Immunisation and public health

by Dr Con Costa

Recent disturbing data on the increased incidence of a number of infectious diseases in Australia has re-awakened the debate on attitudes to public immunisation programs.

Socialist medicine aims at the prevention of illness based on recognition of the basic right of citizens to good health and protection from disease by acting pre-emptively on all factors that threaten the health and wel-being not just of individual citizens but of the entire community.

Medicine thus serves the community as a whole, not as the sum of a number of non-related individuals but as a social whole, in marked contrast with the forces behind the market-driven medicine of contemporary capitalism, which direct attention to mainly curative procedures, with a resulting concentration on the treatment of individuals, and a marked tendency to favour the privileged and to ignore or minimise community concerns.

This difference has both economic and ideological origins, and it is particularly evident — with marked severity — in areas of public health, such as immunisation policies and priorities in health spending. Dr Con Costa, the President of the Doctors Reform Society, here examines some aspects of the immunisation debate.

Introduction

The major reason for declining childhood immunisation rates in Australia is a change in access to and delivery of appropriate medical services, increasing community complacency and the low priority accorded by health authorities to this problem in recent years. An active anti-immunisation lobby, while it is a factor, is not the major factor.

Falling immunisation rates are putting our children at considerable risk from preventable infectious diseases. Vaccination is not without risk, however, and vaccination programs should be restricted to specific, recognised pathogens to which there is no recognised alternative prevention. Inclusion of vaccines in such programs should be by a transparent decision-making process involving the community — not by non-transparent decision-making involving only experts.

The Politics of Immunisation

Federal Health Minister Michael Wooldridge wants to make childhood immunisation a major health priority for his government’s current term.

Efforts to increase childhood vaccination rates deserve to be supported¹ but we must not forget that Wooldridge’s immunisation push will demand new priorities in a health care sector already beset by many competing priorities. Other areas of public health, such as Aboriginal health, high rates of tobacco and alcohol-related deaths mortality, for example, may not get as much attention if already limited resources are diverted to support these new government initiatives.
Vaccination is big business — a business which is getting even more lucrative, with almost unlimited “blue sky” for both technology and investors, while at the same time promising tremendous benefits to the community. Current developments include:
- newer, safer, less reactogenic, and more effective vaccines;
- single dose, slow release vaccines which will replace traditional three-dose vaccines for tetanus, polio, etc;
- combined or genetically-engineered polyvalent vaccines which will effectively immunise people against five, six or even more diseases with a single dose;
- oral preparations will be used more often;
- future vaccines will be used not only for prophylaxis but also in the management of certain diseases, including chronic infections and malignancies.

Newer vaccines will provoke better immune responses not only by activating the humoral (blood mediated) immune response, as with present vaccines, but also cell-mediated immune responses. Vaccines will thus induce immunity better than a natural infection. Recombinant (designer peptide) vaccines, which are already on the drawing board, will offer seemingly endless possibilities.

The most exciting step forward in vaccine technology is the use of naked DNA. The vaccine consists of genes for an antigenic portion of the organism or antigen. Naked DNA is being used experimentally to generate protective immunity against influenza, herpes simplex virus, HIV and TB. This technology has been developed only within the last five years yet already there are three clinical trials under way on humans.

In theory these vaccines will be cheap, stable, single-dose preparations. Of course, there are questions about the safety of using naked DNA in humans and the danger of the DNA integrating into host chromosomes, causing transformation or tumorogenesis, which must be answered. Such substances could persist in the tissues, and cause immunopathology, tolerance or antigenic competition. Designer vaccines could also cause long-term side effects, such as immunosuppression and chronic inflammation.²

Why Wooldridge's Immunisation Initiatives?

The major reason for falling immunisation rates in Australia has to do, as we have said, with changes to service delivery and access, low priority accorded to it by health authorities, and community complacency — not the influence of the anti-immunisation lobby.

In the past, 80 per cent of the children immunised in Victoria were treated through the public system, and only 20 per cent in the private sector, i.e. by GPs. In New South Wales, 50 per cent were vaccinated in the public sector, as part of, for example, council immunisation programs, infant and child health centres, and so on, and 50 per cent privately,

There have been changes to the way that immunisation programs are funded. Public service provision has been whittled away over the last five to ten years. The Federal Government used to provide an allocation for vaccine services to each State. This meant that doctors got vaccines free of charge from the State government, usually from the local government or from hospitals. This responsibility has now been devolved to the States, with loss of Federal control.

Nurses Shut Out

Nurses have always had a more personal approach with mothers and parents, being able to communicate better than doctors with parents. However, nurse involvement in child immunisation is now almost negligible.

The 80 per cent of child immunisation previously provided by the public sector in Victoria and mainly dependent on nurse support, has now been replaced by reliance on over-worked family GPs working on their own, in spite of the fact that immunisation has never been the traditional domain of GPs, although they are now more happy to accept “extra work” as their traditional base is worn away by specialists.

The “fatigue factor” — too many vaccines and injections — now affects GPs more than parents or nurses! This is more the case today, since the recent addition of more vaccines to the immunisation schedule; introduction of HIM (Haemophilus influenza type B) as well as Hepatitis B vaccine for “high risk” children has meant an extra six injections in their first five years for some children. Research shows that it is the providers, i.e. GPs, who are wary of giving an increasing number of injections to the children, rather than consumer disenchantment.³

GPs in Australia have largely itinerant populations, and no provision for monitoring or following-up treated children. In spite of this drawback, many busy parents in today’s stressful world have little time to take their children to council-sponsored vaccination days, and tend to turn to private GP more convenient.

Against this background, the Federal Health Minister Michael Wooldridge has introduced the National Childhood Immunisation Register. This is an attempt to address the fragmentation of immunisation services, as well as providing some monetary incentives for both doctors and parents.

Unfortunately, indications to date are that large numbers of GPs are ignoring the Register, and not filling out vaccination forms despite a $6 incentive per notification form. It follows that the Register is not working as a means of monitoring vaccination rates and their side-effects.

The Australian Scene

In Australia, where early childhood vaccination is non-compulsory, vaccination levels are declining alarmingly.

The cause for alarm is twofold. When vaccination rates fall, they expose the entire community to outbreaks of preventable infectious disease, affecting non-vaccinated children as well as a lesser proportion of vaccinated children, as vaccination is never 100 per cent effective.

This is explained by the phenomenon of “herd immunity”, where a certain number in the community must be vaccinated in order to stop the spread of an infectious disease — with the exception of tetanus, which is not spread by airborne droplets but by spores which are ever-present in the environment.

The percentage of the population that needs to be immunised for “herd immunity” to be effective varies from disease to disease. With haemophilus influenza, the herd immunity figure could be as low as 50 per cent of the population, but for other infectious diseases it is much closer to 80 or 90 per cent. As vaccination is never 100 per cent effective, almost all children need to be vaccinated to achieve such figures.

In the past, the community could support a small number of “conscientious objectors”. The fact that the vast majority of the population were vaccinated meant that the small number of unvaccinated subjects were also protected from infection. In effect, the “conscientious objectors” benefitted from the social responsibility of the rest. In the former socialist countries, however, vaccination was compulsory.

Thus to opt for non-immunisation is no longer the easy cop-out that it was in the past. With community immunisation levels now below 50 per cent, it is almost certain that many children could suffer multiple infectious diseases, and that we may even see a resurgence of diseases such as polio and its crippling side-effects.

No-one claims that immunisation is either 100 per cent safe or 100 per cent effective. What the medical profession is saying is let’s not get complacent. Vaccination programs have led to a reduction of deaths, disabilities and suffering from diseases which are, essentially, not curable nor effectively treatable.

Unfortunately, the very success of vaccination programs in the past, leading to absence of these diseases in our community, can be their undoing. In a risk-benefit equation, a parent may say, “why should I take a one-in-a-million risk of contracting encephalitis from the vaccine when I have never heard of nor seen this disease in my community?”

We take risks every day. Crossing the road involves risk, as does getting in a motor car, swimming at the beach, drinking a glass of water or eating fast foods all involve risk. Vaccines do have a downside of local reactions in the muscle tissue, short febrile illness, or rare major side-effects. All this needs to be fully explained to parents before vaccination takes place. But the benefits to the individual and the community are immense and life-long.

In Australia between 1978 and 1993 there were 200 recorded deaths from infectious diseases that could have been prevented by immunisation — three deaths from Diphtheria, 165 deaths from measles, 19 deaths from whooping cough, three from polio and 37 from tetanus.

There is no cure for these infectious diseases. Once a child is infected, treatment is largely supportive, with a “wait-and-see” approach. Most children will suffer a debilitating illness and some may even die or be left with permanent sequelae. The only cure is prevention.

When Governor Phillip explored the Pittwater area around Sydney in the late 1780s, almost the entire Guringai tribe was wiped out by smallpox, because the Aboriginal people had no natural immunity to smallpox, while it was endemic in the white settler population.

In fact, one of the greatest successes of vaccination programs is the case of smallpox. This was completely eradicated worldwide as a result of an aggressive international immunisation program achieving high vaccination rates, based on principles of herd immunity. A killer disease was completely eradicated by a global vaccination program.

The Anti-Immunisation Lobby

This lobby has its roots in mainly middle-income groups, i.e. those with high school or university educations. Being a more literate group, it is easily targetted by anti-immunisation propaganda cleverly dressed up as “science”.

As a result, we almost need an outbreak of preventable disease (and there have been four recent deaths from pertussis, with all the associated suffering for children and parents) to remind people that these diseases still exist.

The anti-immunisation lobby seems to take a parochial view, i.e. “vaccines are not necessary in Australia because of the generally high standard of living and relative absence of vaccine preventable disease”.

But a disease such as tetanus is always present. It results from a minor, rather than a major, wound, when tetanus spores enter a small puncture wound in the skin. If children are not vaccinated, the alternative is to give penicillin routinely, especially for all minor wounds. Apart from the feasibility of such a procedure, one must question the widespread use of antibiotics in such a way, given the marked negative consequences of their over-use and mis-use that is already evident on a world scale.

The anti-immunisationists, who probably overlap with the anti-western-science lobby, run a campaign which couches its rhetoric in “science”. To the uninitiated and particularly to those who may have reason to be sceptical of the system, this can be very convincing. However, much more information is now freely available to the community, giving a more complete and balanced picture of immunisation.

It is hard to avoid the feeling that the anti-immunisation lobby wants to have it “a bit both ways”. If vaccines "don't work" or "cause the disease instead of preventing it", as is alleged, it follows that vaccination should be opposed internationally as well as nationally, that is, in those impoverished communities where vaccine-preventable disease is rife, and where alternative prevention or adequate health services are absent.

Does the anti-immunisation lobby advocate no vaccination programs in Aboriginal communities? Or in former colonial countries in the under-developed world, where one can see daily on the streets many people affected by the sequelae of polio? At best, and with reason, the world would laugh at us. More likely they would consider such a stance arrogant and self-centred.

Valid Concerns

Not that there are not valid concerns about vaccination and vaccination programs.⁴

Vaccination against infectious diseases is obviously not the only answer. Clean water, sanitation, and better living conditions are a major factor demanding attention. And the introduction of any vaccination programs needs to be strictly controlled and only for specific, recognised pathogens for which there are no known alternative treatments. Vaccination should not be a substitute for better living standards both nationally and globally.

For example, overseas medical experts working in the cholera hospital in Dacca (Bangladesh) were not routinely vaccinated against cholera. They did not drink from contaminated water sources, and therefore the risk of cholera was negligible, and so there was no need to vaccinate.
Transnational drug companies are making huge profits from vaccination, but future growth will be even more staggering as a lot of new technology kicks in. These transnationals have a lot of say at high government levels, and can also influence "expert" committees, especially as government cutbacks lead to down-sizing (some would say "dumb-sizing"). We is needed is a transparent decision-making process involving consumers, which means parents and citizens, though not just for vaccination but in all areas of health planning.
Much more information for parents is needed, and much more information, training and support for doctors who provide vaccination services, including provision of nurse support. GPs and primary health care services would benefit much more from immunisation nurses than from token payments in return for immunising children.
Vaccination programs need to be much more closely supervised and monitored, including cold chain and storage of vaccines as well as post- immunisation monitoring, services that are constantly eroded by cuts in government funding. If for this reason alone, anti-immunisationists should support the National Childhood Immunisation Register.

Summary and List of Demands

Low immunisation rates in Australia are mainly the result of cuts in the health services and of increasing inequities in accessing public health services. This will worsen with the present trend towards a two-tier, Americanised health system.
The Federal Government’s immunisation initiatives can be supported, but will need to be tested regularly to monitor progress. They are initiatives which must not be evaluated isolation, however, but against the background of competing health priorities, including woeful Aboriginal health statistics, unacceptably high levels of alcohol- and tobacco-related deaths, high youth suicide rates, and so on.
Nurses, who have established the best rapport with parents, have been virtually cut out of the system. Over-worked GPs have been thrust into the unaccustomed role of immunisation providers without adequate support, and are most susceptible to the fatigue factor introduced by “too many vaccines”. At the local level, parents should be provided with all possible information and full counselling prior to vaccination. This means that immunisation nurses should be available at any vaccination point.
The National Childhood Immunisation Register has not been the success that was hoped. Whether GPs can deliver the goods and whether the Register can be made to work is yet to be seen. Provision of nurse support for immunisation, including in the field of private general practice, is the way to go. The small economic incentives at present given to GPs should be passed on to the parents.
Scientific progress with the development of new acellular pertussis vaccines as well as the introduction of pentavalent vaccines at present under trial, will make things easier but at a much higher cost. The task of convincing governments to fund higher-cost vaccine programs without diverting funds from other areas of the health system will be a challenging one, but without government subsidies these vaccines will be available only for the wealthy.
We need to address community concerns about the risks at present involved in vaccinating children, especially at a time when the benefits are hard to see. Side-effects ranging from an unhappy child for several days to the very rare risk of more serious consequences can weigh heavily on the parent’s mind. This is even more relevant if the National Childhood Immunisation Register, which was meant to track side-effects, is not working.
At the Federal level the community should have a strong input in decisions regarding vaccination schedules, and only specific pathogens for which there is no known alternative prevention should be included, and this should be by a decision-making process fully involving the community, and particularly parents.
If present government initiatives are not successful, we may need to look at some way to reward parents who are vaccinating their children, including penalties for those who are failing to do so, such as 1) higher Medicare levies to cover the extra health costs for unvaccinated children, as well as 2) stricter school entry requirements and 3) exclusion of unvaccinated children from broader social contacts during disease outbreaks or epidemics.
Compulsion, as in the case of seatbelts in cars and crash helmets for cyclists and motorcyclists, is not appropriate, nor is it likely in the Australian content.