Vaccination policy

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Vaccination policy refers to the health policy a government adopts in relation to vaccination. Vaccinations are voluntary in some countries and mandatory in others, as part of their public health system. Some governments pay all or part of the costs of vaccinations for vaccines in a national vaccination schedule.

Goals of vaccination policies[edit]

Immunity and herd immunity[edit]

Vaccination policies aim to produce immunity to preventable diseases. Besides individual protection from getting ill, some vaccination policies also aim to provide the community as a whole with herd immunity. Herd immunity refers to the idea that the pathogen will have trouble spreading when a significant part of the population has immunity against it. This protects those unable to get the vaccine due to health reasons, such as age, allergies and having received an organ transplant.

Each year, vaccination averts between two to three million deaths, across all age groups, from diphtheria, tetanus, detritus, and measles.[1] This is an extreme shift in disease prevention. These diseases used to be among the leading causes of death worldwide. But now, with modern medical technology, many of these deaths are able to be avoided.

The impact of immunization policy on vaccine-preventable diseases has been listed as one of the top public health achievements of our time.[2][3]

Eradication of disease[edit]

Malaria Clinic in Tanzania helped by SMS for Life program which organizes malaria vaccine delivery

With some vaccines, a goal of vaccination policies is to eradicate the disease - make it disappear from Earth altogether. The World Health Organization coordinated the global effort to eradicate smallpox globally.[citation needed] Victory is also claimed for getting rid of endemic measles, mumps and rubella in Finland.[citation needed] The last naturally occurring case of smallpox occurred in Somalia in 1977. In 1988, the governing body of WHO targeted polio for eradication by the year 2000, but didn't succeed. The next eradication target would most likely be measles, which has declined since the introduction of measles vaccination in 1963.

Individual versus group goals[edit]

Rational individuals will attempt to minimize the risk of illness, and will seek vaccination for themselves or their children if they perceive a high threat of disease and a low risk to vaccination. However, if a vaccination program successfully reduces the disease threat, it may reduce the perceived risk of disease enough so that an individual's optimal strategy is to encourage everyone but their family to be vaccinated, or (more generally) to refuse vaccination at coverage levels below those optimal for the community.[4] For example, a 2003 study found that a bioterrorist attack using smallpox would result in conditions where voluntary vaccination would be unlikely to reach the optimum level for the U.S. as a whole,[5] and a 2007 study found that severe influenza epidemics cannot be prevented by voluntary vaccination without offering certain incentives.[6] Governments often allow exemptions to mandatory vaccinations for religious or philosophical reasons, but some believe that decreased rates of vaccination may cause loss of herd immunity, substantially increasing risks even to vaccinated individuals.[7]

Compulsory vaccination[edit]

Further information: Vaccine controversy

To eliminate the risk of disease outbreaks, at various times governments and other institutions established policies requiring vaccination. For example, an 1853 law required universal vaccination against smallpox in England and Wales, with fines levied on people who did not comply.[8] In the United States, the Supreme Court ruled in Jacobson v. Massachusetts (1905) that states could compel vaccination for the common good. Contemporary U.S. policies usually require children receive vaccinations before entering school, although many states allow for religious and personal exemptions due to philosophical or health reasons. A few other countries also follow this practice. Compulsory vaccination greatly reduces infection rates for associated diseases.[8] Beginning with nineteenth century early vaccination, these policies stirred resistance from a variety of groups, collectively called anti-vaccinationists, who objected on ethical, political, medical safety, religious, and other grounds. Common objections included claims of "excessive government intervention in personal matters" or that proposed vaccinations were not sufficiently safe. Many modern vaccination policies allow exemptions for people with compromised immune systems, allergies to vaccination components, or strongly held objections.[9]

1904 cartoon opposing the mandatory vaccination law in Brazil. "The Congress", depicted as a Roman Caesar, threatens "the People", in rags, with a sharp object and shackles.

In 1904 in the city of Rio de Janeiro, Brazil, following an urban renewal program that displaced many poor, a government program of mandatory smallpox vaccination triggered the so-called Vaccine Revolt, several days of rioting with considerable property damage and a number of deaths.[10]

Compulsory vaccination is a difficult policy issue, requiring authorities to balance public health with individual liberty:

"Vaccination is unique among de facto mandatory requirements in the modern era, requiring individuals to accept the injection of a medicine or medicinal agent into their bodies, and it has provoked a spirited opposition. This opposition began with the first vaccinations, has not ceased, and probably never will. From this realisation arises a difficult issue: how should the mainstream medical authorities approach the anti-vaccination movement? A passive reaction could be construed as endangering the health of society, whereas a heavy-handed approach can threaten the values of individual liberty and freedom of expression that we cherish."[11]

Investigation of different types of vaccination policy finds strong evidence for the effectiveness of standing orders, allowing healthcare workers without prescription authority (such as nurses) to administer vaccines in defined circumstances; sufficient evidence for the effectiveness of requiring vaccinations before attending child care and school;[12] and insufficient evidence to assess effectiveness of requiring vaccinations as a condition for hospital and other healthcare jobs.[13]

Policies and history by country[edit]

In 2006, the World Health Organization and UNICEF created the Global Immunization Vision and Strategy (GIVS). This organization created a ten-year strategy with four main goals:[14]

  • to immunize more people against more diseases
  • to introduce a range of newly available vaccines and technologies
  • to integrate other critical health interventions with immunization
  • to manage vaccination programmes within the context of global interdependence

The Global Vaccination Action Plan was created 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 "strengthen routine immunization to meet vaccination coverage targets; accelerate control of vaccine-preventable diseases with polio eradication as the first milestone; introduce new and improved vaccines and spur research and development for the next generation of vaccines and technologies".[15]

These global actions are telling to the progression of vaccinations. Living in a globalized world that is extremely connected, diseases that are preventable by vaccinations have become part of a larger public health movement: global herd immunity. These task forces and political campaigns that have erected in order to spread availability and knowledge of vaccination are modern attempts to protect the world from vaccination-preventable diseases.

Australia[edit]

In an effort to boost vaccination rates in Australia, the Australian government has decided that from 1 January 2016, certain benefits (such as the universal 'Family Allowance' welfare payments for parents of children) will no longer be available for conscientious objectors of vaccination; those with medical grounds for not vaccinating will continue to receive such benefits. The policy is supported by a majority of Australian parents as well as the Australian Medical Association (AMA) and Early Childhood Australia. In 2014, about 97 percent of children under 7 years have been vaccinated, though the number of conscientious objectors to vaccination have increased greatly.[16]

It has also been suggested to limit children's entry into school unless they were either vaccinated or their parents completed a statutory declaration refusing to immunise them, after discussion with a doctor. (Similar school-entry vaccination regulations have been in place in some parts of Canada for several years.)[citation needed]

The government began the Immunise Australia Program to increase national immunisation rates.[17] They fund a number of different vaccinations for certain groups of people. The intent is to encourage the most at-risk populations to get vaccinated.[18] The government maintains an immunization schedule.[19]

Republic of Ireland[edit]

In the Republic of Ireland, childhood vaccination (up to age 16) requires the consent of the parents. The Department of Health strongly recommend vaccinations.[20]

Malaysia[edit]

In Malaysia, mass vaccination is practised in public schools. The vaccines may be administered by a school nurse or a team of other medical staff from outside the school. All the children in a given school year are vaccinated as a cohort. For example, children may receive the oral polio vaccine in Year One of primary school (about six or seven years of age), the BCG in Year Six, and the MMR in Form Three of secondary school. Therefore, most people have received their core vaccines by the time they finish secondary school.[21]

Slovenia[edit]

According to a 2011 publication in CMAJ:[22]

Slovenia has one of the world’s most aggressive and comprehensive vaccination programs. Its program is mandatory for nine designated diseases. Within the first three months of life, infants must be vaccinated for tuberculosis, tetanus, polio, pertussis, and Haemophilus influenza type B. Within 18 months, vaccines are required for measles, mumps and rubella, and finally, before a child starts school, the child must be vaccinated for hepatitis B.

While a medical exemption request can be submitted to a committee, such an application for reasons of religion or conscience wouldn’t be acceptable, and isn’t allowed, says Alenka Kraigher, head of the communicable diseases and environmental health center at Slovenia’s National Institute of Public Health.

Failure to comply results in a fine and compliance rates top 95%, Kraigher says, adding that for nonmandatory vaccines, such as the one for human papilloma virus, coverage is below 50%.

Mandatory vaccination against measles was introduced in 1968 and since 1978, all children receive 2 doses of vaccine with a compliance rate of more than 95%.[23] For TBE, the vaccination rate in 2007 was estimated to be 12.4% of the general population in 2007. For comparison in neighboring Austria, 87% of the population is vaccinated against TBE.[24]

Pakistan[edit]

The Pakistani government in 2014 following a multitude of minor polio epidemics has now ruled that the polio vaccination is mandatory and indisputable. In a statement from Pakistanis police commissioner Riaz Khan Mehsud "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".

South Africa[edit]

The South African Vaccination and Immunisation Centre began in 2003 as an alliance between the South African Department of Health, vaccine industry, academic institutions and other stakeholders.[25] SAIVC works with WHO and the South African National Department of Health to educate, do research, provide technical support, and advocate. They work to increase rates of vaccination in order to improve the nation's health.

Latvia[edit]

According to a 2011 publication in CMAJ:[22]

Some nations, such as Latvia, say they have mandatory vaccination policies but contend that the notion of “mandatory” differs from that of other nations. “Vaccination is mandatory for state institutions and vaccination providers but for [the] public is recommended and offered free of charge,” Jurijs Perevoscikovs, head of the Epidemiological Safety and Public Health division of the Infectology Center of Latvia, writes in an email.

Vaccines that are not mandatory are not publicly funded, so the cost for those must be borne by parents or employers, she adds. Funded vaccinations include tuberculosis, diphtheria, measles, hepatitis B, human papilloma virus for 12-year-old girls, and tick-borne encephalitis until age 18 in endemic areas and for orphans.

Latvia also appears unique in that it compels health care providers to obtain the signatures of those who decline vaccination. Individuals have the right to refuse a vaccination, Perevoscikovs says. But if they do so, health providers have a duty to explain the health consequences and if the patient hasn’t been persuaded to change his mind, “the health care provider should draw up a refusal in writing which has to be confirmed with a signature by the person to be vaccinated.”

United Kingdom[edit]

Health experts have criticized media reporting of the MMR-autism controversy for triggering a decline in vaccination rates and a rise in the incidence of these diseases.[26] Before publication of Wakefield's findings, the inoculation rate for MMR in the UK was 92%; after publication, the rate dropped to below 80%. In 1998, there were 56 measles cases in the UK; by 2008, there were 1348 cases, with 2 confirmed deaths.[27]

United States[edit]

The Advisory Committee on Immunization Practices makes scientific recommendations which are generally followed by the federal government, state governments, and private health insurance companies.

States in the U.S. mandate immunization, or obtaining exemption, before children enroll in public school. Exemptions are typically for people who have compromised immune systems, allergies to the components used in vaccinations, or strongly held objections. All states but West Virginia and Mississippi allow religious exemptions, and twenty states allow parents to cite personal or philosophical objections. A widespread and growing number of parents claim religious and philosophical beliefs to get vaccination exemptions, and researchers have cited these exemptions as a contributing cause to an increasing number of disease outbreaks that have come from communities where herd immunity was lost due to insufficient vaccination.[28]

The American Academy of Pediatrics (AAP) notes the dilemma faced by many parents in that vaccines are a very safe and important health intervention, but are neither risk-free nor 100% effective. It advises physicians to respect the refusal of parents to vaccinate their child after adequate discussion, unless the child is put at significant risk of harm (e.g., during an epidemic, or after a deep and contaminated puncture wound); under such circumstances, the AAP states that parental refusal of immunization constitutes a form of medical neglect and should be reported to state child protective services agencies.[29]

See Vaccination schedule for the vaccination schedule used in the United States.

Immunizations are often compulsory for military enlistment in the U.S.[30]

All vaccines recommended by the U.S. government for its citizens are required for green card applicants.[31] This requirement has stirred controversy when it applied to HPV vaccine because of the cost of the vaccine, and because the other thirteen required vaccines prevent diseases which are spread by a respiratory route and are considered highly contagious.[32] Persons opposed to vaccinations in any form, can file a waiver request showing that your objection is based on religious beliefs or moral convictions, and that these beliefs are sincere. A waiver form, most likely using either Form I-601, or if you’re a refugee or asylee, Form I-602 is required, along with supporting documents & health examination. [33]

In schools[edit]

In the United States, school vaccination laws have played an instrumental role in the control of vaccine-preventable diseases. The first mandatory school vaccination requirement was enacted in the 1850s in Massachusetts to prevent the spread of smallpox.[34] The mandatory school vaccination requirement was decided after the implementation of the compulsory school attendance law. Mainly because it caused a rapid growth in children in public schools which would facilitate the spread of smallpox. The early movement towards school vaccination laws began in the local level as they included counties, cities, and boards of education. By 1827, Boston had become the first city to mandate all children entering public schools to demonstrate evidence of vaccinations.[34] In addition, in 1855 the Commonwealth of Massachusetts had established their own statewide mandatory vaccination requirements for all students entering school. It would influence other states to implement similar statewide vaccination laws in schools as seen in New York in 1862, Pennsylvania in 1895, and Connecticut in 1872 and later to the Midwest, South and West of the US. By 1963, 20 states had school vaccination laws.[34]

Yet, these school vaccination laws were not easily accepted by many and caused political debates throughout the United States. An example of this political turmoil and resistance was evident in Chicago in 1893 where less than 10 percent of the children were vaccinated regardless of the twelve year state law.[34] Resistance was seen in the local level of the school district as some local boards and superintendents opposed the state vaccination laws which led to the enforcement of state board health inspectors to examine vaccination polices in schools. Resistance proceeded even during the mid-1900s and in 1977 a nationwide Childhood Immunization Initiative was developed to increase vaccination levels in children to 90% by 1979.[35] During the two year period of observation, the initiative reviewed the immunization records of more than 28 million children and vaccinated children that needed to be vaccinated.

In 1922 the constitutionality of childhood vaccination would be examined in the Supreme Court case Zucht v. King. The court decided that a school could deny admission to children who failed to provide a certification of vaccination for the protection of the public health.[35] In 1987, a measles epidemic occurred in Maricopa County, Arizona and another court case, Maricopa County Health Department vs. Harmon, would examine the arguments of an individuals right to education over the states need to protect against the spread of disease. The court decided that it is prudent to take action to combat the spread of disease by denying un-vaccinated children back to school until the risk for the spread of measles was confirmed.[35]

Currently, in a push to eradicate Pertussis, Tetanus, Diphtheria, Polio, Measles, Mumps, Rubella, Varicella, and Hepatitis B from the population, schools across the United States require an updated immunization record for all incoming and returning students. While all states require an immunization record, this does not mean that all students must get vaccinated. Opting out is a state-by-state law; some states allow parents to opt out for a variety of reasons, but all states do require an immunization record at schools. Some of the exemptions for opting out of vaccination is due to medical conditions that increase the risk of having an adverse health effect or reaction due to the vaccine. Other reasons consist of religious beliefs and personal philosophical opposition to mandatory vaccination. As of 2014, 48 states allow religious exemptions except for Mississippi and West Virginia and some states even require proof of religious membership. In addition, only 18 states allow personal philosophical opposition to vaccination as a form of exemption.[36]

See also[edit]

References[edit]

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  33. ^ Template:Url=http://www.nolo.com/legal-encyclopedia/waivers-health-based-inadmissibility-us-green-card-applicants.html
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