believe information that is consistent with their existing views; misjudge the reliability of their sources of information, and are misled by anecdotal evidence; and tend not to revise their opinions even when their original sources of information are shown to be wrong. litigation during the 1980s and 1990s, a number of lawsuits were brought against manufacturers of vaccines, alleging the vaccines had caused physical and mental disorders in children. while these lawsuits were unsuccessful, they did lead to a large jump in the costs of the mmr vaccine, and pharmaceutical companies sought legislative protections. in 1993, merck kgaa became the only company willing to sell mmr vaccines in the united states and the united kingdom. italy in june 2012, a local court in rimini, italy, ruled that the mmr vaccination had caused autism in a 15-month-old boy. the court relied heavily on the discredited lancet paper and largely ignored the scientific evidence presented to it. the decision was appealed. on 13 february 2015, the decision was overturned by a court of appeals in bologna. japan the mmr scare caused a low percentage of mumps vaccination (less than 30%), which resulted in outbreaks in japan. there were up to 2002 measles-caused deaths in japan while there were none in the uk, but the extra deaths were attributed to japan's application of the vaccine at a later age. a spokesman for the ministry of health said that the discontinuation had no effect in measles, but also mentioning that there were more deaths by measles while mmr was being used. in 1994 the government dropped the vaccination requirement for measles and rubella due to the 1993 mmr scare.: 2 it has been called a "measles exporter" by the us centers for disease control and prevention. as another consequence of the scare, in 2003, 7 million schoolchildren had not been vaccinated against rubella. autism rates continued to rise in japan after the discontinuation of the mmr vaccine, which disproves any large-scale effect of vaccination, and means that the withdrawal of mmr in other countries is unlikely to cause a reduction in autism cases. the japanese government does not recognize any link between mmr and autism. by 2003 it was still trying to find a combined vaccine to replace mmr. it was later discovered that some of the vaccines were administered after their expiry date and that the mmr compulsory vaccination was only retracted after the death of three children and more than 2000 reports of adverse effects. by 1993 the japanese government had paid $160,000 in compensation to the families of each of the three dead children. other parents received no compensation because the government said that it was unproven that the mmr vaccine had been the cause; they decided to sue the manufacturer instead of the government. the osaka district court ruled on 13 march 2003 that the death of two children (among numerous other serious conditions) had been indeed caused by japan's strain of urabe mmr. in 2006, the osaka high court stated in another ruling that the state was responsible for failing to properly supervise a manufacturer of the measles-mumps-rubella vaccine, which caused severe side effects in children. united kingdom commenced before the civil procedure rules were promulgated, the mmr litigation had its status as group litigation achieved by the then lord chief justice's practice direction of 8 july 1999. on 8 june 2007, the high court judge, justice keith, put an end to the group litigation because the withdrawal of legal aid by the legal services commission had made the pursuit of most of the claimants impossible. he ruled that all but two claims against pharmaceutical companies must be discontinued. the judge stressed that his ruling did not amount to a rejection of any of the claims that mmr had seriously damaged the children concerned. a pressure group, jabs (justice, awareness and basic support), was established to represent families with children who, their parents said, were "vaccine-damaged". £15 million in public legal aid funding was spent on the litigation, of which £9.7 million went to solicitors and barristers, and £4.3 million to expert witnesses. united states main articles: vaccine court and omnibus autism proceeding the omnibus autism proceeding (oap) is a coordinated proceeding before the office of special masters of the u.s. court of federal claims—commonly called the vaccine court. it is structured to facilitate the handling of nearly 5000 vaccine petitions involving claims that children who have received certain vaccinations have developed autism. the petitioners' steering committee have claimed that mmr vaccines can cause autism, possibly in combination with thiomersal-containing vaccines. in 2007 three test cases were presented to test the claims about the combination; these cases failed. the vaccine court ruled against the plaintiffs in all three cases, stating that the evidence presented did not validate their claims that vaccinations caused autism in these specific patients or in general. in some cases, the plaintiffs' attorneys opted out of the omnibus autism proceedings, which were concerned solely with autism, and issues concerned with bowel disorders; they argued their cases in the regular vaccine court. on 30 july 2007, the family of bailey banks, a child with pervasive developmental delay, won its case versus the department of health and human services. in a case listed as relating to "non-autistic developmental delay", special master richard b. abell ruled that the banks had successfully demonstrated, "the mmr vaccine at issue actually caused the conditions from which bailey suffered and continues to suffer." in his conclusion, he ruled that he was satisfied that mmr had caused a brain inflammation called acute disseminated encephalomyelitis (adem). he reached this conclusion because of two vaccine cases in 1994 and 2001, which had concluded, "adem can be caused by natural measles, mumps, and rubella infections, as well as by measles, mumps, and rubella vaccines." in other cases, attorneys did not claim that vaccines caused autism; they sought compensation for encephalopathy, encephalitis, or seizure disorders. research the number of reported cases of autism increased dramatically in the 1990s and early 2000s. this increase is largely attributable to changes in diagnostic practices; it is not known how much, if any, growth came from real changes in autism's prevalence, and no causal connection to the mmr vaccine has been demonstrated. in 2004, a meta review financed by the european union assessed the evidence given in 120 other studies and considered unintended effects of the mmr vaccine, concluding that although the vaccine is associated with positive and negative side effects, a connection between mmr and autism was "unlikely". also in 2004, a review article was published that concluded, "the evidence now is convincing that the measles–mumps–rubella vaccine does not cause autism or any particular subtypes of autistic spectrum disorder." a 2006 review of the literature regarding vaccines and autism found "he bulk of the evidence suggests no causal relationship between the mmr vaccine and autism." a 2007 case study used the figure in wakefield's 1999 letter to the lancet alleging a temporal association between mmr vaccination and autism to illustrate how a graph can misrepresent its data, and gave advice to authors and publishers to avoid similar misrepresentations in the future. a 2007 review of independent studies performed after the publication of wakefield et al.'s original report found that the studies provided compelling evidence against the hypothesis that mmr is associated with autism. a review of the work conducted in 2004 for uk court proceedings but not revealed until 2007 found that the polymerase chain reaction analysis essential to the wakefield et al. results was fatally flawed due to contamination, and that it could not have possibly detected the measles that it was supposed to have detected. a 2009 review of studies on links between vaccines and autism discussed the mmr vaccine controversy as one of three main hypotheses that epidemiological and biological studies failed to support. in 2012, the cochrane library published a review of dozens of scientific studies involving about 14,700,000 children, which found no credible evidence of an involvement of mmr with either autism or crohn's disease. the article was updated in 2020 and again in 2021, with the authors stating, "we have observed an improvement in the quality of the design and reporting of safety outcomes in mmr and mmrv in recent years both pre- and post-marketing." a june 2014 meta-analysis involving more than 1.25 million children found "vaccinations are not associated with the development of autism or autism spectrum disorder. furthermore, the components of the vaccines (thimerosal or mercury) or multiple vaccines (mmr) are not associated with the development of autism or autism spectrum disorder." in july 2014, a systematic review found "strong evidence that mmr vaccine is not associated with autism", and in march 2019, a large-scale study conducted by statens serum institut following over 650,000 children for over 10 years found no link between the vaccine and autism, even among children with autistic siblings. disease outbreaks further information: measles outbreaks in the 21st century and mumps outbreaks in the 2000s after the controversy began, the mmr vaccination compliance dropped sharply in the united kingdom, from 92% in 1996 to 84% in 2002. in some parts of london, it was as low as 61% in 2003, far below the rate needed to avoid an epidemic of measles. by 2006 coverage for mmr in the uk at 24 months was 85%, lower than the about 94% coverage for other vaccines. after vaccination rates dropped, the incidence of two of the three diseases increased greatly in the uk. in 1998 there were 56 confirmed cases of measles in the uk; in 2006 there were 449 in the first five months of the year, with the first death since 1992; cases occurred in inadequately vaccinated children. mumps cases began rising in 1999 after years of very few cases, and by 2005 the united kingdom was in a mumps epidemic with almost 5000 notifications in the first month of 2005 alone. the age group affected was too old to have received the routine mmr immunisations around the time the paper by wakefield et al. was published, and too young to have contracted natural mumps as a child, and thus to achieve a herd immunity effect. with the decline in mumps that followed the introduction of the mmr vaccine, these individuals had not been exposed to the disease, but still had no immunity, either natural or vaccine induced. therefore, as immunisation rates declined following the controversy and the disease re-emerged, they were susceptible to infection. measles and mumps cases continued in 2006, at incidence rates 13 and 37 times greater than respective 1998 levels. two children who underwent kidney transplantation in london were severely and permanently injured by measles encephalitis. disease outbreaks also caused casualties in nearby countries. three deaths and 1,500 cases were reported in the irish outbreak of 2000, which occurred as a direct result of decreased vaccination rates following the mmr scare. in 2008, for the first time in 14 years, measles was declared endemic in the uk, meaning that the disease was sustained within the population; this was caused by the preceding decade's low mmr vaccination rates, which created a population of susceptible children who could spread the disease. mmr vaccination rates for english children were unchanged in 2007–08 from the year before, at too low a level to prevent serious measles outbreaks. in may 2008, a british 17-year-old with an underlying immunodeficiency died of measles. in 2008 europe also faced a measles epidemic, including large outbreaks in austria, italy, and switzerland. following the january 2011 bmj statements about wakefield's fraud, paul offit, a pediatrician at children's hospital of philadelphia and a "long-time critic of the dangers of the anti-vaccine movement", said, "that paper killed children", and michael smith of the university of louisville, an "infectious diseases expert who has studied the autism controversy's effect on immunization rates", said "clearly, the results of this (wakefield) study have had repercussions." in 2014, laurie garrett, senior fellow at the council on foreign relations, blamed "wakefieldism" for an increase in the number of unvaccinated children in countries such as australia and new zealand, saying, "our data suggests that where wakefield's message has caught on, measles follows." impact on society the new england journal of medicine said that antivaccinationist activities resulted in a high cost to society, "including