Vaccination policy

Vaccination policy refers to the health policy a government adopts in relation to vaccination. Vaccinations are voluntary in some countries and mandatory in some countries as part of the public health system. Some governments pay all or part of the costs of vaccinations for vaccines in a national vaccination schedule.

Goals of vaccination policies

Immunity and herd immunity

Vaccination policies aim to produce immunity to preventable diseases. Besides individual protection from getting ill, with some vaccines policies aim also to provide herd immunity which is based on the idea that the pathogen will have trouble spreading when a significant part of the population has immunity against it.

Eradication of disease

Malaria Clinic in Tanzania helped by SMS for Life program which organizes malaria vaccine delivery

With some vaccines, a goal of vaccination policies is to eradicate the disease - make it disappear from Earth altogether. The World Health Organization coordinated the global effort to eradicate smallpox globally.^{[citation needed]} Victory is also claimed for getting rid of endemic measles, mumps and rubella in Finland.^{[citation needed]} The last naturally occurring case of smallpox occurred in Somalia in 1977. In 1988, the governing body of WHO targeted polio for eradication by the year 2000, but didn't succeed. The next eradication target would most likely be measles, which has declined since the introduction of measles vaccination in 1963.

Individual versus group goals

Rational individuals will attempt to minimize the risk of illness, and will seek vaccination for themselves or their children if they perceive a high threat of disease and a low risk to vaccination. However, if a vaccination program successfully reduces the disease threat, it may reduce the perceived risk of disease enough so that an individual's optimal strategy is to encourage everyone but their family to be vaccinated, or (more generally) to refuse vaccination at coverage levels below those optimal for the community.^[1] For example, a 2003 study found that a bioterrorist attack using smallpox would result in conditions where voluntary vaccination would be unlikely to reach the optimum level for the U.S. as a whole,^[2] and a 2007 study found that severe influenza epidemics cannot be prevented by voluntary vaccination without offering certain incentives.^[3] Governments often allow exemptions to mandatory vaccination for religious or philosophical reasons, but if too many of these exemptions are granted, the resulting free rider problem may cause loss of herd immunity, substantially increasing risks even to vaccinated individuals.^[4]

Compulsory vaccination

Further information: Vaccine controversy

In an attempt to eliminate the risk of outbreaks of some diseases, at various times several governments and other institutions have instituted policies requiring vaccination for all people. For example, an 1853 law required universal vaccination against smallpox in England and Wales, with fines levied on people who did not comply. In the United States, the Supreme Court ruled in the 1905 case Jacobson v. Massachusetts that the state could require individuals to be vaccinated for the common good. Common contemporary U.S. vaccination policies require that children receive common vaccinations before entering school. A few other countries also have some compulsory vaccinations. Compulsory vaccination is believed to have greatly reduced the rates of some infectious diseases.^[5]

Beginning with early vaccination in the nineteenth century, these policies led to resistance from a variety of groups, collectively called anti-vaccinationists, who objected on ethical, political, medical safety, religious, and other grounds. Common objections are that compulsory vaccination represents excessive government intervention in personal matters, or that the proposed vaccinations are not sufficiently safe. Many modern vaccination policies allow exemptions for people who have compromised immune systems, allergies to the components used in vaccinations or strongly held objections.^[5]

1904 cartoon opposing the mandatory vaccination law in Brazil. "The Congress", depicted as a Roman Caesar, threatens "the People", in rags, with a sharp object and shackles.

In 1904 in the city of Rio de Janeiro, Brazil, following an urban renewal program that displaced many poor, a government program of mandatory smallpox vaccination triggered the so-called Vaccine Revolt, several days of rioting with considerable property damage and a number of deaths.^[6]

Having compulsory vaccinations is connected with difficult policy issues where health authorities try to balance health of society and individual liberty:

"Vaccination is unique among de facto mandatory requirements in the modern era, requiring individuals to accept the injection of a medicine or medicinal agent into their bodies, and it has provoked a spirited opposition. This opposition began with the first vaccinations, has not ceased, and probably never will. From this realisation arises a difficult issue: how should the mainstream medical authorities approach the anti-vaccination movement? A passive reaction could be construed as endangering the health of society, whereas a heavy handed approach can threaten the values of individual liberty and freedom of expression that we cherish."^[7]

Reviews of scientific evidence for different types of vaccination policies have found strong evidence for the effectiveness of standing orders, which allow healthcare workers without prescription authority (such as nurses) to administer vaccines in defined circumstances; sufficient evidence for the effectiveness of requiring vaccinations before attending child care and school;^[8] and insufficient evidence to assess the effectiveness of requiring vaccinations as a condition for hospital and other healthcare jobs.^[9]

Policies and history by country

Australia

In Australia, a massive increase in vaccination rates was observed when the federal government made certain benefits (such as the universal 'Family Allowance' welfare payments for parents of children) dependent upon vaccination compliance. As well, children were not allowed into school unless they were either vaccinated or their parents completed a statutory declaration refusing to immunize them, after discussion with a doctor, and other bureaucracy. (Similar school-entry vaccination regulations have been in place in some parts of Canada for several years.) It became easier and cheaper to vaccinate one's children than not to. When faced with the annoyance, many more casual objectors simply gave in.^{[citation needed]}

Malaysia

In Malaysia, mass vaccination is practised in public schools. The vaccines may be administered by a school nurse or a team of other medical staff from outside the school. All the children in a given school year are vaccinated as a cohort. For example, children may receive the oral polio vaccine in Year One of primary school (about six or seven years of age), the BCG in Year Six, and the MMR in Form Three of secondary school. Therefore, most people have received their core vaccines by the time they finish secondary school.

United Kingdom

In the 2000s, public concern about the combined MMR vaccine against measles, mumps and rubella, sparked by media coverage of controversial research linking it to autism, caused a significant drop in vaccinations and a rise in the incidence of these diseases. Prime Minister Tony Blair refused to confirm whether his children had received the vaccine.

United States

The Advisory Committee on Immunization Practices makes scientific recommendations which are generally followed by the federal government, state governments, and private health insurance companies.

States in the U.S. mandate immunization, or obtaining exemption, before children enroll in public school. Exemptions are typically for people who have compromised immune systems, allergies to the components used in vaccinations, or strongly held objections. All states but West Virginia and Mississippi allow religious exemptions, and twenty states allow parents to cite personal or philosophical objections. A widespread and growing number of parents falsely claim religious and philosophical beliefs to get vaccination exemptions, and an increasing number of disease outbreaks have come from communities where herd immunity was lost due to insufficient vaccination.^[10]

The American Academy of Pediatrics (AAP) notes the dilemma faced by many parents in that vaccines are a very safe and important health intervention, but are neither risk-free nor 100% effective. It advises physicians to respect the refusal of parents to vaccinate their child after adequate discussion, unless the child is put at significant risk of harm (e.g., during an epidemic, or after a deep and contaminated puncture wound); under such circumstances, the AAP states that parental refusal of immunization constitutes a form of medical neglect and should be reported to state child protective services agencies.^[11]

See Vaccination schedule for the vaccination schedule used in the United States.

Immunizations are often compulsory for military enlistment in the U.S.^[12]

All vaccines recommended by the U.S. government for its citizens are required for green card applicants. This requirement has stirred controversy when it applied to HPV vaccine because of the cost of the vaccine, and because the other thirteen required vaccines prevent diseases which are spread by a respiratory route and are considered highly contagious.^[13]

References

1. ^ Fine PE, Clarkson JA (1986). "Individual versus public priorities in the determination of optimal vaccination policies". Am J Epidemiol 124 (6): 1012–20. PMID 3096132. 
2. ^ Bauch CT, Galvani AP, Earn DJ (2003). "Group interest versus self-interest in smallpox vaccination policy". Proc Natl Acad Sci USA 100 (18): 10564–7. doi:10.1073/pnas.1731324100. PMC 193525. PMID 12920181. http://www.pnas.org/cgi/content/full/100/18/10564. 
3. ^ Vardavas R, Breban R, Blower S (2007). "Can Influenza Epidemics Be Prevented by Voluntary Vaccination?". PLoS Comput Biol 3 (5): e85. doi:10.1371/journal.pcbi.0030085. PMC 1864996. PMID 17480117. http://www.ploscompbiol.org/article/info:doi/10.1371/journal.pcbi.0030085. 
4. ^ May T, Silverman RD (2005). "Free-riding, fairness and the rights of minority groups in exemption from mandatory childhood vaccination" (PDF). Hum Vaccin 1 (1): 12–5. PMID 17038833. http://www.landesbioscience.com/journals/vaccines/mayHV1-1.pdf. 
5. ^ ^{a b} Salmon DA, Teret SP, MacIntyre CR, Salisbury D, Burgess MA, Halsey NA (2006). "Compulsory vaccination and conscientious or philosophical exemptions: past, present, and future". Lancet 367 (9508): 436–42. doi:10.1016/S0140-6736(06)68144-0. PMID 16458770. 
6. ^ Meade T (1989). "'Living worse and costing more': resistance and riot in Rio de Janeiro, 1890–1917". J Lat Am Stud 21 (2): 241–66. doi:10.1017/S0022216X00014784. 
7. ^ Wolfe R, Sharp L (2002). "Anti-vaccinationists past and present". BMJ 325 (7361): 430–2. doi:10.1136/bmj.325.7361.430. PMC 1123944. PMID 12193361. http://bmj.bmjjournals.com/cgi/content/full/325/7361/430. 
8. ^ Briss PA, Rodewald LE, Hinman AR (2000). "Reviews of evidence regarding interventions to improve vaccination coverage in children, adolescents, and adults" (PDF). Am J Prev Med 18 (1 Suppl): 97–140. doi:10.1016/S0749-3797(99)00118-X. PMID 10806982. http://thecommunityguide.org/vaccines/vpd-ajpm-evrev.pdf. 
9. ^ Ndiaye SM, Hopkins DP, Shefer AM (2005). "Interventions to improve influenza, pneumococcal polysaccharide, and hepatitis B vaccination coverage among high-risk adults: a systematic review" (PDF). Am J Prev Med 28 (5 Suppl): 248–79. doi:10.1016/j.amepre.2005.02.016. PMID 15894160. http://thecommunityguide.org/vaccines/vpd-AJPM-evrev-targeted.pdf. 
10. ^ Ciolli A (2008). "Mandatory School Vaccinations: The Role of Tort Law". Yale J Biol Med 81 (3): 129–37. PMC 2553651. PMID 18827888. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=2553651. 
11. ^ Diekema DS, American Academy of Pediatrics Committee on Bioethics (2005). "Responding to parental refusals of immunization of children". Pediatrics 115 (5): 1428–31. doi:10.1542/peds.2005-0316. PMID 15867060. http://pediatrics.aappublications.org/cgi/content/full/115/5/1428. 
12. ^ United States Department of Defense. "MilVax homepage". http://www.vaccines.army.mil/default.aspx. Retrieved 2007-07-25. 
13. ^ Jordan M (2008-10-01). "Gardasil requirement for immigrants stirs backlash". Wall Street Journal. http://online.wsj.com/article/SB122282354408892791.html. Retrieved 2009-01-18.