Immunisation and public health

by Dr Con Costa

Recent disturbing data on the increased incidence of a number of 
infectious diseases in Australia has re-awakened the debate on attitudes to 
public immunisation programs.

Socialist medicine aims at the prevention of illness based on recognition 
of the basic right of citizens to good health and protection from disease 
by acting pre-emptively on all factors that threaten the health and well-
being not just of individual citizens but of the entire community.

Medicine thus serves the community as a whole, not as the sum of a number 
of non-related individuals but as a social whole, in marked contrast with 
the forces behind the market-driven medicine of contemporary capitalism, 
which direct attention to mainly curative procedures, with a resulting 
concentration on the treatment of individuals, and a marked tendency to 
favour the privileged and to ignore or minimise community concerns.

This difference has both economic and ideological origins, and it is 
particularly evident — with marked severity — in areas of public health, 
such as immunisation policies and priorities in health spending. Dr Con 
Costa, the President of the Doctors Reform Society, here examines some 
aspects of the immunisation debate.

Introduction

The major reason for declining childhood immunisation rates in 
Australia is a change in access to and delivery of appropriate medical 
services, increasing community complacency and the low priority accorded by 
by health authorities to this problem in recent years. An active anti-
immunisation lobby, while it is a factor, is not the major factor.

Falling immunisation rates are putting our children at considerable risk 
from preventable infectious diseases. Vaccination is not without risk, 
however, and vaccination programs should be restricted to specific, 
recognised pathogens to which there is no recognised alternative 
prevention. Inclusion of vaccines in such programs should be by a 
transparent decision-making process involving the community — not by non-
transparent decision-making involving only experts.

The Politics of Immunisation

Federal Health Minister Michael Wooldridge wants to make childhood 
immunisation a major health priority for his government's current term.

1)   Efforts to increase childhood vaccination rates deserve to be 
supported 1 but we must not forget that Wooldridge's 
immunisation push will demand new priorities in a health care sector 
already beset by many competing priorities. Other areas of public health, 
such as Aboriginal health, high rates of tobacco and alcohol-related deaths 
mortality, for example, may not get as much attention if already limited 
resources are diverted to support these new government initiatives.

2)   Vaccination is big business — a business which is getting even more 
lucrative, with almost unlimited "blue sky" for both technology and 
investors, while at the same time promising tremendous benefits to the 
community. Current developments include:

a) newer, safer, less reactogenic, and more effective vaccines;

b) single dose, slow release vaccines which will replace traditional three-
dose vaccines for tetanus, polio, etc;

c) combined or genetically-engineered polyvalent vaccines which will 
effectively immunise people against five, six or even more diseases with a 
single dose;

d) oral preparations will be used more often;

e) future vaccines will be used not only for prophylaxis but also in the 
management of certain diseases, including chronic infections and 
malignancies.

Newer vaccines will provoke better immune responses not only by activating 
the humoral (blood mediated) immune response, as with present vaccines, but 
also cell-mediated immune responses. Vaccines will thus induce immunity 
better than a natural infection. Recombinant (designer peptide) vaccines, 
which are already on the drawing board, will offer seemingly endless 
possibilities.

The most exciting step forward in vaccine technology is the use of naked 
DNA. The vaccine consists of genes for an antigenic portion of the organism 
or antigen. Naked DNA is being used experimentally to generate protective 
immunity against influenza, herpes simplex virus, HIV and TB. This 
technology has been developed only within the last five years yet already 
there are three clinical trials under way on humans.

In theory these vaccines will be cheap, stable, single-dose preparations. 
Of course, there are questions about the safety of using naked DNA in 
humans and the danger of the DNA integrating into host chromosomes, causing 
transformation or tumorogenesis, which must be answered. Such substances 
could persist in the tissues, and cause immunopathology, tolerance or 
antigenic competition. Designer vaccines could also cause long-term side 
effects, such as immunosuppression and chronic inflammation. 2 

Why Wooldridge's Immunisation Initiatives?

The major reason for falling immunisation rates in Australia has to do, as 
we have said, with changes to service delivery and access, low priority 
accorded to it by health authorities, and community complacency — 
not the influence of the anti-immunisation lobby.

In the past, 80 per cent of the children immunised in Victoria were treated 
through the public system, and only 20 per cent in the private sector, i.e. 
by GPs. In New South Wales, 50 per cent were vaccinated in the public 
sector, as part of, for example, council immunisation programs, infant and 
child health centres, and so on, and 50 per cent privately,

There have been changes to the way that immunisation programs are funded. 
Public service provision has been whittled away over the last five to ten 
years. The Federal Government used to provide an allocation for vaccine 
services to each State. This meant that doctors got vaccines free of charge 
from the State government, usually from the local government or from 
hospitals. This responsibility has now been devolved to the States, with 
loss of Federal control.

Nurses Shut Out

Nurses have always had a more personal approach with mothers and parents, 
being able to communicate better than doctors with parents. However, nurse 
involvement in child immunisation is now almost negligible.

The 80 per cent of child immunisation previously provided by the public 
sector in Victoria and mainly dependent on nurse support, has now been 
replaced by reliance on over-worked family GPs working on their own, in 
spite of the fact that immunisation has never been the traditional domain 
of GPs, although they are now more happy to accept "extra work" as their 
traditional base is worn away by specialists.

The "fatigue factor" — too many vaccines and injections — now affects GPs 
more than parents or nurses! This is more the case today, since the recent 
addition of more vaccines to the immunisation schedule; introduction of HIM 
(Haemophilus influenza type B) as well as Hepatitis B vaccine for "high 
risk" children has meant an extra six injections in their first five years 
for some children. Research shows that it is the providers, i.e. GPs, who 
are wary of giving an increasing number of injections to the children, 
rather than consumer disenchantment. 3

GPs in Australia have largely itinerant populations, and no provision for 
monitoring or following-up treated children. In spite of this drawback, 
many busy parents in today's stressful world have little time to take their 
children to council-sponsored vaccination days, and tend to turn to private 
GP more convenient.

Against this background, the Federal Health Minister Michael Wooldridge has 
introduced the National Childhood Immunisation Register. This is an attempt 
to address the fragmentation of immunisation services, as well as providing 
some monetary incentives for both doctors and parents.

Unfortunately, indications to date are that large numbers of GPs are 
ignoring the Register, and not filling out vaccination forms despite a $6 
incentive per notification form. It follows that the Register is not 
working as a means of monitoring vaccination rates and their side-effects.

The Australian Scene

In Australia, where early childhood vaccination is non-compulsory, 
vaccination levels are declining alarmingly.

The cause for alarm is twofold. When vaccination rates fall, they expose 
the entire community to outbreaks of preventable infectious disease, 
affecting non-vaccinated children as well as a lesser proportion of 
vaccinated children, as vaccination is never 100 per cent effective.

This is explained by the phenomenon of "herd immunity", where a certain 
number in the community must be vaccinated in order to stop the spread of 
an infectious disease — with the exception of tetanus, which is not spread 
by airborne droplets but by spores which are ever-present in the 
environment.

The percentage of the population that needs to be immunised for "herd 
immunity" to be effective varies from disease to disease. With haemophilus 
influenza, the herd immunity figure could be as low as 50 per cent of the 
population, but for other infectious diseases it is much closer to 80 or 90 
per cent. As vaccination is never 100 per cent effective, almost all 
children need to be vaccinated to achieve such figures.

In the past, the community could support a small number of "conscientious 
objectors". The fact that the vast majority of the population were 
vaccinated meant that the small number of unvaccinated subjects were also 
protected from infection. In effect, the "conscientious objectors" 
benefitted from the social responsibility of the rest. In the former 
socialist countries, however, vaccination was compulsory.

Thus to opt for non-immunisation is no longer the easy cop-out that it was 
in the past. With community immunisation levels now below 50 per cent, it 
is almost certain that many children could suffer multiple infectious 
diseases, and that we may even see a resurgence of diseases such as polio 
and its crippling side-effects.

No-one claims that immunisation is either 100 per cent safe or 100 per cent 
effective. What the medical profession is saying is let's not get 
complacent. Vaccination programs have led to a reduction of deaths, 
disabilities and suffering from diseases which are, essentially, not 
curable nor effectively treatable.

Unfortunately, the very success of vaccination programs in the past, 
leading to absence of these diseases in our community, can be their 
undoing. In a risk-benefit equation, a parent may say, "why should I take a 
one-in-a-million risk of contracting encephalitis from the vaccine when I 
have never heard of nor seen this disease in my community?"

We take risks every day. Crossing the road involves risk, as does getting 
in a motor car, swimming at the beach, drinking a glass of water or eating 
fast foods all involve risk. Vaccines do have a downside of local reactions 
in the muscle tissue, short febrile illness, or rare major side-effects. 
All this needs to be fully explained to parents before vaccination takes 
place. But the benefits to the individual and the community are immense and 
life-long.

In Australia between 1978 and 1993 there were 200 recorded deaths from 
infectious diseases that could have been prevented by immunisation — three 
deaths from Diphtheria, 165 deaths from measles, 19 deaths from whooping 
cough, three from polio and 37 from tetanus.

There is no cure for these infectious diseases. Once a child is infected, 
treatment is largely supportive, with a "wait-and-see" approach. Most 
children will suffer a debilitating illness and some may even die or be 
left with permanent sequelae. The only cure is prevention.

When Governor Phillip explored the Pittwater area around Sydney in the late 
1780s, almost the entire Guringai tribe was wiped out by smallpox, because 
the Aboriginal people had no natural immunity to smallpox, while it was 
endemic in the white settler population.

In fact, one of the greatest successes of vaccination programs is the case 
of smallpox. This was completely eradicated worldwide as a result of an 
aggressive international immunisation program achieving high vaccination 
rates, based on principles of herd immunity. A killer disease was 
completely eradicated by a global vaccination program.

The Anti-Immunisation Lobby

This lobby has its roots in mainly middle-income groups, i.e. those with 
high school or university educations. Being a more literate group, it is 
easily targetted by anti-immunisation propaganda cleverly dressed up as 
"science".

As a result, we almost need an outbreak of preventable disease (and there 
have been four recent deaths from pertussis, with all the associated 
suffering for children and parents) to remind people that these diseases 
still exist.

The anti-immunisation lobby seems to take a parochial view, i.e. "vaccines 
are not necessary in Australia because of the generally high standard of 
living and relative absence of vaccine preventable disease".

But a disease such as tetanus is always present. It results from a minor, 
rather than a major, wound, when tetanus spores enter a small puncture 
wound in the skin. If children are not vaccinated, the alternative is to 
give penicillin routinely, especially for all minor wounds. Apart 
from the feasibility of such a procedure, one must question the widespread 
use of antibiotics in such a way, given the marked negative consequences of 
their over-use and mis-use that is already evident on a world scale.

The anti-immunisationists, who probably overlap with the anti-western-
science lobby, run a campaign which couches its rhetoric in "science". To 
the uninitiated and particularly to those who may have reason to be 
sceptical of the system, this can be very convincing. However, much more 
information is now freely available to the community, giving a more 
complete and balanced picture of immunisation.

It is hard to avoid the feeling that the anti-immunisation lobby wants to 
have it "a bit both ways". If vaccines "don't work" or "cause the disease 
instead of preventing it", as is alleged, it follows that vaccination 
should be opposed internationally as well as nationally, that is, in those 
impoverished communities where vaccine-preventable disease is rife, and 
where alternative prevention or adequate health services are absent.

Does the anti-immunisation lobby advocate no vaccination programs in 
Aboriginal communities? Or in former colonial countries in the under-
developed world, where one can see daily on the streets many people 
affected by the sequelae of polio? At best, and with reason, the world 
would laugh at us. More likely they would consider such a stance arrogant 
and self-centred.

Valid Concerns

Not that there are not valid concerns about vaccination and vaccination 
programs. 4

1.   Vaccination against infectious diseases is obviously not the only 
answer. Clean water, sanitation, and better living conditions are a major 
factor demanding attention. And the introduction of any vaccination 
programs needs to be strictly controlled and only for specific, 
recognised pathogens for which there are no known alternative treatments. 
Vaccination should not be a substitute for better living standards 
both nationally and globally.

For example, overseas medical experts working in the cholera hospital in 
Dacca (Bangladesh) were not routinely vaccinated against cholera. They did 
not drink from contaminated water sources, and therefore the risk of 
cholera was negligible, and so there was no need to vaccinate.

2.   Transnational drug companies are making huge profits from vaccination, 
but future growth will be even more staggering as a lot of new technology 
kicks in. These transnationals have a lot of say at high government levels, 
and can also influence "expert" committees, especially as government 
cutbacks lead to down-sizing (some would say "dumb-sizing"). We is needed 
is a transparent decision-making process involving consumers, which means 
parents and citizens, though not just for vaccination but in all areas of 
health planning.

3.   Much more information for parents is needed, and much more 
information, training and support for doctors who provide 
vaccination services, including provision of nurse support. GPs and primary 
health care services would benefit much more from immunisation nurses than 
from token payments in return for immunising children.

4.   Vaccination programs need to be much more closely supervised and 
monitored, including cold chain and storage of vaccines as well as post-
immunisation monitoring, services that are constantly eroded by cuts in 
government funding. If for this reason alone, anti-immunisationists should 
support the National Childhood Immunisation Register.

Summary and List of Demands

* Low immunisation rates in Australia are mainly the result 
of cuts in the health services and of increasing inequities in accessing 
public health services. This will worsen with the present trend towards a 
two-tier, Americanised health system.

* The Federal Government's immunisation initiatives can be 
supported, but will need to be tested regularly to monitor progress. They 
are initiatives which must not be evaluated isolation, however, but against 
the background of competing health priorities, including woeful Aboriginal 
health statistics, unacceptably high levels of alcohol-and tobacco-related 
deaths, high youth suicide rates, and so on.

* Nurses, who have established the best rapport with 
parents, have been virtually cut out of the system. Over-worked GPs have 
been thrust into the unaccustomed role of immunisation providers without 
adequate support, and are most susceptible to the fatigue factor introduced 
by "too many vaccines". At the local level, parents should be provided with 
all possible information and full counselling prior to vaccination. This 
means that immunisation nurses should be available at any vaccination 
point.

* The National Childhood Immunisation Register has not been 
the success that was hoped. Whether GPs can deliver the goods and whether 
the Register can be made to work is yet to be seen. Provision of nurse 
support for immunisation, including in the field of private general 
practice, is the way to go. The small economic incentives at present given 
to GPs should be passed on to the parents.

* Scientific progress with the development of new acellular 
pertussis vaccines as well as the introduction of pentavalent vaccines at 
present under trial, will make things easier but at a much higher cost. The 
task of convincing governments to fund higher-cost vaccine programs without 
diverting funds from other areas of the health system will be a challenging 
one, but without government subsidies these vaccines will be available only 
for the wealthy.

* We need to address community concerns about the risks at 
present  involved in vaccinating children, especially at a time when the 
benefits are hard to see. Side-effects ranging from an unhappy child for 
several days to the very rare risk of more serious consequences can weigh 
heavily on the parent's mind. This is even more relevant if the National 
Childhood Immunisation Register, which was meant to track side-effects, is 
not working.

* At the Federal level the community should have a strong 
input in decisions regarding vaccination schedules, and only specific 
pathogens for which there is no known alternative prevention should be 
included, and this should be by a decision-making process fully involving 
the community, and particularly parents.

* If present government initiatives are not successful, we 
may need to look at some way to reward parents who are vaccinating their 
children, including penalties for those who are failing to do so, such as 
1) higher Medicare levies to cover the extra health costs for unvaccinated 
children, as well as 2) stricter school entry requirements and 3) exclusion 
of unvaccinated children from broader social contacts during disease 
outbreaks or epidemics.

* Compulsion, as in the case of seatbelts in cars and crash 
helmets for cyclists and motorcyclists, is not appropriate, nor is it 
likely in the Australian content.

* * *


Notes

(1)   Let us assume Wooldridge is serious, and set aside cynicism about his 
government's anti-people health agenda and its cutbacks to Medicare and the 
public system, which is causing significant morbidity from infectious 
diseases due to falling standards and inadequate regulation and 
legislation, such as, for example, the E Coli outbreak causing haemolytic 
uraemic syndrome, and Salmonella outbreaks, in Victoria and South 
Australia. Public hospitals continue to be starved of funds to the tune of 
$500-600 million, which is given instead to private health funds. Primary 
health care is being attacked by cuts to the Medicare rebate and by 
restrictions on doctors entering general practice — many people wait days 
to see their GP, and bulk-billing is becoming rare in all but the major 
cities.

(2)   Margaret Burgess, Australian Centre for Immunisation Research, Royal 
Alexandria Hospital for Children, Sydney.

(3)  The introduction of pentavalent vaccines in the near future, with 
single injections containing five vaccines may solve provider fatigue 
problems. These are under trial at present. The pentavalent vaccines will 
cost more, as will the introduction of the newer generation acellular 
vaccine for whooping cough which has dramatically less side-effects. Will 
the Federal Government put its money where its mouth is, and fund these 
more expensive vaccines?

(4)  Most concerns, however, stem from poor delivery of health services, 
including the fee-for-service system, and a private medical system which 
operates by piecework and excludes the possibility of a holistic, teamwork 
approach. Many people are disgruntled with "five-minute medicine", 
especially in the provision of health care for the elderly and the 
chronically ill. Medical services are very much better provided and served 
by a salaried system based on a teamwork approach. In such a context, 
Medicare, even though it is under fierce attack by the present government, 
is only a first step to health-care reform in this country.