Indian J Med Ethics. 2014 Oct-Dec;11(4):218-22.
Commentary--Controversies surrounding mercury in vaccines: autism denial as impediment to universal immunisation.
1
Senior Registrar, Department of Paediatrics, St Stephens Hospital, Tis Hazari, Delhi 110 054 India.
2
Consultant Paediatrician and Head of Department of Paediatrics, St Stephens Hospital, Tis Hazari, Delhi 110 054 India.
Abstract
In 2004, the US Center for Disease Control (CDC) published a paper showing that there is no link between the age at which a child is vaccinated with MMR and the vaccinated children's risk of a subsequent diagnosis of autism. One of the authors, William Thompson, has now revealed that statistically significant information was deliberately omitted from the paper. Thompson first told Dr S Hooker, a researcher on autism, about the manipulation of the data. Hooker analysed the raw data from the CDC study afresh. He confirmed that the risk of autism among African American children vaccinated before the age of 2 years was 340% that of those vaccinated later.
Comment on
· Thimerosal as discrimination: vaccine disparity in the UN Minamata Convention on mercury. [Indian J Med Ethics. 2014]
PMID:
25377033
DOI: https://doi.org/10.20529/IJME.2014.055
n 2004, the US Center for Disease Control
(CDC) published a paper showing that there is no link between the age at which
a child is vaccinated with MMR and the vaccinated children’s risk of a
subsequent diagnosis of autism (1). One of the authors, William Thompson,
has now revealed that statistically significant information was deliberately
omitted from the paper (2). Thompson first told Dr S Hooker, a researcher on autism, about the manipulation
of the data. Hooker analysed the raw data from the
CDC study afresh. He confirmed that the risk of autism among African American
children vaccinated before the age of 2 years was 340% that of those vaccinated
later. Hooker published his findings in the peer-reviewed open-access
journal, Translational Neurodegeneration. However, within
hours of CNN publishing the story of the CDC whistle-blower, Hooker’s article
was removed from the website of the open-access journal. It was stated that the
journal and publisher “believe that its continued availability may not be in
the public interest”. The full article is now available only on the PubMed
website (3).
The MMR vaccine contains no Thimerosal, but
the story of Thompson and the paper on MMR serves to illustrate how disputed
the areas of vaccine-related injury and autism have become.
Protection from mercury as
an equity issue
This issue of the IJME features
an article by Sykes and colleagues on Thimerosal – a mercury-based preservative
used in vaccines (4). The article inveighs against the
exemption under the UN Convention on Mercury (Minamata
Convention) that allows the use of Thimerosal-containing vaccines in developing
countries. The authors, who are from the Coalition for Mercury-free Drugs and
the Institute of Chronic Illnesses, argue that developing children and
developing nations are the most vulnerable to toxic exposures and the UN’s
primary aim should be to protect them. They sidestep contentious issues, such
as claims about vaccine-related injury, and dwell mainly on the matter of
unfair discrimination.
The demand for mercury-free vaccines, however,
springs from the perception that the heavy metal added to vaccines is harmful.
It is felt that there was a spike in the incidence of autism in the USA when
the Haemophilus influenza b (Hib)
and hepatitis B vaccines were recommended for universal use (5). This commentary attempts to bring together
the evidence. We discuss the need for mercury in vaccines and the suggestion
that the use of ethyl mercury is safe. It draws extensively on a US House of
Representatives report, “Mercury in Medicine Report” (6).
Thimerosal as preservative
in vaccines
Thimerosal is an organic mercurial compound
made up of equal parts of thiosalicylic acid and
ethyl mercury. Ethyl mercury dissociates from Thimerosal and acts as a
preservative (7). Thimerosal is used to prevent
bacterial contamination of vials which are entered multiple times, ie multi-dose vials of vaccines. Preservatives are not
required for single-dose ampoules.
Methyl mercury experience
Thimerosal has been in use since the 1930s in
a number of biological and drug products (8). The US Food and Drug Administration
(FDA) did not require manufacturers to submit reports on pre-licensure safety
testing until 1938, and efficacy testing until the 1960s, and as such, very few
studies explored the toxicity of ethyl mercury (9). More data is available on methyl
mercury, which was used for its anti-fungal properties from the 1860s when
storing seeds. In the 1950s, methyl mercury toxicity was noticed in the Minamata Bay, Japan, with dead fish being washed ashore,
seagulls falling out of the sky, frenzied cats whirling in a mad dance ending
in death, and doctors reporting patients with a staggering gait. In 1968, the
Japanese government released a statement implicating methyl mercury for the
symptoms (10). It is assumed that the toxicity of
ethyl mercury would be qualitatively similar to that of methyl mercury,
although this has not been proved.
Recommended upper limit of
mercury intake
The FDA has proposed 0.4 µg per kg of body
weight per day as the acceptable daily intake of methyl mercury, on the basis
of the threshold at which paresthesia occurs in adults (11). However, the foetus
and infants are particularly susceptible to mercury toxicity, and long-term
studies in Iraq have shown language delays among infants exposed to mercury (12). On the basis of the findings of the
Iraq studies, the Environmental Protection Agency lowered its reference dose
for methyl mercury exposure to 0.1 µg per kg per day.
Mercury in vaccines
exceeding recommended intake
In 1999, the concern was raised that children
being given the recommended doses of immunisation
could be receiving doses of organic mercury, specifically ethyl mercury, which
exceeded the specifications in the guidelines for the intake of methyl
mercury (13).
Prior to the approval of the Hepatitis B
recombinant vaccine, the only vaccine containing Thimerosal that was routinely
given to infants was the DPT. This contained 25 µg of ethyl mercury, and was
administered thrice in the first 6 months of life (75 mg of ethyl mercury) and
a total of 4 times in 2 years (100 µg). After licensing of the Hepatitis B
vaccine (administered within hours of birth and a total of 3 times in the first
6 months), which contained 12.5 µg of ethyl mercury, and the Haemophilus influenza b vaccine
(administered 3 times in the first 6 months), which contained 25 µg of ethyl
mercury, the cumulative quantity of ethyl mercury administered in the first 6
months went up from 75 µg to 187.5 µg. Using the EPA threshold of 0.1 µg per
kg, the threshold would be 0.5 µg for a baby weighing 5 kg. The cumulative dose
administered to babies receiving 187.5 µg would thus be higher than the
threshold (14). It was feared that autism might
result from the administration of high doses of Thimerosal to genetically
susceptible children.
The autism epidemic
According to the US House of Representatives
report, autism was once considered a rare disease that affected an estimated 1
in 10,000 individuals in the USA. In 2000, federal agencies estimated that
autism affected 1 in 500 children and by 2002, the National Institute of Health
had reported a rate of 1 in 250. The Autism Society estimates that the number
of autistic children is growing by 10% to 17% each year (15). It found that 1 in 149 children
between 3 and 10 years of age was autistic, and the proportion of autistic
children was 10 times higher than that reported by studies conducted in the
1980s. As for children whose condition met all the diagnostic criteria for
autistic disorder, the prevalence was 4 per 1000, while the prevalence of
pervasive developmental disorder and Asperger disorder was 2.7 per 1000. The
study stated that the increase was real and could not be explained by changes
in diagnostic criteria or better diagnosis (6).
A study from the University of California
showed that the number of autistic people in the state grew by 273% between
1987 and 1998 (16). This study did not include people
with pervasive developmental disorder, Asperger syndrome or any milder autism
spectrum disorder (ASD), but only those who received a professional diagnosis
of level one autistic disorder (using the DSM IV criteria) – the most severe
form of autism.
The Autism Research Institute, on analysing its databank of 30,000 cases of autism from
around the world, found that before the 1980s, most parents reported that their
children first showed abnormal behaviour from birth
itself or in the first year of life. However, after the mid-1980s, the numbers
who reported that their babies developed normally in the first year-and-a-half
and then suddenly became autistic doubled. Further, children among whom the
onset of autism was at 18 months came to outnumber those among whom the onset
was at birth by a ratio of 2 to 1. The cause for the increase in cases of
autism and the reason for the rapid growth in late-onset autism are not
known (6).The fact that the increase in the
prevalence of autism coincided with the addition of new Thimerosal-containing
vaccines gave rise to the suspicion that mercury was causing the increase.
Ethyl mercury-specific
studies
Experts have disputed the validity of the
norms laid down for the use of ethyl mercury as these were originally developed
in the context of methyl mercury poisoning. According to a recent WHO review,
there is “no scientific evidence of toxicity from Thiomersal-containing
vaccines” (17).Some of the studies that specifically
examine ethyl mercury toxicity are discussed below.
Use of Thimerosal in
meningitis
In 1931, in the pre-antibiotic era when
meningitis was a killer disease, Powell and Jamieson wrote about 22 meningitis
patients injected with 1% Thimerosal. The only adverse event, observed in two
patients, was sloughing of the skin after local infiltration. The treatment was
not successful and all the patients died of meningitis. The patients did not
live long enough for it to be possible to examine long-term toxicity and
injury (18). However, this study is often quoted
as evidence that intravenous administration of Thimerosal is safe.
Comparison of methyl and
ethyl mercury in murine model
The neurotoxicity and renal toxicity of ethyl
mercury and methyl mercury were compared in rats given the compounds orally by Magos and colleagues. Greater weight loss and renal damage
were observed in the rats treated with ethyl mercury than those given methyl
mercury. Damage to the granular layer in the cerebellum was widespread in the
latter. There was a higher concentration of inorganic mercury in the brains of the
rats treated with ethyl mercury than in the brains of those treated with methyl
mercury. Both damage and mercury deposits were more widespread in the case of
the former (19).
Thimerosal excretion in
infants
A study of the use of a Thimerosal-containing
vaccine in 40 two- and six-month-old babies was reported in the Lancet.
These babies were compared with 21 controls who were given Thimerosal-free
vaccines. Samples of blood, urine and stool were collected between 3 and 28
days after the vaccination to determine how much mercury remained in the blood
and how much was expelled in urine and stool. Of the 40 who received
Thimerosal, blood was tested in 36, urine in 27 and stool in only 22
cases (20). The level of mercury in the blood of
the two-month-olds exposed to Thimerosal ranged from less than 3.75 nmol/L to 20.55 nmol/L (parts per
billion); in the six-month-olds, all the values were lower than 7.50 nmol/L. After the vaccination, the concentrations of
mercury in urine were low, but they were high in the stools (mean 82 ng/g dry
weight in the two-month-olds and 58 ng/g in the six-month-olds). The authors
concluded that the administration of vaccines with Thimerosal to infants does
not seem to raise blood concentrations above the safe values, and that ethyl
mercury is eliminated from the blood rapidly via stools after parenteral
administration of Thimerosal in vaccines.
The Director of the Environmental Toxicology Programme of the Institute of Environmental Health Sciences
in the USA, Dr Christopher Portier,
told the US House of Representatives Committee that given the small sample size
and failure to measure mercury at the peak levels (the blood levels were
checked somewhere between 3 and 27 days, whereas the peak levels would be
within the first day of vaccination), as well as the study’s inability to
measure the ethyl mercury present in the bodies of the subjects, it was
difficult to understand how the authors came to the conclusion that Thimerosal,
as a part of routine vaccines, poses very little risk to full-term
infants (6).
Vaccine Safety Datalink
studies
Using the database of the Vaccine Safety
Datalink established by the CDC, Thomas Verstraeten
and colleagues carried out a two-phase study. In phase I, 124,170 infants were
screened to look for associations between neuro-developmental disorders (NDs)
and exposure to Thimerosal. In phase II, the disorders found to be associated
most commonly with exposure to Thimerosal in phase I were re-evaluated in a
much smaller sample of 16,717 children. The relative risks of NDs were
calculated per 12.5 µg-increase in the estimated cumulative exposure to mercury
from Thimerosal-containing vaccines in the first, third and seventh months of
life.
In phase I, a significant positive association
was found between exposure to Thimerosal and tics (relative risk [RR]: 1.89;
95% confidence interval [CI]: 1.05-3.38). The risks of language delay were
increased in the case of cumulative exposure at 3 months (RR: 1.13; 95% CI:
1.01-1.27) and 7 months (RR: 1.07; 95% CI: 1.01-1.13). In phase II, no
significant associations were found. There was no increased risk of autism or
attention-deficit disorder (21).
Geier and Geier published
details of a meeting of the CDC and other government organisations,
as well as members of the vaccine manufacturers, prior to the publication of
the data of Verstraeten and colleagues. The authors
obtained these details under the Freedom of Information Act. This transcript
reveals that the study initially found a statistically significant
dose–response relationship between increasing doses of mercury from childhood
vaccines containing Thimerosal and various types of NDs. The transcript
documents that the data were real and statistically significant for many types
of NDs, but that the participants of the meeting felt that the data had to be
“handled”. However, some participants expressed the concern that the work which
had already been done would be obtained by others through the Freedom of
Information Act. In this event, even if professional bodies expressed the
opinion that there was no association between Thimerosal and NDs, it would
already be too late to do anything. In addition, other participants pointed out
that the manufacturers of the vaccine were barely in a position to defend
lawsuits alleging that there was a relationship between Thimerosal and NDs,
since given the available data, no one would say that there was no relationship
between the two (22).
Autism rates after
elimination of thimerosal
A study of autism in Denmark and Sweden
reported that autism rates continued to increase in 2002, even though
Thimerosal began to be phased out in 1992 (23). However, the recent 2013 Denmark
study (24) has established that phasing out
of the Thimerosal-preserved vaccines from the Danish vaccination programme resulted in a significant decline in the
percentage of ASD cases in Danish children from 1.5% in 1994-1995 birth cohort
to 1.0% in 2002-2004 birth cohort.
An ecological study was undertaken to evaluate
the NDs (autism, mental retardation and speech disorders) reported to the
Vaccine Adverse Event Reporting System (VAERS) from 1991 through 2004. There
was a peak in the proportion of reports received in 2001-2002 and in the
proportion of reports, by date of administration of the vaccine, in 1998. There
was a significant reduction in the proportion of NDs reported to the VAERS as
Thimerosal began to be removed from childhood vaccines in the US from mid-1999
onwards (25).
Dose–response data
Using the Vaccine Safety Datalink (VDS), a
dose–response relationship between exposure to organic mercury from
Thimerosal-containing vaccines and NDs was found and these data were published
recently. Using the VSD portion available to the researchers, a case-control
study found that, on a “per µg of organic Hg” exposure basis, pervasive
development disorder (odds ratio (OR) = 1.054), specific developmental delay
(OR = 1.035), tic disorder (OR = 1.034) and hyperkinetic syndrome of childhood
(OR = 1.05) were significantly more likely to occur among those exposed to
organic Hg than among the controls (26).
Thimerosal for developing
countries: the economic argument
Thimerosal has been removed from most of the
vaccines used in developed countries, but it is used in vaccines meant for
developing countries. Vaccines are sold to developing countries in multi-dose
vials at a lower cost-per-dose. It is assumed that single-dose vials of
vaccines, which can be preservative-free, are not economical for developing
countries, both in terms of the unit cost of vaccines and cold chain
requirements. These assumptions are simplistic and not necessarily accurate. A
study by WHO has shown that the overall manufacturing cost of a single-dose
vial is 0.257 USD, which is about 2.5 times greater than the cost of one dose
(which is 0.105 USD) from a 10-dose vial (27). The cost-per-dose of the single-dose
formulation would be higher by a mere 0.15 USD, according to this analysis. On
the face of it, multi-dose vials have the added advantage that they occupy less
cold-storage space per dose, but this advantage is offset by vaccine wastage. A
UNICEF study in India reported vaccine-wastage of up to 60% with the use of
multi-dose vials (28). Single-dose vials provide a price
advantage over 10-dose vials if the wastage of the latter is greater than 44%
(based on the price of the hepatitis B vaccine and varying wastage rates for
10-dose vials) (27). Further, single-dose vials simplify
inventory logistics and vaccine tracking. Also, the health worker’s reluctance
to open multi-dose vials for only a few children leads to missed opportunities
and lower coverage rates (27). Thus, under actual usage conditions,
it would appear that multi-dose vials do not afford any real economic benefits
for developing countries.
The marketing of single-dose vials (which do
not need preservatives) is especially inexpensive in India, given the
capabilities of the local industry. For example, the marked maximum retail
price of a single-dose 2-ml ampoule, with 50 mg ranitidine, from Ranbaxy is Rs 3 (0.05 USD), inclusive of the cost incurred by the
manufacturer and his/her profits, dealers’ margin, taxes and transport to
remote parts of the country. Despite such prices, 33 manufacturers, including
the multinational pharmaceutical giant, GSK, are competing to get a market
share of this drug (29). In the Indian context, where
single-dose ampoules are inexpensive to manufacture, switching to
preservative-free single-dose vials may, in fact, save costs.
The Burton Report
conclusions
Well before the dose–response data were
published (27), the “Mercury in Medicine Report” of
the US House of Representatives had pointed out that the lack of conclusive
proof does not mean there is no connection between Thimerosal and
vaccine-induced autism. It stated, “The lack of conclusive proof indicates that
the US FDA has failed in its duties to assure that adequate safety studies were
conducted prior to marketing.” It further stated that after determining that
Thimerosal was no longer “generally recognized as safe” for use in topical
ointments, the agency did not extend its evaluation to other applications of
Thimerosal, in particular, its use as a vaccine preservative. The report said
parents were concerned that there might be an inherent conflict between the
multiple roles of the department, eg promoting immunisation, regulating manufacturers, looking out for
adverse events, managing the programme for
compensation for vaccine injury, and developing new vaccines.
The Burton Report records that the CDC
Advisory Committee on Immunization rejected a statement of preference for
Thimerosal-free vaccines because of a number of factors. These included a
desire to avoid confusion in the public mind and a concern that immunisation rates might fall. However, another factor that
was also considered by the Advisory Committee on Immunization, according to the
Burton Report, was the financial health of the vaccine industry. There was a
desire to reduce the potential for the financial losses they would face due to
the inability to sell their existing inventories of Thimerosal-laced vaccines.
The report goes on to state, “If there is any doubt about the neurological
effects of ethyl mercury – and there were substantial doubts – the prevailing
consideration should have been how best to protect children from potential
harm. However, it appears that protecting the industries’ profits took
precedence over protecting children from mercury damage.” This indictment
applies equally to international organisations like
WHO and the drug regulatory authorities in India.
Conclusion
It is biologically plausible that mercury
toxicity in genetically susceptible persons may contribute to the numbers with
autism and ASD. However there is no clear proof linking the mercury in
Thimerosal to the spurt in cases seen in recent years. The apparent linkage of
autism to the MMR vaccine (which is Thimerosal free) seems to suggest that
mercury exposure through Thimerosal-containing vaccines is not the only factor
that may be responsible for the subsequent “autism” and “ASD” diagnoses in
developing children.
Historically, there may have been reasons to
use Thimerosal with vaccines, but they do not apply any longer as single-dose,
Thimerosal-free vaccines vials are cheaper now. The Burton Report documents
that the CDC Advisory Committee on Immunization rejected a statement of
preference for Thimerosal-free vaccines because it apprehended that immunisation rates might fall if it were to admit that it
had been fallible in the past. It is felt that removing Thimerosal now is akin
to an admission of guilt. With an eye to preserving the faith of parents in the
vaccines, it is mistakenly considered important to deny the fact that the
prevalence of autism is increasing or that autism could be related to the use
of mercury. Often, a person who demands vaccine safety is illogically branded
an anti-vaccine person. This stance may be counterproductive. Long-term harm
may be done to all public health initiatives if international organisations do not act decisively to remove the potential
threat posed by the use of Thimerosal in vaccines. As with Thompson’s
revelations about the paper on MMR (2), if the public comes to perceive
institutions such as the CDC as untrustworthy, it is likely to do more harm to
the vaccine initiative than unscientific rabble-rousers who protest against
vaccination.
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