Friday 24 May 2019

Vaccine wars: can we force parents to take action?

Recent measles outbreaks have reignited a firestorm of debate about the possibility of mandatory vaccination, writes Kathy Donaghy

Health Minister Simon Harris. Photo: Damien Eagers
Health Minister Simon Harris. Photo: Damien Eagers
Dr Andrew Wakefield, the doctor who was at the centre of the MMR row

Kathy Donaghy

We thought they'd been eradicated. But diseases like measles and mumps are on the increase both at home and abroad with the World Health Organisation (WHO) reporting that measles outbreaks have increased by 300pc in the first three months of this year.

This week Unicef warned 170 million children worldwide were unprotected from measles and said every child needed vaccination, whether rich or poor.

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The threat is now so serious that Health Minister Simon Harris is examining controversial proposals to make vaccination a condition of entry to Irish schools and crèches.

In Europe, 83,000 people developed measles last year, 15 times more than two years previously. The statistics have been on rise here, too, over the last three years. In 2016, there were 43 cases rising to 76 cases last year. According to the Department of Health, between January and March there were 49 cases of measles.

The figures for mumps are even more stark: so far this year there have been over 400 cases compared to 575 for the whole of last year.

Why? It's partly about vaccine hesitancy, which is defined by WHO as a "delay in acceptance or refusal of vaccines despite availability of vaccination services". The WHO has named this as a top global health threat.

But experts also believe that we have become a victim of our own success in nearly wiping out diseases that killed in the past.

This means generations of parents today have no knowledge of the ravages of a disease like measles.

In the case of measles, one in every 1,000 children who contract it will develop a serious brain infection. Measles can, in extreme cases, lead to blindness, deafness and death.

Even in healthy children, measles can lead to pneumonia, inflammation of the brain with encephalitis or meningitis-type symptoms. There have been deaths across Europe recently following the increase in cases.

Dr Andrew Wakefield, the doctor who was at the centre of the MMR row
Dr Andrew Wakefield, the doctor who was at the centre of the MMR row

A particularly sad - but thankfully rare - complication of measles is subacute sclerosing panencephalitis (SSPE) which causes brain degeneration many years after you've had the measles, and is always fatal.

Some European countries have taken the step of introducing compulsory vaccination against measles, mumps and rubella (MMR). The MMR vaccine in France and Italy is now mandatory.

A measles outbreak in Brooklyn prompted New York City to declare a public health emergency, requiring unvaccinated people in the affected areas to get the vaccine or face fines. Nearly 400 cases of measles have been reported in New York since last October.

Health Minister Simon Harris has said he believes that sending your child to school unvaccinated is an extraordinarily irresponsible and dangerous thing to do.

He has said he is studying proposals to ban unvaccinated children from schools and crèches.

Speaking to Review, Harris said he was asked a question about mandatory vaccination and he answered it with his gut as a minister and as a father. He and his wife welcomed their first child, a baby daughter, into the world earlier this year.

"The decision to vaccinate your child does not just affect you and your child - it's about the public good. When a minister says something about mandatory vaccination, it creates conversation - that's good. I will seek legal advice on that," he says.

Harris also wants to form a new coalition on vaccines made up of medical experts and patient advocates. "We have to get back on the pitch here. Far too much space has been given to anti-vaxxers. It's high time we started to push back," he says.

And the Minister says he wants to look at the training of health professionals as to how they communicate with parents about vaccination.

But would making vaccination mandatory be likely to work?

According to barrister Simon Mills SC, the Constitution recognises a sphere of autonomy in which parents can take decisions for their children. "

The precise question of whether or not parents can be required to vaccinate their children has never come before the courts, although there was one case in which one parent consented and one refused, and the consent of one parent was sufficient to allow the vaccination to go ahead.

"If a scheme of mandatory vaccination was introduced, then it would be a question ultimately of drafting that legislation very carefully so that its restrictions on parental rights was as limited as possible and its aim in protecting health was as clear as possible. It's possible that such legislation could be constitutional, but if it was introduced, it's probable that there would be a challenge to it," says Mills, a former medical doctor and co-author of the book Medical Law in Ireland.

Vaccination campaigns

One of the country's leading vaccine immunology experts, Dr Anne Moore, believes rigorous research and evidence would be needed before making vaccinations obligatory.

Moore, a senior lecturer in biochemistry and cell biology at University College Cork, says her personal opinion is that mandatory vaccinations may not be the solution. Instead, she believes the focus should be on bolstering public health initiatives to encourage people to vaccinate.

"We need to provide sufficient public health resources to ensure maximum vaccine access and uptake. We should focus our efforts on being even more successful in vaccination campaigns. We need to find out what people need to be less hesitant. Most people are accepting of vaccination. We need to ask what can we do to bring people into the conversation in an informed way," says Moore.

"When you don't see a disease flying around too often there's a perception that you don't need vaccination any more. The only reason we don't have them is because we have defences produced through vaccination," she says.

"If the protection throughout the community is high enough then the virus can't circulate in that community. Vaccines have decreased the amount of infectious diseases in the community. We've been able to eradicate diseases like smallpox because of vaccines; polio is on the cusp of eradication. In Ireland in the 1950s, the fear of children getting polio was huge and it was devastating when it hit communities, from a health perspective but also a societal aspect with respect to fear and isolation," she says.

Dr Lucy Jessop, director of Public Health at the HSE's National Immunisation Office, says it's important that as many people as possible vaccinate their children to ensure protection for everyone.

The latest figures compiled by the Health Protection Surveillance Centre show uptake of the MMR vaccine (that protects against measles, mumps and rubella) in Ireland is at 92pc by the age of two years old.

This may not be enough.

Measles is such a highly infectious disease, Jessop explains, that 95pc of the population need to be vaccinated to ensure the disease doesn't spread.

The relatively high MMR uptake figures suggest only a very small percentage of people oppose vaccines or avoid them for another reason. There are several reasons - other than distrust - why the small minority of children are not vaccinated. Some children with problems with their immune systems cannot receive the MMR and some parents may find vaccine appointments difficult to keep due to work and childcare commitments or language and cultural barriers.

But there is also a niggling doubt in some minds that leads back to the massive anti-MMR sentiment generated two decades ago by the since widely discredited research of British doctor Andrew Wakefield.

The gastroenterologist lost his job and had his scientific paper linking the MMR vaccine and autism retracted by medical journal The Lancet. In 2010, he was struck off the medical register. But despite study after study showing no link between autism and MMR, the seeds of doubt about vaccine safety that Wakefield sowed are still being reaped today.

Earlier this month, the HSE said it was dealing with a measles outbreak in Dublin with 10 recorded cases in children and young adults. And Jessop believes this most recent outbreak may be partly due to what she calls the "Wakefield cohort" - young adults whose parents did not vaccinate them as children and who have not realised that they are still vulnerable to infection as adults and so should be vaccinated.

Complications

"Measles can still be a very serious childhood illness but because of the high uptake of vaccine, not many parents know people who have had it. Unfortunately, cases are now occurring again and the consequences can be very serious with around three in 10 people developing complications and many being hospitalised," she says.

Such messages are still finding it hard to counter the hundreds of websites and millions of Facebook posts that argue vociferously against vaccination.

Those opposed to vaccination are typically deeply suspicious of the role of big pharmaceutical firms in promoting new vaccines and question the validity of mainstream scientific research.

The arguments for and against vaccination have become deeply polarised.

Being an "anti-vaxxer" in Ireland can be a tricky position to defend, even when that position is held very sincerely.

Karen (not her real name), a Dublin mother of one, has serious reservations about vaccinating her child because he had an adverse reaction to his first dose of vaccinations. Karen doesn't want to go into the specifics of his case because she fears repercussions for her and her son if she does. She says she has been stalked online for raising her concerns in the past. But she says she does not wish to vaccinate and is really upset and nervous for her child at the current suggestion of mandatory vaccination.

"People are really upset that this could mean you'd have to segregate your child in 2019. We're going backwards. Will we have to wear a star on our clothes or have some label attached to us? We're living in a time when we're supposed to be tolerant," says Karen.

"All we are doing is researching to make informed decisions based on our families. We shouldn't be attacked or abused, which is what is happening. We've been called emotional terrorists, told that we're selfish and that we're putting everyone else at risk. We are never allowed to put the questions we have to the Minister," she says.

"If my son wasn't here, I'd be going public with my name. The idea that all of us parents are stupid or that we don't understand - that's absurd. We are not allowed a voice. There's nothing from the Government to address our concerns. The point is, if you want to improve the safety of something you have to address the concerns that are coming up," she says.

At his family practice in Killester in north Dublin, Dr John Ball says the vast majority of parents are happy to vaccinate. "We listen to parents and we go through the diseases the vaccines covers against. The vast majority don't have any concerns," he says.

While Ball says other countries have adopted mandatory vaccination, it might not be that palatable to Irish people. "People need to understand that these diseases cause mortality. If we get more measles outbreaks causing children to die, we have look at all the possibilities that would prevent that," says Ball.

"If you do have fears around vaccination, try to address them early on. During your pregnancy, get your doctor to answer your questions. We're the ones providing the vaccination programme. If you wait until your child gets older, you're leaving them longer at risk," he adds.

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