A Tale of Two Cities: Flawed Epidemiology
PEDIATRICS is the journal of the American Academy of Pediatrics (AAP).
I have been a Fellow of the Academy since 1963. This was the first letter to the editor of the journal that I had ever written.
Following is the exact text of my letter:
In “Pervasive developmental disorders in Montreal, Quebec, Canada: prevalence and links with immunizations” (1) Fombonne et al reported that in a group of English-speaking Montreal children born from 1987 to 1998, the prevalence of pervasive developmental disorders (PDD) was high and increasing. They also claimed that during the same period, Measles-mumps-rubella (MMR) vaccination coverage had decreased and concluded, “Thus, pervasive developmental disorder rates significantly increased when measles-mumps-rubella vaccination uptake rates significantly decreased.”
The MMR uptake data used “were available through N. Bouliane, BN, MSc of the Direction de Santé Publique de la Capitale Nationale” and were “routinely collected in the region of Québec among 5-year-old children attending kindergarten during 1993-2004.”
La Capitale Nationale refers to Quebec City, located 265 kilometers from Montreal. Ms. Bouliane confirmed that the MMR vaccination rates were indeed from the Quebec City area but refused to release them to me because they were administrative internal information only intended for research.
There are several published vaccine uptake surveys of Montreal. MMR vaccination rates of children 24 to 30 month-old in the Montreal area increased from 85.1% in 1983 (Baumgarten) (2) to 88.8% in 1996-97 (Valiquette) (3) to 96% in 2003-04 (Health Department Survey) (4).
The above suggests that in Montreal PDD prevalence and MMR vaccination rates were in fact increasing in tandem during the study period.
The readers deserve to know why the authors compared developmental data from a specific group of children in Montreal with MMR vaccination data from the city of Quebec, some distance away.
|1.||Fombonne E, Zakarian R, Bennett A, Meng L, McLean-Heywood D. Pervasive developmental disorders in Montreal, Quebec, Canada: prevalence and links with immunizations. Pediatrics. 2006 Jul;118(1):e139-50.|
|2.||Annexe 1 of "Enquête sur la couverture vaccinale des enfants de 24 à 30 mois de Montréal-Centre" by Valiquette (1998).|
|3.||Table 3 (page 20) of "Enquête sur la couverture vaccinale des enfants de 24 à 30 mois de Montréal-Centre" by Valiquette (1998).|
|4.||Hudson Patricia et al, Are Montreal Children adequately vaccinated? Prevention en pratique médicale. Available on page 5 of http://www.santepub-mtl.qc.ca/Publication/pdfppm/ppmjuly2005.pdf.|
Conflict of Interest
The author is the grandfather of a child with autistic enterocolitis who has evidence of measles virus genomic RNA in the gut.
I received the following response:
Title: Far-Fetched Manuscript number: 2007-0326
Dear Dr. F. Yazbak :
What follows is a copy of Dr. Fombonne's e-mail in response to your Letter-to-the-Editor.
"This person is known to pursue the MMR-autism agenda at all costs in order to 'demonstrate' a link he strongly believes in. The only way ahead is to encourage him to do independent research. All controlled epidemiological research thus far has concluded to the absence of such a link."
As a note, I believe the evidence of no link between MMR and Autism is sufficient. It's not worth publishing more on this subject. We will not be publishing this exchange of correspondence.
Thank you for thinking of Pediatrics.
Jerold F. Lucey, MD
Pediatrics Editorial Office
The first sentence in Dr. Fombonne’s note is correct. I do believe that a link does exist between MMR vaccination and autism in certain genetically -predisposed children.
The rest of the message is inappropriate both in tone and content and Dr. Fombonne’s statement that “all controlled epidemiological research thus far has concluded to the absence of such a link" is irrelevant and unrelated to my letter.
So is the editor’s personal belief about the “link between MMR and Autism”.
I found and reported a glaring error in the paper. The rates of autism in Montreal have as much to do with MMR vaccination rates in Quebec City as pollution in Los Angeles with Diesel buses in Chicago.
The lead author refused to respond to my criticism concerning that simple geographic fact and the editor was unable to force him to do so.
It is as simple as that.
Furthermore, in order to “estimate the pervasive developmental disorder prevalence in Montreal”, Dr. Fombonne only surveyed children enrolled in one of Montreal’s five school boards.
In 2003-2004, that particular English school board only had 14% of all total school boards enrollments in Montreal. In addition, this board was never representative of the true student demographic profile of the city, whose mother tongue is mostly French (43%), followed by various non-English languages (37%) and then English (22%). French and immigrant children who constitute the majority of the school population cannot attend English schools.
My submission to the electronic peer to peer review of PEDIATRICS, also a first, was not published as well.
In 2001, Dr. Fombonne reported in PEDIATRICS the results of another study that he had conducted in the United Kingdom. That publication titled “No evidence for a new variant of measles-mumps-rubella-induced autism” (1) was intended to rebuke Andrew Wakefield’s theory. It received little or no attention.
It is not known how many relevant letters to the editor were rejected at the time.
Discussing the 2001 study in their comprehensive Cochrane MMR Review, Demichelli, Jefferson et al reported that, “The numbers and possible impact of biases in this study is so high that interpretation of the results is impossible.” (2)
When he was in France, Dr. Fombonne was a well known psychiatrist who published articles on psychiatric topics. He was still a psychiatrist when he moved to England …until Andrew Wakefield suggested that the link between MMR vaccination and autism should be further investigated and suddenly… Dr. Fombonne became a “psychiatrist / epidemiologist” and a consultant to the UK medical authorities on MMR vaccination and autism. He published several articles on the subject including, “No evidence for a new variant of measles-mumps-rubella-induced autism” in PEDIATRICS in 2001 (above) but avoided dealing with the Thimerosal issue.
Since his arrival to Montreal, Dr. Fombonne is Chair, Department of Psychiatry and Head of the Division of Child Psychiatry at McGill University. He is also the Director of the Department of Psychiatry at the Montreal Children’s Hospital, yet the lay press often refers to him as an “Epidemiologist”.
Dr. Fombonne was also recognized as an “Epidemiologist” in a Thimerosal-related case in a U.S. Court.
A footnote in the July 2006 publication, “Pervasive developmental disorders in Montreal, Quebec, Canada: prevalence and links with immunizations” reads: “In the United Kingdom, Dr Fombonne has provided advice on the epidemiology and clinical aspects of autism to scientists advising parents, to vaccine manufacturers, and to several government committees between 1998 and 2001. Since June 2004, Dr. Fombonne has been an expert witness for vaccine manufacturers in US thimerosal litigation. None of his research has ever been funded by the industry.”
It is obviously customary to disclose sources of funding. Disclosing sources of “Non-Funding” on the other hand is unusual. In any case, it is nice to know that Dr. Fombonne’s research was never funded by the “Industry”.
The statement proves what I mentioned earlier: That Dr. Fombonne only became interested in MMR vaccination in the UK after Andrew Wakefield published his original research on the subject in 1998. It also raises an important question: How did Dr. Fombonne become an “expert witness for vaccine manufacturers” in 2004 when his very first research on Thimerosal was just published in PEDIATRICS on July 6, 2006?
No wonder, “Pervasive developmental disorders in Montreal, Quebec, Canada: prevalence and links with immunizations” was so important to “protect” and it is no surprise that Dr. Fombonne chose not to respond to my letter. Besides, what could he have said and how could he have justified the strange fact that he compared developmental information about a specific group of children in Montreal with unrelated MMR vaccination data from Quebec City, a good distance away?
I am not anti-vaccine nor have I ever been.
|1.||Fombonne E, Chakrabarti S. No evidence for a new variant of measles-mumps- rubella-induced autism. Pediatrics. 2001 Oct;108(4):E58.|
|2.||Demicheli V, Jefferson T, Rivetti A, Price D. Vaccines for measles, mumps and rubella in children.Cochrane Database Syst Rev. 2005 Oct 19;(4):CD004407. Review|
F. Edward Yazbak, MD, FAAP
TL Autism Research
March 7, 2007