Analysis: Is it time for a compulsory vaccination strategy?

The MMR jab has hit the headlines once again amid calls for the vaccination to be made compulsory for young children, following large outbreaks of measles in England and Wales.

Sir Sandy Macara, former chairman of the British Medical Association (BMA), and Welsh Health Minister Edwina Hart have both spoken out about the possibility of making MMR an entry requirement for all children at nurseries and schools (news, 11 June).

Sir Sandy argued, 'Our attempts to persuade people have failed. The suggestion is that 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.'

More than 286 cases of measles have been reported in Wales and 84 cases have been confirmed in the north-east of England since the outbreaks began in April. Four babies from Hapus Dyrfa, a nursery in Carmarthenshire, Wales, had to be hospitalised (news, 27 Mary 2009; see box). The Welsh National Public Health Service has also noted a huge rise in mumps, with 422 cases confirmed since January, compared with only 329 cases for the whole of 2008.

The rise in measles has been blamed on a low up-take of the MMR jab, which fell from 92 per cent of two-year-olds in 1995 to 79 per cent in 2003, when parents had become anxious about a possible link between the MMR and autism and certain diseases.

At the moment only around 85 per cent of two-year-olds in England and Wales have been given the MMR vaccine. In some schools the rate is thought to be as low as 15 per cent. MMR is usually administered at the age of 12 months and before children start school. To successfully eliminate measles, 95 per cent of a country's population needs to be immunised with the two doses.

FOR AND AGAINST

The arguments for and against compulsory vaccination hinge on children's right to healthcare, parents' right to choice, and the right of the community to be protected from preventable infectious diseases (See 'More information'.)

Supporters of compulsory vaccination, which already takes place in the US, Spain and Greece, argue that children's rights to basic healthcare should override any concern over parental choice. They also argue that measles is a public - not an individual - health concern. Children who are too young to have had both MMR jabs or who cannot be immunised for other reasons rely on a high take-up among the rest of the population to protect them from exposure to a disease that can lead to hearing loss, brain inflammation and even death.

Writing in The Guardian, journalist James Randerson criticised the 'selfishness' of parents who refuse to give their child the MMR jab, after his 11-month-old daughter fell ill with measles in May. He wrote, 'The decision by many of my neighbours not to vaccinate their children is on a par with the drunk who decides to get into his car to drive home. It is a personally reckless action that endangers the lives of everyone else on the road.'

Health experts also argue against splitting up the MMR and administering each component separately as an alternative for parents who are still wary of the combined jab. A 2003 BMA report into childhood immunisation, which considered the case for compulsory vaccination, said, 'There are no health benefits for single vaccines and a number of reasons why they are not the best option. They leave children vulnerable to disease for longer, because vaccination takes longer to complete when single vaccines are administered. In general, fewer children complete the course when single vaccines are used.'

Nursery World found little support for compulsory vaccination from policymakers and health experts, who say that it would be impossible to enforce and might even reduce the uptake.

A spokesperson for the Department of Health said, 'Our strategy is to maintain a voluntary immunisation system and invest efforts in educating parents about the benefits of vaccination and dispelling myths about vaccine safety. We have an MMR Catch-Up programme now in progress and continue to work with the NHS to get more children protected. The campaign will help to reduce the number of cases of measles and also help ensure that children are protected against mumps and rubella.'

Dr Helen Bedford of the Royal College of Paediatrics and Child Health highlights the findings of other countries where compulsory vaccination is already in place. 'In the USA, parents have to show an immunisation certificate or an exemption on religious or philosophical grounds,' she says. 'Some parents then delay vaccination until their child is at school age, which means that children are left unprotected for longer periods.

'The second problem with compulsory vaccination is that there would have to be exemption clauses, for example, on religious grounds. In the USA there are websites that tell you how to set up your own church just so that your child can be exempted from being immunised. The net effect is that countries that have compulsory vaccination do not necessarily have a better vaccination uptake.'

Peter Black, health spokesman for the Welsh Liberal Democrats, has called for a public awareness campaign to promote MMR. He says, 'I am not a big supporter of compulsory immunisation. I think there are issues in terms of trying to force a child to have an injection under stress with parents who are resistant to the idea of vaccines.'

Mr Black notes that measles has not received the same attention as other public health scares. 'Every household in the country received a leaflet with information on swine flu, but this has never been done with MMR. We need to counter the bad press that the vaccine has had and educate everybody, not just parents but anyone who comes into contact with children. Everyone needs to know what the problems are with the alternatives to the MMR vaccine and what the risk of low uptake is.'

FOR THE RECORD

Dr Bedford thinks nurseries and schools should keep records of all children's immunisation status.

'I think that nurseries and children's centres should be actively promoting vaccinations and checking a child's immunisation status on entry,' she says. 'Not to exclude any children, but if there is an outbreak of measles it would be very easy to identify which children are at a greater risk of infection. This would help to prevent the infection from spreading and protect individual children.'

She adds, 'It is important to remember, also, that lots of children are not immunised, not because their parents are against the vaccine, but just because they have forgotten. Checking children's immunisation status would act as a reminder.'

Purnima Tanuku, chief executive of the National Day Nurseries Association, agrees that there is much that early years settings can do to help prevent a measles epidemic. She says, 'With the MMR jab it is important that nurseries support parental choice and beliefs. But they can help families make an informed choice by signposting to sources of advice and providing leaflets. Some nurseries also invite health visitors to speak to parents at the setting and discuss any concerns.

'It is also very important that nurseries have a clear policy outlining the procedure the setting will follow in the event of any outbreak,' Ms Tanuku adds. 'This should not only cover what staff need to do should they suspect a child has a communicable infection, but also how the nursery will inform the relevant regulatory body and the Health Protection Agency. These organisations can then provide further information and advice about dealing with the infection, and advise whether the nursery needs to close for a period of time to avoid an outbreak.'

MEASLES AT THE NURSERY

Having detailed policies on dealing with infectious diseases is vital, says Sioned Saer, co-owner of Carmarthenshire nursery Hapus Dyrfa, where four children, under the age of two, contracted measles.

She says, 'We have reviewed our policies since the outbreak. We now feel that staff are more aware of specific procedures and that parents are more confident.

'We also reviewed the information we ask for when parents register their child. We now ask about children's vaccination status so we know who is and isn't vaccinated. We ask parents to co-operate and work with us so we can update our database. If anything like this happens again we will be better informed and can act even more quickly.'

Nursery staff also now actively help to promote the MMR jab to parents. 'Since the outbreak we have had leaflets at reception and contact numbers and we tell parents that if they have any questions they should speak to us or contact the board of public health,' says Ms Saer.

'We feel we have helped to raise awareness and that there is now improved knowledge all round. It was a very frightening experience, but we hope that something positive has come out of it - it is just sad that four babies had to be hospitalised for it to happen.'

More information:

- www.immunisation.nhs.uk/Vaccines/MMR

- www.hpa.org.uk

- 'Should childhood immunisation be compulsory?' by P Bradley, Journal of Medical Ethics, 1999; 25:330-334, http://ukpmc.ac.uk/articlerender.cgi?artid=1311707

- Childhood Immunisation: a guide for healthcare professionals (BMA, 2003), www.bma.org.uk/health_promotion_ethics/vaccination_immunisation/immunisa tion.jsp