We need a new strategy for vaccination. The University of Auckland’s Nikki Turner explains what that might look like.

Infectious diseases affecting the country’s health has been high on the public agenda over the past few months, with justified alarm over the outbreaks of measles and an early onset of this year’s flu season which has already claimed four lives.  

Vaccines can reduce these threats – and in some cases even prevent them. But the fact that we still experience outbreaks, people still get sick and, although rare, people still die, indicates the way we view and approach our vaccination options needs to change.

We need a new strategy. One that normalises immunisation as “this is what this country believes in for the protection of its population; we offer a quality and accessible service with the most effective vaccines science has to offer us, supported by the best international science/evidence from bodies like the World Health Organisation”. 

It would create a system not about an individual decision but about community protection.   

People would still have an individual right to decline, but that would have to be an active decision, not one made through lack of awareness, motivation or the lack of an effective service. (There have always been individuals in New Zealand who have chosen not to support the overall community decision, and so long as their numbers remain small we can cope.)  

This normalisation of vaccination would cover ‘whole of life’ and encompass protection for all our community for all ages – from pregnancy, infancy, childhood to adolescents, adults and the elderly. The strategy can reduce but not fully control all diseases; for some the vaccines do not give long lasting protection such as whooping cough, or the disease cannot be eradicated such as tetanus that resides in soil. But for others, for example measles or cervical cancer, it could bring elimination of the disease.

Such a change of strategy would bring controversy – public discourse on vaccination always does. Concern over the recent outbreaks, particularly measles, re-ignited the debate over fear of disease versus fear of vaccination. Vocal angry blame was directed at those people who have not had their children vaccinated and have therefore put others in the community, especially vulnerable babies and children, at risk. 

If anti-vaxxers are only a small part of the vaccination ‘missing’ why are other people not taking up opportunities to immunise? 

These people are often grouped together as ‘anti-vaxxers’ and considered an important part of the ‘vaccine hesitancy’ movement that is now listed by the World Health Organisation as one of the top 10 health risks to the world.

But it is not that simple. 

We only have to look at the flood in demand we experienced for the measles vaccine when news of the outbreak was reported. Those who had missed out and now wanted vaccines weren’t anti-vaxxers, they were people who saw the reality of a disease and wanted to get themselves and their children protected. We saw the same sudden demand for the flu vaccine when international and local media reported on people in intensive care and dying. These people too weren’t anti-vaxxers. 

However, without disease in the forefront of our minds, the motivation to act is often way down the list of other multiple competing priorities in our increasingly complex and often somewhat chaotic lives. It is this, rather than a commitment to ideology, that is at the root of most vaccine hesitancy.

The fact is, the numbers of true diehard, utterly convinced anti-vaxxers is very small. In New Zealand, those who decline one or more vaccination is around 5 percent, and not all of these are completely opposed to all vaccines. Overall, around 8 to 9 percent of infants miss out on all their vaccinations and unfortunately this figure increases in older age groups.  About 10 percent of four-year-olds are missing out; nearly a third of our teenagers miss out on HPV vaccination; less than two thirds of our elderly get influenza vaccination and the most disappointing of all is that around two thirds of pregnant women miss out on influenza and whooping cough vaccination to protect themselves and their newborn infants. 

So if anti-vaxxers are only a small part of the vaccination ‘missing’ why are other people not taking up opportunities to immunise? 

There are many barriers that get in the way of people taking steps to preventive health care. People just ‘don’t get around’ to it for myriad reasons, and many of these reasons add upon each other to create additional barriers – they are too busy, they can’t get to the surgery, it is hard to get time off work and there are no weekend clinics, their neighbour felt unwell after their last vaccine and although told it was not vaccine-related it still raised fear. 

Further, many of us hate needles and put it off; there is a lot of misinformation on the social media ‘kumara vine’ that creates concern about the vaccine, and the disease is just too out of sight and out of mind to prioritise in busy day-to-day lives. 

But then, when we have an outbreak, disease becomes a visible reality, people get scared, try harder to overcome the multiple barriers, demand shoots up and we can run out of vaccine supplies in the rush as we have just seen with the flu vaccine shortage.

At times like this, immunisation talk can often turn to making vaccinations mandatory. However, mandating policies have mixed outcomes. They can work in some contexts but can also backfire. Without tackling the multiple, mixed and complex barriers to vaccination, and without making the process more understood and easily accessible for all, a mandatory policy runs the risk of creating even more health inequities. It is the most vulnerable children, often from the most challenging economic and social situations, who would run the highest risk of missing out. 

The US has mandatory policies but does not achieve higher coverage than New Zealand – a fact which confirms mandatary vaccination alone is not a ‘magic bullet’.

So this brings me back to ‘normalisation’ as a strategy for those who miss out on health protection, not through ideology but because it’s at the bottom of a list of things to do and never quite makes it to the top. The New Zealand immunisation programme is what this country actively recommends and effectively offers. To choose to opt out would remain a personal choice in our New Zealand environment, but it should require an active decision, not a passive accident. 

Nikki Turner is Immunisation Advisory Centre Clinical Director and Associate Professor in General Practice and Primary Health Care at the University of Auckland.

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