Whenever stories about vaccination hit the headlines, just how deeply we value vaccines becomes strikingly clear. Whether it’s the celebration of new vaccines, the outrage at disease outbreaks, or the anger at those who don’t vaccinate, it’s clear that most Australians want vaccine programs to succeed.
Sometimes it only takes one or two stories of disease affliction, powerfully conveyed to spur people into action. This was most strikingly illustrated with the whooping cough epidemic, which continued into its third year and tragically has killed seven infants since 2008.
The causes for this epidemic are complex and the solutions multifactorial but the motivation to act is strong.
Health authorities have initiated a number of strategies since 2009:
the age at which infants can first be vaccinated was brought forward to six weeks and the pre-school booster can be given at three-and-a-half years;
most states and territories have implemented cocooning strategies – where those caring for infants are vaccinated to reduce infection of babies who don’t acquire full vaccine protection until a second or third dose; and
the federal, NSW and Victorian governments launched awareness campaigns to reduce the spread of infection to infants and promote vaccination.
The flu
Meanwhile, another vaccine-preventable disease – influenza – caused deaths in children in 2011 but the media remained very quiet about it. The impact of influenza is under estimated; it continues to affect thousands of Australians.
There may be a little reluctance to wholeheartedly promote influenza vaccines to children following the suspension of the seasonal influenza vaccines for children aged five years in 2010.
Brought about by an unacceptably high rate of febrile convulsions in children (500 to 700 for every 100,000 doses), it turned out that just CSL’s Fluvax was to blame and that vaccine is no longer approved for use in children under five years of age. The influenza vaccines now available for children have a much lower risk of febrile convulsions in children (seven to 18 febrile convulsions per 100,000 vaccine doses).
The 2010 vaccine suspension did highlight the need for improvements in coordination and communication of reporting adverse events following immunization, as documented in the 2011 Horvarth Review. Many will be waiting in earnest to see how government plans to implement its recommendations in 2012.
Human papilloma virus
Last week, the Pharmaceutical Benefits Advisory Committee recommended that boys aged 12 to 13 years receive the quadrivalent human papilloma virus (HPV) vaccination as a cost effective measure to prevent disease related to the vaccine HPV types. The PBAC also recommended a short term catch-up for boys in the two year groups above. To most boys, this might feel like the public health equivalent of Mum recommending that Aunty Dora buy you some socks for Christmas: useful but not relished.
Promoting the vaccine in boys will be tricky. First, it’s largely been marketed as a cervical cancer vaccine, even though the quadrivalent vaccine Gardasil has been recently shown to prevent infection and anogenital disease in young males. Then, there are the unfounded safety scares, largely brought about by anti-vaccination lobby groups and families of girls who attribute their health problems emerging after the vaccine, to the vaccine.
In September, Republican presidential candidate, Michelle Bachman did nothing to help this when she dropped the morsel about meeting a woman claiming her daughter had “mental retardation” from the vaccine. This spurious claim was resoundingly decried by the medical community but has probably helped to chip away at public confidence a little further. It’s a pity because the vaccine is very safe and already appears to be effective.
Funding shots
An even more effective way to limit the number of people having a vaccine is to make them pay for it. Then, it’ll be just a minority of well-resourced people who take it up. For the HPV vaccine to be available in an equitable way to all boys, the government will need to fund it. But former health minister Nicola Roxon made it very clear earlier this year that the government will continue to exercise its right to delay full funding PBAC-recommended medicines to keep spending in check.
Unfortunately, this once again creates a system of pharmaceutical funding that is much more vulnerable to political whims and pressure groups rather than proven cost effectiveness as the final arbitrator. Let’s hope incoming health minister Tanya Plibersek sees this as an opportunity to make her mark on disease rates, especially for men who have sex with men and who, without vaccine, bear a disproportionate burden of HPV–related cancers because they benefit less from the immunity of vaccinated females.
Conversely, money also talks as an incentive to have free vaccines. In November, the government overhauled its incentives program, removing a payment of A$258 for every household and instead linking full vaccination to the existing Family Tax Benefit Part A supplement of up to A$2100 for eligible families.
Some have called this change to incentives the removal of a carrot and the wielding of a stick. The cattle metaphor is popular in vaccination, whether it’s horses and water, and carrots and sticks or the concept of “herd immunity”. Staying in that vein, in changing immunisation incentives for parents the government has effectively removed all those carrots and said, “OK, you can have your hay still, but only if you show your kid is vaccinated or you claim an exemption”. Vaccine-refusing parents can still get access to the payments, as long as they register as conscientious objectors.
Deliberate non-vaccinators
It’s this group of parents who raise the most ire in public arenas. It’s a small group, with 1.7% of the parent population lodging conscientious objections in 2010, but the cause of significant angst, especially in regions where they cluster and compromise community immunity.
In one such region, the north coast of New South Wales, lives Meryl Dorey, the president of the Australian Vaccination Network (AVN), an anti-vaccine lobby group. Efforts to stop the AVN have continued in earnest this year with a recent social media campaign against Meryl Dorey speaking at the Woodford Folk Festival.
So far the festival organisers have refused to remove her from the bill but in the meantime, the campaign has generated considerable media attention. The question that remains is whether her group has a direct influence on the decisions of parents to refuse some or all vaccines.
My view is that we must better understand people who sit on the fence – how many there are and what influences them. Even though Australia’s immunization rates are fairly high – around 92% and very stable, if not improving – we can’t afford to be complacent. So for Christmas, I would like the government to support an annual vaccine confidence index, like a consumer confidence index. Then we can pick up downshifts early and act quickly.
Second, Australia needs a national approach to vaccine-related communication with comprehensive information for consumers and a broader strategy for listening, engagement and responding to concerns. Perhaps governments could even get a little bold and use social media.
And the neighbours
Most of all, Australia should continue its support of vaccination programs in low-income countries where vaccines stand to bring the greatest benefit. This year the federal government pledged an additional A$140 million of funding from 2011 and 2014 to GAVI Alliance but the need for such funds is ongoing.
Polio eradication is on the horizon and there are concerted efforts to stamp out this disease in the remaining endemic countries of Pakistan, India, Afghanistan and Nigeria.
The GAVI Alliance, with help from donor countries, global health organisations and the Bill and Melinda Gates Foundation will help make new and more expensive vaccines like the one for HPV available to citizens in low-income countries where the need is greatest. That’s the kind of news that brings hope during the festive season.
Acknowledgements: I thank Kirsten Ward, Melina Georgousakis and Helen Quinn for their insights and helpful comments.