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Tuesday, March 25, 2014

The joy of (giving) books

One of the joys of my life, since childhood has been reading. Having been read to as a small child - I have pleasant memories of this still - I may have had a head start in school. I was blessed with an ability to recognise words immediately, so interpreting the text was never a chore, and I became one of those children who always had their nose in a book. This may have been partly because I was bored at school and, until my middle ear problems were sorted out, a bit deaf; but I got genuine pleasure from reading. I was only about 7 when my parents started having to tell me to stop reading, turn out the light, and go to sleep. (Swallow and Amazons!)

As I got older and went to secondary school my self imposed sleep deprivation continued, and my long commute provided further opportunities to read. I discovered not only the school library, but also the school bookshop, and its stock of cheap paperbacks.

I can't claim that all of my reading was of great literary merit. I read great books, "unsuitable" books (Freud at 14?), and pot boilers. Ian Fleming, Alexander McLean, Desmond Bagley, Robert A Heinlein, Frank Herbert, Laurie Lee, John Wyndham ... These were among my companions. I generally enjoyed the set books we had to read - Dickens, Harper Lee, Shakespeare... School set books introduced me to books I might never, otherwise have enjoyed; as did books given or loaned to me by friends or relatives. The teenage me would never have read Mansfield Park if my godmother hadn't given me a copy: it surprised me, and I thoroughly enjoyed it.

The giving and receiving of books was routine; birthdays and Christmases invariably included a few.

My friends and family were mostly readers, and one of the pleasures associated with reading was talking about the books we'd enjoyed. I'd learn, from these conversations something about the sort of books somebody else enjoyed. More than that, however, I might form an idea about a book that they wouldn't have thought about reading.

So, a joy related to the joy of reading became the joy of giving somebody else a book they hadn't thought of reading, and which they enjoyed.

That's why Amazon's persistent refusal to allow Europeans to give each other Kindle books is so annoying; and it's part of the reason why the Home Secretary's grandstanding gesture forbidding prisoners' friends and relatives to give them books seems so cruel, vindictive, and pointless.

Monday, March 24, 2014

Lentils soup/stew

I've just enjoyed one of my favourite store-cupboard meals. It's too good a meal to keep just for emergencies but, like emergency risotto the basic ingredients keep well, and may well be in your cupboard already.

You start with some onion, chopped. One or two, it's not critical. And some garlic - about one clove for every onion  used, but it's up to you. Soften slowly in oil, so they don't burn.

I find some potato improves the taste and texture. I dice it quite small - about 5mm dice. Toss this in. Add some chilli, and other vegetables - whatever you've got on the floor of the fridge; carrots (don't cut them too small) are particularly good, courgettes not far off.

A bit of stock powder - I usually use swiss vegetable bouillon; but it's not critical.

If you've got it, and you're not vegetarian, some chorizo sausage - chopped up (a bit bigger than the potato - approximately 1cm dice will do) adds a lot to the dish.

Then add lentils - I used the green Puy lentils today - they work best in my opinion. Unlike the yellow, or orange lentils, which tend to turn to a flavoursome mush, they don't lose their shape and texture completely.

Then add plenty of water - about twice the volume of the ingredients so far. The lentils will absorb a lot of water.

Then simmer on a low heat, for about half an hour, until the lentils are soft and cooked through. Keep an eye on it to make sure it remains moist - you want a thick soup like texture.

That's it! Ladle into a bowl and enjoy on its own, with a nice glass of wine, some bread, and a companion.

Cheap, fairly quick, delicious, and nutritious.

Monday, February 17, 2014

Something must be done!

I just read an article about Syria, by Stephen Hawking.

"As a father", he writes, "I watch the suffering of Syria's children and say: no more".

"Where", he goes on, "is our emotional intelligence, our sense of collective justice?"
The problem with relying on "emotional intelligence" is that it often says to us "something must be done!". Which is fine. If there's something useful to do.

But often - and in this case - it's not at all clear what can be done, which won't make things worse. The risk is that we'll decide that something must be done, and then somebody will make a suggestion. "This is something!", we'll all cry, "So this is what we must do!".

But the chances are that whatever the action is, it will make matters worse and more intractable.

That's why we need to be very wary of responding to our "emotional intelligence". It isn't cold and unfeeling to not rush into doing something for fear of making matters worse.

I'm don't think that Hawking is suggesting a rush to military action - indeed, it's not at all clear what it is that he thinks should be done. 

Let's not make the mistake of thinking that just because a situation is intolerable, we have to do something to change it - not unless we can be very sure that what we plan to do will have the desired effect, without too many unintended and unwanted consequences.

Thursday, January 30, 2014

On care.data

I entirely agree that we need to be able to access data about individuals. Take the MMR/autism scare, for example. With the right data, it would be easy to do the studies - to see if people who'd had MMR jabs were more likely to go on to develop autism; and whether people with autism were more likely to have had MMR jabs. (Both studies have been done, and both found no link - but they would be so much easier with a care.data like system.)

We need something like care.data if we are to be able to recognise genuine (and possibly long-term) ADRs, and to be able to provide rapid reassurance to counter ill-founded scares; as well as to have the information needed to provide effective healthcare systems as economically as possible.

BUT

Stories about the potential for data to be shared with organisations with a commercial interest are alarming, especially if these are to include e.g. insurance companies who might be interested in individuals' medical histories in order to decide premiums for individuals.

I am not at all clear what the facts are; but either the system has been set up without necessary safeguards, or the information about it has been badly mismanaged.

SUMMARY
Essential for: distinguishing genuine ADRs from false alarms; research; and planning. Requires much better assurances.

UPDATE
See also:

  1. Ward A. Privacy fears over NHS database in aid of medical research. Financial Times 2014; Updated January 30; Accessed: 2014 (January 31)
  2. Web site about care.data by Dr Neil Bhatia, GP and Caldicott Guardian for the Oaklands Practice in Yateley.

Monday, December 16, 2013

Using sex to sell vaping - should this be allowed?


Let's be clear. Smoking is harmful. Very harmful. If a smoker finds a substitute for smoking that enables them to stop, that must be a good thing.

E-cigarettes or "vaping" may expose the vaper to poisonous, even carcinogenic fumes; but almost certainly to a far lesser extent than smoking. So switching from smoking to vaping must be good for individual smokers.

But I remain concerned that the tobacco industry sees vaping as a way to make cigarettes acceptable again, at a time when smoking in public has become unacceptable. The marketing of e-cigarettes to children, as I demonstrated in a previous blog makes me think they are keen to recruit more nicotine addicts to e-cigarettes - which will continue to make them a profit, whether or not they move on to traditional tobacco products.

And now they are running TV adverts which use heavy sexual innuendo to further glamorise and sexualise vaping.


[Update - the link above to the sexy "put it in my mouth" advert has been updated. I'm not sure if these are the original adverts that appeared on TV in December 2013. The story was widely covered at the time - see e.g. AdWeek, Marketing Magazine, Independent, Daily Mail, Express...]

The companies and vaping advocates will tell you there's no evidence that e-cigarettes are a gateway product, recruiting new addicts; simply a useful aid to help smokers reduce or stop smoking. But the products are so new - of course there's no evidence. Yet.

I don't think we should wait to be able to prove it can do this. Yes, advertise e-cigarettes as a substitute for smokers. But let's ban this glamorising advertising.

UPDATES
It has been "Ministers will seek to restrict the sale of e-cigarettes to adults (age 18 plus) Ministers will seek to ban the sale of e-cigarettes to children under 18 this week (commencing 27 Jan 2014) and make it illegal for adults to buy e-cigarettes for children." New rules on advertising also seem likely.

More articles, published since my original post, relate to this:

  1. Kmietowicz Z. EU agrees rules to allow most e-cigarettes to be sold as consumer products. BMJ 2013;347. on the regulatory system
  2. Andrade Md, Hastings G, Angus K. Promotion of electronic cigarettes: tobacco marketing reinvented? BMJ 2013;347. 
  3. McCarthy M. New York City votes to ban e-cigarettes from public places. BMJ 2013;347.
  4. McCarthy M. E-cigarette use doubles among US middle and high school students. BMJ 2013;347 (which refers to Notes from the field: electronic cigarette use among middle and high school students - United States, 2011-2012. MMWR Morb Mortal Wkly Rep 2013;62(35):729-30  PMID: 24005229.
  5. English PM. Marketing of e-cigarettes should follow the rules laid down for tobacco advertising. BMJ 2014;348:g316.
  6. Meg Carter. Last gasp for e-cigarette ads that glamorise the habit? BMJ 2014;348:g475
  7. Simon Chapman. Simon Chapman on e-cigarettes: the best and the worst case scenarios for public health. 2014 (14 Mar). BMJ Blogs.

    ANDRADE et al ARTICLE
The second of these articles (de Andrade et al) cites three ways in which e-cigarettes threaten public health:

Firstly, e-cigarettes are being promoted as lifestyle accessories using a combination of evocative advertising, sponsorship, and celebrity endorsement, all of which have an obvious appeal to young people. This risks non-smokers being pulled into nicotine use, a danger that is exacerbated by the development and promotion of products for first time use. Furthermore, many of these products replicate cigarettes so closely, both in appearance and how they are consumed, that vaping looks just like—and hence models—smoking. Even when the behaviour is unequivocally vaping, it still models the idea of nicotine self medication by inhaling a vapour into the lungs, along with the implication that there is another more dangerous way of doing this. This suggests the potential for e-cigarettes to inadvertently promote smoking.

Secondly, the marketing of e-cigarettes risks undermining wider tobacco control policies. The visual similarity between conventional and electronic cigarettes, as well as between smoking and vaping, means that e-cigarette advertising and point of sale activity can be mistaken for (the now outlawed) tobacco promotion. Similarly, the promotion of dual usage undermines one of the key health benefits of smoke-free legislation—the stimulus it gives smokers to quit.

Thirdly, the tobacco industry is moving into the e-cigarette market and using e-cigarettes and harm reduction to build links with public health, policy makers, and other stakeholders. This process is accelerating: a wholly owned subsidiary of British American Tobacco announced plans to license an alternative nicotine delivery device with the Medicines and Healthcare Products Regulatory Agency. This is jeopardising Article 5.3 of the Framework Convention on Tobacco Control, which requires that development and implementation of public health policy should be completely protected from industry influence.13
It concludes:
These problems demand a swift regulatory response. The Medicines and Healthcare Products Regulatory Agency’s decision in June to regulate e-cigarettes as medicines acknowledges the need for controls, but these cannot wait for the three years it has proposed. Specifically young people need protection, marketing must to be tightly reined in, existing tobacco control policy reinforced, and the tobacco industry explicitly excluded from the policy making arena. One obvious first step would be to regulate e-cigarettes as tobacco products. 
McCARTHY NYC ARTICLE
The McCarthy article on NYC quotes a tobacco marketeer as saying that "Sound public policy should be based on scientific data and factual information, not unsubstantiated claims."  I agree. But pertmitting the purveyors of tobacco and nicotine to bring in a new formulation of one of the most addictive products known to man without a lot more evidence that it will do no harm should require much better scientific data and factual information than is currently available - it's the information available regarding its safety (at public health level, rather than for individual smokers who switch to vaping) which amounts to "unsubstantiated claims.

This is particularly so when you consider McCarthy's other article...

McCARTHY REPORT OF MMWR ARTICLE, AND THE ORIGINAL ARTICLE
The MMWR article shows that about 20% of e-cigarette users do not smoke conventional cigarettes. No doubt marketeers of vaping would claim that this doesn't prove that the products are a gateway product to smoking; but it clearly casts doubt on their claim that they aren't.

Donald Bucklin on the KevinMD.com blog has added his voice to this discussion in this blog. He concludes: "Let’s not fool ourselves that these cute “personal vaporizers” are out there to get 60-year-old smokers to quit. The real purpose is getting 16-year-olds to start."

CHAPMAN ARTICLE
Chapman is a veteran campaigner on tobacco control. His article sums up the situation perfectly, I think.

Wednesday, November 06, 2013

HPV vaccine not as effective in black women - what's behind the story?

There have been a number of reports recently suggesting that HPV vaccine is not as effective at preventing cancer in some "races" as in others.[1-3] As far as I can tell, these reports are based on a paper presented at  a conference (the "12th annual International Conference on Frontiers in Cancer Prevention Research: Abstract B11, presented October 28").[3]

There are several factors operating here. Some questions we can answer; others remain unknowns.

The probability of a woman getting a cancer caused by a particular viral type is, of course, the product of the probability of her being infected with that subtype, and the probability of that subtype causing cancer (its "oncogenicity").

We know, for example, that the prevalence of different viral subtypes differs between populations. I am not sure that we really understand the reasons for this, but it is not news.[4] (I do not propose here to consider further the word "race"used in some of the reports - other than to note that the word is complex and loaded, and its use risks conflating biological, genetic differences with social and economic factors; and that in the USA being "black" or "hispanic" is associated with a wide range of markers of relative deprivation.)

We know that the oncogenicity of viral types depends on how persistent they are; how good the immune system is at clearing them. In general type 16 is the most persistent subtype, and the type most likely, if you have been infected with it, to cause cancer; followed by type 18. Whether this applies to all women, or differs between populations, I am not certain; but I suspect this is less likely to vary than the probability of being infected with those subtypes. If types 16 and 18 are the subtypes most likely to cause cancer in all groups, then preventing infections with these groups is still worthwhile in all women. What will differ is the probability of individuals in different population groups being infected with these subtypes.

What matters, of course, isn't the strain(s) of HPV you are infected with, but whether they will give you cancer. While the prevalence of carriage of HPV types is different amongst different populations, I haven't checked (is it known?) whether or to what extent the prevalence of cancer caused by different subtypes differs in these different populations. If my guess is correct, and the oncongenicity of a given type is similar across populations then, given that types 16 and 18 are more oncogenic than other strains, I would expect to see the bulk of cancers in populations to be caused by these strains, unless an extremely small proportion of individuals infected with HPV in these populations are infected by these subtypes.

In terms of cancer causation, after HPV types 16 and 18, types 45 and 31 are the most oncogenic, followed by types 33 and 52. In total, the four types, 16, 18, 45, and 31 together account for 80% of cervical cancer cases world wide; and types 33 and 52 contribute approximately another 5–7% of cases.[13]

Pharmaceutical companies are already working on HPV vaccines that cover a wider range of HPV subtypes, and it may well be that African American women - and indeed women in other populations where types other than 16 and 18 cause many cases of cancer - will benefit more from these vaccines than white European and US women. Merck's "V503" vaccine covers, in addition to the strains in Gardasil, HPV types 31, 33, 45, 52, and 58.[5-8]  Data on this vaccine will were presented at the European Research Organisation on Genital Infection and Neoplasia (EUROGIN) Congress during a late-breaker oral session on Tuesday, November 5.[5]  The study reportedly found that in CIN2/3, HPV 16, 18, 33, 39, and 59 were the most common genotypes detected in white women, whereas HPV 31, 35, 45, 56, 58, 66, and 68 were the most prevalent in African American women - two of the types most common in African American women are included in the trial vaccine.

A cynic might wonder whether the appearance of this story at this time  might be designed to create awareness of a "problem" that Merck's new vaccine is designed to address, thus enhancing the likelihood of the new vaccine being recommended and thereby enhancing Merck's profits. Note that the stories about HPV types 16 and 18 being less common in some women than in others appeared only a few days before the presentation of data on the trial vaccine.

Nevertheless, if the new vaccine isn't very much more expensive than the previous vaccines, and is as safe and effective, and in particular as effective against the additional subtypes (with no loss of efficacy against the most important types 16 and 18) it should further reduce HPV related disease, including in many of those women who are least likely to be able to access screening and treatment for cancer.

It's worth noting that recent studies suggest that, rather than requiring three doses of HPV vaccine, two, or even a single dose, might suffice.[9-12]

REFERENCES
  1. Alter C. The HPV Vaccine and the Case for Race-Based Medicine. Time health and family 2013; Updated Nov. 01, 2013; Accessed: 2013 (6 November).
  2. HPV Vaccine May Not Protect Against Subtypes That Most Commonly Affect African American Women. Huffpost healthy living 2013; Updated 30 October; Accessed: 2013 (6 November).
  3. Mulcahy N. Vaccines Do Not Cover Most Common HPV Types in Black Women. Medscape public health and prevention 2013; Updated 28 October 2013; Accessed: 2013 (6 November).
  4. Clifford G, Franceschi S, Diaz M, Munoz N, Villa LL. Chapter 3: HPV type-distribution in women with and without cervical neoplastic diseases. Vaccine 2006;24(Supplement 3):S26-S34.
  5. Merck. Merck's Investigational 9-valent HPV Vaccine, V503, Prevented 97 Percent of Cervical, Vaginal and Vulvar Pre-cancers Caused by Five Additional HPV Types, in Phase III Study, 2013.
  6. Loftus P. Merck's Experimental HPV Vaccine Shows Promise in Late Stage Trial. 2013; Updated 3 November; Accessed: 2013 (6 November).
  7. Taylor NP. Vaccines a rare bright spot in Merck's gloomy financials. FierceVaccines 2013; Updated 29 October; Accessed: 2013 (6 November).
  8. Carroll J. Merck's next-gen HPV vaccine looks good in PhIII, but sales may disappoint. FierceBiotech 2013; Updated 3 November; Accessed: 2013 (6 November).
  9. Smith B. HPV Vaccine Effective In Just A Single Dose, Says Study. 2013; Updated 4 November; Accessed: 2013 (6 November).
  10. Safaeian M, Porras C, Pan Y, Kreimer A, Schiller JT, Gonzalez P, et al. Durable antibody responses following one dose of the bivalent human papillomavirus l1 virus-like particle vaccine in the costa rica vaccine trial. Cancer prevention research (Philadelphia, Pa) 2013;6(11):1242-50  PMID: 24189371.
  11. Lamontagne DS, Thiem VD, Huong VM, Tang Y, Neuzil KM. Immunogenicity of Quadrivalent HPV Vaccine Among Girls 11 to 13 Years of Age Vaccinated Using Alternative Dosing Schedules: Results 29 to 32 Months After Third Dose. J Infect Dis 2013 PMID: 23901077.
  12. Dobson SR, McNeil S, Dionne M, Dawar M, Ogilvie G, Krajden M, et al. Immunogenicity of 2 doses of hpv vaccine in younger adolescents vs 3 doses in young women: A randomized clinical trial. JAMA 2013;309(17):1793-1802  PMID: 23632723.
  13. Jenkins D. A review of cross-protection against oncogenic HPV by an HPV-16/18 AS04-adjuvanted cervical cancer vaccine: importance of virological and clinical endpoints and implications for mass vaccination in cervical cancer prevention. Gynecol Oncol 2008;110(3 Suppl 1):S18-25  PMID: 18653221.






Monday, October 14, 2013

Shingles vaccine has been introduced - and there's a shortage of it!

I have blogged previously about shingles vaccination. When I first blogged about this, there wasn't enough manufacturing capacity to start shingles vaccination in the UK; since then more plant has been built, and there is enough. At least, we thought there was enough.

Just to update people about the current programme... The UK decided, on advice from the Joint Committee on Vaccination and Immunisation (JCVI), to vaccinate everybody in the UK age 70 to 79. The JCVI's varicella subgroup recommended in 2009 that herpes zoster vaccination should be introduced to people aged 70 years and over; and on January 31 2010 the main JCVI endorsed this decision. In a more detailed statement, published on 29 March 2010, they explained their reasoning for recommending vaccination for 70-79 year olds. They explained that vaccinating people aged 60-69 years "could be cost effective", but the duration of vaccine efficacy and the effect of a second dose were uncertain, so there would be a risk of leaving them unprotected when the risk was greatest.

The government implemented the recommendation - to vaccinate everybody 70 to 79 years of age -starting in September 2013. Detailed information on the programme is provided in a number of documents, including this  guidance document for health professionals, published on 23 July 2013 (you don't have to be a health professional to read it). It is not clearly stated (or if it is, I've missed it) why the programme didn't attempt to vaccinate everybody aged 70-79 in the first year. It is possible that the manufacturing capacity wasn't sufficient to provide the amount of vaccine that would be required; and even if there had been sufficient vaccine, trying to vaccinate all of this age group in one year would have put a huge stress on an already grossly over-worked primary care service.

What was decided, instead, was to start a programme to vaccinate all 70 year olds. In addition to this, in the first year of the programme all those aged 79 years would be offered the vaccine - the first year of a catchup programme. The people identified for vaccination were those aged 70, and 79 years old on 1 September 2013. The plan, as I understand it, is that on 1 September 2014 people age 70 (the usual vaccination programme) and 79 will be offered the vaccine over the following year. These people would, of course, have been 69 and 78 respectively on 1 September 2013.

So each year people who turn 70 and 79 on the previous 1 September will be offered the vaccine, until everybody the people who were 70 on 1 September 2013 turn 79, when the catch-up programme will be complete.

Of course, this programme could be amended in the meantime if there's sufficient vaccine and staff and other resources to deliver it.

Recently, however, there have been reports of shortages of the vaccine, as described in this Pulse article, which claims that GPs have been blamed for the shortage. I have been hearing from GPs and practice nurses who are very upset - they had set up clinics and made appointments to give the vaccine, but supplies to practices are being capped. Not only is this hugely embarrassing to GPs  and their staff, when people turn up for the vaccine and have to be turned away; but it is also expensive. The time is committed, and the payment to GPs for giving the vaccine was negotiated on the basis that it would be given with the flu vaccine - but instead, a second dose is required.

It's not entirely clear why there is a shortage of vaccine. There doesn't seem to be a shortage in the USA (or at least, there wasn't on 11 September). The Vaccine Update refers to some "short term" supply problems. According to Pulse, Public Health England has blamed practices for ordering more vaccine than they need. Some GPs have responded angrily, saying that even if they'd wanted to, their fridges aren't big enough.

It seems to me that there are several reasons why there might be a shortage - all might, to some extent apply. They include:

  • There may have been problems with manufacturing capacity. A new plant was opened in North Carolina, recently; but perhaps it has taken longer to get working to full capacity than expected; or maybe there has been a problem at one of the other plants.
  • Perhaps some practices have ordered more than Public Health England anticipated. They may - based on previous experience - have front-loaded their order, so that they would have a cushion of vaccine to fall back on in the event of deliveries not turning up. "Just in time" is no good if people turn up, and the vaccine wasn't delivered on time, after all. But Public Health England may not have anticipated this.
  • It has been suggested that some practices may have misunderstood the criteria, and ordered sufficient vaccine for everybody in their practice age 70 to 79. I haven't heard of any verified instances of this, however, so it could just be black propaganda.
  • It is always possible, of course,  that there is no shortage. After all, in In November 2005 a Department of Health spokesperson went on the Today Programme and spent several minutes accusing GPs of wasting flu vaccine (which he seemed not to know had been purchased by and belonged to the GPs), when actually - as it turned out a few days later - the apparent shortage was because DH had divided the amount of vaccine available for England by the population of the United Kingdom.

No doubt the reason for the shortage - assuming it exists - will become clearer in time. I, for one, am very keen to understand what has gone wrong.

MMR and the courts: a missed opportunity

A recent court case has, again, decided that it would be in a child's best interests to be vaccinated with the MMR vacine. Sadly, it failed to reclassify MMR vaccination as a normal, rather than a controversial, procedure.

To fully understand the importance of this missed opportunity, you need to understand the law on consent for minors in the England and Wales (it may differ in Scotland and Northern Ireland).

Prior to a court case in 1999, consent for a minor who was did not have capacity ("Gillick Competence") to give consent on their own behalf was required from only one "person with parental responsibility". The court case related to a situation in which one parent wanted the child circumcised (a much less common procedure in the UK than in the USA, and one which has recently become more controversial – but that’s a topic for another day...). In this case the court decided that for “controversial” procedures – like circumcision – the consent of all persons with parental responsibility was required. Without this, or a court order, the procedure could not be undertaken.

In 2003, at the height of concerns about MMR caused by Andrew Wakefield's fraudulent and since discredited research, an appeal court heard appeals in two cases where parents held contrary views about whether a child should receive the MMR vaccine (see e.g. here, here, and here). In each case the court found that it would be in the best interests of the child for the vaccine to be given, and ordered for this to proceed. However, sadly, the court also decided that MMR vaccination was a “controversial” procedure, like circumcision; and made it clear that his decision related only to the two children involved in those two cases. Each such case in the future would have to be decided on its merits, by a judge.

MMR vaccination was never, for anybody aware of and able to understand the medical literature, a controversial procedure – even if it did temporarily become one in the UK for many people, due to ignorant and/or irresponsible press reporting. Since then we have learned about Wakefield's fraud; and further research has completely disproven the scare stories he raised. While it may have been understandable for a judge to have decided in 2003, at the height of the scares, that MMR was "controversial", it is clearly not controversial now; and it would have been very helpful for the court in the recent case to make this point, and to end the situation where the consent of all persons with parental responsibility is required before MMR vaccine can be given.

I’d just like to add another couple of practical notes about UK practice.
  • It is very clear in guidelines that if a child is brought for vaccination, a healthcare worker (usually a GP or practice nurse) is entitled to assume that the parents have consented to the vaccine. Unless, that is, the parents have previously stated that they object (or do so at the time they bring the child in to discuss the vaccine, for other vaccines, or whatever), the fact of the child being brought in is considered evidence enough. When cases such as the one that went to court arise, parents have usually made their views on vaccination clear to the practice in advance.
  • The recent case actually considered two sisters, aged 15 and 11. The law on consent for minors allows a person under 18 to consent to treatment, if they understand the implications of the treatment, and it is thought to be in their best interests. From the age of 16 the ability to understand is assumed – for most practical purposes 16-year-olds are not considered minors in UK medical practice. Bizarrely, however, minors – technically including all of those under the age of 18 years – do not have the right to withhold consent. If a parent – or all parents in the case of a “controversial” procedure – give consent, and the procedure is thought to be in their best interests, the individual minor may not withhold consent. In theory the procedure could be given against their consent. However the “best interests” part usually comes into play here: it would seldom if ever be considered to be in the best interests of a competent adolescent to perform a procedure on them – even one as benign as vaccination – against their wishes.