Introduction
Childhood immunisation can be a contentious political issue in many countries (Smith et al., 2019), despite the prevalent acceptance of the benefits as a public health measure (cite bunch). The phenomenon of ‘immunisation hesitancy’, where parents worry about ingredients and safety or believe that their children might not need immunisation because they live healthy lifestyles (Dube et al., 2013), is becoming a common feature of life in high income countries, with a recent 67-country study finding the lowest rates of immunisation confidence in Europe (Larson et al., 2016).
Ministry of Health has a target that 95% of children have voluntarily completed the primary course of immunisation by age 5. As at June 2019 the current rate of completion is under 90% and has remained at this level for the last several years (cite MoH).
While many countries, including New Zealand, have relatively high rates of immunisation many have a core of the population that refuse to participate in the immunisation programmes. These parents see the majority of the population as a hostile and brainwashed group that threatens their rights to make their own decisions about their families (Attwell et al., 2018).
Smith et al, 2019 states while mandates may be powerful tools for increasing immunisation rates, some researchers worry that compulsion may cause a backlash, dividing opinions on political lines and weakening the overall pro-immunisation consensus.
The immunisation programme in New Zealand is managed by PHARMAC (PHARMAC, 2018) and delivered almost entirely by nurses in general practice environments (Taylor, Turner, & Poutasi, 2017). Some exceptions occur to this such as the recent meningococcal outbreak in Northland region where the immunisation programme was led by the local district health board (Ministry of Health, 2019a).
The proposed policy change is that children are unable to enrol in a state funded school unless they have completed the required immunisation programme by time of enrolment. A review of a similar approach in Australia called ‘No Jab, No Pay’ will be made and what change this could have in the immunisation rates in New Zealand and other possible impacts over the next five years.
Source Case – ‘No Jab, No Pay’
Australia is unique in employing financial incentives to increase participation (Haire et al. 2018) mainly using various child care subsidies and tax benefits of up to $8,350 per year linked to the immunisation programme (Ward, Hull, and Leask 2013). This was further extended by an Australian Federal government policy (‘No Jab, No Pay’) that was introduced in 2016 which withholds payments to child centres if children attending are not fully immunised (cite). As payments are made from federal government to state governments and in turn to the actual centre this meant that at state level policies were implemented to exclude children from childcare facilities if they have not been fully vaccinated according to the National Immunisation Program Schedule. As well as the funding impact on the state government, Directors of child care centres who do not comply with the new requirements under the legislation will face a fine of up to $5,500. (State of NSW, 2017).
The purpose of the policy was to remove the conscientious objection ability which was previously allowed for non-medical reasons. The percentage of children under seven years with a conscientious objection recorded on the Australian Childhood Immunisation Register (ACIR) has risen from 0.23% in 1999 to 1.77% in 2014.[8]
The Federal government expects the change will result in savings of $508.3 million over five years due to the reduction in child care subsidies (cite) as well increase the number of children with the required level of immunisations.
In Australia, registered ‘‘conscientious objection’’ rates had remained consistently below 1.8% [cite]. Six months after the introduction of No Jab No Pay, the Minister for Social Services announced that 5,738 children with previous registered objection were now fully immunised [cite]. Before the implementation of No Jab, No Pay there were a total of 30,092 objections registered for children aged 7 or less, suggesting that 20% of objectors complied with the new requirements within 6 months.
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The ‘No Jab, No Pay’ policy did not deliver any consequences for medium-to-high income vaccine refusers whose children were not in daycare, which is attended by approximately one quarter of Australian children [50]. Publicly available data from the National Health Performance Authority in December 2015 reportedly showed that the percentage of fully immunised 5-year-old children was lower in the ‘rich’ suburbs of Melbourne and Sydney, among other affluent suburbs, and this sparked much public debate.
In 2017, a survey of 1,945 parents by the Australian Child Health found 93% preferred their children to have all the recommend immunisations and 72% supported ‘No Jab, No Pay’ policies that exclude children from childcare facilities if they are not fully immunised (Rhodes, 2017). Recent research by Smith et al. (2019) has shown support for both immunisations and mandates is very high, with no significant opposition from any political subgroup.
Overall the policy has increased immunisation rates for 5 years old’s to 94.7% from 92.6% after two years (cite), reduced the contentious objectors list by 20% while still maintaining broad support for both immunisations and the mandate. It is not known if the changes have had any impact on those that did not rely on the child care subsidies as the children were not in any form of child care. These areas are more likely to be the higher economic suburbs which already had pockets of lower immunisations rates before this policy change occurred. [as X states] while the immunisation rates have increased if the policy does change the behaviour of the wealthy as they can be avoided, then has the policy failed to achieve the desired public health goals?
Policy change in NZ (Option A)
The current rate of voluntary childhood immunisation at 5 years is 89.6% nationally, however the last several years the growth in the immunisation rate has slowed and ability to reach the 95% target without policy changes is at high risk (Ministry of Healthy, 2019b). Of those that have not immunised, 5.7% of parents have either declined at least one immunisation by the time the child is aged 5 years (5% of all those eligible) or have opted out of the National Immunisation Register (0.7%) (Ministry of Health, 2019b). This means that a minority of the population for whatever reason (Van Hulst & Yanow, 2016) has explicitly decided to not complete the recommended childhood immunisations. The remaining population (4.3%) has not completed the immunisation programme but has not explicitly declined involvement either.
To reach the 95% target it is proposed to make any child attending a state funded school in New Zealand to have the completed the required immunisations for their age starting from 5 years old (Option A). While this means that immunisations are not mandatory it does mean for the vast majority of students unless they attend a private school or are home schooled immunisations will be required when they first enter the school system.
The key aspect of this policy change is ensuring parents and the child have the information on the immunisation programme and ease of ability to have the required immunisations. At the moment the vast majority of immunisations are administered by the local doctor with funding for the visit paid for by Ministry of Health for children under 13 and a fee of $21.37 paid to the doctor for the immunisation with PHAMRAC paying for the actual vaccine.
To address the access to immunisation information and ease of access for parents and child it is proposed that nurses from the local district health boards (district nurses) provide ‘clinic days’ at each school around the common enrolment periods and at regular times throughout the year (such as ‘first Monday of the month’). These district nurses are already community based as they provide nursing and supervision to patients in their homes. Including regular immunisations clinics at local schools is an obvious extension to the current district nurse role, the immunisation aspects already happens, albeit less regularly and often epidemic related.
As students could be immunised at the school by the nurse on pre-set days it would be more efficient than going to a local doctor for those students that do not have the required immunisations. This would provide greater access for the parents as well as savings to the government compared to the doctor visit fee and the $21.37 paid for providing the immunisation.
For those parents that did not wish their children to have the immunisations then information can be provided on the benefits of the programme and their options if they choose for the immunisations to be avoided. In this case it would be enrolment at a private school or home school unless the child has a medical reason on why the immunisations can not occur. The information provided can also direct the parent to their local doctor if they wish to discuss the immunisation programme in more detail.
This change is a de facto compulsion as for most parents they will be unable to afford private or home schooling for their child. By providing both information and actual immunisations programme at their local school by a community-based nurse means that access to a doctor is eliminated as a reason for lack of required immunisations. The legislation will be worded that unless an approved medical reason is provided then the children will receive any required immunisation during the next visit by the district nurse. This means that the parent will either need to opt out of the enrolment process for their child or provide a valid medical exemption for any immunisations to not be given. Repeated failure of the child attending during the immunisation clinics would result in the child being referred to the district nurse or their doctor to stop this being an avoidance method by the parent.
This approach is based on the process implemented in Australia. In Australia it is implemented for child entering child care centres (age 2 and up) rather than the proposed school age but does not address the process for children gaining access to the required immunisations.
The fundamental success of the policy change can be measured by how many children have the required immunisations by the time they start school (which is normally age 5). Secondary aspects that can be measured is what, if any, reduction occurs in the children that have explicitly declined an immunisation or have opted off the National Immunisation Registry and expected cost decrease of administering the programme by district nurses rather than local doctors. Finally, as the reason for the immunisations in the first place is to reduce hospital admissions this can be tracked as to the impact of any change in the immunisation levels.
Evaluation
The current immunisation rate in New Zealand for children at 5 is 89.6%. The same rate of immunisations in Australia 2018, 2 years after the ‘No Jab, No Pay’ change, was 94.7%.
The table below shows the comparison of New Zealand and Australian immunisation rates from July 2010 to July 2019 are as follows (data since 2018 has not been published for Australia). Both countries since 2012 have the same target of 95% of all 5 years old’s having completed the required immunisations.
Figure 1 NZ and Australian immunisation rates
This figure shows that Australia has always had a higher immunisation rate for 5 years old’s and that it continues to increase since the ‘No Pay, No Jab’ policy was introduced. The rate of immunisation in New Zealand has increased significantly since 2010 but growth has slowed since 2017 and is notably lower than the target of 95%. Extrapolating current trends means that the 95% target is unlikely to be achieved based on current policies.
The evaluation model is based on the status quo and Option A being implemented and each being evaluated in 2025. The following evaluation criteria are being used:
Immunisation rates of 5 years old’s based on the total population
This is the same criteria being used for the current policy and target. (cite)
National Immunisation Register (NIR) ‘Opt outs’ and explicit declines
This is the same currently measurement being tracked. (cite)
Immunisation Administration Fee
As well as the Ministry of Health providing free doctor visits for those under 13 (cite) which the doctor is paid for a further fee is provided to the doctor for administering the immunisation and updating the NIR. (cite)
Reduction in Hospital Visits
Any change in the immunisation rate will have a co-relation on the number of hospital visits.
Estimates will be based on reduction of 450 hospital visits per annum from chicken pox vaccine being included in the required immunisation programme (cite sciblog) and adding the rotavirus vaccine to the schedule is forecasted to prevent up to 1200 hospital admissions per year (a reduction in 75%) (https://www.pharmac.govt.nz/about/2017/vaccines-story/ and https://www.pharmac.govt.nz/about/annual-review/2014/therapeutic-group-review/vaccines/). Based on this data for each 1% increase in immunisations rates hospital admissions will reduce by 1,000 per annum.
2025 Status Quo
| By 2025 | Status Quo | Comment |
| Immunisation rate at 5 years | ~92% | A slow increase in immunisation rate is forecasted. |
| Opt out/Declines | 5.5% | No material changes to these rates. |
| Administration Fee for providing immunisation | $21.37 (to doctor) | No change to payments made for providing the immunisation. |
| Reduction in hospital visits (pa) | 3,000 | Due to the increase in immunisation hospital visits is forecasted to reduce. |
2025 Option A
| By 2025 | Option A | Comment |
| Immunisation rate at 5 years | ~95% | This is based on much higher immunisation rate than status quo due to the school enrolment aspect. Not higher due to private schools and home schooling. |
| Opt out/Declines | 4.5% | Reduction of 20% compared to 2019 based on the experiences of reduction in Australia. |
| Administration Fee for providing immunisation | $16 (via District or Community based Nurse) | Due to the use of existing district nurses the cost of providing the immunisation programme is expected to reduce. Estimated reduction is 25% compared to the 2019 payment to doctors. |
| Reduction in hospital visits (pa) | 6,000 | Due to the increase in immunisation hospital visits is forecasted to reduce. |
2025 Status Quo/Option A summary
| By 2025 | Status Quo | Option A |
| Immunisation rate at 5 years | ~92% | ~95% |
| Opt out/Declines | 5.5% | 4.5% |
| Administration Fee for providing immunisation | $21.37 (to doctor) | $16 (via District or Community based Nurse |
| Reduction in hospital visits (pa) | 3,000 | 6,000 |
References
- Attwell K., Smith D.T. and Ward P.R. (2018) ‘The unhealthy other’: How vaccine rejecting parents construct the vaccinating mainstream. Vaccine 36(12): 1621–1626.
- Dube E., Laberge C., Guay M., Bramadat P., Roy R., and Bettinger J. (2013) Vaccine hesitancy: An overview. Human Vaccines and Immunotherapeutics 9(8): 1763–1773.
- Larson H.J., de Figueiredo A., and Xiahong Z., (2016) The state of vaccine confidence 2016: Global insights through a 67-country survey. EBioMedicine 12: 295–301.
- Ministry of Health. (2018a) Health targets: Increased immunisation. Retrieved from https://www.health.govt.nz/new-zealand-health-system/health-targets/about-health-targets/health-targets-increased-immunisation
- Ministry of Health. (2018b) Immunisation coverage. Retrieved from https://www.health.govt.nz/our-work/preventative-health-wellness/immunisation/immunisation-coverage
- Ministry of Health. (2019a). Meningococcal W information release. Retrieved from https://www.health.govt.nz/about-ministry/information-releases/general-information-releases/meningococcal-w-information-release
- Ministry of Health. (2019b) National and DHB immunisation data. Retrieved from https://www.health.govt.nz/our-work/preventative-health-wellness/immunisation/immunisation-coverage/national-and-dhb-immunisation-data
- PHARMAC. (2018) Delivering value in vaccines. Retrieved from https://www.pharmac.govt.nz/about/2016/value-vaccines/
- Smith, D. T., Attwell, K., & Evers, U. (2019). Majority acceptance of vaccination and mandates across the political spectrum in Australia. Politics.)
- Taylor, L., Turner, N., & Poutasi, C. (2017). Identifying best practice in childhood immunisation: a study into best practice in achieving high rates of childhood immunisation shows the keys include effective teamwork, creating good connections with parents and caregivers, and taking a systematic approach. Kai Tiaki: Nursing New Zealand, 23(6).
- Van Hulst, M., & Yanow, D. (2016). From Policy “Frames” to “Framing”: Theorizing a More Dynamic, Political Approach. The American Review of Public Administration, 46(1), 92-112.
- Haire, Bridget & Komesaroff, Paul & Leontini, R. & Macintyre, Chandini. (2018). Raising Rates of Childhood Vaccination: The Trade-off Between Coercion and Trust. Journal of Bioethical Inquiry.
- Ward K., B.P. Hull, and J. Leask. 2013. Financial incentives for childhood immunisation—a unique but changing Australian initiative. Medical Journal of Australia 198(11): 590–592.
- State of NSW. (2017) New vaccination rules for child care. Retrieved from https://www.nsw.gov.au/news-and-events/news/new-vaccination-rules-for-child-care/
- Klapdor M. and Grove A. (2015) ‘No Jab No Pay’ and other immunisation measures. Parliament of Australia Budget Review 2015–16 Index
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