Aussie ‘no jab, no pay’ unlikely to make disease go away.

By Helen Petousis Harris 15/04/2015


The Australian proposal to remove financial benefits from families who fail to immunise their children seems like a politically motivated point-scoring move based on emotive lobbying by media, namely the Sunday Telegraph.  It would appear to have arisen from the outcry about anti-vaccination parents putting others at risk following the deaths of two infants too young to be vaccinated.

I am not entirely sure what the problem to this rather draconian solution is. Australia has had reasonably high immunisation coverage (~93%) for many years now. In fact the Australian Government consider that Australia has an excellent record in national immunisation coverage. Here is a link to their coverage information. One of their strategies has involved a carrot, which has worked quite well – under this system parents need to produce evidence of their kids’ vaccination status in order to receive certain payments. This is a No Form, No Pay system. Parents were still able to decline immunisation based upon medical contraindication or religious/personal belief.

The new proposal will see this shift to a No Jab, No Pay system.

Very different me thinks and a move that lacks evidence . In Australia about 7% of children under two years of age are not fully immunised (This is about 6% in NZ at the moment).

Who are these unimmunised children in Australia?

In Australia, and many other countries, most unimmunised children are from families who have social, geographic and other practical obstacles to getting vaccinated. These families are more likely to be dependent on financial assistance from the government. While the ‘conscientious objections’ are recorded on the Australian National Immunisation Register this was 1.77% as of December 2014 for children 0 – 7 years of age, although other sources suggest this is more like 3%.. To be recorded as an objector the parent or guardian must sign a form to acknowledge the risks and benefits have been explained to them. These families are more likely to be wealthier and less dependent on government financial incentives and benefits.

So it is difficult to see how linking benefits to immunisation status is likely to be helpful in increasing immunisation rates to over the 95% if it is targeting anti-vaccination parents.

What about NZ? Who are the unimmunised kids here?

In NZ most of the unimmunised children are from families with high levels of social deprivation and are more likely to be Māori. In addition about 3-4% of parents actively decline vaccination, usually because they have been persuaded by scaremongering and pseudoscientific nonsense.

Coverage slides with cover Dec2014
Graph from Immunisation Advisory Centre, University of Auckland. Based on data from the NZ Immunisation register.

How do we get our immunisation rates up a bit more without resorting to coercion?

NZ has moved immunisation coverage rates from around 60% to 94% simply by improving systems, measuring coverage and setting targets. We now have a pretty good idea about who is not getting immunised and most of these are children who are falling through the system. The solution is to keep tightening the nets so as to catch them before they fall. This is a work in progress and given the dramatic improvement thus far I am sure we can get there.

I think a key point that needs to be made is that the objective of a vaccination programme is to prevent disease. Therefore we need to ensure we attain and maintain high coverage. Despite the fact that that people who choose not to vaccinate their children are capitalising on the fact that most people do (‘freeloaders’), there is currently no evidence that denying non vaccinators financial benefits will measurably prevent disease outbreaks or overall vaccine coverage.

We will always have people vehemently opposed to vaccination and nothing in the world will change their minds. This has been the case since the 18th century and is rooted in beliefs not facts. While we can maintain high coverage then even though we may disagree with these beliefs and get angry when we see people benefiting from the herd immunity provided by the rest of us, introducing punitive action is ultimately unlikely to reduce disease.

For two Australian expert commentaries on this topic see the blog from Social Scientist Dr Julie Leask and article from The Conversation by Associate Professor in Paediatrics Dr Kristine Macartney.

And finally, in case you were wonder where this magic ‘target’ of 95% comes from – below is my table that shows some vaccine preventable diseases and the proportion of the community that need to be immune to prevent transmission from occurring. You can see that the 95% is based on preventing measles and pertussis, the two most infectious diseases known to man.

Several vaccine preventable diseases with basic reproduction number and the proportion of the population that need to be immune to prevent transmission. Adapted from Plotkin. Vaccines. 5th Edition. *Trotter CL, Gay NJ, Edmunds WJ. Dynamic Models of Meningococcal Carriage, Disease, and the Impact of Serogroup C Conjugate Vaccination. Am J Epidemiol 2005 1 July 2005;162(1):89-100. **calculated as (1-1/R0)
Several vaccine preventable diseases with basic reproduction number and the proportion of the population that need to be immune to prevent transmission. Adapted from Plotkin. Vaccines. 5th Edition. *Trotter CL, Gay NJ, Edmunds WJ. Dynamic Models of Meningococcal Carriage, Disease, and the Impact of Serogroup C Conjugate Vaccination. Am J Epidemiol 2005 1 July 2005;162(1):89-100.
**calculated as (1-1/R0)