The number of measles cases in Malaysia increased about 10 times from 195 cases in 2013 to 1,934 cases in 2018 with six deaths in 2018, all of whom were not immunised.
Meanwhile, the number of cases who had no vaccination against measles increased about 11.7 times from 125 in 2013 to 1,467 in 2018.
Measles infections have also spiked in many countries in recent years, e.g. Singapore, Indonesia and the Philippines in Asean, and many developed countries.
In addition, diphtheria cases in Malaysia increased from four cases in 2013 to 32 cases in 2017 and 18 cases in 2018, with five deaths in 2018, of whom four were not immunised.
Pertussis cases have fluctuated between 222 in 2013, 939 in 2015, 353 in 2017 and 892 in 2018, with 22 deaths in 2018, of which 19 were not immunised.
Vaccine refusals in Malaysia increased from 637 in 2013 to 1,603 in 2016 and 1,404 in 2017.
According to the World Health Organization (WHO), one of the ten threats to global health in 2019 is vaccine hesitancy, i.e. the reluctance or refusal to vaccinate despite the availability of vaccines, which threatens to reverse the progress in tackling vaccine-preventable diseases.
A proposed intervention to this problem is mandatory vaccination – an approach that has been perennially debated and which is currently being studied by our Health Ministry.
The proponents of mandatory vaccination have often quoted and extrapolated the dramatic positive impact of smoking bans and car seatbelt usage on public health and safety.
On the other hand, there is lack of evidence on the effectiveness of mandatory vaccination.
Vaccination saves lives
Vaccines are one of the most effective public health interventions, having saved lives and enhanced health. Only clean water has performed better.
Vaccines have eradicated smallpox and nearly eradicated polio. However, vaccine-preventable diseases have not all disappeared.
According to Shot@Life, a grassroots advocacy campaign of the United Nations Foundation, vaccines save 2.5 million children from preventable diseases annually, i.e. about 285 children every hour.
When a critical percentage of a population is vaccinated against a contagious disease, it is unlikely that a disease outbreak will occur, so most members of the community will be protected – this is known as herd immunity.
The population that cannot be immunised because of medical reasons, depend on herd immunity to prevent their infection by vaccine-preventable diseases.
As vaccines have controlled and eradicated disease, the devastating effects of vaccine-preventable diseases have disappeared from human comprehension.
Vaccine hesitancy has been partly due to concerns about vaccine safety, with misplaced anxiety or concerns about vaccine safety prevailing over concerns about the disease itself.
Declines in vaccination rates will lead to a resurgence of vaccine-preventable diseases.
Low national coverage, or even small pockets of low coverage within a country, have led to large measles and diphtheria outbreaks, causing many deaths and disabilities in many countries over the past decade.
For mandatory vaccination
All 50 states in the United States require all children above five years of age to have been immunised prior to school admission.
However, all the states have exceptions based on medical and religious grounds, and a few based on philosophical objections.
Some children get immunised only when they start school.
States with the strictest laws have lower pertussis (also known as whooping cough) and measles rates, suggesting that mandatory vaccination may be effective.
Compliance to child vaccination schedules in Australia have been linked to pre-school admission (i.e. “No jab, no play”) and family assistance payments (i.e. “No jab, no pay”).
Most governments and international medical organisations state that vaccines are safe as the ingredients in them are safe in the amount used.
Adverse reactions to vaccines are extremely rare. The most common adverse reaction, i.e. a severe allergic reaction known medically as anaphylaxis, occurs in about one per several hundred thousand to one per one million vaccinations.
There is a difference between association and causation.
Combination vaccines like the one for mumps, measles and rubella (MMR) have been used since the 1940s without adverse effects.
There is no evidence that the MMR vaccine causes autism, or that the diphtheria, tetanus and acellular pertussis (DTaP) vaccine causes diabetes; or that the killed influenza vaccine causes seventh cranial nerve (Bell’s) palsy or precipitates asthma.
Against mandatory vaccination
There are many countries that have high vaccination rates despite vaccination being voluntary, e.g. the United Kingdom and Finland.
The US Centres for Disease Control and Prevention (CDC) estimate that the risk of anaphylaxis is one per one million children, i.e. about the same risk of being harmed by flying in an aeroplane.
According to the National Vaccine Information Centre, a US organisation dedicated to preventing vaccine injuries and deaths, vaccines may be linked to learning disabilities, asthma, autism, diabetes, chronic inflammation and other disabilities.
The rarity of fits, coma and brain damage attributed to DTaP and MMR vaccines makes it difficult to determine causation.
According to the US CDC, there are extremely rare reports of severe rash, pneumonia, hepatitis, meningitis, fits or general severe infection with the virus strain from the chickenpox vaccine, while reports of the association between the influenza vaccine and Gullain-Barre syndrome – an affliction of the peripheral nervous system – have changed from season to season.
There are claims that some of the vaccines contain harmful ingredients, e.g. thiomersal, aluminium and glutaraldehyde.
Other arguments include the infringement upon personal rights of choice and religion, that vaccines are unnatural, that infection produces more effective immunity, that vaccine-preventable diseases have almost disappeared, and that most vaccine-preventable diseases are relatively harmless.
There are counter arguments to both sides of the debate.
The basic question to be address-ed is the goals of vaccination policy. Is it individual or herd immunity (vaccine uptake), or is it the eradication of disease?
Where is the balance between individual rights and societal goals?
There are legal, ethical and public health implications to mandatory vaccination.
If there is mandatory vaccination, what vaccine-preventable diseases would be included? How will it be enforced with the increasing number of children involved in home-schooling?
What would be the grounds for exclusion? What would be the penalties for non-compliance?
If a child suffers an adverse event near the vaccination date, would the government be liable?
There is scanty evidence of the benefits of mandatory vaccination, which may have unintended consequences like the strengthening of anti-vaccine sentiment, as happened in Italy.
If exclusions are permitted on religious and philosophical grounds, they would be difficult to manage, and if allowed, would reduce the effectiveness of mandatory vaccination.
The European Union Asset project found no clear link between mandatory vaccination and vaccine uptake.
The experts’ position was that mandatory vaccination might fix a short-term problem, but is not a long-term solution.
Better organisation of health systems and strong communication strategies may prove more effective.
Research findings suggest that vaccine uptake rates amongst vaccine-hesitant parents improved when they had discussions with trusted healthcare professionals.
Easy access to vaccines and healthcare are vital as the parents of many children who were not vaccinated were not vaccine-hesitant, but had difficulty getting convenient appointments or were not reminded when their children were due for vaccination.
In summary, vaccine hesitancy has to be addressed by education, not coercion, which may have unintended consequences.
In this respect, general practitioners (GPs) have a critical role with their close relationships with parents in their community.