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Autism : A Recent Rise in FinlandDate: Wed, 25 Apr 2001 13:07:06 -0700
Autism: A Recent Serious Rise in Finland
F. Edward Yazbak, MD, FAAP
K. Yazbak, BA, MA
There have been several published and frequently quoted studies from Finland concerning the safety and efficacy of the combined measles, mumps and rubella vaccines (MMR). Some of these studies were joint efforts by the Departments of Pediatrics and Public Health at the University of Helsinki, the National Public Health Institute and the National Research and Development Center for Welfare and Health. The studies were often supported by grants from the vaccine manufacturer.
The two first studies, by Peltola et al, were published in The Lancet in 1986, four years into a large and extensive National Vaccination Program. Both were of limited scope and interest. (1,2)
The next publication whose main author was also Professor Peltola of the Department of Pediatrics appeared in the New England Medical Journal in 1994. It was comprehensive and detailed: The elimination of indigenous measles, mumps, and rubella from Finland by a 12-year, two-dose vaccination program. (3)7
It essentially stated that over a period of 12 years, 1.5 million of the 5 million people in Finland were vaccinated, that coverage exceeded 95 percent, and that the program using two doses of combined live-virus vaccine had eliminated indigenous measles, mumps, and rubella from Finland. The study also stressed that no deaths or persistent serious problems were directly attributable to vaccination and that the most frequent complication requiring hospitalization was acute thrombocytopenic purpura, which occurred at a rate of 3.3 per 100,000 vaccinated persons. Autism and irritable bowel disease (IBD) were never mentioned.
The study concluded that protection against measles might not be achievable, even among revaccinees, when children are confronted with intense exposure to measles virus.
In February 1998, Andrew Wakefield published in The Lancet his well-known study (5), which described specific gut changes in autism and raised for the first time, the possibility of a link between MMR vaccination and late-onset or regressive autism. Dr. Wakefield drew no conclusions but simply called for more research.
In a prompt response, Peltola and Associates contributed a research letter to The Lancet, which was published in May 1998 (6). Since then all vaccine authorities have been assuring everyone that MMR vaccination has not been associated with autism and IBD in 3 million vaccinees followed up for 14 years.
This Peltola letter and a study from the UK by Brent Taylor et al (7) have become the main arguments used by Wakefield's opponents to neutralize his on-going research and findings.
The "damage control" nature of the research letter from Finland is clearly apparent in its very own title: No evidence for measles, mumps, and rubella vaccine-associated inflammatory bowel disease or autism in a 14-year prospective study.
This obviously is misleading. The study terminated in 1996, two full years before Wakefield published his original findings and when he was specifically questioned, Professor Peltola stated that the study had not been designed to identify autism as a complication.
In the letter, Professor Peltola reported that about three million doses of the combined live-virus vaccine [MMR or Virivac Merck, West Point, PA, USA] had been administered in Finland between 1982 and 1996. He also listed the adverse events reported shortly after vaccination and their follow-up. The study, which was supported by a grant from Merck, did not investigate or report complications, which started weeks or months after vaccination. Again, Autism and IBD were not suspected to be, in any way related to MMR vaccination before 1998, and had not once been mentioned in the original 1994 publication.
In the same issue of The Lancet (Volume 351, Number 9112, 02 May 1998) Andrew Wakefield responded to Peltola and refuted each of his statements. He also highlighted the fact that "In the five year period to 1991, there was a 300% increase in the numbers of Crohn's Disease in Finland, an extraordinary observation that remains unexplained (Gastroenterology 1997, 1417; 112:A-732)". In his conclusion, Dr. Wakefield stated that "The authors have failed to address the issue raised in our study and this ad hoc retrospective and fundamentally irrelevant report contributes nothing to the scientific debate surrounding this issue. Neither does it mitigate the failure to have conducted prospective, long term safety studies of MMR vaccine."
Two years later, Dr. Wakefield notified the authorities, several months in advance of his forthcoming publication Measles, Mumps, Rubella Vaccine: Through a Glass, Darkly (8) to allow them time to prepare for any possible fall-out. This precipitated the production of yet another Finnish paper (9), which detailed the more serious adverse events of the same study. This latest contribution by Dr. Annamari Patja (with Professor Peltola listed last) was also supported in part by a grant from Merck. Patja stated that there were only 173 "potentially serious reactions claimed to have been caused by MMR vaccination" among the 1.8 million individuals who received some 3 million doses of MMR vaccine. All occurred within four weeks from vaccination and several of them were followed longitudinally till 1996. They included one death, 77 neurological, 73 allergic, and 22 miscellaneous reactions. Some 45% of them, according to the authors, were probably caused or contributed by some other factor. Minor adverse events among 437 vaccinees were listed casually but were excluded from further analysis. According to Dr. Patja, "Idiopathic thrombocytopenic purpura was also excluded because it has been analysed previously", this in spite of the fact that thrombocytopenic purpura following MMR vaccination was the most frequent complication requiring hospitalisation. (3)
The references as to the absence of autism and IBD were clearly added on in rather unrelated paragraphs. The study was promptly and thoroughly criticized by Welsh in Scotland, Shattock in England and us (10) and is receiving less attention now.
What has been most intriguing is that neither Patja in December 2000 nor Peltola in May 1998 ever mentioned the incidence of autism in Finland during the duration of their MMR study or since. One would have certainly expected that they would have, if indeed they had examined autism and its relationship to MMR. But they NEVER did.
What is more disturbing is that Dr. Patja appears to have ignored a recent study from Oulu University (11) which describes an impressive rise in autism in Northern Finland, similar in magnitude to that in other Western countries. This study by Kielinen et al was submitted for publication in November 1999 and was published in the journal of European Child & Adolescent Psychiatry in 2000. All professionals reporting on the specific subject of autism, in a country with only 5 million people should have been aware of its results.
The Kielinen study included all children born between 1979 and 1994 in the northern Provinces of Oulu and Lapland (which represent 1/8 of the total population of Finland), and who were therefore 3-18 year old on December 31, 1996 when the Peltola study ended.
The authors personally reviewed records from all selected cases of autism, to determine that they fulfilled the present criteria of ICD-10 and DSM-IV. Their careful review revealed a cumulative incidence of autism in Northern Finland of 12.2/10,000 an alarming increase when compared to the previously reported incidence of 4.75/10,000 in 1991. (12)
More concerning is the fact that the increase in younger children, all born in the second half of the MMR campaign, was even more spectacular. The cumulative incidence in the 5-7 age group specifically was 20.7/10,000 or more than 1 in 500 children. It certainly is possible but rather unlikely that such an increase is due to better diagnosis. A label as ominous as autism is not imposed lightly in a country where each and every disability becomes immediately the sole responsibility of the State. In fact, as in the United States, these are probably conservative figures.
The reported increased incidence in the younger age group is of particular concern as it could indicate an accelerating increase in autism overall. Equally concerning is the fact that there are no incidence studies from the rest of Finland where the exact increase in autism remains a mystery. There is NO REASON to think that it will be less impressive than in the northern provinces. A similar situation just took place in the Unites States. In 1999, the California report (13) was the first detailed documentation of an autism explosion. Since then, alarming autism rates have been reported in all states. (14,15)
A fortunate aspect of autism in Northern Finland (if one dares put autism and fortunate in the same sentence) is the fact that almost 50% of children in the Kielinen study had a tested IQ above 70. This is remarkable because many tests are based on verbal abilities, which are less adequate in children with autism and do not represent their real functional level, as the authors pointed out.
Generally speaking in the past, only one fifth of children with autism had IQs of 70 and above. Of late, higher ability and performance are being reported in increasing numbers and seem to be more prevalent in children with late-onset autism. If this is truly so, then one must consider a trigger that may affect the child after a period of normal development. In Finland the MMR vaccine has to be examined, before it is ruled out. Absolving it, a priori, when independent longitudinal studies of its safety are lacking, is reckless.
It is unconceivable that a disease affecting more than 1 in 500 children has received so little attention. Autism is the present and real epidemic in Finland and Peltola, Patja and their talented associates should turn their attention to it, instead of spending their time defending the MMR vaccine. It should be easy to interview parents of affected children and to ask them if they believe there is an autism-vaccine connection. The Government of Finland should initiate and finance studies in which every aspect and every possible cause of autism are scrutinized. It is unlikely that the vaccine manufacturer will fund or support such studies.
1. Peltola H, Karanko V, Kurki T, et al. Rapid Effect on Endemic Measles, Mumps and Rubella of Nationwide Vaccination Pro-gramme in Finland. Lancet 1986; 1:137-9
2. Peltola H, Heinonen OP et al Frequency of True Adverse Reactions to Measles-Mumps-Rubella vaccine: a double-blind placebo-controlled trial in twins. Lancet 1986; 1: 939-42
3. Peltola H, Heinonen OP, Valle M, Paunio M, Virtanen M, Karanko V, Cantell K. The Elimination of Indigenous Measles, Mumps, and Rubella from Finland by a 12-year, two-dose vaccination program. N Engl J Med 1994; 331: 1397=AD402. )
4. Mikko Paunio, Heikki Peltola, Martti Valle, Irja Davidkin, Martti Virtanen, and Olli P. Heinonen. Explosive School-based Measles Outbreak. Intense Exposure May Have Resulted in High Risk, Even among Revaccinees. Am J Epidemiol 1998;148:1103-10
5. A J Wakefield, S H Murch, A Anthony, J Linnell, D M Casson, M Malik, M Berelowitz, A P Dhillon, M A Thomson, P Harvey, A Valentine, S E Davies, J A Walker-Smith. Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children. Lancet 1998; 351: 637-41
6. Heikki Peltola, Annamari Patja, Pauli Leinikki, Martti Valle, Irja Davidkin, Mikko Paunio.
No evidence for measles, mumps and rubella vaccine-associated inflammatory bowel disease or autism in a 14-year prospective study.
Research letters: Lancet: Volume 351, Number 9112, 02 May 1998
7. Taylor B, Miller E, Farrington P, Cetropoulos M, Favout-Mayaud JL, Waight P. Autism and measles, mumps, and rubella vaccine: no epidemiological evidence for a causal association. Lancet 1999; 353: 2026-29.
8. Wakefield AJ, Montgomery SM. Measles, Mumps, Rubella Vaccine: Through a Glass, Darkly. Adverse Drug Reactions and Toxicology Review,. 2000,19 (4) 1-19.
9. Patja A., Davidkin I., Kurki T., Kallio M., Valle M., Peltola H Serious adverse events after measles-mumps-rubella vaccination during a fourteen-year prospective follow-up. Paed. Infect. Dis.J. 19 1127-1134 (2000)
10. Yazbak FE, Yazbak K.An Unconvincing Finnish Study.
11. Kielinen M, Linna S.-L, Moilanen I. Autism in Northern Finland; European Child &Adolescent Psychiatry 9:162-167 (2000)
12. Vinni I, Timonen T Behavioral Analytical Point of View. Finnish Association for mental Retardation, Helsinki (1991)
13. Changes in the population of persons with Autism and Pervasive Developmental Disorders in California's Developmental Services system : 1987 through 1998. A report to the legislature
14. Yazbak FE Autism 99: A National Emergency.
15. Yazbak, FE Autism 2000: A Tragedy.
These personal observations may not represent the views of organizations to which we belong.
Copyright © 2001