Of measles and flu

When was the last time you saw a case of measles? If you're in a developed country and are under 40, the answer may be never. But that might be about to change, provided of course that you recognise what you see. The number of cases is increasing steeply in the UK, bringing predictions of the re-emergence of endemic measles. Meanwhile, as Perviz Asaria and Eithne MacMahon point out (p 890), clinical experience of measles has declined. They offer a reminder of the clinical features, complications, and management strategies.

They also call for increased measles vaccine coverage if the UK is to meet the World Health Organization's target of elimination by 2010. UK vaccination rates remain below those achieved before Andrew Wakefield published his Lancet paper on MMR in 1998, and efforts to regain lost ground have been only partially successful. In the battle for hearts and minds, the media and anti-vaccine groups have mounted a far more compelling case than the Department of Health.

In view of this, plans to pursue Wakefield for misconduct through the General Medical Council seem doomed and dangerous. Doomed if the main charge is publishing flawed research because that would set an impossible precedent. So much research is flawed, the GMC would be overwhelmed. Dangerous because, even if successful, the case would refuel the controversy and present Wakefield's supporters with a platform. Part of the problem is the perception that no one in an official position has taken seriously the concerns of families who believe their children have been damaged by the vaccine. The denial that the vaccine has caused the damage, though almost certainly accurate, doesn't sound very sympathetic and leaves Wakefield with a monopoly on taking these concerns seriously.

Some say that the Wakefield saga may have helped medical science by making us all more careful about the research we perform and publish. (I note that two of the research papers in this week's BMJ are randomised trials, the other being a well performed qualitative study.) But it would be bad if we became too cautious, especially if journals shied away from controversy. I see no sign of that.

As if to prove the point, we publish this week a broadside (based on a systematic review of the literature) about the lack of evidence for influenza vaccine. Why, asks Tom Jefferson (p 912), is there such a gap between evidence and policy? Governments go to great lengths to promote and provide the vaccine. But there is almost no valid evidence that it does any good. Jefferson puts the gap down to our desire to do something, combined with “optimism bias”—an unwarranted belief in the value of interventions. Would randomised trials be unethical? No, says Jefferson, they are the only ethical response to the possible waste of resources on ineffective or only partially effective care. The problem is that the UK has no transparent process for evaluating the effectiveness or cost effectiveness of vaccines. NICE would like to take this on. The government should let it.