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Dear Editor

Informing education policy on MMR

I read with interest the article on balancing individual freedoms and collective
responsibilities around MMR vaccination1 because Sense (for people with deaf
blindness and associated disabilities) has been involved in supporting people with
congenital rubella syndrome for 50 years and we have taken an active role in
promoting immunization.
The distinction between the duty of care parents may feel for the welfare of their
child and collective responsibilities that are owed to present and future communities is
blurred when we consider the situation of rubella. The benefit of rubella immunization
is greatest to pregnant women and their unborn child, rather than to the child
receiving the vaccination. Sense knows of examples where pregnant mothers, who
subsequently gave birth to babies born deafblind with congenital rubella syndrome,
caught the rubella from their own children. Parents do need to be reminded that those
we seek to protect with MMR are not some ‘herd’ community, but those close to us,
including our immediate family.

Joff McGill, Sense, London, UK. E-mail:

Contact: Sense, 11!1/ 3 Clifton Terrace, Finsbury Park, London N4 3SR, UK. Tel: +44 (0)20
7272 7774; Fax: +44 (0)20 7272 6012; Text: +44 (0) 20 7272 9648; Web site: http://

Wood-Harper J. Informing education policy on MMR: balancing individual freedoms and
collective responsibilities for the promotion of public health. Nurs Ethics 2005; 12: 43!/58.

Response to letter to the Editor from Joff McGill, by

Janice Wood-Harper
I acknowledge the relevance and valuable contribution of the point made by Joff
McGill regarding the particular benefits of rubella vaccination to pregnant women and
their unborn children within the families of children being considered for vaccination.
I am in agreement with the comment that the significant health risks posed by
nonimmunized children to these individuals are greater than the relatively rare risk of

Nursing Ethics 2005 12 (5) # 2005 Edward Arnold (Publishers) Ltd 10.1191/0969733005ne823xx
538 Letter to the Editor

serious side effects of the vaccine itself or health complications associated with an
unvaccinated child contracting the disease.
In the light of these comments, I feel that it may be useful to clarify the extent to
which these considerations affect the main arguments that I discussed in the article:
. The article deals with the issues raised by reduced uptake levels of the combined
MMR vaccine, as opposed to the single rubella vaccine. Therefore, although
certainly the risk to pregnant women and their unborn children is a relevant and
important concern, it is the cumulative effects of lowered population immunity to
measles, mumps and rubella that constititue the basis for discussion in the article.
. Even taking the case of the single rubella vaccine, I consider that the argument for
recognition of collective responsibilities would still remain valid. If the present
lowered immunity levels to rubella were to be maintained for a long period of
time, with a probable increase in the incidence of infection in the population, this
could result in affected births in future generations of nonimmunized pregnant
women, both within and outside the immediate family.
. This foreseeable situation further substantiates the need for parents to appreciate
the wider and longer term consequences of their present vaccination decisions
and, in particular, for ways to increase general awareness of the repercussions of
such decisions in public health. I have acknowledged in the article that the extent
to which parents could be expected to prioritize such considerations over the
immediate health interests and welfare of their children (and family members) is
questionable. Nevertheless, it is suggested that truly informed parental decision
making on vaccination for their children calls for the inclusion of communication
and assessment of understanding of the implications beyond those affecting
individual children (both born and unborn) in governmental education policy
initiatives. Such recognition of wider responsibilities for potential harms could be
effective in contributing to increased vaccine uptake.
. I believe that these arguments become even more persuasive in relation to the
combined MMR vaccine. For as long as immunity levels to all three diseases
remain below the critical level for protection of the ‘herd’ community, the
incidence of harmful side effects of infection in vulnerable, unvaccinated
individuals is likely to rise. This situation could contribute to additional harms
for society in terms of allocation of limited health care resources. It is my view
therefore that consideration of public health interests should be an integral part of
parental decision processes about vaccination for their children.
Hopefully this suggested approach would be effective in helping to reduce the
incidence of debilitating conditions in children such as those identified by Joff McGill.

Janice Wood-Harper, School of Community, Health Sciences and Social Care, University of
Salford, UK. E-mail:

Reply to Janice Wood-Harper by Joff McGill

Thank you for your thoughtful reply; I agree with your conclusions. I want to clarify
that I was not making an argument for a single rubella vaccine, rather that parents and
the public should be reminded about the dangers of rubella to pregnant women and
their unborn children. Often the arguments are concentrated on the danger of measles,

Nursing Ethics 2005 12 (5)

Letter to the Editor 539

yet the case of protecting against rubella is persuasive both in terms of both public and
private health benefits.
Sense is a strong supporter of the MMR childhood immunization programme and
believes it is the best way to prevent congenital rubella syndrome. We have
consistently argued against the introduction of a choice of single vaccines. We do
believe that women who are considering becoming pregnant should have their rubella
immunity levels checked and that those who are susceptible, and indeed those that are
picked up as being susceptible to rubella in the current antenatal screening
programme, should be offered a rubella-containing vaccine at the appropriate time.
Currently women are offered the MMR, and we support this.

Joff McGill

Nursing Ethics 2005 12 (5)