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Vaccine hesitancy: Margie Danchin at DFTB18


Children have a right to receive healthcare regardless of the decisions made by their parents. This week, the RACP released a further statement citing refusal to treat patients for non-vaccination as ‘unethical coercion’. Whilst most paediatricians are clear on the benefits of vaccinations, parents can choose not to vaccinate their children. Under the No Jab No Pay policy, this choice can lose their right to Child Care Rebate. However, it should not lose them their right to receive healthcare. A poll by the Royal Children’s Hospital in Melbourne found that 17% of children who were not fully vaccinated had been refused healthcare. But what does ‘refused’ actually mean? And how do we best serve our vaccine hesitant families?

What was the poll?

Dr Andrea Rhodes leads the Australian Child Health Poll team at RCH. It runs a quarterly poll on contemporary child health issues by conducting national surveys across Australia. The latest poll, released earlier this week, looked at the vaccination perspectives of Australian families.

Data was collected from 1945 parents (with 3492 children). They were asked questions relating to the vaccination status of their children and attitudes to vaccinations.

What were the key findings around vaccine hesitancy?

95% of the children were fully up to date with their vaccinations

30% of parents had some concerns about vaccination

9% of parents did not agree that “…it was important to vaccinate their child to protect the community (herd immunity)”

Of those not up-to-date, 17% had been refused healthcare (29 children)

Why are children not up-to-date with their vaccinations?

24% had delayed some vaccinations due to minor illnesses, and there were misconceptions about when to defer.  36% thought vaccines should be postponed in children with a runny nose, but no temperature and 47% thought they should be delayed if the child was on antibiotics. 22% thought vaccines should be postponed due to a local reaction from a previous vaccination.

18% had a preference against vaccinations, and perhaps worryingly 10% thought that vaccinations were linked to autism and a further 30% felt unsure about the link.

22% had delayed because of barriers to education and access. Half of these struggled to attend for vaccination, and the other half had questions about vaccinations that they could not answer. This emphasises the importance of our role. This sizeable group needs our input as paediatricians – to offer information, be open to discussion and assist with making vaccinations accessible.

What can we take from this?

This is the first poll in Australia providing information about refusal to provide healthcare.

Our role is to provide healthcare for each child regardless of their circumstances and certainly regardless of any actions of their parents. This poll makes it clear that there is a sizeable group of parents with uncertainty about vaccination who are interested in engaging and accessing services. We would be doing them a disservice by refusing to treat their children. And even where parents have made a specific decision not to vaccinate, we still have a duty to provide healthcare for their children. It is only by keeping the channels open that we can support, educate, and engage.

The RACP has released a clear statement on this which reinforces their Immunisation Position statement.

It is inappropriate to refuse to treat unvaccinated children, firstly because it represents unethical coercion and secondly because the children will be further disadvantaged.

Yes, we know that vaccinations are beneficial. And yes, we want to increase vaccination rates and ensure our patients are vaccinated. However, we are disadvantaging them even further by denying unvaccinated children healthcare. The RACP goes as far as to call this unethical coercion. We need to provide healthcare and not use it as a bargaining chip.

However, the concept of refusal may not be clear-cut. This poll did not collect data on the circumstances of refusal, so we do not know which provider has refused treatment or how that refusal occurred. Parents may perceive that healthcare professionals are not happy to treat them and classify this as outright refusal.

Research in the US has shown that providers worry that unvaccinated children will pose a risk to young babies in their waiting rooms, or that the unvaccinated child themselves is at risk of catching a serious infection. These are reasonable concerns and therefore steps may need to be taken to minimise these risks. If unvaccinated children need to sit separately, could this constitute refusal in the eyes of parents? If the parents have to engage in an awkward 10 minutes of discussion with the paediatrician about the benefits of vaccination, could this constitute refusal in the eyes of the parents?

So the answer is not as clear cut as the RACP’s statement makes it seem. Of course, we should not refuse to treat a child because their parents didn’t vaccinate them. But it is also our role to encourage vaccinations and discuss their benefits. This engagement may make vaccine refusers uncomfortable and affect their perception of our willingness to provide healthcare. This is not the same as refusal to treat.

Margie Danchin is a general paediatrician working at the Royal Children’s Hospital in Melbourne. She has a special interest in immunisation and vaccine hesitancy and it is this that she shared with the audience at DFTB18. This was the paper that started it all…

Wakefield AJ, Murch ST, Anthony A, Linnell, Casson DR, Malik M, et al. Ileal lymphoid nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children [retracted]. Lancet 1998;351:637-41.

By suggesting that vaccines were linked to autism, Andrew Wakefield and his colleagues kicked off a vaccine scare that has yet to fade away and still sees many children succumb to diseases that are highly preventable and highly fatal. So what is the actual level of risk?

There is a tendency to forget just how dangerous the diseases we are trying to prevent can be. Spend a moment to read Roald Dahl’s short letter about the death of his daughter, Olivia, with what is a highly preventable illness – measles.

See how Margie handles these tricky cases in her talk from DFTB18.

For more information on vaccine research as well as some tools to aid your discussion take a look at the National Centre for Immunisation Research and Surveillance website.

And for Grace Leo’s take…

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Selected references

Wakefield AJ, Murch ST, Anthony A, Linnell, Casson DR, Malik M, et al. Ileal lymphoid nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children [retracted]. Lancet 1998;351:637-41.


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