccinology taught by measles virus.

Why this subject at all? It's huge, it's complex, and highly, highly controversial, largely because so much has been invested intellectually, emotionally and financially, while so much remains unknown, unexplained, and indeed, off limits to valid scientific inquiry and public debate. And after studying this for 25 years, trying to understand the reasons behind the discord and the ignorance that pervade the debate at every level, the most basic understanding, never was there a field in science or medicine where beliefs are held with such certainty, where at the same time, so much remains unknown and indeed precariously uncertain.

And so, the purpose of this series is to illustrate with basic concepts in the simplest way the issues, and generate questions, many of which have no answers at this stage, and to encourage a much more open-minded discussion on the issue. And finally, to take our understanding, such as it is, and set it alongside the public health and industry message, the dominant narrative, to see how the latter truly informs or misleads. What I will present is my understanding, my interpretation based upon that imperfect knowledge. No doubt others will hold very different views. As a fundamental underlying principle, we need to pay a great deal of respect to infectious agents, and indeed microbes in general. Our experience with antibiotics has taught us this. In less than 100 years, we have gone from miracle to nightmare. This has come about because antibiotics have been used inappropriately, there has been industry greed pushing highly potent antibiotics into first-line therapy. There has been widespread use in agriculture, but most importantly, we are dealing with the collective intelligence of an extremely versatile set of microbes that are geared to adapt, to survive, and to come back and haunt us if we take them for granted.

The lessons from antibiotics are very clear. The growing threat of antibiotic resistance in bacteria portends what is now called a post-antibiotic apocalypse, and the end of modern medicine, as common medical interventions including surgical procedures become extremely risky. Not only have bacteria developed resistance, but the evolutionary pressures that drove the development of such resistance may have generated more dangerous, more pathogenic strains. In fact, according to Dame Sally Davies, the UK's Chief Medical Officer, the antibiotic apocalypse may already be upon us, with an estimated 50,000 people dying every year in Europe and the US from infections that antibiotics have lost the power to treat. She says the projected figures are much more worrying.

And is this issue relevant to vaccines and viruses, for example? I believe it is. Now, why measles? Measles is a major human pathogen that has taught us so much about immunology and the way in which social change and patterns of transmission have influenced the natural history of measles as a human disease. It's a major target for vaccination and eradication. And measles is the disease that raises its head above all others in the conflict, in the public relations conflict between public concerns on the one hand over vaccine safety, and public health and industry objectives on the other. The overall objective of this series is to understand concepts like herd immunity. Why? Because the dominant narrative focuses upon measles and the need to maintain herd immunity to protect the vulnerable from infection, and through a better understanding of all of these things to predict what the future might hold.

Why is there growing concern? And this is reflected in the dominant narrative from Dr. Heidi Larson, an anthropologist and Director of the Vaccine Confidence Project at the London School of Hygiene & Tropical Medicine. And she writes in her New Year's message to the world, "In an attempt to quell the spread of measles across Europe, France, Italy and Germany announced various new vaccine mandates and fines would be introduced. Germany and Italy enacted new laws last year, while France's new 11 vaccine mandate, up from three previously, went into effect on the first of January." Why you would need 11 mandatory vaccines to prevent the spread of measles is somewhat perplexing. Nonetheless, as she continues, the key is herd immunity.

"Contrarian views," she says, "become problematic for a technology like a vaccine, whose success, or at least for many vaccines, depends upon the herd. The success of vaccination depends upon the public accepting the voice of experts and government, both of whom are facing waning trust in many countries around the world." Larsen bemoans the waning trust in the voice of experts in government, and in this series, we seek to examine the issue against the background of the question, "Why?" Have expert opinion and government earned the public's trust based upon their assurances that measles-containing vaccines are safe and effective? And that a term such as herd immunity as portrayed by these experts is a valid concept that's adequately understood?

Greg Poland has a lot to say on this issue. Greg Poland is a senior vaccinologist working at the Mayo Clinic. He says in this paper, The Age-Old Struggle Against Antivaccinationists, "Antivaccinationists tend towards complete mistrust of government and manufacturers, conspiratorial thinking, denialism, low cognitive complexity in thinking patterns, reasoning flaws, and a habit of substituting emotional anecdotes for data." And so there is measles. Measles itself, the disease, the rash, and under the high power electron microscope in a rare fatal encephalitis caused by measles, the actual core of the particle itself.

We need to embrace certain terms if we are to understand this series of lectures, starting with morbidity. Morbidity is the state of suffering from the disease itself, suffering, say, from measles. And that may be mild on the one hand to severe on the other hand, and mortality, clearly death from the disease, and I would include complications of the disease, because measles is immunosuppressive and people often die, when they die, of secondary bacterial infection, for example, pneumonia or diarrheal disease. And I want to introduce the concept, a very, very important concept of subclinical disease. What does that mean? The person is in communication with measles, they're susceptible, they get infected, but they have a case of measles that is so mild that it is not recognized as measles or is not reported. And this is a growing issue, and a very interesting one.

In order to understand measles and the evolution and dynamics of a major human disease, we need to understand, for example, where measles came from. Say, 8,000-9,000 years ago, how did measles find its way into human beings, what has changed over time, and what happens when an old-world disease, perhaps one originating in Europe or Asia, is introduced to and emerges in the New World, the Americas? Measles virus infection in what are called virgin soil populations, such as the American Indians, who had never seen it before, what are the consequences of an infection in that sort of virgin soil population? Why did measles ravage troops amassed in barracks, hospitals, and on the battlefield in the American Civil War? And what happened to the Yanomami Indians in the Orinoco Basin, where a variant of measles virus caused very serious disease with very high mortality in that virgin soil population?

We will need to explore the basic concepts of human immunology, immunology taught by measles virus. Vaccination seeks to recapitulate, to mirror the immunity induced by natural infection. To what extent does it achieve this? And what happens if it falls short? And to do this, we will examine vaccination versus natural infection, vaccination with measles vaccine alone, or combined with other viruses or other vaccines and their ingredients. And in a world of one-size-fits-all vaccination policy, we will examine the different immune response to measles within individuals and populations, and take a glimpse into the future, what the immune response might or might not be or undo in due course.

We need to understand the apparently dichotomous and irreconcilable world that I and a growing number of people occupy, compared with that occupied by the vaccinologists and the public health workers. Our common aim is to help children, to protect them from disease. So why these two completely divergent views of the approach that has been adopted? The perspective from which our perception and our imperatives originate is most important. Sadly, the real concern, vaccine safety, is often drowned out in the high decibel, high dollar public relations epithet of anti-vaccine, anti-science, anti-medicine. Laboratory vaccinologists such as Poland and Jacobson see us in the clinical arena, at the very least, as peddlers of bombast, and at worst, as executioners of innocents. Why is there this gulf in our perception, our understanding, and our goals? My goal for this series is to explore the question, "Why?"

A word of caution, and that is caution about numbers, how they're portrayed, and how they're used and interpreted: Before the introduction of measles vaccine in 1963, it was estimated that there were 400,000-500,000 cases reported annually. Measles was a reportable disease, but it was estimated that there were at least five million cases of measles at the same time. That is a huge gulf between the number of cases reported and the actual estimated number of cases of measles. Why? Why is there this underestimate of at least tenfold between the numbers reported and the actual numbers? And this may reflect in large part the growing level of subclinical disease, a very important concept. So beware at least of morbidity and mortality data based upon reported cases. Just bear that in mind, because it does not take account of subclinical infection, and we'll deal with that.

Again, a further word of caution on flu deaths. Flu results in about 250,000-500,000 yearly deaths, according to Wikipedia. And the typical estimate in America is 36,000 deaths a year reported by NBC citing the Centers for Disease Control and Prevention. But if we go to the National Vital Statistics System in the US, annual flu deaths in 2010 amounted to just 500 per year. 500 versus 36,000. What is real and what is not? So beware of the numbers. And this concept is supported by Peter Doshi, who wrote a paper entitled, Are US Flu Death Figures more Public Relations than Science?

Data. In terms of data, they are perhaps more credible when there was clinical familiarity with measles, which meant that case reporting was more accurate. Doctors now who have not seen measles are often mistaken in the clinical diagnosis that they make. That historically was not necessarily the case when people were used to seeing measles all the time. When data collection was objective, for example in generating numbers, you were not trying to make a case for developing or instituting a vaccination policy or profiting from that. And latterly, as diagnostic testing became available in the laboratory for objectively saying, "Is a case of measles really a case?" Four examples come from Sub-Saharan Africa between 1987 and '98. It was recorded that of 3,035 measles cases, only 4% were positive on diagnostic antibody testing. In other countries in Africa, it ranged from 69% in Burkina Faso to 9% in Togo. But it gives us a clear example of how the true number of cases confirmed in the laboratory is very different from the number of cases estimated clinically in the community.

So as an exercise, in going forward in this series, I want you to first open your mind to how history can inform us and help predict the future. There's a lesson for my students, when I was teaching medical students, I said, "Half of what I tell you will be right, and half will be wrong. The problem for me is I don't know which half is which, and it's up to you to question what I say, to address those questions, and refine the answers so that we can move forward."