The UK vaccination programme is very successful with high rates of vaccine uptake and as a result, low disease rates. In the UK vaccination is the norm, with the overwhelming majority of parents automatically having their children immunised. However, recently there has been a small decline in vaccine uptake of a few percentage points which has attracted a lot of attention in the media. One tabloid has even run a campaign: “Give the children their jabs”. The stories suggested this decline in uptake is due to the effects of mis-information about vaccines on social media, or parents’ ‘complacency’ about the seriousness of diseases like measles and lots of references to the rise of ‘anti-vaxxers’. One suggestion to improve rates, made by the Secretary of State for Health, is to make vaccination compulsory. At first glance, this seems sensible. Immunisation is a very safe and highly effective means of protecting our children against diseases that can be very serious, so making it compulsory seems the obvious quick fix to improve rates. But is this the best way?
First, we need to look at the reasons for the decline in rates. Contrary to some news headlines, most under-immunisation is not due to parents declining vaccines - in fact, the number of parents who do this is very small and there is no evidence to suggest there has been an increase recently. In fact, surveys, including one by Mumsnet, show that more UK parents than ever are confident in vaccination and consider it to be important for their children’s health. More practical reasons such as difficulties getting an appointment because of the conflicting pressures of busy family life and working schedules and forgetting that vaccines are due, particularly for pre-school children are more often the causes of under-immunisation. General practice, where most baby vaccines are given, has been under a lot of pressure lately with increasing workloads and fewer resources including a shortage of nurses. There has also been a decline in numbers of health visitors who provide families with advice and support in the early years including about vaccination. It is certainly true that some people may not think vaccines are so important any more as the diseases are now uncommon, but calling this ‘complacency’ is not helpful. If you have no experience of a disease, how can you be expected to know what it’s like? So wouldn’t it be better to improve all these things first and if they don’t work, then think about introducing more radical solutions?
What could mandation look like? Other countries have different ways of mandating, in some like the USA it’s a requirement for school entry, in Australia you don’t get certain benefit payments unless children are vaccinated and in some European countries, a fine is imposed. The evidence about whether this actually works to increase rates is not clear. If you are going to introduce such laws you have to make it easier for families to get vaccinated and also publicise it, otherwise it’s not fair and it might be these improvements that have the impact of increasing rates where that happens, not mandation itself.
We also have to think about the possible harms of such a measure. If we introduced a system where children had to be vaccinated before they could start school, one possible consequence would be that parents who did not want their children to be vaccinated would have to find alternative ways of educating them. This would disadvantage children in poorer families more than those of richer parents, who would have the resource to pay for quality alternative education. In some countries, <a class="break-all" href="https://www.google.com/url?q=www.nature.com/articles/d41586-019-02232-0&sa=D&ust=1573126764565000&usg=AFQjCNGNT0ZByOtQ9wYKGBP_pR3fO1ZAew" rel="nofollow" target="_blank">legal requirements have resulted in more vaccine resistance among parents already unsure about vaccination. Health professionals are an important source of advice for parents about vaccination, with many parents saying they trust them and their advice, but what would happen to these conversations if the starting point was that the child had to be vaccinated? Would requirements mean that healthcare providers were less willing to spend time discussing vaccination with them as it was no longer a choice? Finally, while a legal requirement may be appropriate and acceptable in some countries, we know little about the views of the UK public on this issue and it would be important to establish these first. In a Mumsnet survey, 77% reported they would support such legislation, but does this actually just reflect support for vaccination?
As vaccination protects the community as well as individuals, one important benefit of high vaccine rates is that people who cannot be immunised are protected by the immunity in the rest of the community. This includes young babies, people with health conditions and pregnant women. This, it is often argued, is why we need to introduce compulsory vaccination. While community immunity is extremely important, I would argue that to introduce compulsory vaccination would require considerable extra resources. This would be better spent improving our current systems and organisation to strengthen the things that we know work to improve uptake, rather than moving straight to legislation which could be harmful.