Vaccination is one of the more effective interventions that the Health system undertakes. The early vaccines were life savers – historical accounts of diptheria for example were harrowing. Polio virtually disappeared, and would have done so completely but for ideological and political opposition in some parts of the world. Whooping cough is a distressing and potentially damaging illness, particularly in younger children. Tetanus is deadly but is virtually unknown in vaccinated subjects. General Practice has provided a major proportion of vaccination services, though other providers such as pharmacies are now doing so.
Commercialization
But of course like everything else in the health system vaccines are now a commercial opportunity – more and more are produced for “edge cases” where the disease they are preventing causes less and less morbidity and virtually zero mortality. For example, Chicken pox used to be regarded as a “nuisance” childhood illness, albeit with occasional serious morbidity. RSV vaccine for adults has been promoted recently – as a clinician I dont recall a single case of RSV related disease in older adults. The absolute incidence worldwide varies, but is probably of the order of 100/100,000 annually – ie 0.1%. Like all in Medical Evidence nowadays, these commercial drivers bedevil discussion about vaccines – what was once an undeniable benefit has become marginal.
Objectors
In spite of its effectiveness, vaccination has generated enormous resistance from some groups with conspiracy theories and misinformation rife. These groups generate significant publicity and political heat, particularly via social media. The political response has been to over-regulate vaccination with onerous requirements for training and recording.
Complexity and Administrative burden
The vaccine schedule has become increasingly complex with all these new vaccines. Of course, each state Health Department has different views on priorities. Sometimes this is justified – for example, Hepatitis B had a carrier rate of up to 30% in some populations in the NT. This has now dropped dramatically as a result of vaccination. But the end result is that the vaccine schedule is different in each state. Funding may determine which vaccine is given. Some groups are funded by Government, while others are not – records have to be kept of subsidized vaccines all the way down to individual serial numbers. Even wastage must be recorded. A provider must search various clunky, separate databases to ensure that the patient has not already received the vaccination. A duplicate dose is treated as a major incident when probably the worst that will happen is that patient will have better immunity. Due to the complexity of the schedule, it may be difficult to decide what vaccines are due, particularly for clients from interstate and for “catchup” vaccination. There are various requirements for notification to databases eg the Australian Immunization Register (AIR), some of which are quite onerous. All these requirements increase the complexity and administrative burden for the vaccine provider.
Cold Chain
Vaccines must be stored at a defined temperature range from production to administration or they risk being destroyed or degraded. This is certainly a problem in the third world in vaccine delivery to Remote places.
In Australia, cold chain requirements for vaccine storage are onerous and expensive – special temperature controlled refrigerators with data logging are required. The standard temperature range for storage is 2 to 8 degrees Celsius. While it is true that freezing denatures many vaccines, periods of over-temperature may only shorten storage life and the vaccine may still be usable. Vaccination bureaucrats from the local Primary Health Network organizations (PHNs) seem to think they have the right to walk into a private GP practice, inspect vaccine storage arrangements and demand logs of temperature readings. They regard any deviation from the standard temperature range as requiring disposal of the vaccine, often at the cost of the private practice.
Are rates declining?
The rate of vaccination has increased steadily over many years but has reached a plateau and now appears to be declining (Australian Govt data).
It is probably still at a level where “herd immunity” (population immunity) overall is good enough to prevent outbreaks of vaccine preventable disease. But there are local areas where herd immunity is lower and here the risk of vaccine preventable disease is increased.
Why are rates declining?
There are many possibilities – the very success of vaccines has made the diseases they prevent rare. Most members of the public have no experience of these conditions and may not see the necessity for many vaccines as a result. Vaccine objectors have become more common with widespread misinformation on social media. Perhaps they have a point as vaccines are increasingly produced for “edge cases” with little morbidity or mortality.
Agency nurses in Primary Care (common nowadays) may simply refuse to give vaccinations – “Oh no doctor, I dont have the certificate”. They may continue to refuse even when informed that anyone can give a vaccine under doctor supervision. As a result of the complexity of the schedule, onerous training requirements, cost of infrastructure and administrative “overhead”, many providers simply bypass the vaccination when it is due and move onto more lucrative work. As a safe procedure, vaccination is now massively over-regulated and complex. In my opinion this administrative “overhead” has started to have an impact on vaccination rates. Less vaccination services are being provided in General Practice as a whole due to it’s decline and the cost of providing infrastructure and Practice Nurses.
Actions
If we are to reverse the decline in rates, I would advocate removing mandatory training, reducing the complexity of the schedule, harmonizing and connecting databases and reducing the administrative complexity of vaccination.
References
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