Political Views And Vaccine Refusal Rates An Increasing Concern For Policymakers And Public Health Officials

Or they should be. That’s the conclusion of a recent study published in the medical journal Vaccine. The study focused on political views of parents in the state of California, who had chosen not to vaccinate their nursery-school aged children. And it tracked the number of parents who had filed personal belief exemptions (PBEs), applications for permission to avoid vaccinations over a 5-year period to 2015.

Swiss vaccination campaign

A disproportionate number of parents filing such forms were from Republican or conservative neighbourhoods, according to researcher Kevin A Estep, from the health administration and policy program at the university. Applications from more liberal neighbourhoods also showed a rise in the number of PBEs, although to a lesser degree. Interestingly, the number of applications increased in conservative neighbourhoods over time. “If conservatives are becoming more concentrated in particular communities and are, at the same time, more likely to oppose mandatory vaccinations, this combination of factors could produce clusters of PBEs in communities where conservative values are widely shared,” said Estep.

Clusters are a worry for policymakers, because of the risk of outbreaks of disease. At the same time as these rises in vaccine hesitancy, the US experienced outbreaks of diseases not seen for decades. A particular nasty one started in Disneyland. By 8 February 2015, 110 Californians had contracted measles, whose source is now known to be one of the patrons at the theme park.

The US Centers for Disease Control (CDC) reported that 45 percent of the Californians were unvaccinated, several had not received all the doses recommended, and 43 percent had unknown or undocumented vaccination status. But interestingly, of the 37 remaining vaccine-eligible patients, 28 (67 percent) were intentionally unvaccinated because of personal beliefs.

But the clusters of PBEs appear to be doing something interesting to politics, said Estep. “Because opposition to mandatory vaccines is increasing in conservative communities, Republican lawmakers are likely to face mounting pressure to support laws that expand exemptions, or to vote against laws that make it harder to opt out,” he explained.

He cited Texas, where a Republican state representative was harshly attacked by his own constituents in 2015 when he proposed a bill to eliminate PBE altogether. Parental rights groups insisted he withdraw the proposal. He caved under pressure.

In such areas, he said, there is a staunch commitment to parental rights, suspicion of government intrusion into personal choices, and distrust of science. Combined, that may foster opposition to mandatory vaccines.

“Although this individual level explanation is most likely the primary driver of these results, the social consequences and administrative barriers to opting out may be lower in settings where conservative beliefs are widely shared,” he added.

Heidi J. Larson, an anthropologist and director of The Vaccine Confidence Project (VCP) based in London, said political ideology has long been tied up with views on vaccines. “It’s often a barometer for distrust in government,” she explained.

Take Italy, for example, which has been governed by two populist parties since the beginning of June. Giulia Grillo, Italy’s new health minister, earlier this month reportedly said parents no longer had to provide schools with a doctor’s certificate proving their children had been vaccinated.

This is a year after her predecessor introduced 12 mandatory vaccines before school-aged children could enter state schools. It had done so in response plummeting vaccine rates across the country. Measles cases had risen fivefold in the year since April 2017, according to Italy’s health research institute, Instituto Superiore di Sanità (ISS).

It’s unlikely that views on vaccines are being shaped by politicians, says Larson, just reinforced by them. They have long used contentious issues to strengthen their own political agendas. “Look at Italy. Historically, politicians look for what are current debates, whatever the issues are and see what’s polarising and whether their constituencies vote actively against something, whether it’s abortion or vaccination,” she explained. “And they see these as people they want to recruit. In this case it happens to be vaccines.”

But what the study and the situation in Italy reveals is the very interesting reactions to idea of mandates on vaccination, rules that compel people to vaccinate their children. Mandates are relatively unusual but are of great interest to many countries and policymakers around the world given dramatic drops in vaccination rates and a growing number of more vocal and organised groups of sceptics.

The United States is not the only country seeing unexpected outbreaks. Europe has seen voluntary vaccinations plummet and an increase in outbreaks not previously seen for many years. For the year to April 2018, 28 EU/EEA Member States reported 13,475 cases of measles according to the ECDC, in its most recent report. The most cases were reported by Italy (4,032), Greece (2,752), France (2,436) and Romania (2,127), accounting for 30%, 20%, 18% and 16%, respectively, of all cases reported by EU/EEA countries.

“Public trust in immunisation is one of the major factors currently impacting on vaccination uptake in Europe,” said ECDC Director Andrea Ammon on publication of this latest report. “This is a global health issue, affecting the achievement of public health goals. In the context of this new ‘post-factual’ era, we strongly need new targeted intervention strategies to support immunisation programmes.”

For policymakers, the priority is to stop vaccine rates from affecting herd immunity. If enough people in population are vaccinated, the disease can’t circulate effectively, and that provides protection, or herd immunity, to those who can’t be vaccinated, even if they wanted to. For these, more vulnerable people may be too young, immunocompromised, after cancer or other treatments.

Once vaccine rates drop to below the level at which herd immunity kicks in, diseases that once killed can spread again. Deaths have been seen from Italy to Germany already.

Italy is one of the few countries to introduce a mandate for vaccination. It followed France, which has also recently introduced mandatory vaccines. The US states have for years mandated immunisation before children can enter kindergarten or the school system; they are seen to be one contributing factor to the (previous) elimination of transmission in the US.

Rules vary widely between states, however. Some countries are compelling people to vaccinate, using penalties. Australia’s No Jab, No Pay initiative stops welfare to families when children are not immunised for non-medical reasons. Mandates can vary, however. They may only apply to health workers or those in emergency situations, for example, or only apply for particular diseases such as polio.

Other countries are looking into the idea of mandates. A debate raged in Germany after an outbreak in Berlin and is revisited regularly in the United Kingdom.

Mandatory vaccines are one way of doing it, but so are public health campaigns that try to counter unscientific myths. Some are successful, as seen with MMR (measles, mumps and rubella) in the UK. And, not all those who do not vaccinate do so out of any religious or personal belief system. Many haven’t had the time, have health systems that are difficult to access, or just forgot. So other strategies, such as text message reminders, may help them.

Mandates are often seen as a blunt force, however. Larson said she prefers strategies that spread constructive information about vaccines rather than force people to have them. “I’m not a big fan of mandatory in general. The more we can get the public to do it under their own conviction, the better.” she said.

Certainly, mandates can drive those with entrenched views opposed to vaccines underground; they may move to enclaves where rules are less stringent or begin to homeschool their children instead.

Research by Julie Leask, a researcher at the Sydney Nursing School and School of Public Health, University of Sydney, said the Australian mandate may disadvantage some of the poorest in her society the most. Not only do they lose benefits, children are taken out of school to be homeschooled, and their mothers can’t join the workforce. In a report she said: “They compound the disadvantage for children already at greater risk of vaccine-preventable diseases and they create more alienation from a healthcare system that vaccine rejecting and hesitant parents already struggle to trust.”

Curiously, however, the very exemptions looked at in the Creighton study may offer one option to policymakers.

Exemptions are allowed for medical, religious and non-medical use, although the rules differ from state to state. So, perhaps making it harder to get a non-medical or PBE exemption, may be a way of improving rates, say researchers. In some states, applying for a PBE is extremely simple. Parents may just have to print out a form or tick a box. But other states have made the process more onerous, said Saad B. Omer, professor of Global Health and professor of Epidemiology & Paediatrics at Emory University (US), who has studied these mandatory rules in the US in detail.

“When you apply for a non-medical exemption you have to go to a physician and you have to be counselled around the risks of non-vaccination as well that you’re putting yourself and others at risk,” he explained.

Making PBE is more difficult to come by ensures that those who are a little hesitant, but not enough to go through a long bureaucratic process, still vaccinate and herd immunity is maintained. As one observer put it, “if they have to put a lot of effort into challenging it, they give in.”

“These laws have consequences. They are nudges in the sense that they move the balance of convenience from vaccination refusal to vaccination. When you change the balance that results in lower rates of exemption,” explained Omer.

Having an exemption in the first place may also be vital, he said. It allows those with entrenched views to be heard by doctors, policymakers and politicians alike. Not listening to the worries of parents has been blamed for the great rise in organised groups.

“The mandate works like a pressure valve. We have shown that the ease of these procedures is associated not only higher rates of vaccine refusal but also higher rates of disease itself,” he said. The risk of not doing so, maybe to drive such parents underground.

That’s why it will be so interesting to see the effects of banning non-medical exemptions, as has been done in California since 2015. Estep noted that tightening up the rules around PBE, and the effect of Disneyland, caused record numbers of vaccinations reported last year. But, worries Omer, parents who are staunchly anti-vaccine may react to this ruling by moving out of state, or forming clusters of home-schooled, unvaccinated children, vulnerable to outbreaks.  “It’s unclear what the long-term consequences will be,” he said.

Image Credits: Government of Switzerland.

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