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
908
LETTERS TO THE EDITORdrawback 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
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
TherapyTo 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