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Are conscientious objectors wrecking our immunisation program?

There is an ineradicable mystique about immunisation. The mystique occurs because, by immunisation, biologically active material is introduced into the body of the recipient that is destined to alter his or her body’s functions.

02 Sep 2012

There is an ineradicable mystique about immunisation.

The mystique occurs because, by immunisation, biologically active material is introduced into the body of the recipient that is destined to alter his or her body’s functions.

In symbolic and real ways, immunisation is unnatural. Occasionally things go wrong and, because the population being immunised is healthy and these side effects are caused not by a treatment but by a preventive agent among otherwise fit people, concern runs high.

Immunisation coverage is currently around 94 per cent for two year olds nationally. But resistance to immunisation is intense enough among perhaps 1 to 2 per cent of parents to drive a decline in overall immunisation. These parents may worry that they are not doing the right thing for their child by agreeing to have him or her immunised. The worry may grow as more vaccines are added to the list of those required.

A new approach to encouraging immunisation shifts responsibility and reward from the doctor to the patient or parent. As of May 2013, all GP immunisation-related payments will cease, with the exception of the Australian Childhood Immunisation Register (ACIR) notification payment. From that date, the incentives will be directed at parents. Unless they either immunise their children on time or declare themselves to be conscientious objectors (COs), the majority will forfeit up to $2178 in the Family Tax Benefit Part A. 

Incentives for immunising one’s child are not new in Australia. But in the past they were smaller, and it took time for parents who did not want their children immunised to become aware of what was on offer. Consequently, there has been a small increase – from 0.23 per cent in 1999 to 1.44 per cent this year – in the proportion of parents registering as COs.

The new system – of linking the Family Tax Benefit Part A with full immunisation – still has a get out clause. COs do not have to have their children immunised, and yet they will still receive the payment. Should we be worried? 

Dr Julie Leask, a research fellow and public health academic at the National Centre for Immunisation Research and Surveillance in Sydney, writes: “Prospectively, the registered conscientious objector rates will increase as the new larger incentives come into play – possibly to 2 or 3 per cent. This will be because more parents (who were otherwise not bothering to register as conscientious objectors for just $200) will now make the effort to register because they stand to lose up to $2178.”

How far should we go in pressing the case for universal immunisation? Three observations are pertinent in forming a policy response.

First, you don’t need everyone to be immune to prevent an epidemic occurring. If 90 per cent or more are immune, they create sufficient fire breaks to prevent the easy transfer of most infectious diseases. So, good levels of public health could be maintained even if the CO rate climbed substantially – which it is not likely to do in real terms.

Second, the ethical context is complex. Strong incentives may raise the immunisation rates but damage voluntarism, just as paying for blood for transfusion in other countries erodes the ethic of giving gifts. While incentives have helped maintain high immunisation coverage, reservations exist about highly disadvantaged groups missing out because it’s just too hard to get vaccinated on time.

Third, with regard to compulsory immunisation, a distinction exists between compelling parents to immunise their child for their child’s sake and compelling them to be immunised for the sake of the community – to assure herd immunity.

The essence here is about ensuring all groups can get easy access to immunisation.

The erosion of provider incentives may be unfair by not removing the ‘push’, and depending only on the ‘pull’ to encourage immunisation.  

The last words belong to Dr Leask: “I would warn people to be very careful about over-interpreting increases in CO rates and coverage drops in the next year or two. “Next year, varicella, meningococcal C and pneumococcal vaccines will be included in the ‘fully vaccinated’ algorithm for children aged less than five. This may create an appearance of a decline in immunisation rates as the criteria for full vaccination become stricter.”

I agree. In practical terms we are not facing an immunisation crisis.

Published: 02 Sep 2012