Compulsory childhood vaccination

Abstract

The UK faces an outbreak of measles virus infection on a scale not seen since vaccination became available. Figures released in February for England and Wales show a 36% rise in confirmed cases of measles, from 990 in 2007 to 1348 in 2008, the highest number since monitoring was introduced in 1995. A further 382 cases were reported in the first 3 months of this year. According to the Health Protection Agency, most cases are among children who have not been fully vaccinated with the combined measles, mumps, and rubella (MMR) vaccine. Across the UK, one in five children do not receive both doses of MMR vaccine by the age of 5 years. An irony of this situation is that worldwide the number of measles deaths fell by 74% in the 7 years leading up to 2007 (197 000 deaths) because of the success of vaccination programmes. In response to the rise in measles cases, Sir Sandy Macara, former chairman of the British Medical Association, has called for vaccination to be made compulsory. He is quoted as saying, “we ought to consider making a link which, in effect, would make it compulsory for children to be immunised if they are to receive the benefit of a free education from the state”. Similarly, in Wales (where health is the responsibility of the devolved government) health minister Edwina Hart was reported to be exploring compulsory vaccination. Wales has been struck by its largest measles outbreak for 20 years, with 264 confirmed cases as of June 4, of whom 32 required hospital treatment. Mandating childhood vaccination before school admission is hardly a new notion, being the situation in the USA, Spain, Greece, and most of Australia. But is it the solution to low vaccine uptake? There can be little doubt that parental concern about vaccination with MMR arose from publication by Andrew Wakefield and colleagues in The Lancet in 1998 of a small case series showing a new form of inflammatory bowel disease in children with autism. The parents of some of the children described in the paper reported that MMR vaccination preceded the onset of autism. Unfortunately, at a press conference, Wakefield recommended in a seemingly arbitrary fashion that single vaccines be given rather than the combined MMR vaccine. Subsequent irresponsible coverage by some parts of the mass media in the UK led to a fall in the MMR take-up rate to a level below that necessary for herd immunity. The link between MMR and autism suggested in the Wakefield paper has been discounted by an overwhelming body of more rigorous research; indeed, there has been a partial retraction of the paper by most of its authors. Nevertheless, at a time of low public confidence in government, the suspicion persists among a substantial minority of people that vaccination is not as safe as health authorities make it out to be. This mindset is not aided by an anti-vaccination lobby for whom weight of evidence and rationality are anathema. Thus compulsion would fall on the set of parents least likely to respond favourably to an imposition on their freedom of choice. A repetition of scenes in Maryland, USA, in 2007, when 800 parents of unvaccinated children were forced through the courts under the supervision of the police, hardly seems desirable or appropriate. In a democratic society, a new compulsory scheme would have to make provision for exceptions—for both parents and doctors—on conscientious, religious, or medical grounds that might render it worthless. And would non-compliant parents be sent to jail while their children were forcibly immunised? Better, we think, that parents are allowed to make a choice based on provision of facts rather than fear of the courts. By and large, parents will make the right choices for their families if provided with the best information. Although appropriate information is available to parents, the UK government has seemed reluctant to publicise widely the benefits of MMR, for fear that this might just reignite controversy over the vaccine's safety and have a counterproductive effect. Given the rising number of measles cases, which will help balance in the public mind the very real risk of disease against the tiny risk of vaccination, now might be the time for government to promote actively the vital role of immunisation. Indeed, in Wales, MMR uptake has started to rise as the ongoing outbreak becomes a public health concern. There might also be a place for offering catch-up vaccination at the time children enrol in primary school. A more proactive approach to reaching the necessary 95% vaccination rate is warranted, but compulsion is not the way forward.