By Margaret Perrott
The media are once again focusing on the low immunisation rates of Australian children. The federal health minister, Dr Michael Wooldridge, dismisses the 2-5% of parents who actively oppose it. He has proposed "incentives" to parents to vaccinate their children, "Immunisation Days", which will obviously require massive, expensive, advertising campaigns and McDonald's meal vouchers.
The government now proposes penalising "lazy" parents by deducting$200 from their government maternity allowance and restricting their access to child-care cash assistance and rebate schemes.
The incentives and threats of penalties, which begin next January 1, may slightly improve the immunisation figures for 1997. But they will have little impact on the ongoing problem of providing vaccination programs for the 95% of the population who do not actively oppose it, and will do nothing to alleviate the fears of, or enter into rational debate with, the minority.
Although Wooldridge rejects compulsory immunisation for school entry, the media are beating up this angle in order to inflame the small but vocal anti-immunisation lobby.
By parading the parents of a few children with developmental delay, who believe their child's problem was caused by vaccination, or disgruntled parents who "could not stand" the side effects (and were probably not warned about them), they satisfy their need for "good" TV combined with scare-mongering, scapegoating and a pinch of government "caring".
At the same time, they are quick to latch on to the idea that it is because most parents are "lazy" or neglectful that immunisation rates are low.
In order to find a solution to the immunisation rate problem, one has to look at the reasons behind the figures. In the February 5 issue of GLW, Dave Riley quotes a 29% immunisation rate at school entry and states that "97% of parents presented their children for their first vaccinations at two months of age".
Examination of the statistics in more detail does not indicate a rejection of immunisation by the community, or some sudden change in the willingness of parents to vaccinate their children after two months. It reveals the problems of access to immunisation by the parents of 0-5 year olds.
Figures obtained in NSW, where an Immunisation Certificate has been required at school entry since 1994, indicate that approximately 60% of children entering school are "fully immunised".
A study of 2-3 year olds in child-care centres in 1995, by the Illawarra Public Health Unit, reveals that although complete immunisation rates reach 82.6% at two months, by 18 months the rate has dropped to 69.9%. "Late" immunisations show a steady increase over time.
The number of children receiving the measles/mumps/rubella (MMR) vaccination in the Illawarra, at 12-13 years of age, when free mass school immunisation programs are available, approaches 90%. Only 12% of these are administered by GPs. The vaccination rate for ADT/OPV (adult diphtheria & tetanus/Sabin) for year 10 students is 85%.
The gradual fall in immunisation during the first five years and the high vaccination rates of high school students reflect the life patterns of young children and their parents, as well as the lack of immunisation services.
Attendance rates at early childhood (baby health) clinics, whose target population is 0-5 year olds, show the same trends. Most parents attend during the first months of their child's life, and then drop off dramatically after six months, with a small minority attending after 18 months, and only a tiny group accessing services up to five years.
So why do we see such appalling vaccination rates, as those quoted from the Queensland experience, at school entry?
"I didn't get around to it", is the most common response of parents who have failed to complete the full course recommended in the "Childhood Immunisation Schedule", and the Illawarra experience shows that many parents "got around to it" a bit late.
Why did they not "get around to it"? During the first few months of a child's life most parents are "geared" to the health aspects of the child. The experience of birth and the subsequent concentration on "baby" things such as feeding, sleeping and the bodily well-being of the child encourage parents to seek medical advice and access health services.
As time goes on and the baby becomes part of the family, this focus lessens. Life for the parent of a 0-5 year old is often hectic. There is often lack of money or resources.
Contraindications to vaccination are poorly understood. Children between the ages of six months and five years, experience up to 60 viral illnesses, so they are often "unwell" during these years. Most parents, and some immunisation providers (notably GPs), wrongly believe that immunisation should not be given when a child is "unwell".
The fact that the immunisation clinic visits your suburb for only two hours a month compounds other difficulties standing in the way of the 92-95% immunisation rates necessary for adequate disease control.
"Why don't parents take responsibility for their children and go to the GP?", cry the parent blamers.
Many parents do, but there are valid reasons why GPs are not used as immunisation providers. Some GPs do not offer immunisation because they find difficulty with storage. Parents may be required to purchase the vaccine from the chemist and bring it back to the surgery for administration. GPs are seen as illness oriented, and their waiting rooms are not always the healthiest of places.
The Australian Childhood Immunisation Register project, which began in January 1996, is supposed to address the lack of provision of immunisation by GPs, by offering them a $6 reward for each immunisation. The register also generates reminder notices for parents at appropriate times.
It is ironic that the federal government claims to be promoting immunisation when it has just passed the Health Insurance Bill which denies Medicare provider numbers to 400 newly registered doctors annually, thus significantly reducing the future pool of trained immunisation providers.
The encouragement of GPs and reminders to parents, while laudable, are not enough. This focus neither recognises the realities of life nor addresses the problems of immunisation by GPs, but it limits parents' choice of immunisation providers by denying the need for public programs. Over the last 10 years, the funds for public immunisation programs have not increased and in some areas have been steadily reduced.
The traditional provider of public vaccination clinics, local government, has been divesting itself of this responsibility, due to insufficient government funding. The already stretched resources of community health services have been forced to shoulder the burden, resulting in fewer clinics.
Funds to local area health services are being slashed by state governments, in response to Commonwealth government cuts. Local health authorities, while professing a belief in health promotion, are forced to provide hospital services before community health or disease prevention services, which are less visible, less acute and less popular.
It is a cynical exercise indeed that the Howard government is proposing. It stands to save hundreds of thousands of dollars by denying child welfare benefits to parents who fail to complete the recommended immunisation program for their children.
Once again it will be the most disadvantaged, those whose lack of resources compounds the difficulties of early parenthood, who will suffer.
Another "campaign" will not solve the problem for parents or the community, and will certainly not fulfil the promise of immunisation. Meanwhile, the anti-immunisation lobby is used to justify poor outcomes which are really due to inaccessibility of services and lack of resources.
[Dr Perrott is an immunisation provider and a member of the Illawarra Immunisation Task Force]