Issue 11 Volume 1
Vaccines are indubitably one of the great successes of public health, on par with clean water and basic sanitation. They have saved millions of lives, and even eradicated infectious diseases such as smallpox.
Yet, regardless of these achievements, the legitimacy and safety of vaccinations are still questioned. Earlier this year Australian One Nation Senator Pauline Hanson urged parents to take a non-existent “vaccine-reaction test”, and United States (US) President Donald Trump called for a commission into vaccine safety. Furthermore, the recent implementation of stricter childhood vaccination policies (No Jab No Pay; No Jab No Play) in Australia has raised contentious ethical issues regarding consent and balancing medical paternalism and parental autonomy in the provision of healthcare to children.
Reasons behind vaccination hesitancy
For as long as vaccines have been around, there have been those who oppose them. Vaccine opposition began in early 1800s in Europe with the first vaccination mandates. Scientists, doctors, and members of the public questioned the scientific basis of vaccines, even citing that they would disturb with God’s “natural control over the balance between the blessed and the damned”. The modern manifestation of vaccine objection is simply another iteration of this longstanding phenomenon.
Ironically, the great success of vaccinations in dramatically reducing, and even eradicating disease is contributing to their own downfall. As diseases like measles and polio are no longer endemic in Australia, parents no longer directly face the harms of these highly virulent and contagious diseases. Consequently, they may perceive the risks from vaccinations to be greater than the likelihood of contracting the very diseases they prevent.
In fact, surveys of Australian parents show that the primary reason for vaccine hesitancy or objection is concerns about their safety and a third of parents believe children are over-vaccinated. Newer vaccines, like the HPV vaccine, can be perceived to have a lower risk-benefit ratio, as they protect against diseases that are less prevalent or virulent. Older vaccines also face doubts, as the diseases they prevent are less common or even eliminated in the Australia, such as measles. Furthermore, concerns about adverse reactions to vaccination are growing. This could be attributed to the fact that such reactions are perceived to be more common than the diseases that they prevent.
Common misconceptions regarding vaccines
Rare but severe adverse reactions to some vaccinations attract great public interest, and give rise to misconceptions or over-estimations regarding their harms. For instance, the 1955 Cutter Incident in the USA involved administration of 380,000 doses of incompletely inactivated polio vaccinations to healthy children, which resulted in 40,000 cases of abortive polio (a minor form that does not involve the central nervous system), 51 cases of permanent paralysis and five deaths. It also started a polio epidemic, leaving even more people in the community affected.
This event severely undermined public confidence in the safety of vaccinations, even after it prompted the instigation much safer and stricter regulation of vaccines. Incidents such as this undermine trust in vaccine safety, and these fears must be addressed in the community.
Commonly, anti-vaxxers also claim that while they are not against vaccinations themselves, they oppose the adjuvants and preservatives that are potentially harmful, like thiomersal. However, studies have not been able to identify any harmful effects related to thiomersal, and even so, it was removed from all Australian childhood vaccines.
One of the most infamous controversies surrounding vaccine safety was Andrew Wakefield’s retracted 1998 paper that linked the Measles, Mumps and Rubella (MMR) vaccine to autism and bowel disease. His study was severely flawed, involving a sample of only 12 children, and Wakefield was deregistered and discredited. In comparison, a Danish retrospective cohort study investigated over 500,000 children who received the MMR vaccine and proved that there was no association between the vaccine and autism. Despite this, many of the general public still believe in the association between the MMR vaccine and autism as a consequence of Wakefield’s study.
Vaccine objection in the context of Australian vaccination policies
As of January 2016, the nationwide legislation called “No Jab No Pay” has been put into effect, removing conscientious objection from exemption criteria to immunisation requirements for Centrelink childcare payments worth up to $19,000. A press release by then Prime Minister Tony Abbott and Health Minister Scott Morrison stated that “the choice made by families not to immunise their children is not supported by public policy or medical research nor should such action be supported by taxpayers in the form of child care payments”.
In contrast, public health experts believe that this policy is may be misplaced in its aims to reduce conscientious objection to vaccination, rather than addressing the more prominent barriers of access to services, logistical issues, and missed vaccination opportunities. A policy such as this could also threaten the validity of a patient’s informed consent, which is outlined in the Australian Immunisation Handbook as being “given voluntarily in the absence of undue pressure, coercion or manipulation”. This has generated a fresh debate into the ethics of mandating vaccines through paternalistic policy.
Statistics released in July 2016 show that following the implementation of this policy, 148,000 incompletely vaccinated children had caught up, including 5,738 children of parents with previous conscientious objections.
Implications as medical professionals
Public attitudes towards vaccinations are complex, as they are affected by a wide range of sources, including the media, personal experiences, and health providers. A variety of strategies should be implemented to influence such attitudes. For instance, willingness to vaccinate could be encouraged by focusing on improving awareness of the risks of vaccine preventable diseases, rather than discrediting or refuting myths about vaccine dangers. An intervention based on this strategy showed that higher risk perception of diseases resulted in an increased willingness to vaccinate. It was also shown that rates of conscientious objection were reduced in areas with more administrative barriers to obtaining one.
As future health professionals, we need to develop skills to practise evidence-based medicine. We need to be able to formulate our opinions based on verified facts, before helping parents to make informed decisions about vaccinations. We too can also be influenced by the vast amount of facts and misinformation disseminated about vaccinations in the media. Thus, it is our responsibility to stay up-to-date with the latest literature and separate fact from fiction, in order to provide the best care for our patients.
Elissa is a 4th year medical student at UNSW. She currently conducts research on parental attitudes towards vaccine policies and media portrayals of vaccine safety at the UNSW School of Public Health and Community Medicine.
Supervisor Prof. Raina MacIntyre, UNSW
Conflict of Interest
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