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Measles, mumps and rubella. The new MMR
Editorial
517
(a) when the available treatment is partially effective, i.e. the sanitorium regime and artificial pneumo-thorax, and (b) when fully effective treatment (e.g. chemotherapy) becomes available for most patients. In the early situation an unfortunate effect o f partial treatment can be to prolong morbidity by reducing mortality. In the later stage, prevention and control of spread are also enhanced because contact tracing and case finding have an effective treatment to back them up, This is probably why the problems have cleared up so rapidly since 1948_in the U K , although the political will and resources o f the N H S have been substantial contributions that have sometimes been lacking in other continents where tuberculosis still presents great problems. It should not be forgotten that in Stage 3, Public Health doctors have been prepared to give clinical support where they have felt the greatest problems lay, such as in Sanitoria and Dispensaries. This is because of the time lag between the introduction o f an effective treatment and its widespread application to patients. This m a y be for economic reasons, if the treatment is expensive, but it is usually due to the need for trained staff. While, therefore, it has been usual for Public Health doctors to renounce the practise o f clinical medicine for a commitment to epidemiology disease control and prevention, in the interim when there has been a shortage o f clinicians, m a n y Public Health doctors have responded by redeveloping their clinical skills as a special interest. Finally, since smallpox has been eliminated as a h u m a n disease during the last decade, elimination must now be the ultimate target for h u m a n tuberculosis; but are there too m a n y and too wide-spread animal hosts for this to be possible? This is perhaps the ultimate challenge that the next generation of Public Health doctors will take up. F. N. GARRETT
Measles, M u m p s and Rubella. The N e w M M R The U K has a poor vaccination record. We m a y have led the world in 1798 when Edward Jenner first observed that inoculation with cowpox prevented smallpox, but our recent record is abysmal. Rubella vaccination has been one of the most successful, but in 1986-87 there were 372 infections with rubella in pregnant w o m e n confirmed by laboratories in England and Wales. ~ The main risk is o f congenital rubella syndrome (CRS) causing deafness, mental retardation and often other abnormalities in the fetus. Infection occurring in the first 9 weeks of pregnancy causes fetal d a m a g e in up to 90% o f cases. On average 20 cases o f CRS are notified annually and m a n y more pregnancies are terminated to avoid this outcome. Measles is another disaster area. The complications cause 2,600 hospital admissions each year in England and Wales. ~ Encephalitis occurs in up to 0.4% o f cases. U p to 15% of these die while a further 25% suffer permanent brain damage with mental retardation or epilepsy with or without paralysis. 3 Subacute sclerosing panencephalitis is a rare complication, occurring in 1:1,000,000 cases. It causes progressive deterioration of behaviour and intellectual function with death after a b o u t six months. 3 There are 10-20 deaths a year from measles in the U K , about half occurring in children who are immunosuppressed as a result of treatment for diseases such as leukaemia which nowadays carry a good prognosis, so it is doubly tragic that such children should be killed by an infection perhaps carried to them by a close friend or relative who should have been vaccinated. M u m p s causes about 1,200 hospital admissions each year in England and Wales. It can cause permanent deafness (usually in one ear only) and in the U K there has been virtually
518
Editorial
no vaccination given against this disease. Orchitis occurs in 15-25% of males and very rarely may lead to sterility. It is the c o m m o n e s t form of viral meningitis but fortunately this is usually benign. Mumps, measles and rubella vaccine ( M M R ) has been in use in m a n y other countries for several years from Costa Rica and Czechoslavakia to the USA. It has been estimated from the United States that every million children vaccinated will prevent 75,000 cases of mumps, 226 cases of meningocephalitis, 329 cases of orchitis and 3 deaths. They have also had impressive results with rubella. A population five times that o f the U K had only 2 cases of CRS in 1985. For measles, the USA figures give a cost benefit of 14: 1, with 2,872 cases a year compared with 3,325,000 without an immunisation p r o g r a m m e , and 1 case of measles encephalitis compared with an estimate of 1,164 without an immunisation p r o g r a m m e ? It is vital that the new M M R project is a success. T o o m a n y children suffer and are permanently handicapped because we have not been sufficiently vigorous in protecting them from these diseases. We have become too complacent accepting measles, m u m p s and rubella as if they were an acceptable part of the complex tapestry of life. They are N O T . The Department of Health is m o r e used to our brickbats than our praise, but on this occasion it deserves our congratulations for the vigour it is showing in master-minding this campaign, and more importantly, it deserves our support. F r o m October 1988, M M R is being given to children of both sexes in place of measles vaccine during the second year of life. ~ Children of both sexes aged 4~5 years should be given M M R before starting primary school providing that the parents consent, that there is no documented record of M M R vaccination, no laboratory evidence o f immunity to measles, m u m p s and rubella, and no valid contraindications. A. M. B. GOLDING References I. Immunisation against Infectious Disease. Health Education Authority (DHSS) 1988 (an Information Pack distributed by DHSS to all doctors and many others with a covering letter PL/CMO (88) 19 PL/CMO (88) ll). 2. Immunisation against Infectious Diseases (HMSO) 1988. 3. Fact Sheet 3 issued by Smith Kline and French Laboratories Ltd. Sept. 1988. 4. Fact Sheet 4 issued by Smith Kline and French Laboratories Ltd. Sept. 1988. Adieu It is with mixed feelings that I write this farewell note to you, my readers. This is the last issue of the last volume which I shall edit. My friend and colleague D r Maurice Beaver takes over, and will be the editor responsible for volume 103. I know that he will make a good job of it. Doubtless he will make changes just as I did when I took over twelve years ago. Maurice Beaver has served an apprenticeship on my Editorial Board for several years and has recently been 'reviews editor'. I have enjoyed the task o f editing Public Health for the past twelve years, but having been retired from my post in the N H S for several years, I feel less in touch with the day to day problems o f the service, and m a y be losing the ability to judge what is likely to be of interest and concern to you. It is thus time for me to hand over. T h a n k you all for your support over the years. Your encouragement has helped me to deal with the difficulties and m a d e my task seem worthwhile. I a m sure that you will give Dr Beaver the same support which you have given me. T o b o t h you, my readers, and to you Maurice, I wish the very best of good fortune. J. S. ROBERTSON
517
(a) when the available treatment is partially effective, i.e. the sanitorium regime and artificial pneumo-thorax, and (b) when fully effective treatment (e.g. chemotherapy) becomes available for most patients. In the early situation an unfortunate effect o f partial treatment can be to prolong morbidity by reducing mortality. In the later stage, prevention and control of spread are also enhanced because contact tracing and case finding have an effective treatment to back them up, This is probably why the problems have cleared up so rapidly since 1948_in the U K , although the political will and resources o f the N H S have been substantial contributions that have sometimes been lacking in other continents where tuberculosis still presents great problems. It should not be forgotten that in Stage 3, Public Health doctors have been prepared to give clinical support where they have felt the greatest problems lay, such as in Sanitoria and Dispensaries. This is because of the time lag between the introduction o f an effective treatment and its widespread application to patients. This m a y be for economic reasons, if the treatment is expensive, but it is usually due to the need for trained staff. While, therefore, it has been usual for Public Health doctors to renounce the practise o f clinical medicine for a commitment to epidemiology disease control and prevention, in the interim when there has been a shortage o f clinicians, m a n y Public Health doctors have responded by redeveloping their clinical skills as a special interest. Finally, since smallpox has been eliminated as a h u m a n disease during the last decade, elimination must now be the ultimate target for h u m a n tuberculosis; but are there too m a n y and too wide-spread animal hosts for this to be possible? This is perhaps the ultimate challenge that the next generation of Public Health doctors will take up. F. N. GARRETT
Measles, M u m p s and Rubella. The N e w M M R The U K has a poor vaccination record. We m a y have led the world in 1798 when Edward Jenner first observed that inoculation with cowpox prevented smallpox, but our recent record is abysmal. Rubella vaccination has been one of the most successful, but in 1986-87 there were 372 infections with rubella in pregnant w o m e n confirmed by laboratories in England and Wales. ~ The main risk is o f congenital rubella syndrome (CRS) causing deafness, mental retardation and often other abnormalities in the fetus. Infection occurring in the first 9 weeks of pregnancy causes fetal d a m a g e in up to 90% o f cases. On average 20 cases o f CRS are notified annually and m a n y more pregnancies are terminated to avoid this outcome. Measles is another disaster area. The complications cause 2,600 hospital admissions each year in England and Wales. ~ Encephalitis occurs in up to 0.4% o f cases. U p to 15% of these die while a further 25% suffer permanent brain damage with mental retardation or epilepsy with or without paralysis. 3 Subacute sclerosing panencephalitis is a rare complication, occurring in 1:1,000,000 cases. It causes progressive deterioration of behaviour and intellectual function with death after a b o u t six months. 3 There are 10-20 deaths a year from measles in the U K , about half occurring in children who are immunosuppressed as a result of treatment for diseases such as leukaemia which nowadays carry a good prognosis, so it is doubly tragic that such children should be killed by an infection perhaps carried to them by a close friend or relative who should have been vaccinated. M u m p s causes about 1,200 hospital admissions each year in England and Wales. It can cause permanent deafness (usually in one ear only) and in the U K there has been virtually
518
Editorial
no vaccination given against this disease. Orchitis occurs in 15-25% of males and very rarely may lead to sterility. It is the c o m m o n e s t form of viral meningitis but fortunately this is usually benign. Mumps, measles and rubella vaccine ( M M R ) has been in use in m a n y other countries for several years from Costa Rica and Czechoslavakia to the USA. It has been estimated from the United States that every million children vaccinated will prevent 75,000 cases of mumps, 226 cases of meningocephalitis, 329 cases of orchitis and 3 deaths. They have also had impressive results with rubella. A population five times that o f the U K had only 2 cases of CRS in 1985. For measles, the USA figures give a cost benefit of 14: 1, with 2,872 cases a year compared with 3,325,000 without an immunisation p r o g r a m m e , and 1 case of measles encephalitis compared with an estimate of 1,164 without an immunisation p r o g r a m m e ? It is vital that the new M M R project is a success. T o o m a n y children suffer and are permanently handicapped because we have not been sufficiently vigorous in protecting them from these diseases. We have become too complacent accepting measles, m u m p s and rubella as if they were an acceptable part of the complex tapestry of life. They are N O T . The Department of Health is m o r e used to our brickbats than our praise, but on this occasion it deserves our congratulations for the vigour it is showing in master-minding this campaign, and more importantly, it deserves our support. F r o m October 1988, M M R is being given to children of both sexes in place of measles vaccine during the second year of life. ~ Children of both sexes aged 4~5 years should be given M M R before starting primary school providing that the parents consent, that there is no documented record of M M R vaccination, no laboratory evidence o f immunity to measles, m u m p s and rubella, and no valid contraindications. A. M. B. GOLDING References I. Immunisation against Infectious Disease. Health Education Authority (DHSS) 1988 (an Information Pack distributed by DHSS to all doctors and many others with a covering letter PL/CMO (88) 19 PL/CMO (88) ll). 2. Immunisation against Infectious Diseases (HMSO) 1988. 3. Fact Sheet 3 issued by Smith Kline and French Laboratories Ltd. Sept. 1988. 4. Fact Sheet 4 issued by Smith Kline and French Laboratories Ltd. Sept. 1988. Adieu It is with mixed feelings that I write this farewell note to you, my readers. This is the last issue of the last volume which I shall edit. My friend and colleague D r Maurice Beaver takes over, and will be the editor responsible for volume 103. I know that he will make a good job of it. Doubtless he will make changes just as I did when I took over twelve years ago. Maurice Beaver has served an apprenticeship on my Editorial Board for several years and has recently been 'reviews editor'. I have enjoyed the task o f editing Public Health for the past twelve years, but having been retired from my post in the N H S for several years, I feel less in touch with the day to day problems o f the service, and m a y be losing the ability to judge what is likely to be of interest and concern to you. It is thus time for me to hand over. T h a n k you all for your support over the years. Your encouragement has helped me to deal with the difficulties and m a d e my task seem worthwhile. I a m sure that you will give Dr Beaver the same support which you have given me. T o b o t h you, my readers, and to you Maurice, I wish the very best of good fortune. J. S. ROBERTSON