UNSW: The Australian Federal Government has announced that it will end the conscientious objector exemption on children’s vaccination for access to childcare benefits or family payments from 1 January 2016. This is a poorly thought out and ill-informed strategy that may end up worsening, rather than improving the alleged problem in a country that boasts among the best immunisation rates in the world. It was under a coalition government in 1998 that Australia introduced financial incentives to improve immunisation rates by linking timely and completed infant immunisation to payment of the maternity allowance and childcare benefits. This scheme has always allowed parents who refuse immunisation for their children to still claim these financial benefits, but require them to register their conscientious objection to immunisation.
This places an additional administrative hurdle for parents who
refuse immunisation, and therefore is likely to separate genuine vaccine
refusers from those who are hesitant or simply delay vaccination, and
has been shown to be effective in improving immunisation and parental
willingness to vaccinate.
Why, then, does the current government want to punish vaccine
refusers? Allowing parents to refuse vaccination without punishment is
thought to be important in maintaining public confidence in vaccination.
Most democratic societies allow conscientious objection to vaccination without punitive measures against parents who exert this choice.
Introducing punitive measures may have the opposite effect to the
intended effect, and may increase public mistrust of vaccination and
resentment of coercion. It also allows the anti-vaccination lobby to
represent themselves as persecuted martyrs.
I will need to see more evidence to be convinced there is a problem
at all. A rigorous public health approach would be to first define and
understand the problem, if indeed there is one, and then address it with
an appropriately targeted strategy.
We are told in the media that the number of vaccine refusers has
doubled in a decade. Which vaccines is this number referring to?
This is not the only question that remains unanswered.
Have new vaccines for different age groups been added to the schedule
in that time, such as adolescent HPV vaccine and is refusal for these
vaccines being counted in this number?
What relationship, if any, does this "increase" in vaccine refusers
have to the cessation of GP immunisation incentives in 2013?
What other reasons could there be for an increase in refusals? Have
vaccine adverse events increased? Do parents have other concerns which
we need to address?
We have an obligation to understand and address the concerns of
parents, instead of punishing them. Maintaining public confidence in
vaccines and trust in immunisation programs is key to the success of
No vaccine is 100% safe or 100% effective, and sometimes we do get it
wrong. For example, the case of the 1998 introduction in the United
States of the first rotavirus vaccine, Rotashield. This vaccine was withdrawn
when post-licensure surveillance revealed an increased risk of
intussusception, a serious, potentially fatal side effect which was not
picked up by initial clinical trials, because these trials were too
small to detect this risk.
In times like this, any public perception of force, coercion or
punishment for non-vaccination can cause significant damage to
vaccination programs. Immunisation programs are a partnership in trust
between those who deliver the programs and the parents who bring their
children for vaccination. This trust needs respect to be maintained, and
punitive measures will erode trust. There are many historical examples
of public backlash when such trust is eroded by overly dogmatic or
forceful government actions.
Past experience tells us that genuine vaccine refusers are a small
but vocal minority, and there is a larger group of hesitant or uncertain
parents who can be positively influenced to vaccinate their children.
Hard core vaccine refusers are unlikely to change their views, but
there are far more potential gains in working constructively, using
proven strategies, with the uncertain parents. Instituting draconian
punitive measures runs the risk of driving the uncertain group to
becoming hard core refusers instead of the desired effect of making them
vaccinate their children. These parents, after all, work and pay taxes
like the rest of us, so from an equity point of view should still be
allowed to access financial benefits.
Finally, the problem first needs to be defined in terms of risk of
vaccine-preventable diseases. What diseases that can be prevented by
vaccines on our immunisation schedule are causing epidemics and deaths
in Australia? What are the vaccination rates for these diseases? What is
the cause of poor disease control?
Real problems which have been identified include a lack of a
universal funding mechanism for catch-up vaccination of under-immunised
migrant and refugee groups including both adults and children and
buck-passing between states and Commonwealth. Recent epidemics of
measles in Australia have clearly been linked
to under-immunised migrant groups, mainly adolescents and adults. In
fact, the infant vaccination rates in the most affected part of Sydney
for the measles outbreaks of 2012-13 was 95%, indicating that the
problem lay elsewhere.
Even the tragic deaths of infants from pertussis are usually in
infants too young to have received the full pertussis immunisation
schedule, such as the recent tragic death of baby Riley,
who was only 4 weeks old and too young for his pertussis vaccinations.
The problem is adults who are susceptible to pertussis, and who can then
infect vulnerable infants.
The problems of identified gaps in adult immunisation are the
pressing issue facing us today, which no amount of punishment of parents
who refuse infant vaccination will fix.
Professor Raina MacIntyre is Head of the School of Public
Health and Community Medicine at UNSW and Professor of Infectious