So, what were the Daily Mail and Jerome Burne thinking when they put together this latest compilation of innuendo framed by the emotive photograph of a distressed child who seems trapped between two uncaring, faceless white coats?
One of the last times we mentioned Jerome Burne, co-author of Food Is Better Medicine Than Drugs with
Former Visiting Professor Patrick Holford, he had failed to meet the usual high standards of The Economist (Part 1, 2, 3), presenting a distortion of evidence that was at odds with the authors of the papers he cited in support of his writing. We also mentioned that for one who is associated with those who style themselves after the Salem Witches in their ability to detect a conflict of interest in others, he was more than a little blithe concerning the perception of his own. So, here we are again, only this time it is the Daily Mail that is the venue for these distorted interpretations of research findings and a vaguely menacing, anti-vaccination message.
Jerome Burne is almost certainly not responsible for the sensationalist headline for the story but it is a nice set-up for the mis-information he is about to disseminate: Why giving children the chicken pox jab could give YOU shingles. Now, for anyone who knows anything about shingles, that’s an unpleasant prospect. First impressions for some readers might be that somehow, it is possible to catch chickenpox from a freshly-vaccinated child and that this exposure triggers shingles in adults – the rather more sophisticated and nuanced clarification does not occur until considerably later in the piece.[a]
Children might soon be vaccinated against chicken pox, according to recent reports. But some experts question the need for a vaccine against an infection that’s so mild – especially when it could put thousands of elderly people at greater risk of shingles.
Well, that depends on who you style as experts with a valid opinion and the questions and answers that you report from actual experts. Plus, how many readers are slightly startled to move from the soothing claim that chicken pox is “mild” to the following dramatic report?
Chicken pox causes up to 50 deaths a year, 40 of them children, and it seems the Government’s Joint Committee on Vaccination and Immunisation is considering adding a vaccine against it to the MMR jab.
50 deaths? In the UK? It seems not (see below) but this is difficult to interpret without some indication of whether this figure is for the UK, Europe, USA or the world.
Burne moves on to alarm the reader.
But there is widespread concern about [discussion of a universal chickenpox vaccination programme]. First because a similar MMR super jab now used in America has been found to double the risk of fits in some children.
The source of this claim, oddly enough, is a report on the Merck ProQuad vaccine by the CDC.
Now, watching any child have a fit is distressing. Watching your own child have a fit can make it seem like your heart has stopped for the duration. So, ‘doubling the risk of fits’, isn’t that really rather alarming and, on the face of it, completely unacceptable?
As so often happens when journalists resort to quoting relative risk rather than absolute numbers, that rather depends on a number of factors and your interpretation of them.[b]
One in 33 children experiences at least one fit (febrile seizure) before the 6th birthday. The majority of these fits occur within the first few hours of a child’s fever. Patient UK details the three classes of fit, which range from momentary (commonest) to a duration of more than 30 minutes (rare). Patient UK also offers some good advice on an appropriate response to the fit and how to care for the affected child.
Although alarming, a febrile seizure is not usually dangerous. Full recovery is usual. Most illnesses which cause fever and febrile convulsions are the common coughs, colds, and virus infections which are not usually serious. However, the illness that causes the fever is sometimes serious, for example, pneumonia. [Emphasis added.]
For further information there is a good NHS Clinical Knowledge Summary on children’s febrile seizures. However, it is clear that common infections such as colds as well as preventable childhood diseases can trigger a febrile convulsion.
Returning to the troubling issue of ‘doubling the risk of fits’, Dr Iksander of the CDC’s Advisory Committee on Immunization Practices told Web MD that:
The highest incidence [of fits] is between 14 and 18 months of age. That’s right at the time we give [children] MMR and varicella vaccinations.
That’s one potential confounder but even so, what does this ‘doubling of risk’ mean for a child? Helpfully, a CDC Safety Study on ProQuad gives the absolute numbers:
Four out of every 10,000 kids who got separate MMR and varicella shots on the same day had a febrile seizure seven to 10 days later. Nearly twice as many kids who got ProQuad — nine in 10,000 — had febrile seizures seven to 10 days after vaccination.
Looking at those figures and bearing in mind the natural incidence of fits in children, perhaps that ‘doubling of risk’ isn’t quite as shocking or sensational as it might otherwise seem. It is even at some variance with an earlier US study of 3298 children that reported no increase in fits (the numbers may have been too small to show a small effect). Similarly, a NZ study did not report an increase in adverse events.
What about studies in Europe and other versions of the combined MMRV vaccine? HolfordWatch located a recent publication about the GSK combination vaccine for MMR and varicella from Germany but Burne oddly excludes that report despite the encouraging finding that:
the clinical profile of this combination vaccine, in terms of injection-site and general tolerability, is similar to that of the component vaccines. A higher incidence of low-grade fever has been noted following the first dose of MMRV vaccine, although it is no different from component vaccines following the second dose.
So far, we are barely into the story and we’ve had to point out that Jerome Burne cherry-picked a particular study and headline figure without attempting to place it in context.
What of the rest of the story? It is only now that he explains the mechanism by which a chickenpox vaccination programme for children might raise the incidence of shingles for adults.
[T]he jab has raised the rate of shingles among the old – according to one U.S. study, cases have risen by 90 per cent. Here even the Government health watchdog, the Health Protection Agency, has predicted that a vaccine could cause a 20 per cent rise in shingles cases.
But how could a vaccine for children make old people ill? Chicken pox and shingles are caused by the varicella virus – after a childhood attack of chicken pox, the virus lies dormant in the nerves until triggered in later life when it flares up as shingles.
The belated explanation is welcome but, again, note the lack of detail for the striking 90% statistic that makes it difficult to identify even for readers who are familiar with the clinical literature. The HPA does place its forecast of a 20% increase in cases in the context of a medium-term trade-off that should be accounted for in any decision-making process.
Burne fails to report that the 90% increase in shingles, following a vaccine-associated decline in chickenpox was reported from preliminary data and is in conflict with another large US study that did not report an increase. The authors who reported the 90% increase were considerably more tentative about their findings and were careful to include appropriate nuance.
Our study is subject to several limitations…
As varicella vaccine coverage in children increased, the incidence of varicella decreased and the occurrence of herpes zoster increased. If the observed increase is real, widespread vaccination of children is only one of several possible explanations. [Emphasis added.]
However, there is a considerable disparity between 20% and 90% and a reader’s alarm might be, understandably, exacerbated on reading:
[S]hingles is often a nasty condition in the elderly. By the age of 85, 65 per cent of us will have suffered this often extremely painful disease.
It begins as a burning sensation along the nerves down which the virus is moving, followed by the rash and fever, usually lasting three to five days. But in some cases – as many as 20 per cent of those over 50 – severe pain will be there six months later.
40 per cent of sufferers will have long-lasting pain due to permanent nerve damage, according to the Shingles Support Society.
If the virus reaches your eyes, it can cause blindness. If you have to go to hospital for chicken pox, your average stay will be three days, but for shingles it is 11 days and you are six times more likely to die.
Although the inflammation doesn’t kill you, it can lead to fatal conditions such as pneumonia, inflammation of the brain or severe bacterial infections in the eruptions in the skin leading to toxic shock. Some experts put the death rate from shingles at five times that from chicken pox…
In a paper published in the International Journal Of Toxicology, Dr Goldman claimed that since shingles results in three times as many hospitalisations and five times as many deaths as chicken pox, this increase meant the vaccination made no sense. [Emphasis added.]
65% by the age of 85 is an extraordinary statistic that, paradoxically, makes a nonsense of the 90% increase figure. If you were to put those figures together, you would need to be counting recurrences of shingles in the same person because you would have 123.5 cases per 100. This smacks, more than a little, of cherry-picking the most alarming figures.
The UK HPA reports a rather less alarming figure of 1 in 5 as a lifetime occurrence of shingles. Just to make sure, HolfordWatch contacted the HPA and they confirmed that they stand by that estimate and explain that the incidence varies from one year to another from around 1 in 5 to 1 in 7. We may add more detail from the HPA later.
HolfordWatch is not in a good position to judge how easy it would be for a general reader who is unfamiliar with the clinical literature to disentangle Jerome Burne’s gaullimaufry of conflicting numbers that seems strangely slanted towards frightening rather than informing. Careful readers might wonder why it is so difficult to identify any reputable sources for these figures and why the only comparatively-identifiable one is not reported as contentious (Scopie’s Law might hint at the repository where you will find this: Goldman paper (pdf).) It might also be difficult to recall that Burne described chickenpox as “mild” with a ‘low mortality rate’, so again, although these percentages look alarming, the absolute numbers may be comparatively small and Goldman does not give a clear source for his figures.
As for Burne’s alarming reference to shingles-related “blindness”, the Shingles Support Society reports that shingles in the eyes is a ‘rare’ complication that left “untreated” may damage the eyes.
Unabashed, the article continues, paying lip-service to the chickenpox vaccination’s reduction of childhood illness and death but then questioning it.
[C]oncerns are being raised about the benefits of the chicken pox vaccine for children. The U.S. vaccination programme cut the number of infections by 79 per cent, with a corresponding drop in the number of hospital visits and deaths; down from 100 to 20.
But critics say reporting the disease is no longer mandatory in the U.S. – making it appear less common – and that those who died before vaccination were very often already ill.
Now, that seems to be an easily-verifiable claim. Jerome Burne does not, however, turn to any of the authors of the 2007 UK surveillance report for chickenpox who compiled the mortality and morbidity statistics for a comparable UK perspective. No, Jerome Burne’s expert of choice is Dr Richard Halvorsen, author of a book that refers to vaccination as an experiment in which ‘children are guinea-pigs’, and (unmentioned by Burne) the director of the BabyJabs clinic that sells single-jabs and offers parents an a la carte vaccination schedule. Dr Halvorsen is also featured on the website of Burne’s co-author, Patrick Holford.
A recent UK study used to support the idea that we should start vaccinating found that in just over a year, 112 children had chicken pox badly enough that they had to go to hospital and eight died,’ [Halvorsen] says. ‘But one of those eight was still in the womb and five also already had serious medical conditions.
‘In fact, out of a population of 10 million children in the UK, only one previously healthy child died from chicken pox. It’s tragic of course, but is it really worth all the other risks, not to mention the millions it will cost, to reduce those figures?’
‘We don’t know why the UK child died, but American research suggests some of the drugs used to treat serious cases, such as antibiotics and steroids, may make it worse, he adds.
The study authors stressed that their figures show a “minimum estimate of severe complications and death resulting from varicella in children in the UK and Ireland”. They carefully described their criteria for including children in their figures and they were considerably more complex than Halvorsen’s “children had chicken pox badly enough that they had to go to hospital”.
The case definition was any child <16 years of age hospitalised with complicated varicella, as defined by list of clinical conditions (table 1), or admitted to ICU/HDU with varicella or one of its complications. The list of clinical conditions was determined by literature review and reference group consultations involving infectious disease paediatricians, virologists and public health specialists…
This study could not have included data on all varicella hospitalisations, as this would have been unmanageable with the methodology used…It was therefore necessary to restrict ascertainment to severe cases….We therefore decided to specify which clinical presentations would be considered as severe complications. This gave clear inclusion criteria but may have excluded other presentations considered just as severe. Indeed, 28 of the initial reports (15%), while reporting true varicella complications, did not meet the case definition. These included presentations of cellulitis, abscess or osteomyelitis in the absence of bacteraemia, cerebral infarct, acute renal failure, orchitis, idiopathic thrombocytopenic purpura, stroke and ataxia not requiring hospitalisation. It is worth emphasising that most children admitted to hospital in the UK and Ireland as a result of varicella will not have met our case definition. Such children often appear to have secondary bacterial infection of skin lesions, manifest by fever and cellulitis, yet infrequently have positive blood cultures or meet criteria for toxic shock syndrome or necrotising fasciitis. [Emphasis added.]
We hope that it is plain that the version of this that Jerome Burne has attributed to Halvorsen does not match the facts.
Either Burne or Halvorsen mis-states the number of deaths. Using the authors’ careful criteria, there were 6 deaths:
UK varicella deaths have been reported previously, from routine statistics, to be an average of 4 (1991–2000),  4.7 (1995–97),  or 8.5 (1967–1985)  deaths per year for children aged 0–14 years. Our figure of six deaths, including one intrauterine death, is within this range. The lower figures are for more recent years, which may reflect the wider use of prophylaxis in high-risk contacts and/or earlier treatment of high-risk cases.
Halvorsen’s summary of the dead children seems a little off-hand. Although 4 of them had underlying health problems, it is not clear that they would, necessarily, be such that the child might not have been expected to have a reasonable life-span. The health problems included:
HIV, cerebral palsy (n = 2) and cardiac skeletal myopathy…
One of the deaths reported in our study was in a child with HIV. High varicella mortality rates for HIV patients are not typical, with other studies reporting few deaths. [28 29] However, fulminant varicella with concomitant cytomegalovirus presented with HIV in this individual.
Our finding of a high proportion of cases having infectious complications is similar to other studies. [9–13, 16, 18–23] In particular, there has been recent concern over the relatively high number of invasive Group A Streptococcus infections,  as found in our study.
From all of the above, it may be seen that Burne’s account and his report of Halvorsen’s account is difficult to rely upon for a fully-rounded picture. There are many important factors that must be taken into account before there can be a full justification for accepting or rejecting a universal vaccination programme for chickenpox for UK children. The issue of whether there will be a combined MMRV or two separate jabs delivered at the same visit is another consideration. However, such a discussion is hindered, not helped, by spreading as much mis-information as the Daily Mail, Jerome Burne and Richard Halvorsen have in this article. This isn’t facilitating the public understanding of difficult issues, it is preventing discussion of them.
All told, putting together this has probably taken about 8-9 hours of work from different contributors and we didn’t have suffient time or resources to rebut all of the canards. Casual readers who only see the Daily Mail version of events will be left with a very skewed impression of varicella and shingles and it would take a mass of detail to disentangle those impressions. Detail such as the ones we have provided: details that could not possibly be addressed in a normal conversation with a GP or Health Visitor. Details that could not be presented in the course of normal conversation without overwhelming the parents or other concerned individuals.
Here at HolfordWatch, we don’t know what the answer is – but we are certain that the Daily Mail has failed its readers. If they had wanted to provide an informed and balance article, then they would have asked a credible expert to write it.
[a] Chickenpox (varicella) is caused by the varicella zoster virus (VZV). VZV also causes shingles. A first infection with VZV will result in chickenpox after which the virus lies dormant. However, if the virus is then reactivated (and this may happen for a number of reasons), it may result in shingles. Effectively, at the risk of sounding like a immunological version of A Tale of Two Cities, when somebody has had chickenpox, VZV remains in the nerve cells and can be recalled to life to wreak havoc at any time in that person’s life.
[b] Burne gives an absolute number but it is near the foot of the piece and easily missed after the alarm call of the opening story: we thought we might illustrate the diminished impact of that by placing this information in a footnote.
The number of extra cases was small, about one more in 2,000, but there is another difference between the two regimes. Proquad contains five times the amount of chicken pox virus as the single dose. Whether that caused the additional convulsions is disputed.
It is not said by whom that causation is made or their evidence for it nor why they believe that the number of antigens from an attenuated strain of virus should be causally related to the “additional convulsions”.
[c] The distortion may lie in Jerome Burne’s version of what Dr Halvorsen said rather than Halvorsen’s own error but it does not seem much at variance with Halvorsen’s typical stance on matters that relate to vaccination.