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LETTERS TO THE EDITOR 907

REFERENCES

1. Livingston, S.: Drug therapy’ for epilepsy’.

Springfield, Illinois: Charles C Thomas, 33

pp., 1966.

2. Kokenge, R., Kutt, H., and McDowell, F. : Neti-rological sequelae following dilantin overdose in a patieiit an(l in experimental animals.

Neurology’, 15:823, 1965.

Mumps Virus Vaccine

To THE EDITOR:

For several years a number of pediatricians

have been on an advisory committee Oil

im-munizations to the Montana State Board of

Health. At the last meeting I was commissioned to write the Committee on Control of

Infec-tious Diseases regarding the mumps virus

vac-cine and the recommendations which at that time had not been revised, but which

subse-quently have been. I am taking the liberty of

also sending a copy of this letter to the editor

of PEDIATRICS.

Our main concern is the confusion which

the present recommendations have caused to

private practitioners in general. In the first

place, we are wondering wily a vaccine which has been developed for this troublesome dis-.

ease and which is said to be safe and

effec-tive is not being recommended for general

use. This is apparently one of the first vac-cines ever limited by the profession under the assumption as stated, “in view of the usually

benign nature of mumps.” It would appear

to us that any vaccine for a disease that has

the potential of producing complications which can be fatal, and which can be prevented, should be given universal acceptance,

ap-proval and recommendation. Since none of us is able as yet to predict which case will be serious and which will not, it seems to us

somewhat risky to assume that all of the cases

will be benign and that the vaccine

there-fore should not be available and used

uni-versally. I might state also that, in speaking

of the advisability of the mumps vaccine to

my patients, they tend to be somewhat

con-fused about our recommendations and have the idea that if these recommendations for

one vaccine are valid, then perhaps the rest of them are not too important either.

Second, since mumps is frequently a

sub-clinical disease without parotitis, what proof have we as yet that it cannot affect the

em-bryo and forming fetus and therefore increase

the danger of reproducing abnormal children?

Third, I think niost of us have seen menin-geal encephalomyelitis as the result of mumps

in children un(ler the adolescent age, in some cases vith a fatal outconie. The possil)ility of nephritis as a complication also iiitist be considered and, of course, should iiot

per-manent nerve deafness, which according to

the otologists is one of the niajor sequelae

of mumps, be prevented if we are to serve

in our capacity as physicians who emphasize

preventative medicine?

Fourth, one wonders if there might not be some inherent danger in the use of this

vac-cine which has not yet been published which

makes you reserve your unqualified endorse-ment.

As a matter of clarification, our committee would appreciate any correspondence which

could be initiated as a result of this letter.

We are also concerned about the

develop-ment of the triple vaccine which includes

rubeola, rubella, and mumps vaccine in the

same injection, and we are wondering about

your recommendations relative to use of this triple vaccine.

Thank you very much for any help you

can give us relating to the above stated

prob-lems.

Miles City, Montana

LEwIs L. BOCK, M.D. Garberson Clinic

EDITOR’S NOTE: For the Committee, Dr.

Margaret Smith replied as follows:

Thank you for your thoughtful letter al)out

mumps virus vaccine. We have had several

letters over tile past year from individuals and groups who, like yourselves, have been perturbed about tile recommendations for the

use of mumps vaccine. Let me first point out

that the recommendations for the use of

mumps vaccine, which seem to you confused

and which others have referred to as “wishy-washy,” are not those alone of the Committee

Oil Control of Infectious Disease, but that

they concur very closely with those of the

Advisory Committee on Immunization Practice of the Surgeon General. Thus, there is a rather

large group of people who have the same

feeling about mumps vaccine.

The mumps vaccine certainly is as far as

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908

LETTERS TO THE EDITOR

drawback associated with the administration of mumps vaccine.

As far as your second point is concerned,

I know of no evidence that mumps does

af-feet the embryo and increase the danger of

reproducing abnormal children. This has been

looked into rather carefully by several groups,

and I do not have the references readily at

hand. Nevertheless, I think it fair to say that

mumps has not been included among the

po-tentially teratogenic viruses.

As for your third point, I would certainly

agree that meningo-encephalomyelitis is a very common complication of mumps. In fact,

in the preadolescent group, it is by far the

commonest complication of mumps. So far as

serious sequelae are concerned, there

fortu-nately have been very few serious sequelae

from mumps meningo-encephalomyeiitis. For

my own part, I have seen one case of trans-verse myelitis, and that I believe is the only

really serious central nervous system

compli-cation of mumps I have ever seen after being associated with busy contagious disease

ser-vices for a great many years. There is no

doubt that deafness does occur, and that it is

a terribly serious complication; fortunately, it

too seems to be rare.

I think that the reservations in the minds

of those who make recommendations for the

use of vaccines are based on the following considerations. In the first place there is a

great difference between mumps vaccine and

vaccines against smallpox, polio, and measles.

The difference is that those diseases are among

the great scourges of mankind, so any vaccine

which offers a reasonable degree of

protec-tion is acceptable. On the other hand, mumps

is a disease with an extremely low mortality

and an extremely low incidence of serious

and permanent sequelae. Under these

circum-stances, the public has a right to demand

an extremely efficient vaccine with a very low

rate of sequelae. As far as we know, mumps

vaccine meets these requirements. On the

other hand, it will be a good many years

be-fore we are sure that immunity is permanent,

and it will take an enormous number of

im-munizations before we are sure that there is

not a low incidence of some sort of

compli-cation. The very fact that the incidence of

severe complications from mumps itself is so

low makes it difficult to evaluate the relative incidence of complications from mumps

vac-cine. For example, a couple of dozen cases

of severe central nervous system disease have

now been reported with the use of live

at-tenuated measles virus vaccine; when you

consider that several million doses of measles

vaccine have been given, there is no question

that the incidence of complications from the

vaccine is much lower than the incidence of

complications from measles itself. However,

it will take a good deal more information than

is presently available before we can be sure

of the situation with mumps vaccine.

We know now that antibody to mumps

persists in high titer for at least 3 years

fol-lowing the administration of mumps virus

vaccine. We do not know how durable this

immunity will be, and one wonders whether it is advisable to immunize on a large scale

against an illness which is, on the whole,

rather mild in infancy and childhood and

rather unpleasant in adults, without being

perfectly sure how durable the immunity is.

It would be unfortunate to simply postpone

mumps Ill large population groups until adult

life!

Furthermore, now that the great scourges

such as poliomyelitis and measles are more

or less under control, or can be brought under

control, we are beginning to worry a little

more about the disadvantages of injecting

many antigens into younger individuals. There

is some suggestion that injection of large amounts of antigenic material may be

ac-companied by untoward side effects. Also, we

have no way of knowing for sure that

acces-sory viruses might be present in the live

virus vaccine, viruses which we have

abso-lutely no way to test for. You may not be

aware that this drawback looms so large in

the minds of the Scandinavian and British

virologists, that they are not in favor of using any live virus vaccine on a large scale, not

even polio and measles virus vaccines.

Finally, many of us are reluctant to

recom-mend the use of mumps vaccine on a large

scale until such time as vaccines against more

serious diseases such as poliomyelitis and

measles are more extensively used in all

popu-lation groups. If the groups which make

rec-ommendations concerning the use of virus

vaccines were to “go all out” in

recommend-ing mumps virus vaccine for everyone, it

would put certain public health authorities in

the position of having to supply mumps

vac-cine even before the basic immunization

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LETTERS TO THE EDITOR 909

Thus, the recommendations for the use of

mumps vaccine are designed, hopefully, to

be sufficiently permissive so physicians

en-gaged in private practice can use them on

their own patients to the extent they wish to

do so, but sufficiently lukewarm, so public health groups with limited budgets can

pro-ceed with other programs which they deem

to be of higher priority.

I hope that this lengthy letter will clarify

your thinking for you! If not, please let me

know.

MARGARET H. D. SMITH, M.D.

Tulane University School of Medicine 1430 Tulane Avenue

New Orleans, Louisiana 70112

Annual Summary of Vital Statistics-1967

To THE EDrroR:

I am pleased with the continuous decrease

of the infant mortality rate.

As a pediatrician involved in community

programs as veil as in hospital programs, I

feel that some data have to be presented in evaluating the infant mortality rate.

For instance, it will be helpful to know how flluch of the infant mortality the

neo-natal death rate represents and how much

of the neonatal death the prenatal death rate

represents. After this breakdown, let us

com-pare with other countries the infant mortality

rate divided in age groups: 0 to 1 month, 1 to 3 months or 1 to 6 months, and 6 to 12

fllOIlthS.

By applying this system to the states, we

gain helpful data regarding the immediate

measures which are necessary for our evalu-ation.

If, for instance, in Mississippi the neonatal death rate represents almost all the infant

nlOrtality, we can improve this index by

tak-ing rapid measures which will lower the neo-natal death rate. It seems to me that a large

iiumber of deliveries occur at home in this

state, as I read last year. Some examples from other countries in Europe in this direction might be helpful without experimenting with

new methods.

I also feel that it is necessary to have a community program sponsored by the

Amen-can Academy of Pediatrics and the Maternal

and Child Health Bureau in order to provide

adequate care for children.

This program has to be shaped for each state by the state’s officials. In this way, the Director of the Child Health Bureau in each

city will be deeply involved with these pro-grams.

The centralization of the community

pro-grams will help, at least at the present time,

in developing adequate medical care for

chil-dren and especially for infants. I do not feel

that it is necessary to experiment all over the country with different types of community

program systems and to waste time and money.

I feel that it is necessary to have only one

program in a community.

If the foregoing statements are not clear

enough, I can present you with some examples

which will illustrate better what I am re-ferring to.

MARCEL BILTu, M.D.

Assistant Chairman

Department of Pediatrics

Hospital of Saint Raphael 1450 Chapel Street

New Haven, Connecticut 06511

Familial Non-Hemolytic Jaundice:

Light

Therapy

To THE EDITOR:

After reading the tragic case report of a 16-year-old with non-hemolytic jaundice by Blumenschein, S. D., et al. (PEDIATRICS, 42:

786, 1968) , the question of a trial with

fluo-rescent light to reduce serum bilirubin, as

recommended by Lucey,

J.

(PEDIATRICS, 41:

1047, 1968) , occurred to me. I would

appre-ciate the views of the authors (on the editors

of PEDIATRICS

)

On the use of fluorescent light in the event of a future case.

MYRON M. NICHOLS, M.D.

Associate Professor

Department of Pediatrics The University of Texas

Medical Branch

Galveston, Texaa 77550

EDITOR’S Nom: Dr. Jerold F. Lucey

com-mented as follows for the Editorial Board of

PEDIATRICS:

Very little experience has been reported Oil

the use of fluorescent phototherapy in the Crigler-Najjar syndrome in older children. The

only case report of which I am aware (Ann.

Pediat., 43:829, 1967) indicates that, while

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con-1969;43;907

Pediatrics

Margaret H. D. Smith

Letter to the Editor

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(5)

1969;43;907

Pediatrics

Margaret H. D. Smith

Letter to the Editor

http://pediatrics.aappublications.org/content/43/5/907.2

the World Wide Web at:

The online version of this article, along with updated information and services, is located on

American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

References

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