Katrina Clarke | Feb. 6, 2015 | Toronto Star
As measles outbreaks spread across North America, one question is creeping back into the public health discourse: Are compulsory vaccines in the interest of the greater good?
On Friday, public health officials confirmed there are now six cases of the highly infectious, potentially deadly disease in Toronto. At least three patients were not vaccinated — no great surprise considering while public health bodies push for vaccines and the province has legislation mandating measles vaccinations for children — people can easily slip through the cracks.
“This is always the tension in public health,” said Dr. Vinita Dubey, associate medical officer of health with Toronto Public Health. “To what point you have to balance an individual’s rights versus the rights of the public in general — that’s a balancing act.”
The balancing act works well so long as the “herd immunity” — the rate of people vaccinated necessary to limit a widespread outbreak and protect vulnerable people — remains high. Public health officials say an effective herd immunity rate for measles is above 95 per cent.
“The point of vaccines in general is you’re protecting yourself but you’re also protecting the people around you,” she said. “While you think the vaccination is just about your child — it’s not.”
But arguments about the greater good aren’t good enough to sway hesitant parents.
“What researchers have found is that parents respond far more positively to arguments about the personal benefits of vaccinating their children than to talk about the community benefits,” said Jason Schwartz, a fellow at Princeton University’s Center for Human Values who studies vaccine policy. “They put their child first and foremost.”
Schwartz said this sociological observation makes it all the more important to stress the “clear benefits” of getting their child vaccinated.
“We need to make the point… that even though these vaccine-preventable diseases seem rare, they seem remote, that’s not the case – that the risks are there even if we haven’t seen them,” he said.
In fact, Schwartz sees the current U.S. measles outbreak — which began at California’s Disneyland in December and has now infected upwards of 100 people — as a possible “tipping point” for vaccine hesitant parents, numbers of which have been growing in the U.S.
“There is a clear example of the consequences of not vaccinating,” he said.
Sociological observations aside, questions remain about whether or not the option should even be available for parents to not vaccinate their children.
In Ontario, parents can complete a “statement of conscience or religious belief” form, which must be signed by a commissioner of oaths. Parents don’t need to provide an explanation for why they want this form. There is also a medical exemption form for those who cannot have vaccinations for medical reasons.
Some argue these regulations need to be tightened in the interest of the public good.
“I think we could do away with the personal exemptions easily,” said Maya Goldenberg, an associate professor of philosophy at the University of Guelph who is writing a book on vaccine hesitancy.
Goldenberg said other warranted actions could include banning children with non-medical exemptions from public schools and daycares. She also suggested parents could sue other families if their vulnerable child contracts the disease.
The vulnerable people for whom MMR (measles, mumps and rubella) vaccinations aren’t recommended include babies under the age of 12 months and people with compromised immune systems, such as those with HIV or undergoing chemotherapy. However, even 5 per cent of people who are vaccinated and those born before 1970, who are presumed to have immunity, can still catch the disease – as was the case in two of the Toronto patients.
Symptoms of the disease include a rash and cold-like symptoms. Around 10 per cent of people will experience complications including ear infections, pneumonia or encephalitis, or brain swelling. One in 3,000 infected people may die.
“We make lots of things mandatory from a public health point of view,” said Joel Lexchin, an emergency department physician who teaches health policy at York University, citing the example of laws against drinking and driving and requirements that children get an education.
“Unless you’ve got a medical condition that prevents you from being vaccinated, there’s an obligation to (get vaccinated) – not necessarily just for yourself but for everybody else,” he said. “It’s forcing people to do things that they might not want to do.”
But even with of the ethical implications of exposing vulnerable children to a potentially deadly disease, Goldenberg doesn’t think compulsory vaccinations are the solution.
“It’s not the parents’ choice to not vaccinate the child that is what everyone is upset about right now. What they’re upset about is the risk it presents to other people — to other innocent people. And there are ways of doing that that don’t need to involve forcing vaccination,” she said.
The experts the Star spoke with overwhelmingly settled on a position that argued for education, not legislation.
Despite arguments about the social contract and the greater good, the risks of imposing compulsory vaccines likely outweigh the rewards, they said.
“I don’t think we’re going to fix this through regulation,” said New Democratic Party MPP and heath critic France Gelinas. “That’s the way to get a whole bunch of young mothers mad.”
Historically, attempts to introduce mandatory vaccinations have only resulted in driving resistors underground and deepening the divide between pro and anti-vaxxers.
However, tweaks to Ontario’s system were recommended by many, including Gelinas and Dr. Vinita Dubey at Toronto Public Health. They say parents requesting non-medical exemptions should be required to speak with a health professional.
In fact, a similar recommendation was made by an advisory committee established by the Chief Medical Officer of Health in March 2014.
“For example, local public health units could offer to notarize philosophical exemptions and use that opportunity to educate parents about the risks,” read the Advisory Committee for Ontario’s Immunization System Review report.
In an email to the Star, Ontario’s Health Minister Eric Hoskins suggested the rules around exemptions could one day be re-examined.
“Our goal is to see as many Ontarians receive vaccinations as possible. As with all our policies, we are constantly looking for ways to improve patient safety and enhance our policies — and that includes looking at the rules around exemptions,” he said.
But even requiring an interaction with a health professional might not change the minds of vaccine-hesitant parents.
Alison Thompson, an assistant professor in the Leslie Dann Faculty of Pharmacy and the Dalla Lana School of Public Health at the University of Toronto, conducted a qualitative study in 2012 to 2013 looking at vaccine skeptical Toronto parents.
She interviewed 12 mothers, all of whom had strikingly similar stories — they were all white, upper middle class, university educated and had researched childhood vaccines thoroughly.
“In many respects I think public health has created them,” said Thompson. “They’re like these hyper-vigilant, risk-averse people who are just trying to do what’s right for their kids.”
They are also the parents who ask their doctors, “What’s in the needle?” and are frustrated when they don’t get answers, she said.
“You create these people who are kind of skeptical by nature of all these risks and when you ask them to trust blindly that all these things are safe, they don’t,” Thompson said.
Some of the women were selective about vaccines —accepting some and rejecting others. They relied on their “mom network” of friends for information but also regularly visited family doctors. They had mistrust in “Big Pharma” but rejected studies from the likes of Andrew Wakefield, a former surgeon who authored a now-discredited 1998 research paper purporting to link vaccines to autism.
They wanted a guarantee their child would not have negative side effects from the MMR vaccine — some people experience a fever or rash. Serious reactions are rare.
“You can’t say that this little boy in front of me right now will not get injured (by the vaccine),” she said.
Thompson said many of the mothers were aware of the danger their children could pose to others but thought they could combat the risks with “health strategies,” such as isolating a child if they caught measles. They weren’t aware children are contagious four days before they get the telltale rash, she said.
Forcing vaccines on these steadfast parents would not only be ineffective — likely prompting anger and pushback — but could also infringe on their human and Charter rights, say experts.
“You don’t want, in a free and just society, to punish people for their beliefs,” said Dr. Ross Upshur, head of the clinical public health division at the University of Toronto’s Dalla Lana School of Public Health. “Compulsory vaccination … would actually, in some eyes, be considered assault because you would be forcibly asking somebody to accept a medical intervention against their will.”
For the time being, Ontario’s vaccination rates are high enough that an outcry over the exemption forms is unlikely, unless rates change or the outbreak explodes.
But the North American outbreak has experts thinking seriously — where should we draw the legislative line when it comes to allowing non-medical vaccination exemptions to exist?
“It needs to be a very big dialogue. It can’t just start with politicians. Policy makers have to be involved, healthcare professionals have to be involved, parents themselves also need their voice heard,” said Dubey. “Proactively, we should definitely start having those conversations in Ontario and Canada.”