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Punishing the children of vaccine refusers is a step too far

8 September 2015
Vaccine refusal is a particularly vexed problem.

Harsh sanctions against the anti-vaccination lobby could risk reinvigorating it, argues Associate Professor Julie Leask.

The most effective and ethically sustainable policies to increase vaccination rates remind parents and make it inconvenient to opt out so that only the most entrenched anti-vaccination supporters do so. 

Around the world vaccination saves about 3 million children's lives each year. Vaccine refusal is a particularly vexed problem because it can be hard to change the minds of people who fear vaccines. Governments worldwide have sought answers, with some settling on monetary sanctions and refusal of childcare and school entry for the children of vaccine refusers. 

On August 16 the Victorian government announced it would implement a "No Jab No Play" policy from January 2016. This means the children of parents who refuse some or all recommended vaccines will be unable to be enrolled in childcare or kindergarten in Victoria. 

This in effect removes the vaccine objector exemption that had been part of the original policy plan announced in January. In that plan, the children of vaccine refusers could still access childcare and kindergarten if their parents obtained an exemption signed by a doctor or immunisation provider. New South Wales had amended its Public Health Act in 2014 to enable enhanced childcare entry immunisation requirements, while retaining exemptions.

Victoria's recent decision was possibly influenced by the federal government's decision to remove, from January 2016, vaccine objector exemptions for certain family assistance payments, which had been in place since 1998. Queensland is considering legislation to enable childcare providers to exclude the unvaccinated at their discretion. Further afield, California has removed an exemption that had enabled children of vaccine refusers to attend school.

Despite the prima facie appeal of the sterner policies, removing vaccine objector exemptions for childcare entry punishes children for the decisions of their parents. It contravenes the National Partnership Agreement signed by Commonwealth and the states and territories that "All children have access to affordable, quality early childhood education in the year before formal schooling". It doesn't address the majority of families of the under-vaccinated who want vaccinations but are not up to date for a range of practical reasons and need a nudge. 

Mandatory certificate requirements, like those implemented in NSW, are sufficient. 

The bans target parents who actively refuse some or all scheduled childhood vaccines. But will the bans work? Currently in Australia 1.61 per cent of children have parents who register an objection to vaccination. A significant number of them are likely to be entrenched in their beliefs, as indicated by them having actively refused all vaccines – estimated to be about half of all registered objectors. Unable to access childcare, they may seek other care arrangements, which could corral the unvaccinated, giving a critical mass of non-immune to more readily seed an outbreak.

Punitive sanctions also run the risk of invigorating the anti-vaccination lobby, perpetually ready to draw new recruits from the ranks of the disenfranchised. Compulsory smallpox vaccination in the 19th century in Britain and the Unites States galvanised anti-vaccination leagues and connected them with rights-based campaigners who may have otherwise ignored the vaccination issue.

Each health professional who is committed, confident and competent with vaccination can influence many parents.
Associate Professor Julie Leask

History tells us there will always be vaccine refusers. Governments can keep them at a minimum and keep communities safer by ensuring the exclusion of the un-vaccinated from school or childcare during an outbreak and requiring registration of exemptions with a healthcare provider. Making it inconvenient to secure an exemption means only the entrenched do so and the late or ambivalent are prompted to vaccinate. Requiring an exemption also means parents must discuss their decision with a health professional before the form is signed. A few change their minds. Also, these professionals have a crucial role to play in helping buffer hesitant parents from the impact of misinformation. Each health professional who is committed, confident and competent with vaccination can influence many parents. 

Active refusal of vaccines is only one reason for incomplete vaccination of children. For every child whose parents refuse vaccines there is at least one other whose parents face logistical and practical barriers. They might lack transport, their child might have been sick at the time vaccination was scheduled or their child was born overseas and faces a complex catch-up schedule. 

To fix this problem, the Health Minister Sussan Ley announced a $6 incentive payment made to doctors and other immunisation providers who identify children who are more than two months overdue for their vaccinations and catch them up. 

The public should also be concerned about the low vaccination rates among adults and adolescents who may also unwittingly spread diseases such as whooping cough and measles. Uptake of recommended and free vaccines can be as low as 30 per cent in adults. 

Expanding the Australian Childhood Immunisation Register to all of adulthood was a very significant and welcome reform buried in the federal budget papers.

Other countries face large epidemics that require robust vaccination programs to control them. Australia also has an obligation to help poor countries to achieve vaccination targets. To do this, it could increase the generosity of its pledge to the Global Alliance for Vaccines and Immunisation. 

Unlike mandatory helmets, seat belts and indoor smoking restrictions, vaccines are medicines. They come with enormous benefits but also risks of rare serious side effects. If implemented, mandates heighten even further a government's obligation to provide compensation. New Zealand and 18 other countries have implemented a no-fault compensation scheme for serious adverse events attributed to vaccination. The Australian government has indicated no such plans.

Vaccination is backed by evidence. The strategies to improve vaccination rates should also be backed by evidence and implemented in a way that is both effective and ethically sustainable. 

Associate Professor Julie Leask is an NHMRC career development fellow in the School of Public Health, Sydney Medical School.

This article was first published in Fairfax Media

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