In the second of our blogs on immunisation (the first asks whether you should get your child immunised – the answer being, for the good of all of us, a resounding yes!), Jess gives a brief overview of how immunisation works, looks at the current state of immunisation in New Zealand (it is good news) and why the poor and sick are the ones that lose out when people choose not to have children immunised.
As we covered in our last blog, vaccinations are effective at preventing disease, though they are not without risks. However, the risks from vaccines are far less than those from catching the disease itself. The crucial thing is that the more people that are vaccinated, the lower the chances are that non-vaccinated people can contract the disease in question. The key target is 95% coverage, where we reach something called ‘herd immunity’ – effectively the 5% not vaccinated are safe too. However, that doesn’t mean 5% of society should opt out of vaccinations – we need that 5% for the vulnerable kids that for various reasons can’t get immunised – e.g. kids with cancer receiving treatments, who can’t handle a vaccine and have a high chance of dying if they contract a disease.
Progress is good, but we aren’t there yet
In general NZ is a nation of vaccinators, our latest coverage rates at 6 months of age (an age when children are really vulnerable to disease) are up near 80% and have been steadily climbing since the introduction of a National Immunisation Register in 2005. The register helps keep track of children and their vaccinations, and ensures parents and GPs know when a child is due for their booster and when they have missed one. In 2005 various outreach programmes to improve uptake in vulnerable groups were also implemented. Even better news is that at 8 months and 2 years of age our overall coverage rates are past 90% – this is edging ever closer to the magic number of 95% of children being fully immunised (when herd immunity is reached).
So if 95% is the target, who do we need to get vaccinated? There are two groups – the ‘objectors’ who choose not to immunise their children and those from deprived communities.
The small number of objectors need to pull their heads in
There is a small group of parents (around 3-6%) who decline vaccinations. Internationally this rate is low, which goes to show Kiwis are generally team players. However, zero would be the ideal; remember that New Zealand is not yet at herd immunity rates of 95% (though we are getting close), and we need that 5% for the kids who simply cannot have vaccinations and need protecting. There is also a group of vulnerable kids missing out on vaccinations, as we will see below.
By opting out, these parents are taking a free-ride on the back of more vulnerable kids in our society. The way that herd immunity works means we need to reserve that small number of non-immunised spaces for those with the greatest need. So while the 3-6% of decliners is small (and it has not grown recently despite being vocal in media and on immunisation blogs like this), we cannot be complacent and we should work hard to reduce it. These parents need to understand that immunisation doesn’t just protect their own kids, it also protects the most vulnerable.
Other kids are missing out
Immunisation rates are still lower for the most deprived parts of our society. Slightly less than 70% of our most deprived children are fully immunised at 6 months compared to 80% of the least deprived children. This gap remains at 6 months, but by 2 years is closing up.
Figure 1. Immunisation Coverage in NZ for all 6 month old babies by Deprivation (Level of Wealth in a Community).
Kids whose parents identify them as being Maori have a full immunisation rate of just over 65% at 6 months, this is compared with a 90% rate in kids whose parents identify them as Asian.
So the children of parents who are poorer, Maori and are younger tend not to be immunised at the same rate as their peers. There is work to do, especially because these are the kids that already have a lot to cope with. These are children living in overcrowded and poor quality housing, experiencing a lot of environmental & physical stressors, like dampness and mould in their rooms, some who have weakened immune systems. These kids are through no fault of their own at greater risk of experiencing ill-health. While there are a number of social, environmental and financial interventions that can address many of health impacts of these circumstances (many of which we are looking into now), a universal immunisation programme is one really effective, cheap (relatively speaking) and fair way of reducing the risk these kids face.
The problem is, that until we reach herd immunity rates it is these non-immunised kids, and the kids who are immune compromised, who are at the sharp end of the stick during any outbreak of disease. When we say immune compromised we mean kids with cancer who are having chemotherapy, kids born with conditions like cystic fibrosis, which make their immune systems more vulnerable to disease, and babies who are too young to be vaccinated.
Do these kids have bad parents?
It is easy to judge other parents as negligent because they don’t take their kids to the doctor or get them vaccinated. But studies have shown there are a bunch of reasons vulnerable kids miss out on vaccinations in New Zealand (and all over the world). This list unsurprisingly includes a whole range of things from how we deliver health care through to individual knowledge. They include:
- A delivery system that is not organised and proactive (that is immunisations just can’t get to the kids that need it as we have not sorted out the best, easiest way to get the kids and the health practitioners together),
- Not having services that enrol a baby really early (at birth) in an immunisation programme,
- A lack of awareness or understanding about the benefits from parents,
- Limited or difficult access to the doctor,
- The way a midwife, Plunket nurse, doctor or nurse talks about immunisation (or does not talk to you about it at all),
- Language differences and
- Poverty and deprivation are what primarily prevents or delays immunisation.[1]
What do we mean when we say poverty prevents immunisation?
Put yourself in the shoes of two parents working long hours, with no transport and in jobs where taking time off for kid’s medical appointments (and the time you need to spend calming and caring for them afterwards) does not really meet your boss’s threshold for leave. For these parents getting that booster shot for a two year old exactly on time might be less critical than managing all the other issues they are facing. This is especially true if no one has taken time to talk through why initial immunisation and booster shots (at two years) are really critical, and they recently heard another parent talk about all the nasty stuff in the injections. For such parents and their kids, outreach programmes, where the vaccination goes to the child, not vice versa have been found to have a real impact in improving rates of uptake.
So we still have some work to do still to ensure all kids in New Zealand have equal uptake of vaccinations. In the meantime ensuring high rates of immunisation across the rest of society will mean the vulnerable kids who need protection are less likely to come in contact with the disease.
It is important that for the parents of vulnerable kids, receiving immunisation discouraging information does not become a more critical factor in not immunising.
This is not about making it illegal to not vaccinate your child, it is about having high quality effective conversations about the risks and benefits of immunisation. Parents SHOULD express interest and concern about any intervention their child receives, it shows a totally appropriate level of engagement with the job of being a parent and caring for your child. A recent survey on immunisation attitudes indicated that about 5% of people surveyed are unsure about vaccinating and another 5% have concerns about the vaccine safety, this simply indicates people are engaged with the issues. Good clear evidenced-based communication helps answer their concerns.
We can do better at talking about immunisation.
Let’s face it, we could talk about these issues more clearly and assume less is known and accepted by parents. Mainstream media in New Zealand is often not a reliable source of vaccination information. It is not unlike climate change reporting – 99% of scientists and doctors say immunising your child is a very very low risk activity and highly effective against some awful outcomes, a few other people (not scientists) say it is not, but the arguments are presented as a debate of equal and valid merit. Fact versus opinion – it is hard to be informed.
If the first time a parent hears about a vaccination from a health professional is the point at which their lovely chubby and happy newborn is about to get jabbed in the thigh with some unknown substance (but they have heard some alarming stuff on Facebook and from friends with kids), then that parent is unlikely to be entirely happy with a one minute conversation from the Plunket nurse telling them their bundle of joy will be just fine!
So yes the health system could do better in talking about the risks of vaccination, the risks of disease AND the risks of disability and death if a disease is caught, as well as the benefits. With an appropriate level of engagement with parents before a child needs vaccinating and outreach programmes, we see that the vast majority of parents choose vaccination. They understand that immunisation is a fantastic, fair, cheap and effective way to keep kids everywhere, no matter what their circumstances, free from some pretty debilitating outcomes. It is a pretty easy way for parents to say ‘I care about my kid’s health, but I care about your kid’s health too’.
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