Elsevier

Vaccine

Volume 24, Issue 18, 1 May 2006, Pages 3921-3928
Vaccine

The MMR vaccination and autism controversy in United Kingdom 1998–2005: Inevitable community outrage or a failure of risk communication?

https://doi.org/10.1016/j.vaccine.2006.02.033Get rights and content

Abstract

Background

The report of an hypothesised link between measles–mumps–rubella (MMR) vaccination and autism in 1998 became a major public health issue in the United Kingdom (UK), leaving most experts surprised by the overwhelming influence it had on public opinion about MMR vaccination. Coverage rates fell dramatically, and did not start to recover until 2004. Could this public reaction have been predicted?

Methods

We used Sandman's model of components predicting community outrage to assess the MMR controversy.

Results

The controversy fulfilled all of Sandman's 12 primary components and six of the eight additional components.

Conclusions

The Sandman model provided a useful framework to analyse this controversy and explained a significant portion of the community reaction and subsequent fall in vaccination coverage rates.

Introduction

Like all medical interventions, vaccination is a subject that requires careful communication of risk. Public concern about that risk has the potential to be amplified [1], [2], particularly via the anti-immunisation lobby which occasionally receives significant press coverage. The report of 12 children with an hypothesised link between measles–mumps–rubella (MMR) vaccination and autism in 1998 by Wakefield et al. became a major public health issue in the United Kingdom (UK) as the popular media ran with such a dramatic story [3]. The effects of this were far more than the usual anti-immunisation rhetoric. Parents were gravely concerned about the vaccine and measles coverage decreased, in some areas to levels below those which maintained herd immunity. Herd immunity is the level of population immunity above which sustained transmission is unlikely—this is estimated at >90% for measles and mumps and >85% for rubella. In fact, MMR coverage dropped to its lowest point since the program was introduced in 1988 after this controversy, falling from 92% in 1995–96 in England to 80% in 2003–2004 [4] (Fig. 1) and in London to as low as 58%. Later, outbreaks of measles and mumps occurred throughout the UK. [5], [6]. The effects were felt outside the UK in the USA, Australia, New Zealand and elsewhere, but nowhere were coverage rates so adversely affected [7]. Recent research from New Zealand showed that parents who chose not to immunise their children often cited a possible link between immunisation and autism [8]. Furthermore, as recently as July 2002, one-third of health providers in New Zealand still had significant uncertainty about whether MMR caused autism [9]. This is therefore a worthwhile subject to analyse. On the basis of published information, we tried to determine why the controversy generated so much public outrage—was it an inevitable reaction or did risk communication fail? As the scenario will probably be played out again, just as MMR followed a similar path to the pertussis vaccine controversy 2 decades before, we also suggest ways to improve risk communication in the future [10].

Section snippets

Factors responsible for causing high alarm

Sandman's model of components explaining community outrage (see Box) provides a useful way of reviewing the components of these events which increased the perception of hazard in the community [11]. These well-established rules of thumb are based on a large body of research about people's perception of health risks [12], [13].

The usefulness of models like Sandman's is that they emphasize that ‘experts’ (the medical profession, the Government or public health officials) often focus only on

Primary components of Sandman's model and how they applied to the MMR controversy

There are 12 primary components in Sandman's model. These are shown in Fig. 2 with some non-MMR illustrative examples and degree to which the component applied in the MMR controversy.

Secondary components of Sandman's model and how they applied to the MMR controversy

The eight secondary components in Sandman's model are shown in Fig. 3. Six of these were important in this issue.

What could have been done differently to communicate risk and minimise outrage?

This was an extremely difficult case for The Department of Health to handle, given the way the press reported the events and the emotion involved. As Elliman stated: “it is much easer to create doubt and damage a vaccine's reputation than it is to restore it” [20]. In 2005, the claim of a link has essentially been withdrawn, MMR immunisation rates have begun to recover [4] and community trust appears to be increasing.

Although the department strongly supported the use of MMR, it never made its

Postscript

“Popular Media responds to drama, whether in the form of victims of vaccines or epidemics. It serves to reduce the complex … arguments to … human interest stories” [10].

Although 10 of the 12 authors officially withdrew their interpretation of the original paper [22], the issue of measles and mumps diseases only really made headlines again when outbreaks began in the UK in 2004, reigniting the newsworthiness of the story, because controversy and fears of epidemics make good headlines. At the

Acknowledgement

We wish to thank Dr. Jill Forest for her help with the preparation of this manuscript.

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