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Earl Howe: My Lords, my noble friend Lord Hodgson has put his finger on some issues of very considerable public importance and I for one am grateful to him for giving us the opportunity to debate a topic that is never far from the newspaper headlines and not infrequently dominates them.
The key word in his Question, as he emphasised, is the word "trust"; and it is right that we should acknowledge as a general backdrop to this debate two recent trends. The first is the growing propensity of patients and the public to abandon the kind of unquestioning trust in politicians and doctors that was typical 40 or 50 years ago, although trust in doctors remains a whole lot more buoyant than trust in politicians. The second is the growing tendency for the lay patient to regard himself as an authority in his own right on matters medical, however ill-informed he actually is. So for a politician—I am not making a party point—to step forward and assure the public of the safety of this or that is almost bound to be greeted by instant suspicion, if not instant rebuttal, no matter who that politician may happen to be.
The debate about the safety of MMR has suffered from that kind of blanket mistrust and pressure group assertiveness, which have served to make it that much more difficult to achieve balance and clarity. Before pursuing that thought, I should perhaps make my own position clear. I do not dissent—I do not believe that any of us sensibly can—from the view of the World Health Organisation that, after the provision of clean water, vaccination is the most effective health intervention known to man. No vaccine can ever be totally safe but, in general, the risks associated with being vaccinated are infinitesimal compared with the risks of not being vaccinated.
I believe that we can say unequivocally that MMR has a proven track record of safety and efficacy over many years and I am a firm advocate of it. I am also a firm advocate of all other vaccines administered under the NHS including, let me say now, the new five-in-one vaccine introduced a few weeks ago for diphtheria, pertussis, tetanus, hib and polio.
However, none of that can obscure the separate but parallel issue of whether the public's mistrust of what they are told about vaccines is in some way understandable. Earlier this year, the Lancet published a case-control study drawn from a large number of records from across UK general practice that showed that the hypothesis of a link between the MMR vaccine and increased risk of autism or other pervasive developmental disorders has no convincing evidence to support it. Of all the studies published on the issue, that one, funded by the Medical Research Council, was by common agreement one of the most authoritative to date. The results showed that 78 per cent of cases diagnosed with a pervasive development disorder had
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been given the MMR vaccine, but a slightly higher proportion of controls, 82 per cent, who had received the vaccine did not have a disorder.
Authoritative the study may be, but are the parents of autistic children convinced? They are not. The reason that they are not is very simple, and was alluded to by the noble Countess, Lady Mar. It is that conclusions drawn from statistics and percentages are no substitute for conclusions based on direct observation of real children. Rule one in the art of medical diagnosis is always supposed to be, "Listen to the patient". In this case, it is, "Listen to the parent". The questions that parents want the researchers to ask are: what is wrong with this child and why did this child change from being healthy to being autistic?
Epidemiology has its place, but it is a blunt tool when it comes to reassuring particular individuals about why they or their children are suffering. Parents of autistic children do not feel that their worries are being treated with due respect and seriousness. They point to the tenfold rise in autism since 1988 and say that the only way that we shall be able to determine the causes of autism is by examining children who are autistic. Until now, none of the published studies has done that.
Meanwhile parents' anxieties are fuelled in other ways. Earlier this year Professor Jeff Bradstreet delivered to the vaccine safety committee of the Institute of Medicine in the United States a paper which purports to show two things: first, the presence of the measles virus in the cerebrospinal fluid and brains of children with autism; and, secondly, the toxic role of thiomersal in the autoimmunity and neurodevelopment of individuals with certain genetic characteristics. I am in no position to judge the merits of that paper, except to say that, for parents of autistic children, it is couched in terms that appear almost bound to perpetuate fears rather than to allay them.
One positive development in recent months has been the enhancement of the yellow card scheme to allow for direct reporting by patients. Potentially, the piloting of different ways of reporting adverse reactions holds out not only the prospect of providing more data to researchers but, perhaps equally importantly in the context of this debate, also the promise of a much higher level of confidence and trust among patients. One of the main complaints of the mothers of autistic children who believe that vaccinations were implicated in their children's autism was the failure, as they saw it, of the yellow card system. It would be helpful to hear from the Minister how well the pilot is proceeding.
I know all this about the parents involved because I have met some of them. I can tell the Minister that they are not fanatics; they are perfectly reasonable, intelligent people. I welcome much that the Government have done to try to allay their concerns about vaccine safety but I would only add, in the gentlest way, that perhaps it is in the Government's interests to look also at some of the things that I have been talking about, so that the deep anxieties of these individuals no longer boil to the surface, as they have had a habit of doing, thus causing alarm among a much wider public.
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As it is, rates of MMR take-up in London are only 70 per cent, with the figure as low as 62 per cent in south-east London. That is clearly a serious situation. A measles epidemic over the next few months has been predicted as highly probable. One can only hope that, as in previous years, the prediction is not borne out by events. The new programme of PCTs offering MMR jabs in schools is an excellent initiative. As an aside, the immunisation targets for GPs, although perfectly laudable on one level, do not help to build confidence in vaccines, in a prevailing climate of suspicion.
I hope that the Minister will tell us that the uptake of the new five-in-one vaccine has been universal. If it is, the Department of Health has escaped disaster by the skin of its teeth. By that I mean simply that the manner of the vaccine's announcement in August was so disorderly and ill managed as to have risked undermining its credentials from the word go. Only the reassuring intervention of Dr David Salisbury from the department restored a measure of equilibrium. But the episode brought home to many of us that the lessons of MMR have, sadly, not been fully learnt. I am sure that in hindsight the communication strategy would have been handled differently, but the fact remains that it is no use wishing away or ignoring the public's suspicions on such matters because the suspicions are there.
I am wholly persuaded that the new vaccine is safer and better than its predecessors. I am afraid that a lot of nonsense is talked about the risks of overloading babies' immune systems with an excessive number of viral and bacterial challenges. An understanding of the underlying biological science is one of the things that must be promoted if the battle for public trust is to be won. It is no wonder that Dr Salisbury was quoted as saying that the conflicting views about thiomersal had left parents feeling like,
His clear view is that the dangers of thiomersal have been seriously overstated. With due deference to my noble friend, I respect that opinion absolutely.
The principal benefit of the five-in-one jab is not so much the removal of thiomersal but the introduction of acellular pertussis and the replacement of a live polio vaccine with dead virus. There is a lower chance of an adverse reaction to the vaccine, not a higher one. Nevertheless, perhaps it would have been better to have introduced the vaccine in an even greater spirit of openness; for example, by allowing public access to meetings of the Joint Committee on Vaccination and Immunisation. Understandably, many questions were asked about the vaccine's safety record. Although the Government have provided largely reassuring answers, the Canadian experience may not have been quite as benign as has been made out because of possible widespread under-reporting of adverse reactions. I should be delighted if the Minister could knock that story on the head.
My only other point relates to the Medicines and Healthcare products Regulatory Agency (MHRA). Last month the Minister made a welcome announcement to
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promote even greater transparency in the regulation of all medicines. There are much tighter rules on conflict of interest for the chairman and members of the new commission, and a greater role for patients and the public. Pharmaceutical companies are being encouraged to be more open with their clinical trials data. All of that is good. But my noble friend has posed some good questions about regulation and independent advice.
One idea that the Government might consider is whether in the specific context of new vaccines NICE could be given a role in the evaluation of safety. In my judgment, NICE has gained a very wide measure of public confidence in the way that it works. It already evaluates safety issues in the context of new interventional procedures. So the principle of NICE, as a non-partial body, examining the safety of new vaccines would not be a radical departure. If it served further to reassure the public, as I believe it would, that could only be positive.
I agree with the noble Baroness, Lady Barker, that communicating with the public on the benefits and risks of vaccines—NICE has learned to communicate particularly well—is a sine qua non of a less frenzied and more measured climate of public debate, a state of affairs most earnestly to be desired.
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