Vaccination: A Global Perspective

We have seen how detrimental vaccine preventable diseases can be and how an unvaccinated person can be a disease threat to others.

A short video below will further illustrate this point. Megan shared her frightening experience of caring for her ill baby who contracted measles from a visit to her paediatrician’s waiting room.

In an attempt to eliminate such outbreaks, several governments and health organisations have implemented policies on mandatory vaccinations.

Let’s begin by having a closer look at some of the previously successful policies:

1853 Mandatory vaccination against measles

Under the Act of Parliament in 1853, the British government implemented mandatory smallpox vaccination. People who refused to get vaccinated would incur a penalty or fine. In 1905, The U.S. Supreme Court in the case of Jacobson v. Massachusetts upheld the authority of various states to enforce compulsory smallpox vaccination laws.

Outcome: By 1900, smallpox had been eradicated from several countries in Northern Europe. Furthermore, the incidence of small pox decreased substantially to low levels for most industrialized counties by 1914

1997 Seven Point Plans – Australia

1. Initiatives for parents
Maternity immunisation allowance with childcare assistance and cash rebate
Provide incentives to parents for ensuring that their child’s immunisation schedule was up to date

2. A bigger role for GPs:
The General Practice Immunisation Incentives (GPII) Scheme (Medicare Australia)  rewards GP who monitor, promote and provide age appropriate immunisation service to children under the age of 7
GPII scheme was introduced on the basis that 93% of children had regular visits to their GP on an average of 7x a year.

3. Monitoring and evaluation of immunisation target

4. Immunisation days:
The Commonwealth and the States and Territories piloted a series of immunisation days (2 August, 4 October and 6 December 1997) which aimed to immunise areas with low coverage.
Over 4,600 individuals were vaccinated on these days, at a total of 195 sites.

5. Measles eradication:
In late 1998, a one-off school-based MMR vaccination was offered to all primary school aged children.
96% of school aged children between 5-12 years old were vaccinated during the campaign.

6. Education and research:
In 1997, an educational campaign was conducted via the mass media to target people from different cultural and linguistic backgrounds.

7. School entry requirement:
The Commonwealth and State and Territory Governments enforced school entry requirements which require mandatory provision of immunisation record during enrolment.
Allows identification of children who are up to date with their immunisation schedule
Allows for disease outbreak mitigation through quick identification and exclusion of unvaccinated students.
“Parents must provide certification of immunisation at the time of enrolment at a Victorian primary school. If school does not have documentation of immunisation status, either because not vaccinated or no documentation, the principal is required to exclude the child from school if an outbreak was to occur”

Outcome: 90% of children below the age of 5 and 93% of children below 2 years old are fully vaccinated.

Current Initiatives by World Health Organisation (WHO)

Global Vaccine Action Plan 2011 – 2020

The Global Vaccination Action Plan was organised by the World Health Organization and endorsed by the World Health Assembly in 2012. The plan, which is set from 2011-2020 is intended to improve health and expand the full benefits of immunization to all people, regardless of where they are born, who they are, or where they live in.

Through this, global herd immunity can be achieved.

Below are the 5 goals WHO wishes to fulfill by 2020:

goals

Maternal and Neonatal Tetanus (MNT) elimination

The MNT Elimination Initiative aims to reduce MNT cases to levels whereby the disease is no longer a major public health problem (less than one case of neonatal tetanus per 1000 live births in every district). In countries with poor sanitation, MNT are prevalent as unhygienic deliveries place mothers and new-borns at risk of contracting tetanus. Mortality rates are extremely high, especially when appropriate medical care is unavailable. Unlike polio and smallpox, tetanus cannot be fully eradicated as its spores are ubiquitous. However, MNT deaths can be easily prevented by clean delivery, cord care practices and/or by vaccinating pregnant mothers with tetanus vaccine.

Interesting vaccination policies across the globe 

Australia 

Under the National Immunisation Program (NIP), essential vaccines are available free of charge to eligible infants, children, adolescents and adults. NIP is internationally recognised as a strong and successful program, with a national average of over 90% coverage for most childhood vaccines. Australia’s achievements in immunisation have met international goals set by the World Health Organization (WHO) under the Global Immunization Vision and Strategy (GIVS).

European Union 

14 European countries have at least one mandatory policy for infant and early childhood vaccination, which often includes school entry vaccination requirements. Most of the policies are disease-specific and thus, not all vaccinations are compulsory.

Slovenia has one of the world’s most aggressive and comprehensive vaccination program. It encompasses mandatory vaccinations for 9 diseases (TB, tetanus, polio, pertussis, Haemophilus influenza type B, MMR, hepatitis B), whereby only medical exemptions are accepted.

Indonesia and Malaysia 

Both Indonesia and Malaysia have implemented nationwide school vaccination programs for decades in an attempt to vaccinate primary school children as a cohort. School nurses or team of medical staff from outside school will visit primary and secondary schools on annual basis to administer basic life vaccine. Children in Indonesia will receive diptheria vaccine in year 1, tetanus vaccine in year 2 and 3 and one shot of measles during their primary or secondary school. Therefore, most children would have received their essential vaccines by the time they finish secondary school.

Pakistan

goals

Polio virus currently affects 10 countries worldwide, and is endemic in three countries, including Pakistan. Following the re-emergence of polio cases in a country once thought to be on the verge of eradicating the deadly disease, the Pakistani government enforced mandatory polio vaccination in 2014.

“There is no mercy, we have decided to deal with the refusal cases with iron hands. Anyone who refuses (the vaccine) will be sent to jail,” Deputy commissioner Riaz Khan Mehsud said

The Pakistani government says it will set up mandatory immunisation points at airports and border crossings to help stop its polio outbreak from spreading.

United Kingdom

Currently in the UK, there is no legislation in place for mandatory vaccination or school entry vaccination. The absence of stringent vaccination policies, alongside the Wakefield controversy in late 1990s, has contributed to the dramatic rise in measles outbreaks. Thus, the UK has reinvigorated discussions pertaining to vaccination legislations, such as mandatory vaccination and school entry requirements.

United States

Mandatory school entry vaccination requirements are the primary strategy to increase vaccine uptake in all 50 states in USA. They are all state-based so variations exist between different states. Medical exemptions are allowed in all states, but only 48 states, other than Mississippi and West Virginia, allow for religious exemptions. 19 states allow parents to cite philosophical objections against childhood vaccination.

Strategies adapted by many countries to improve vaccination rates include:

Sending recall letters and updating record, increase vaccination settings closer to patients’ homes, expanding clinic hours, offering drop-in vaccination services (for example via home visiting service), integrate vaccination with health assessment (usually for hepatitis B).

Campaigns to raise awareness:

World Immunization Week 2015

World Immunization Week, which will be held from 24-30 April 2015, will signal “a renewed global, regional, and national effort to accelerate action to increase awareness and demand for immunization by communities, and improve vaccination delivery services.”

The theme of World Immunization Week 2015 is “Close the immunization gap”: the gap whereby there is still 1 in 5 children who do not receive basic vaccinations, as well as the existing gaps towards the targets set by the Global Vaccine Action Plan (GVAP).

National Infant Immunisation Week (NIIH) – USA

National Infant Immunization Week (NIIW) and Toddler Immunization Month (TIM) are annual observances that highlight the importance of routine vaccinations in protecting infants (younger than 2 years old) from vaccine preventable diseases. It will be held on the 18th-25th April 2015.

Text References

World Health Organization. Global Vaccine Action Plan 2011-2020 [Internet]. Geneva (CH): World Health Organization, 2013 [cited 2015 Apr 5]. Available from: http://www.who.int/immunization/global_vaccine_action_plan/GVAP_doc_2011_2020/en/

World Health Organization. Maternal and Neonatal Tetanus (MNT) elimination [Internet]. Geneva (CH): World Health Organization, [updated 2015 Mar 3; cited 2015 Apr 5]. Available from: http://www.who.int/immunization/diseases/MNTE_initiative/en/

National Centre for Immunisation. Summary of strategies to increase vaccination uptake in Australia [Internet]. Sydney (NSW): The University of Sydney, 2012 [cited 2015 Apr 5]. Available from: http://www.ncirs.edu.au/research/social/Strategies%20to%20improve%20vax%20uptake_Table1_FOR%20WEB.pdf

Department of Health and Ageing (AU). Immunise Australia: Seven Point Plan [Internet]. Melbourne(VIC): Australian Government; Department of Health and Ageing; [updated 2013 May 15; cited 2015 Mar 30]. Available from: http://www.health.gov.au/internet/immunise/publishing.nsf/Content/history-of-ia-prog

National Centre for Immunisation. School Entry Vaccination Requirements: Summary of the Evidence [Internet]. Sydney (NSW): The University of Sydney; Department of Health (AU), 2013 [cited 2015 Apr 5]. Available from: http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/5A30200F245EF140CA257B890005A116/$File/school-entry-vaccination-provisions-13062013.pdf

BBC News. Pakistan to immunise people going abroad against polio [Internet]. BBC, 2014 [cited 2015 Apr 5]. Available from: http://www.bbc.com/news/world-asia-27292868

ABC News. Pakistan police arrest parents for refusing polio vaccine amid fresh immunisation campaign. ABC News [Internet]. 2015 Mar 3 [cited 2015 Apr 5]; Available from: http://www.abc.net.au/news/2015-03-03/pakistan-police-arrest-parents-for-refusing-polio-vaccine/6277204

World Health Organization. School based immunisation [Internet]. Geneva (CH): World Health Organization, [updated 2014 Nov 21; cited 2015 Apr 5]. Available from:http://www.who.int/immunization/programmes_systems/policies_strategies/school_based_immunization/en/

World Health Organization. School Immunisation Programme in Indonesia: 26 November – 5 December 2007 [Internet]. Geneva (CH): World Health Organization, 2008[cited 2015 Apr 5]. Available from: http://www.who.int/immunization/programmes_systems/policies_strategies/Indonesia-School-immunization.pdf

Image References:

World Health Organization. Global Vaccine Action Plan 2011-2020 [Internet]. Geneva (CH): World Health Organization, 2013 [cited 2015 Apr 5]. [Figure], Global Vaccine Action Plan 2011-2020. Available from: http://www.who.int/immunization/global_vaccine_action_plan/GVAP_doc_2011_2020/en/

World Health Organization. Global Vaccine Action Plan 2011-2020 [Internet]. Geneva (CH): World Health Organization, 2013 [cited 2015 Apr 5]. [Figure], Goals of the Decades of Vaccines (2011-2020). Available from: http://www.who.int/immunization/global_vaccine_action_plan/GVAP_doc_2011_2020/en/

The Guardian (AU). Pakistan jails 471 parents who refused to give polio vaccine to children [Internet]. The Guardian (AU), 2014 [cited 2015 Apr 5]. [Figure], A health worker gives a polio vaccine to a child in Peshawar, Pakistan. Available from: http://www.theguardian.com/society/2015/mar/02/parents-jailed-pakistan-refusing-children-polio-vaccinations

CartoonStock. Medical Service Cartoon [Internet]. London (UK): CartoonStock; 2014 [cited 2015 Mar 7]. [Figure]. That was quick! Available from: https://www.cartoonstock.com/directory/m/medical_service.asp

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