IN January 2016, the federal government embarked on a remarkable experiment aimed at improving immunisation rates across Australia. It introduced No Jab, No Pay legislation that for the first time debarred all parents of children who were not fully vaccinated from collecting family assistance payments. Previously, conscientious objectors to vaccination had been exempt from such measures, but not any longer.

Several states have implemented No Jab, No Play legislation, which requires children attending childcare centres to be immunised. Such laws are in place in New South Wales, Queensland and in Victoria, where they are the strictest, requiring full immunisation for attendance.

But are these laws appropriate and do they work? It’s the topic of a new Perspective published in the MJA, authored by three experts from the National Centre for Immunisation Research and Surveillance (NCIRS) and the University of Sydney.

The authors, led by Dr Frank Beard, point out that Australian immunisation rates are actually quite high compared with other developed countries, and have topped 90% since at least the early 2000s.

At the same time, the number of people strongly opposed to vaccination is low, with little evidence that this number is increasing. But as their views tend to be entrenched, there’s little scope to change their behaviour, and there’s not much evidence that No Jab, No Pay will do the trick, the authors write.

However, they say that most parents of incompletely vaccinated children are not actually like these hardliners. Rather, they are people who don’t necessarily disagree with vaccination but have had logistical and access challenges to getting their children immunised.

For these people, the best solutions may be carrots, not sticks, the authors suggest. The aim shouldn’t necessarily be to penalise people by taking away their benefits, but to break down their barriers to immunisation. Measures may include client reminder and recall systems, new incentives, opportunistic vaccinations in primary and tertiary care, catch-up plans, home visiting and minimising out-of-pocket expenses to access services and vaccines.

For Associate Professor Kristine Macartney, a paediatrician at Sydney’s Westmead Hospital who is also involved in the NCIRS, the jury is still out on whether the No Jab, No Pay policy is a good one.

“It’s probably having some effect: there’s increased compulsion for bringing children up to date, and there are aspects of it that are promoting higher coverage,” she told MJA InSight.

But she said that the case was much weaker for No Jab, No Play policies that restrict access to childcare in some states.

“That’s where we have to be very careful and say: is that the right thing to do? Is refusing childcare to children who aren’t up to date truly going to have an impact on disease?”

Professor Peter McIntyre, one of the three authors of the Perspective, agreed that restricting childcare could be counterproductive.

“We know that a child missing out on early childhood education opportunities is really bad in terms of later education progression,” he told MJA InSight in an exclusive podcast.

He said that the presence of unvaccinated children in childcare centres didn’t necessarily pose a huge risk to the immunised children.

“It’s a little bit of a myth that there are these terrible disease risks that other kids will be exposed to. Childcare in general is a fantastic way to get infections, but hopefully only a small amount of those would be vaccine preventable.”

Dr Macartney said that the key in these cases was to have clear knowledge about who was vaccinated and who wasn’t.

“We need an extremely efficient, state-of-the-art Australian immunisation register to support vaccination measures, and I don’t think we’re there yet.”

Such an immunisation register has been recently launched, but Dr Macartney said it was disappointing that the latest Federal Budget hadn’t provided more funding to improve this crucial component in Australia’s immunisation strategy.

“We don’t want people to have their benefits withheld because the data aren’t there about whether their child was immunised. We haven’t seen a high-level strategy around the development of the register. We know there’s a potential for under-reporting to the register, and in fact we know on the ground that this is happening.”

But the Budget wasn’t all bad news for immunisation, Dr Macartney noted.

“There were some really excellent announcements. One was additional funding for communication, because it’s very important to explain immunisation measures to parents and there’s a lot of misinformation out there.”

Another Budget measure was extending funding for catch-up immunisation, so that children who, for whatever reason, missed out could get free access to vaccines. Free vaccines for refugees and humanitarian entrants were also announced.

But there are still some missing pieces to the puzzle. Dr Macartney said that she would like to see a no-fault compensation scheme for those extraordinarily rare cases when a vaccine causes an injury.

“When someone has a serious reaction through no fault of the doctor or the vaccine, we need a streamlined way to assess and support these people. Pretty much, all developed countries have a scheme for this. But we don’t.”

 

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16 thoughts on “No Jab, No Pay: does it actually work?

  1. Tony Krins says:

    All drug use should be decriminalised and medicalised and privacy should be protected.

  2. John Taylor says:

    Many industries already have mandatory drug and alcohol testing before starting work. These are where there could be a risk to the worker, their colleagues, the industry or the public. Somehow health workers have managed to resist this! If there is to be testing of welfare recipients, the health sector should not remain immune to this standard. Driving under the influence of drugs and alcohol is considered dangerous to the public. Treating people with any illness is no less dangerous to the public!

  3. Anonymous says:

    “Does it work” depends on what we mean by “work”. The bottom line should be whether or not it overall improves the health of children – right? I have tried and tried but I cannot find evidence of any serious effort to evaluate this outcome. There is of course, the issue of whether vaccination per-se raises health, as well as the issue of whether it does so UNIVERSALLY. In certain very narrow short-term outcome measures, for a certain section of the population, it probably does improve health.

    But as a one-size fits all intervention – and in terms of long-term health and chronic disease burden, such as increases in autoimmmunity, allergies, degenerative diseases and so on, and the burden of long-term care for the inevitable cases of severe vaccine injury – nobody really knows, because there has not been a credible effort to make a comparison of vaccinated vs unvaccinated people. On the other hand there is huge growing body of anecdotal and observational evidence of a very significant downside. It is also impossible to prove if a vaccine works for any individual, because we cannot predict who will actually get sick without it.

    And so this should not be an academic question or a matter of opinion. It should be a matter of rigorous ongoing evaluation. So far the only measure by which ‘success’ of the programme has been judged is the number of children vaccinated, which is frankly very worrying in that it suggests an official indifference to whether this is really for the best. Behind this measurement for ‘success’ is the notion of herd immunity and the necessary assumption that the more people vaccinated the better – no sense of risk versus benefit judgement on an individual basis. If it helps some people then it must help all people, and the matter of collateral damage is far too inconvenient to compute.

    Unfortunately, it is a fact that NO medical intervention is completely without risks and nor is it ever 100% effective. Furthermore, it seems reasonable, given that vaccines are highly promoted as neccessary and without downside, that those who are most reluctant to vaccinate may be the ones with the best reasons not to. For a great many people with no apparent risk, full vaccination may be beneficial overall. Even if this can be proven clearly (without reference to emotive and historical arguments), there is great danger in extrapolating that into a certain benefit for every last child immunised. The theory of herd Immunity from vaccines has only ever been supposed, it has never been proven. And when it does not accord with experience of outbreaks among highly vaccinated populations, there is always a race to seek an explanation for such ‘exceptional’ events, and absolutely no effort devoted to finding out how exceptional they really are.

    I would suggest a much better notion than Herd Immunity would be ‘Peak Immunity’, whereby it is recognised that past a certain point increasing vaccination (both in numbers of people vaccinated and the numbers of shots they receive) is a matter of diminishing returns. We cannot endlessly increase the adaptive load upon developing immune systems and realistically expect the harm not to outweigh the benefits at some point. It should be assumed that, as well as those who will benefit from vaccines, there will be those who don’t benefit, those who only benefit from a limited or a delayed schedule, and those who are harmed.

    Unfortunately there is yet no clear science to say who will get the most benefit and who will have the worst reactions. And so this absolutely MUST remain a matter for the individual patient and his or her family, in consultation with the doctors and other experts they consult, on the basis of full disclosure of absolutely any information those parties deem relevant. And the burden of proof must not lie with the person on the receiving end of medical treatment. All of that means that political ideology should remain outside of the doctor-patient relationship: and informed consent, without coercion, should remain a central pillar of that engagement.

    Let us remember that NJNP is not a medical policy, but a social services policy. Medics should be concerned about their own expertise and scope of practice being usurped by outsiders who, for all the expert advice they receive, lack the training of those responsible for delivery. Whatever the social, political and legal pressures upon doctors in the arena of vaccination, they must at all times remember that the patient in front of them is the focus of their duty. If they forget this, then the small benefit of this policy may be severely outweighed by the social damage and the loss of trust in both the direction of public health and the medical profession tasked with delivery.

    Yes, if ‘works’ means coverage has been increased, going by the numbers, then NJNP has certainly ‘worked’. But that is a pretty hollow definition for success.

  4. Anonymous says:

    Well yes – No Jab No Pay works.

    It gets more children immunised from the larger group of people who are happy to vaccinate but need prodding.

    I fail to understand how a lack of effect on the tiny fraction of hard core vaccine-deniers has anything to do with saying it does not work overall for the whole population. The policy is very effective in the general population.

    Also, Dr McIntyre might not realise, there are a number of infants under 6 months in child care centres these days, who are at higher risk of very severe outcome from vaccine-preventable diseases.

  5. Randal Williams says:

    Absolutely agree with ‘no jab no pay’ and am surprised with some of the wishy- washy responses from the ‘experts”. Prevention of serious diseases by vaccination is one of the many benefits we have of living in the modern age; failure of parents to have children vaccinated either through misplaced ideologies, or just plain laziness , is child neglect as well as a public health issue, and has to carry significant penalties.

  6. Anonymous says:

    Freedom from oppression is another a benefit of the modern age, which we can also lose if we are not careful. Parents seldom ‘fail’ to get their children immunised, they deliberately decline to do so, after exploring the pros and cons. It is all very well saying vaccines are safe and effective and have saved us from all these diseases: these are parents who have already had good reason to doubt those suppositions. How many people blindly comment without checking these things for themselves? Be honest now… The benefits, the risks, these are not certain and informed parents realise this is not so simple..

    The vast majority of parents sleepwalk into vaccinating their kids, actually it is they who are ‘failing’ in their duty of care and consideration. I don’t mind if people choose to vaccinate or not vaccinate their kids, but they should do so for the right reasons, and they should be informed when giving their consent. Money, social pressure and emotional blackmail are absolutely NOT the right reasons.

    Honestly, I think some people forget that disease is not the only peril the human race has risen above.

  7. Randal Williams says:

    ‘Anonymous’ should be prepared to put his name to his comments; it is easy to fire off these unsubstantiated attacks on vaccination from a cloak of anonymity. Vaccination is one of the great success stories of modern medicine. Read the history books to find confirm this. I suspect “anonymous” has not lived through the ravages of smallpox, diphtheria, and poliomyelitis.

  8. Anonymous says:

    I do not agree with the No Jab No Pay policy.

    Questions regarding Vaccine Safety need to be expanded including the neurological implications of aluminium-based adjuvants.

    I am glad to see that vaccine manufacturers are beginning to remove the preservative thiomerasol from many vaccines when offered as single doses.

    Funding for further studies on the development of preservative-free, aluminium adjuvant-free vaccines, non-injectable vaccines need to be made available not only to universities but also Australian companies, particularly biotechnology start-ups.

  9. Peter Elepfandt says:

    Hey anonymous, what about freedom from oppression when people are forced to wear a seatbelt in the car? There are extremely rare accidents were being ejected from the car is safer than being stuck with a seatbelt. However in the vast majority of severe accidents it reduces morbidity and mortality. What about the poor conscious objectors of seatbelts?
    Or the conscious “smoking with a neonate in the backseat”?
    Or the conscious “I use my mobile phone for texting whilst driving”?
    Or the conscious selling of illicit drugs?
    And so on…..

    All these actions put the person and/or other people at risk. For all of these prohibited actions you can construct examples why this might be beneficial for a particular case but in general they are causing more harm than good. Therefore our society – by proxy of their politicians – has decided to put fines on these actions.

    Only if you want to question the fundamentals of our society you really have a point.

    Kind regards

  10. Anonymous says:

    [Thanks Randal, I think there is more than one anon here but I take it you mean me!]

    Let the discussion be about the issues, not personalities. People get attacked for having these discussions, so, thanks but no thanks. You will notice from my comment I have not in any way attacked vaccines, I have simply stated I think it is completely reasonable for parents to ask questions, weigh up the pros and cons and decide for themselves. However, NJNP definitely forces a pro-vaccination view on everybody, so I don’t entertain the idea it is me who is on the attack.

    I have said if the point is to raise health, then let the discussion be about health. Doing it for the money is the wrong reason. It seems quite bizarre that you would think this anything other than a middle-of-the-road position.

    As a parting shot, I most certainly have read the history. If you had, then you would realise that we cannot be sure vaccines are going to do what they promise in future, based on what we know of the past. Now you can take the blue pill or the red, it is up to you. But if you wish to live in a world where the experience and opinions of others do not matter because they disagree with yours, that certain people need telling what to think and do for the common good, be very careful what you wish for.

  11. Anonymous says:

    Hey Peter Elepfandt

    Any comments on the other points that I made.
    Just think??? I am a vaccinologist.

  12. Randal Williams says:

    My final comment to the “anonymous’ sceptic of compulsory vaccinations is; Have you been vaccinated yourself, and are you availing yourself of other advances of modern medicine ? If so is your position valid? It is hard to imagine that a modern doctor could question the efficacy and necessity of vaccination in our communities, to protect us all. There are a lot of things we are compelled to do for the good of the community such as obeying speed limits, wearing seat belts, etc. Children cannot protect themselves and rely on their parents. A child that gets eg measles encephalitis through failure to be vaccinated has been the victim of child neglect.

  13. Anonymous says:

    I am anonymous too, and write to thank those anonymous writers above for their articulate and rational discussion. To the medical professionals who are obsessively dogmatic, let me remind you of ethical principles to respect:
    a. Personal autonomy
    b. Non- maleficence
    c. Free, prior, and informed consent.
    You may say that NJNP does not violate these, after all, parents can say no. However, consent is not free when coerced, and those being coerced through financial penalties are more likely to be socially disadvantaged. This regressive policy violates the personal autonomy of the poorest. It has an ethical sting. You have argued that this is ok- after all, society restricts our autonomy over things like use of seat belts, speed limits, etc. These public health related policies pertain to those who choose to drive, are not invasive (you are not forced to inject a chemical in your child’s blood stream to drive a car, etc).

    There is no question that vaccination is one of the most successful public health strategies since the Industrial Age (remember, questioning vaccination is not the same as anti- vax). Don’t confuse these issues. However, if you practice evidence- based medicine you will understand that many factors influence vaccine efficacy (chronic disease, immunocompetence, etc) and such efficacy varies with the vaccine. The absolute risk reduction is often not reported (it is usually very low) and effectiveness is always referred to in relative terms (ie relative risk reduction of influenza is 50% after flu vax. This means your risk will be reduced by 50% of what your absolute risk of developing influenza was prior to the vaccine. Your risk of influenza is influenced by the incidence of disease in the community, by your risk of exposure, by your immunity, whether you have predisposing illness, etc. So if the cumulative incidence of flu is 2% for your age group, risks, etc (2 in every 100 people aquire influenza), the individual absolute risk after vaccination will be reduced by 1% to 1% (ie. 50% relative risk reduction). It would not be unreasonable to decline vaccination given that you have a 98/100 chance of not getting influenza, and balance that with the risk of adverse effects from the vaccine. These sorts of decisions are complex, require skills in shared-decision making, and respect for people who seek this discussion. Medicine is not about merely following a recipe book. If it was, then we should relax training requirements. Perhaps this is why task substitution such as pharmacy vaccination makes sense.
    So, a policy such as the NJNP policy is very concerning. It is a socially sanctioned policy undermining clinical autonomy as well as the patients autonomy, undermines shared decision making, fosters anti- vax views, and penalises the poorest. Examination of all these harms, versus the marginal gains, I think suggests this is bad policy.

  14. George says:

    Disappointed by the weak responses by some of the experts quoted. NJNP laws are essential to keeping our vaccination rates some of the highest in the world. Backdown will be treated as a lessening in seriousness by the well-meaning skeptical, and as a victory by organised opponents to vaccination.

    We know from decades of behaviour change research that incentives are only partially effective, and that punitive sanctions – as distasteful as they may be in some sections – work well in ensuring compliance. We need both good pathways to vaccination, and strong reminders for those laggards, and then effective sanctions for deliberate laggards and those who purposely endanger their childrens and our health.

    The vaccine schedule will only get larger, and the pool of potentially locally eradicable diseases will only expand. These laws should be expanded to the HPV vaccine, and include all additional future childhood vaccinations.

    Wavering and backdown by the public health community will only undermine the effectiveness of the messaging and implementation of our world-class vaccination programs.

  15. Sue Ieraci says:

    The anonymous comments repeat many of the tropes of the organised anti-vaccination movement. It’s important to look at this issue rationally, and with a basis of evidence.

    First, we need to note that there HAS been a “carrots rather than sticks” approach – in the form of the Maternity Immunisation Allowance, which was instituted in 2010. The allowance was paid in two separate amounts for families in which children were fully immunised between 18-24 months of age and between four and five years of age, before starting school. (https://www.dss.gov.au/about-the-department/publications-articles/corporate-publications/budget-and-additional-estimates-statements/2009-10-budget/maternity-immunisation-allowance-alignment-of-indexation-with-other-family-payments).

    This allowance was subsequently rolled up into the Family Tax Benefit Part A supplement, with the requirment to immunise to qualify for the benefit maintained.

    Vaccination is not compulsory in Australia, but vaccination is required to qualify for the FTB Part A supplement, which incorporates the immunisation allowance. Like all targetted benefits, one needs to qualify for the benefit.

    There is good data showing a large number of additional children completing vaccination since the measure was instituted.

    In summary, then, NJNP is a carrot approach, and there is evidence that it is working.

  16. Tim Bailey says:

    Well said Sue. I read this article in the hope that there would be a comprehensive analysis of EVIDENCE and OUTCOMES. I am not interested in hearing, yet again, an assortment of opinions whether “pro” or “anti” or “cautionary” about the vaccination issues and vaguely related “ethical” issues regarding NJNP.

    I therefore have to say I am disappointed in the false advertising on this issue which has been supported and propagated by the publisher.

    If you are advertising “information” – give it. If you are advertising “a chance to give opinion” – advertise it as that, not as something else altogether. I expect better from the MJA!

    Anecdotally, I suspect the NJNP move has been an outstanding success, from my daily experience of parents who have not had their children immunised, turning up to have it done after receiving notification of the consequences of not doing it. With no exceptions yet, all have no apparent objection, BUT had failed to prioritise the immunisation issue over various others in their busy lives. Good job I say. I’d love to see some real information provided re 1. Efficacy of the ‘persuasion’ and 2. Efficacy of any increase in immunisation rates on prevalence of immunisable diseases

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