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Making mandatory vaccination truly compulsory may result in more harm than good, and drive hesitant parents to become anti-vaccination, warn Daniel Salmon, Raina MacIntyre and Saad Omer.
The United States, Australia, and approximately half of European countries have mandatory vaccination requirements. The US and Australian experience has been well studied. The US vaccine mandates are implemented by requiring proof of vaccination or exemption at school entry. Whereas, in Australia, many provinces have school entry requirements and nationally mandatory vaccination has been traditionally implemented by denying child care benefits to vaccine refusers – unless they provide proof of exemptions.
Both countries have historically offered non-medical exemptions to their compulsory laws to accommodate the minority of parents who object to vaccination. Studies have shown that easily granting non-medical exemptions have been associated with higher rates of refusal and higher rates of pertussis. Therefore administrative requirements for exemptions may decrease rates of vaccine refusal.
Amid considerable media attention surrounding a measles outbreak that originated in Disneyland, California, well-intentioned legislators in several states including California and North Carolina have proposed legislation to get rid of non-medical exemptions, making mandatory vaccination truly compulsory. Vermont recently got rid of their philosophical exemption while a religious exemption still stands. In 2012, after a contentious debate over elimination of the philosophical exemption, those opposed to compulsory vaccination formed a well-organised coalition.
Rather than eliminate the philosophical exemption, restrictions were added to both non-medical exemptions. In 2015, the debate resurfaced after legislation to eliminate the philosophical exemption was introduced. With strong support from the medical and public health community, the philosophical exemption was removed.
Similarly, Australia eliminated a non-medical exemption to a vaccine requirement for childcare benefits. Australians now must either vaccinate their children or forgo significant child care and family tax benefits. This change introduces financial penalties for refusal, in a context where many families cannot afford childcare without these benefits.
These legislators are well intentioned. They see more parents worried about the safety of vaccines and more parents are delaying and refusing vaccines through non-medical exemptions. As legislators, they are looking for a direct legislative fix by proposing to eliminate non-medical exemptions altogether.
Unfortunately, while well intentioned this approach is imprudent. The problem of vaccine hesitancy is far more complex than can be addressed with a simple elimination of non-medical exemptions. Parents no longer fear diseases such as measles that have been largely controlled through vaccination. So parental fear has shifted from the diseases to the vaccines.
Despite a remarkable safety record, vaccines are not perfect and many parental safety concerns have remained unaddressed. We lack effective tools at the provider, community and national levels to address vaccine hesitancy. Trust in pharmaceutical companies that make vaccines and governments that purchase and promote vaccines are at an all time low. A more draconian approach may result in more harm than good, and may even backfire by driving hesitant parents to become anti-vaccination.
This lesson was learned in the UK more than 150 years ago when they made smallpox vaccination compulsory, initially without non-medical exemptions. Anti-vaccination groups were joined by libertarians, and 20,000 demonstrators took to the streets in Leicester. Parents who refused vaccines became martyrs. The UK ultimately resorted to a non-medical (conscientious) exemption.
Rather than repeating history, we need to learn from it. In fact, the recent legislative efforts have resulted in substantial backlash. This backlash has been a factor in the defeat of proposed laws in Washington and Oregon that proposed to restrict exemptions. There is substantial value in making exemptions more stringent and requiring health education.
Getting rid of non-medical exemptions and making mandatory vaccination truly compulsory risks substantial public backlash and may be counter-productive to our ultimate objective of reaching and sustaining high rates of immunisation coverage and controlling disease.
(Source: UNSW, Lancet Infectious Diseases Journal)
