Imposing Penalties for Vaccine Rejection Requires Strong Scrutiny

"Efforts to address vaccine rejection often fail because its underpinning is complex..."

Australia and other countries have considered or implemented policies that ramp up the penalties for rejection of vaccination. As Australia evaluates "No Jab, No Pay", which withholds child benefits from parents who do not vaccinate their children, and as other countries consider implementing similar measures, this viewpoint article examines the evidence base and effectiveness of penalties to address vaccine rejection through the lens of ethical principles relevant to public health immunisation programmes.

There are some benefits to mandatory vaccination, including potential to increase immunisation rates, reduced risk of exposure to incompletely vaccinated children in child care, savings for government, and increased knowledge and awareness about the importance of immunisation. Regarding the latter, the No Jab, No Pay legislation attracted considerable publicity in major media and online outlets when it was announced on April 12 2015, when it passed in November 2015, and when it was implemented beginning on January 1 2016. Articles featured messages that affirmed the importance of vaccination, and some states ran specific campaigns to strengthen the immunisation message alongside the announcement of their policy, such as Victoria's "Immunity for Community" campaign. This intensified focus highlighted the existing and new requirements and more broadly the importance of immunisation.

Risks of such a policy include:

• Imposing penalties on vaccine rejectors does not target one of the largest contributors to under-vaccination: children of the vaccine-supportive who were late for a range of practical and logistical reasons related to access or disadvantage.
• Evidence suggests that less restrictive options - e.g., those that remove barriers to vaccine access - can bring larger gains.
• Imposing sanctions will not shift many vaccine objectors. For No Jab, No Pay, many vaccine objectors have incomes that are too high to be eligible for FTB-A (supplement) and the Child Care Benefit, so they may not be motivated to comply.
• The bill removes the incentive for parents to discuss their vaccine rejection decision with a health professional: To meet the requirements in place between 1999 and 2015, parents who objected to vaccination had to request that a doctor or immunisation provider sign a conscientious objection form, which stated that the risks and benefits were explained to them. The removal of objection requirements has meant that this encounter, which represents an opportunity to address vaccine concerns, is no longer incentivised at a national level.
• The bill places pressure on providers to give unwarranted medical exemptions, which has the potential to introduce considerable conflict in the doctor-patient relationship.
• Because Australia currently has no other way of monitoring vaccine sentiment at a regional level to enable local planning, monitoring of vaccine rejection rates ceases through loss of national registration of vaccine objection. Without such information, local planners may not develop solutions that match the cause of the problem. For example, a region may have low vaccination rates but low objection rates, meaning that improving services would work better than launching an education campaign to address vaccine safety concerns.

As noted here, any policy instituted to improve vaccination rates should ensure that it is the right fit for the problem and should be evaluated for effectiveness. Box 2 includes suggested parameters for the evaluation of penalty-based policies.

Some of the ethical principles of note in assessing a policy like No Jab, No Play:

• Equity: Vaccine objectors on higher incomes are not equally penalised (because two of the payments are income-tested), and there is a greater effect on families living in poverty or migrant and refugee families. Equity of access to child care is also affected through it being made less affordable for some families affected by the removal of rebates and benefits. "Hence, penalising for vaccine rejection is neither the most effective nor fair way to improve vaccination rates when it brings significant social and economic risks for the most vulnerable."
• Autonomy: "The loss of autonomy in vaccination is particularly problematic for those at the margins of vaccine acceptance (the highly hesitant parents as opposed to the refusers) who value their agency in their parental decision-making, which this policy is undermining."
• Reciprocity: "If parents are obliged by government to vaccinate their children and face not just benefits, but possible risks of rare serious side effects, it is beholden on government to reciprocate. Yet the 'No Jab, No Pay' amendment bill has been implemented without a no-fault vaccine injury compensation system..."
• Trust: According to the authors, policies like No Jab, No Pay bring financial hardship and limit access to early childhood education, contradicting the goals of vaccination: the health and wellbeing of children and society. "The discord between the means and ends engenders more alienation from a health care system that vaccine rejecting and hesitant parents already struggle to trust."

Having argued that No Jab, No Pay is not supported by evidence, yet acknowledging that vaccine rejection is an ongoing problem for vaccine programmes, the authors present a series of recommendations. Two examples include: (i) Provide comprehensive support for health professionals in communication approaches and resources to be used when interacting with vaccine-hesitant and rejecting parents; and (ii) investigate more collaborative approaches to working with communities with higher rates of vaccine rejectors and the professionals who influence them. For example, a peer-to-peer educator programme was implemented in Washington State, United States (US).

"In conclusion, an evidence-based approach to under-vaccination involves comprehensive, multifactorial approaches. Regulatory approaches to vaccine rejection should be firm but fair, enabling hard-to-reach exemptions that promote engagement, not alienation from the health system."