With vaccination rates stable, 'no jab, no play' rules are beside the point
22 May 2013
A recent News Limited campaign to enable childcare centres in NSW to refuse entry to unvaccinated children is gaining momentum, with the legislation expected to be introduced to NSW parliament this week.
The proposal stems from a public outcry about vaccination rates arising from profound levels of support that most Australians have for vaccination. This support is warranted - vaccines have saved millions of lives.
But the "no jab, no play" campaign is flawed: not only would such a measure be unfair on these children, the campaign is partly based on a false assumption that vaccination rates are declining - and that could have unintended consequences.
Let's get the facts
Nationally, 92 percent of children are fully vaccinated by the age of two. Importantly, childhood vaccination rates have been stable and even increased slightly in the four year-old age group.
In 2012, 1.49 percent of parents registered their vaccine refusal - a requirement if they wish to be eligible for government payments. This figure has climbed from 0.23 percent in 1999 but the gradual increase is likely due to a greater awareness of these government payment provisions for non-vaccinating parents rather than a true increase.
In regions where non-vaccinating parents cluster, there has been no significant change, just a persistent problem that needs addressing.
But recent headlines have painted a picture of vaccination rates in free fall, caused by hordes of selfish parents in wealthy suburbs wilfully free-riding off the immunity of others. Some media ran with the easy formula: pitting vaccination opponents against proponents and parading case examples of non-vaccinating parents. One editorial went so far as to call for separate schools for unvaccinated children.
Some of the current media coverage risks polarising communities. It does little for under-vaccination and may unwittingly worsen it. Parents who may have never seen nor considered anti-vaccination arguments are introduced to them. Some may see refusing vaccines as a new trend worth considering, emulating others perceived to be more knowledgeable. Those who may be tentative or leaning away from vaccination could be further alienated.
This polarisation could lead to ideologically dogmatic debate and then isolation for parents who are merely cautious. In such a harsh environment, these parents might be readily labelled as "anti-vaccination" and their concerns attacked.
Make no mistake, under-vaccination remains a significant problem in some regions and population groups and it needs to be addressed.
But we need to understand the causes and evidence on how to address this problem. Some parents have difficulties in accessing services or lack the practical support required to get their kids immunised fully and on time. Others actively reject immunisation often because they believe the harms outweigh the benefits.
Improving vaccination rates
Mandatory vaccination at any level may seem compelling but is not necessary: it's poorly targeted and ignores the low-hanging fruit already in place.
Australia could do more to enforce current provisions in states and territories for universal vaccination record checks at the time of enrolment in school or childcare. This ensures those who are incompletely vaccinated or unvaccinated can be excluded during outbreaks. Importantly, it also prompts late parents to catch up their children - an area where significant gains in vaccination rates could be made.
But many schools and childcare centres are not insisting on the documentation and the requirements vary considerably between states and territories. Accordingly, federal health minister Tanya Plibersek recently announced a move to strengthen these requirements when children enrol in school.
This strategy recognises that the biggest impediment to full and timely vaccination is busy parents with competing demands. Strategies that prompt them when a vaccine is due are demonstrably effective in raising vaccination rates. That's why NSW Health recently introduced the "Save the Date to Vaccinate" campaign that includes a smart phone application for parents.
Changing the minds of vaccine refusers
For the small group of parents actively declining vaccines - now officially known as "vaccine refusers" - the solutions are more challenging. While nationally they may be up to 2 percent of parents, they tend to cluster in regions like the Northern Rivers of NSW and Sunshine Coast of QLD. This is of concern because diseases prevented by vaccines are more likely to occur in such regions. Parents in these communities are committed to their views and hard to change.
The solutions in these communities should be built around listening, engaging and building trust. Supporting local health professionals and encouraging peer advocacy are two approaches being explored in Washington State in the United States and are now being considered in Australia.
There have been calls for parents who refuse vaccines to not be denied childcare support payments and family tax benefits.
But to register as a vaccine refuser (and receive these payments), parents must discuss the risks of their decision with a health professional. Health professionals report that occasionally this discussion ends in the parent changing their mind and consenting to receipt of at least some recommended vaccines. Removing the incentive for such an encounter removes an opportunity for health professionals to encourage parents to reconsider their decision.
Why 'no jab, no play' won't work
The proposed legislation seeks to reduce the risk of a vaccine-preventable disease outbreak. But it may actually increase the risk by corralling unvaccinated children together where an outbreak of a disease such as measles could spread much more rapidly. This is effectively punishing children for their parents' decision.
Systematically enforced universal record checks of children's vaccination status serves to remind late parents nearly as well as bans would, while allowing the children to participate in society without further disadvantage.
As for the parents who actively decline vaccines, they do so out of a desire to do the right thing by their children. These parents may be genuinely misguided about vaccination, but they are not wilfully selfish. For them - and the vaccine-hesitant parents - listening, respectful communication, and quality information are more likely to win them over than castigation and coercion.
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