Børnesygdommenes politik: Mæslinger, fåresyge og røde hunde og indførslen af MFR-vaccination i Danmark 1987

Translated title of the contribution: The politics of childhood diseases: Measles, mumps and rubella, and the introduction of MMR vaccine in Denmark 1987

Anne Hagen Berg

    Research output: ThesisPh.D. thesis

    Abstract

    In 1987, the combination vaccine against measles, mumps, and rubella
    (MMR) was added to the Danish childhood vaccination program. By
    then, most industrialized countries had immunized against one, two or
    all three diseases for years, even decades. The Danish health authorities
    were aware of the vaccination strategies abroad but considered the
    vaccine unnecessary under Danish conditions well into the 1980s.
    Taking its analytical starting point in this deviance, the dissertation
    studies the process that eventually led to the introduction of MMR. It
    discusses both why the vaccine was not introduced simultaneously with
    neighboring countries, and why it was then introduced in 1987 – and
    not later or even not at all. I trace the diseases several decades back in
    time to see when and how they were initially constructed as health
    threats and to follow the changing perceptions of the vaccine. The
    analysis focuses on the social and technological construction of disease
    and prevention, path dependency in disease prevention, and political
    structures as determinants of the decision.
    The MMR vaccine protects against three different diseases with
    different associated risks. Measles can cause serious complications like
    pneumonia, inflammation of the brain, and it can be mortal. In highly
    developed countries, serious complications are rare, but measles is a
    serious health threat in developing countries. The first vaccine was
    licensed in 1963, and during the 1960s and 1970s, most European countries introduced measles vaccinations. Rubella is a mild disease in
    children, but it can cause severe birth defects if a woman is infected
    during pregnancy. The first vaccine was licensed in 1969 and within a
    few years, it was taken into use in many countries. Mumps is considered
    unpleasant, but harmless in children. In adult males, however, it can in
    rare cases cause sterility if the virus spreads to the testes. A vaccine was
    licensed in 1967. The combined MMR vaccine was first licensed in 1971
    but was not generally taken into use in the European countries until the
    1980s. While the combination vaccine could simplify vaccination
    schedules, its use did not necessarily make sense in terms of
    epidemiology and complications.
    Until the early 1980s, the Danish health authorities did not consider the
    three diseases as related to each other. In the 1940s, congenital rubella
    syndrome was discovered. In Denmark as well as abroad, abortion was
    the only means of prevention before 1969. In the 1956 abortion law,
    rubella was made a legal indication for abortion. But rubella was often
    symptom-free, so it was hard to identify the infected mothers, and no
    diagnostics were available. Following the 1962 isolation of the virus,
    laboratories abroad set about to develop a vaccine to protect women
    before pregnancy. In the Danish State Serum Institute, however,
    researchers developed a diagnostic tool (using blood samples) to
    identify infected pregnant women to offer them abortion. In 1969, the
    same year as the licensing of the vaccine abroad, the diagnostics were
    taken into use by Danish doctors. Following that, the problem of
    congenital rubella syndrome was continuously being solved with
    abortions. Despite an increasing public demand for rubella vaccinations
    during the 1970s, the health authorities were reluctant to switch
    strategy. The explanations for this Danish Sonderweg are path
    dependency and an institutional tendency to consider their own
    technology and evidence as superior to those from abroad. This tendency also applied to the perception of the other diseases. In
    1971, the National Board of Health established a working group to
    assess the need for new vaccines, especially those against measles,
    mumps, and rubella. The availability of the vaccines – and their use in
    other European countries – put the diseases on the agenda in Denmark.
    However, in 1973 the working group concluded that measles was
    harmless under Danish conditions and that the evidence supporting
    foreign use of the vaccine was inadequate. Mumps remained of no
    interest until the combined MMR vaccine was considered in the 1980s.
    In 1983, the National Board of Health issued a recommendation for the
    introduction of MMR. This was motivated by several political and
    institutional changes, nationally and internationally. International
    health agencies like the World Health Organization and UNICEF
    sharpened the focus on primary health care, child health, and
    immunization in the late 1970s and onwards. One goal was to enhance
    global immunization against measles and in 1983 the WHO criticized
    Denmark for being a ‘net exporter’ of the disease – to the
    embarrassment of the health authorities. Furthermore, public health
    prevention had become a political priority both in Denmark and
    internationally, and several actors and institutions used that as an
    argument in favor of MMR. Related, the National Board of Health
    reconsidered the epidemiological data, changed their perception of
    both the diseases and the vaccine and found that there were reasons to,
    a) eliminate measles and mumps and b) switch strategy regarding
    congenital rubella syndrome. By introducing universal vaccinations, the
    abortion practice could be abolished over time.
    Furthermore, a new type of evidence influenced the perception
    of the vaccine. In 1985, a working group under the National Board of
    Health issued a cost-benefit-analysis showing that the MMR vaccine
    would result in large cost savings on the national budget over 20 years.
    Earlier vaccinations – e.g. against polio and diphtheria – had been introduced as a response to grave epidemics. With the introduction of
    MMR, the childhood vaccination changed from only preventing mortal
    diseases to prevent less dangerous, if unpleasant, diseases.
    Danish hesitancy in adopting the MMR vaccine was initially
    motivated by skepticism against vaccines and evidence from abroad.
    But after MMR was put on the political agenda, the further delay was
    the result of the tight state budgets under the 1980’s Conservative-led
    government. In late 1985, motivated by the international agenda and
    the cost-benefit-analysis, the municipalities planned to introduce MMR
    as a local program. These plans made the central health authorities
    nervous about losing control over the immunization program.
    Simultaneously, the Social Liberal Party (Det Radikale Venstre) as well
    as the public demanded the introduction of MMR. In early 1986, the
    government gave in, and by 1 January 1987, MMR was part of the
    universal childhood vaccination program. Thus, the political structures
    came to play a determining role in the decision.
    MMR is perhaps best known due to the 1998 accusations by Andrew
    Wakefield in The Lancet that it could cause autism. This claim has been
    disproved by several studies since, but it prevails in anti-vaccination
    groups. The dissertation also traces the Danish MMR controversies and
    shows that, contrary to common understandings, the 1998 Lancet
    paper was not the offset of the controversy. During the 1990s the media
    questioned the safety of MMR, most notably in two TV documentaries
    that aired on the public Danish Broadcasting Corporation in 1993 and
    1996. Both times it claimed that MMR was linked to autism, and in the
    1996 documentary, Andrew Wakefield appeared as an expert. In
    contrast to, e.g., the UK, Denmark did not have a history of strong
    vaccination resistance. The 1990s’ controversies revolved around three
    themes: 1) Informed consent and whether parents were entitled to full
    disclosure of all possible side effects. 2) Trust in authorities. 3)
    Vaccinations as risky procedures. Despite media attention to the accusations about MMR and autism, the uptake of the MMR vaccine
    remained stable throughout the 1990s.
    The Danish MMR history thus contributes not only to the
    policymaking history but also to the history of the MMR controversy. In
    both cases, the dissertation provides new insights and new perspectives
    on the history of MMR, measles, mumps, and rubella.
    Translated title of the contributionThe politics of childhood diseases: Measles, mumps and rubella, and the introduction of MMR vaccine in Denmark 1987
    Original languageDanish
    Awarding Institution
    • University of Southern Denmark
    Supervisors/Advisors
    • Petersen, Klaus, Principal supervisor
    • Starke, Peter, Co-supervisor
    Publisher
    Publication statusPublished - Mar 2020

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