Sam was brought in for the one-year well check by both parents. His growth, development and examination were all completely normal, indicating that he was doing just fine. The baby was eating well and sleeping through the night, leaving the parents with no concerns or questions about how he was doing. As we got to the end of the visit, I pulled out the immunization card to see what shots would be needed.
“Looks like Sam will be getting his MMR (measles, mumps and rubella), Varivax (chicken pox) and the fourth and last Hib vaccine,” I told them. I could sense uneasiness on their part. I must have had a perplexed look on my face, as Sam’s dad chimed in with an unsure voice, “You probably think we are crazy, but we don’t want Sam to get the MMR.” Sam’s mom produced a stack of e-mails and faxes that they had collected over the Internet. “We’ve been doing a lot of reading about this, and we are just plain scared. It looks like the MMR might be one of the causes of autism. For now, we don’t want him to get the immunization,” she said in a determined voice.
Autism is a poorly understood disorder of children that actually represents a broad spectrum of clinical findings, from mild speech delay to severe developmental and behavioral delay. The cause of autism is not known, and there is no test to prove or disprove its diagnosis. The diagnosis is made purely on clinical grounds. The most recent reports suggest that the incidence of autism is around 1:500 children. Most experts feel that autism has a genetic basis. If there is a close family member diagnosed with autism the incidence jumps to 1:30 – 50. The brains of autistic children seem to be a bit larger than the brains of other children of the same age. There are subtle structural differences as well, leading experts to hypothesize that autism actually begins in the womb when the fetus’ brain is developing.
As there is no single test for autism, it is a difficult diagnosis to make. Speech delay is a big part of the autism syndrome. Since children start to put words together and form phrases between one and two years of age, it may take awhile before a delay is addressed. A child may have chronic otitis media (ear infections) that has impacted his hearing, and subsequently his speech. This child may be thought of as autistic…incorrectly.
A review of eight studies showed that nearly 80% of the cases of autism diagnosed in the United States are made by the age of 21/2 years. Forty percent of these are made by 18 months of age. Of noted interest, the MMR vaccine is routinely given at one year of age.
Controversy in trying to link the MMR in some way with autism stems from an article written by Andrew Wakefield, M.D., a British gastroenterologist, that appeared in THE LANCET in 1998. He reported finding some intestinal abnormalities in 12 autistic children. These ranged from mild inflammation to canker sore-like lesions of the intestine. Parents of eight of the children felt that there was a definite relationship with the onset of the behavioral symptoms of autism and the child receiving the MMR shot. Dr. Wakefield went on to hypothesize that the MMR caused an inflammatory reaction in the intestines. This led to malabsorption of vitamin B-12, which is important for central nervous system development, and, as a result, to autism. At a meeting held in March of 2001, he said that he had performed endoscopies on over 150 autistic children. The findings of inflammation were the same in most cases.
This article caught the attention of the international media. It sparked a firestorm of controversy that was debated in the mainstream media as well as over the Internet. Concern and fear followed on the part of parents who didn’t know where to look to get the facts. Many felt that if it was on the Internet, it must be factual. It is a discarded fact that nothing appearing on the Internet has to pass the scrutiny and approval of a peer review editorial board, such as one would find with a reputable medical journal.
As this controversy began taking on a life of it’s own, the medical community looked closely at this question in a scientific and non-biased manner. In June of 2000, the American Academy of Pediatrics convened a multi-disciplinary conference in Oak Brook, Illinois. Many interesting and reassuring facts came out of the conference. In England, it was found that there was nearly a fourfold increase in the number of cases of newly diagnosed autism between the years of 1988 and 1993. The prevalence of the MMR vaccine was constant at 95% during this time. It also showed that there was no temporal relationship between the time MMR was given and the onset of the symptoms of autism.
Similar experiences were found in Sweden and Finland. It was determined that there were no more cases of autism in a group of children receiving the MMR vaccine as compared to a group of children NOT receiving the vaccine. Clearly, if the MMR was implicated in the genesis of autism, this would not have been the result.
A study done in California showed that the rates of MMR immunization have been relatively stable since 1998. They do not correlate with the increased number of cases of autism observed since 1985.
A conference held in Oak Brook was attended by parents of autistic children, nurses, researchers, doctors and specialists in the field. The sole goal of the conference was to look at this controversy with an open and unbiased mind. The conclusion was as follows: autism is a complex disorder of uncertain and multiple causes. Most likely, there is a genetic pre-disposition to autism. The abnormal brain development in autism probably occurs before the 30th week of gestation. The recent “increase” in the number of newly diagnosed cases of autism is most likely a result of increased awareness and better reporting.
As a result of the findings at this conference, AAP and the Center for Disease Control do not recommend changing the immunization schedule, which is to give the MMR vaccine at one year of age. They stand strongly opposed to separating measles, mumps and rubella vaccines (three separate shops) as recommended by some.
Studies are ongoing to try to unlock the mystery of autism, as well as looking further into the MMR issue. Until there is convincing evidence to the contrary, all children 12 – 15 months of age should receive the MMR vaccine.
Sam’s parents listened intently as I went over these facts. They seemed more confused after our visit since they had been headstrong against the MMR shot when they arrived. Now, they shrugged their shoulders and looked at each other as if to say, “Well, what do YOU think?”
Sensing their dilemma, I didn’t want to put them on the spot. “Let’s do this,” I said in a direct voice. “You go home and think about it. Talk it over and make a decision that you are comfortable with. If you have any questions, call me. If you decide to have Sam get the MMR, just call and come in. You don’t have to make another appointment. The only thing I ask is that you make an informed decision.”
Sam was in the next day for his MMR.