No Jab No Play: vaccination rules should be fair to all children

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In this article, Dr Julie Leask describes the complexities surrounding vaccination policy, and looks at what the evidence suggests works to best halt the spread of vaccine-preventable diseases.

Dr Julie Leask

Dr Julie Leask

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The Prime Minister Malcolm Turnbull has announced he will urge the states and territories to institute ‘No Jab No Play’ in childcare policies.

The government should be commended for its sustained interest in improving vaccination rates. Vaccination programs are a pillar of public health.

In Australia, measles vaccination alone has brought a net financial benefit upwards of $9.2 billion and averted at least 4 million cases since its introduction.

Along with considering No Jab No Play to address the 7% of under-vaccinated children in Australia (with caveats mentioned below), COAG should make progress on other ways to protect children.

One neglected area is improving vaccination rates of staff in childcare centres. One 2012 Australian study found that less than one third of childcare staff were up-to-date for their whooping cough vaccine. This is unacceptable, and further investigation and action in the sector is essential.

In his announcement, Mr Turnbull said, “we must give parents the confidence that their children will be safe when they attend childcare and preschool.”

Childcare worker vaccination is an essential component of minimising risk but it’s never possible to completely eliminate risk in these institutions.

First, even vaccinated children can still occasionally get the disease because vaccine effectiveness can be sub-optimal.

Second, children too young to be vaccinated can acquire vaccine preventable diseases, and pass them on.

Because of these complexities, policies should work well and be fair to all children.

There are versions of No Jab No Play that improve vaccination rates without punishing children for the decisions of their parents.

Right now there’s a patchwork of policies in each state and territory. Some states have luke-warm policies. In Queensland it’s at the discretion of the childcare provider to check vaccination records and decide what to do (except for during outbreaks, when unvaccinated children may be excluded from child care for a period of time). Victoria has the harshest policy, excluding any child of a vaccine refuser with no exemption allowed and only exemptions for children with medical contraindications.

Not being able to access childcare or family assistance payments (the federal ‘No Jab No Pay’ policy) because of vaccination objection has had a major affect on some families, with cases described here in box 1.

NSW strikes a more reasonable balance – excluding the unvaccinated or incompletely vaccinated but making an exemption available via a form that must be co-signed by a GP and the parent.

As you can see below, there is little difference in immunisation rates for 5 year olds, between VIC, ACT and NSW, noting that the graph starts at 85%.

Immunisation rates have clustered around 92% in the states and territories since 2014, regardless of rules about child care and pre-school entry. *UPDATED 14 March 2017*
Immunisation rates have clustered around 92% in the states and territories since 2014, regardless of rules about child care and pre-school entry. *UPDATED 14 March 2017*

Below is an extract from a submission I made to the NSW government on 2 June 2016 when they sought input on the amendments to the Public Health Act which included whether the above exemption (allowing vaccine objectors to access childcare after registering their objection) should be removed.

In the end it wasn’t. NSW still has vaccination rates close to Victoria’s, showing that childcare entry rules can support high vaccination rates without being excessively punitive.

Underneath these figures is a story of other state-based measures, such as phoning parents who are late having children vaccinated, and fixing registry data errors, which have also contributed. Therefore, we must interpret any policy’s effectiveness with concurrent measures in mind.

Modified from submission to NSW government, 2 June 2016

Regulation of vaccination programs is essential to maintaining high coverage, and helped national coverage rise in the late 1990s.

However, experts in vaccination policy in Australia and overseas have recommended not to completely remove vaccine objector exemptions but to make them more procedurally complex to acquire.

The 7% who remain under-vaccinated have a wide range of reasons for not being fully vaccinated. They need other strategies, not simply harsher penalties.

Removing the vaccine objection exemption:

  • Punishes the children for the decisions of their parents by denying their right to education. 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”.
  • Is not a panacea for disease control because others too spread disease and need boosters – parents, childcare workers, travelers and health care workers. One review found that up to 50% of infants hospitalised with pertussis contracted it from a parent or sibling. Staff in childcare centres also spread disease and a NSW study of 319 childcare centers containing 3574 workers found that only 29.4% were fully vaccinated.
  • Will not convince the highly entrenched who, unable to access childcare, may seek unregulated care arrangements as has been observed recently. Such centres would then corral the unvaccinated, causing a critical mass of non-immune to more readily seed an outbreak.
  • Undermine valid consent for vaccination and community trust in programs, where a sense of agency and choice are highly valued by fence-sitting

Having regular requirements for exemptions strikes a balance between reminding forgetful parents through record checks, while making things procedurally complex for vaccine objectors. It is fair and proportional to the contribution that objectors make to under-vaccination which was recorded as 1.2% in NSW in December 2015.

Vaccine refusal is a problem, particularly since it clusters in some communities.

Government can keep vaccine refusal to a minimum, and communities safer, by:

  • Continuing to enforce the exclusion of the un-vaccinated during an outbreak.
  • Regulatory support and enforcement for centres in fulfilling the requirements of the Act so that universal record checks are occurring. NSW Health produced a comprehensive package of support in 2014 which has been formatively evaluated. Impact evaluation may indicate to what extent the requirements are enacted across all services and what, if any, barriers are experienced by services.
  • Yearly registration of a vaccine objection exemption with a healthcare provider. This maintains these parents’ engagement with the healthcare system. Studies show that some objectors regularly review their decision and professionals have reported to us instances of being able to persuade them to vaccinate – especially during windows of opportunity such as local outbreaks, the child getting older, or overseas travel.
  • Funding a parent peer educator program in refusing communities. The experience in Washington State may provide a model for such programs.
  • Teaching health professionals counselling techniques with vaccine-hesitant and objecting parents. Our current research with health professionals shows that many would welcome more support in these interactions. We are currently developing a package called Sharing Knowledge About Immunisation in partnership with the National Centre for Immunisation Research and Surveillance.

The most effective and ethically sustainable policies to increase vaccination rates include strategies to remind late parents, and to make it inconvenient to opt-out so that only the most entrenched objectors do so.

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Dr Julie Leask is Associate Professor in the School of Public Health at The University of Sydney. She is a visiting Senior Research Fellow at the National Centre for Immunisation Research & Surveillance. In 2015 she was awarded a Sax Institute Research Action Award for her work in vaccination communication with hesitant parents.

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