- Email: [email protected]
Disclosure of non-paternity
Correspondence
Author’s reply Ken Campbell makes a valid point, and I am grateful for his careful reading of the column. Spontaneous mutation is a possibility that should be included in pretest and post-test counselling. Campbell is also correct in his assertion that nonpaternity should not be assumed without solid evidence. However, the scenario in the column was meant to imply that such evidence existed: the tests revealed that the father “is not a carrier, and could not have been the boy’s father”. That is, the doctor did not draw conclusions merely from the fact that the father did not carry the recessive gene, but from additional test results confirming non-paternity. Therefore, she was not acting on an unfounded assumption, as Campbell asserts. Regarding the option of the doctor making a “devastating accusation”, it would be improper for her, in any event, to present test results this way; nor does the column so advocate.
Joal Hill [email protected] c/o The Lancet, 32 Jamestown Road, London NW1 7BY, UK
Anniversary of rubella epidemic As we approach the 40th anniversary of the devastating rubella epidemic in the USA, we would like to comment on and applaud The Lancet’s continued coverage pertaining to the lack of a causal link between the measles, mumps, and rubella (MMR) vaccine and autism. The original study that connected the MMR vaccine to autism planted a seed of doubt in the minds of parents and ultimately led to a reduction in the rate of immunisation for rubella in the USA.1 Infants born to women who contract rubella during the first trimester of pregnancy are born with ocular, cardiovascular, auditory, and other systemic abnormalities, which are common manifestations of congenital rubella syndrome (CRS). These abnormalities can range from non328
apparent to severe, depending on the stage of pregnancy during which the mother contracted the rubella infection.2 The dominant characteristic of CRS is the diversity and multiplicity of the disabilities associated with it. The estimated burden of disease for one case of CRS exceeds US$200 000.3 The Helen Keller National Center, located in the USA, has been providing services to adults with congenital rubella syndrome for many years. We have watched several individuals with CRS develop additional late-onset medical problems caused by the virus. These include diabetes, glaucoma, thyroid disorder, endocrine imbalance, oesophageal anomalies, and, in rare cases, a systemic degenerative process. Rubella is still a public-health issue today. WHO has estimated that there are more than 100 000 infants born with CRS every year, worldwide.4 Because babies born to mothers who contracted rubella in the USA during the 1960s turn 40 this year, we are again reminded of the unparalleled and continuing effects of this insidious virus. Awareness should also be promoted to identify late-onset manifestations in individuals with CRS. Further research is still needed to investigate the emerging problems occurring in this unique population. Health-care providers need to encourage and enforce immunisation practices, and the public needs to be aware of the consequences of not being vaccinated.
*Normadeane Armstrong, Nancy O’Donnell [email protected] Helen Keller National Center, 141 MiddleNeck Road, Sands Point, NY 11050, USA 1
2
3
4
Mitchell S. UK measles outbreaks pose risk to US. http://www.upi.com/print.cfm?StoryID =20031031-044151-8440r (accessed June 23, 2004). Armstrong N, O’Donnell N. Rubella: 40 years after the epidemic. Am J Nurse Practitioners 2004; 8: 51–56. White CC, Koplan JP, Orenstein WA. Benefits, risks, and costs of immunization for measles, mumps, and rubella. Am J Public Health 1985; 75: 739–44. World Health Organization. Guidelines for surveillance of congenital rubella syndrome and rubella: field test version. Geneva: WHO, 1999.
Why is measles still endemic in Japan? Japan has been confronting the problems of uncontrolled measles for more than a decade now, and WHO has taken the initiative to eliminate measles worldwide. Despite these global efforts, however, measles is still endemic in Japan: there were an estimated 200 000 cases and 88 deaths (mainly in children) in 2000.1,2 But measles is not only a domestic problem. The US Centers for Disease Control and Prevention has reported that Japan is the country that exports measles to the USA most frequently.3 Japan has contributed a great deal financially to the global movement to eliminate measles through the United Nation Children’s Fund (UNICEF), and infant mortality in Japan is among the lowest in the world. Nevertheless, many Japanese children still die from a vaccinepreventable disease. Why is that? The measles vaccine was first introduced in Japan in 1966, and the measles, mumps, and rubella (MMR) vaccine followed in 1989. Subsequently, in 1993, the MMR vaccine used in Japan was withdrawn owing to unexpectedly high rates of aseptic meningitis associated with the mumps Urabe AM 9 strain.4 In 1994, major changes were made to the country’s immunisation law, such that all childhood immunisations were no longer mandatory. Individuals would be given “strong recommendations” to get the vaccine, but ultimately it would be their choice. Since 1994, the Japanese government has played a very passive part in the formulation of vaccine policies, mainly because of strong public opposition to the reinforcement of mandatory vaccination. As a consequence, the general public has not been well educated on vaccine-preventable diseases and is not aware of the significance of those diseases. Measles vaccine coverage rates are lower than in other countries such as the USA, where domestic measles has been almost eliminated. Moreover, even though many countries have already implemented a two-dose regimen of measles vaccine, Japan has not. Until www.thelancet.com Vol 364 July 24, 2004
Author’s reply Ken Campbell makes a valid point, and I am grateful for his careful reading of the column. Spontaneous mutation is a possibility that should be included in pretest and post-test counselling. Campbell is also correct in his assertion that nonpaternity should not be assumed without solid evidence. However, the scenario in the column was meant to imply that such evidence existed: the tests revealed that the father “is not a carrier, and could not have been the boy’s father”. That is, the doctor did not draw conclusions merely from the fact that the father did not carry the recessive gene, but from additional test results confirming non-paternity. Therefore, she was not acting on an unfounded assumption, as Campbell asserts. Regarding the option of the doctor making a “devastating accusation”, it would be improper for her, in any event, to present test results this way; nor does the column so advocate.
Joal Hill [email protected] c/o The Lancet, 32 Jamestown Road, London NW1 7BY, UK
Anniversary of rubella epidemic As we approach the 40th anniversary of the devastating rubella epidemic in the USA, we would like to comment on and applaud The Lancet’s continued coverage pertaining to the lack of a causal link between the measles, mumps, and rubella (MMR) vaccine and autism. The original study that connected the MMR vaccine to autism planted a seed of doubt in the minds of parents and ultimately led to a reduction in the rate of immunisation for rubella in the USA.1 Infants born to women who contract rubella during the first trimester of pregnancy are born with ocular, cardiovascular, auditory, and other systemic abnormalities, which are common manifestations of congenital rubella syndrome (CRS). These abnormalities can range from non328
apparent to severe, depending on the stage of pregnancy during which the mother contracted the rubella infection.2 The dominant characteristic of CRS is the diversity and multiplicity of the disabilities associated with it. The estimated burden of disease for one case of CRS exceeds US$200 000.3 The Helen Keller National Center, located in the USA, has been providing services to adults with congenital rubella syndrome for many years. We have watched several individuals with CRS develop additional late-onset medical problems caused by the virus. These include diabetes, glaucoma, thyroid disorder, endocrine imbalance, oesophageal anomalies, and, in rare cases, a systemic degenerative process. Rubella is still a public-health issue today. WHO has estimated that there are more than 100 000 infants born with CRS every year, worldwide.4 Because babies born to mothers who contracted rubella in the USA during the 1960s turn 40 this year, we are again reminded of the unparalleled and continuing effects of this insidious virus. Awareness should also be promoted to identify late-onset manifestations in individuals with CRS. Further research is still needed to investigate the emerging problems occurring in this unique population. Health-care providers need to encourage and enforce immunisation practices, and the public needs to be aware of the consequences of not being vaccinated.
*Normadeane Armstrong, Nancy O’Donnell [email protected] Helen Keller National Center, 141 MiddleNeck Road, Sands Point, NY 11050, USA 1
2
3
4
Mitchell S. UK measles outbreaks pose risk to US. http://www.upi.com/print.cfm?StoryID =20031031-044151-8440r (accessed June 23, 2004). Armstrong N, O’Donnell N. Rubella: 40 years after the epidemic. Am J Nurse Practitioners 2004; 8: 51–56. White CC, Koplan JP, Orenstein WA. Benefits, risks, and costs of immunization for measles, mumps, and rubella. Am J Public Health 1985; 75: 739–44. World Health Organization. Guidelines for surveillance of congenital rubella syndrome and rubella: field test version. Geneva: WHO, 1999.
Why is measles still endemic in Japan? Japan has been confronting the problems of uncontrolled measles for more than a decade now, and WHO has taken the initiative to eliminate measles worldwide. Despite these global efforts, however, measles is still endemic in Japan: there were an estimated 200 000 cases and 88 deaths (mainly in children) in 2000.1,2 But measles is not only a domestic problem. The US Centers for Disease Control and Prevention has reported that Japan is the country that exports measles to the USA most frequently.3 Japan has contributed a great deal financially to the global movement to eliminate measles through the United Nation Children’s Fund (UNICEF), and infant mortality in Japan is among the lowest in the world. Nevertheless, many Japanese children still die from a vaccinepreventable disease. Why is that? The measles vaccine was first introduced in Japan in 1966, and the measles, mumps, and rubella (MMR) vaccine followed in 1989. Subsequently, in 1993, the MMR vaccine used in Japan was withdrawn owing to unexpectedly high rates of aseptic meningitis associated with the mumps Urabe AM 9 strain.4 In 1994, major changes were made to the country’s immunisation law, such that all childhood immunisations were no longer mandatory. Individuals would be given “strong recommendations” to get the vaccine, but ultimately it would be their choice. Since 1994, the Japanese government has played a very passive part in the formulation of vaccine policies, mainly because of strong public opposition to the reinforcement of mandatory vaccination. As a consequence, the general public has not been well educated on vaccine-preventable diseases and is not aware of the significance of those diseases. Measles vaccine coverage rates are lower than in other countries such as the USA, where domestic measles has been almost eliminated. Moreover, even though many countries have already implemented a two-dose regimen of measles vaccine, Japan has not. Until www.thelancet.com Vol 364 July 24, 2004