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Should Vaccination Be Mandatory?

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I am a mother of 3 young children. I had to face many different choices when they were born. Should I try formula, when breastfeeding was too hard? Should they sleep in their own beds, and not in mine? I would welcome discussions on these topics.

Not, however, when it comes to vaccination. I am firmly in the camp that believes vaccines save lives.

When news broke in late February of the 2-year-old boy who died from diphteria, it was reported that the boy had not received a single shot of vaccination throughout his life.  I read the news with great sadness, and frustration. One death from a vaccine-preventable disease is one death too many.

This is nothing new. 18 cases of diphtheria were reported in Malaysia in 2018.  The 5 deaths reported were all children below 10 years.  Four of those children were not vaccinated.

The World Health Organisation has listed vaccine hesitancy as one of the top health threats of 2019. 

Support for mandatory vaccination is growing

The death of the young boy in Johor Bahru was a wake-up call for many. There has been growing support for mandatory vaccination in Malaysia.  More than 120,000 supporters have signed an online petition at Change.org.

Other health advocates, such as the Malaysian Islamic Doctors Association (PERDIM)’s President, and Malaysia i-Medik’s deputy president, are proposing that unvaccinated children should not be allowed entry into public schools.

This, in turn, has prompted a strong response from UNICEF Malaysia. They believe all children have a right to education, vaccinated or not.

When we posed the question to readers of makchic on our Facebook platform, it was clear that there was strong support for the move. Reader and contributor Alena Couzet said the ‘No Jab, No Pay‘ (and ‘No Jab, No Play’) policy in Australia has made a positive impact on vaccination coverage after the law’s introduction in 2016. She added that it is not the state that is barring access, but parents who “have chosen to deny the children access to education, by their failure to comply with the law.”

But the Ministries are not on the same page

Earlier in March, Health Minister Datuk Seri Dr. Dzulkefly Ahmad confirmed that the Health Ministry is considering a proposal by the Malaysian Paediatric Association (MPA) to make at least 2 vaccines, the MMR and the DtaP, compulsory for all. Taking both shots would confer protection against 6 to 7 common childhood illnesses, including measles and diphtheria.

The National Childhood Immunisation program, which is provided for free, has been effective in maintaining high coverage. However, the Health Ministry’s strong and collaborative partnership with the Education Ministry also plays a pivotal role. The comprehensive School Health Program automatically includes children in vaccination programmes in schools. Parents need to choose to opt out of the program.

While the Health Ministry is moving towards making vaccination mandatory, this sentiment is not shared by Education Minister Dr. Maszlee Malik, who sees vaccination and access to education as two separate issues. The Deputy Prime Minister Dr. Wan Azizah has also confirmed that no restriction will be placed on unvaccinated children.

You are not legally required to vaccinate your children in Malaysia. However, many have referred to broad provisions under Section 31 of The Child Act 2001 as a way to penalise parents who refuse vaccination for their children.  If found guilty, parents could face a fine up to RM20,000, or jail term up to 10 years, or both. But, if vaccination is not mandatory, how could these cases be tried in court?

Just the facts, Ma’am

Let’s take a look at the numbers. Let’s not even look at all vaccine-preventable diseases. Just with one – measles.

Before the introduction of a vaccine for measles in 1963, there were 4 million cases every year, in the U.S. alone. 48,000 would be hospitalised. 500 would be dead. Most of these cases were children.

Young children below 5 years are more likely to face complications, such as pneumonia, blindness, and inflammation of the brain. One to 2 out of 1,000 children would die.

Boy with measles. There are fewer photographs like these in modern times due to the success of vaccinations, but will they return? Photo credit: Centers for Disease Control and Prevention

Fifty years later, measles is no longer the leading cause of death in children. In fact, we have seen a near 100% reduction in death caused by vaccine-preventable diseases.

Dr. Romina Libster, one of Argentina’s leading scientists, was not wrong when she said that “vaccine is one of the greatest successes of 20th-century public health. After potable water, they are the inventions that have most reduced mortality – even more than antibiotics.”

We have only seen the reemergence of measles when parents have stopped trusting vaccines to work, and when herd immunity goes below the threshold required to protect the population from the spread of the infection.

Too many freeloaders in the herd

You will hear a lot about herd immunity when we discuss vaccination as a public health policy. When large numbers of individuals in the population are immune, the risk of infection is lower. Epidemics, which are terrifying, are less like to occur. This threshold required to confer herd immunity could be different from one disease to another. For measles, this threshold is 90 – 95%.

Most of us would agree that vaccinations are important. But they do carry certain costs, just like any other medicine out there: time, money, and possible side effects.

Game theories have explored the concept of “freeloaders”. In a society with high levels of protection, the ‘selfish’ strategy would be to rely on and benefit from indirect protection conferred by herd immunity. With a lot of misinformation out there, parents are asking, “Why risk my kid?”

But when you exercise this individual choice e.g. refusing to vaccinate, this goes against the needs of the community. With higher number of parents refusing vaccine due to safety concerns and religious beliefs, we have seen increasing incidences of vaccine-preventable epidemics in recent years.

The question remains – Why are parents so hesitant? It is hard to list all the concerns parents might have over vaccination. We will address some of the key concerns here.

Before vaccinations, the reality of death from diseases was all too real. A Danish gravestone and the sign next to it is in memory of the Larsen’s five children who died of diphtheria within four days in 1903. Photo credit: JouwPF/Reddit

Is it safe?

The fraudulent paper published by Andrew Wakefield was the beginning of decades-long struggle by public health officials to debunk reports about vaccine safety.

To understand how safe a vaccine is, it is also important to understand how vaccine production works.  It usually takes a long time, between 10-15 years, and with many years of research, before it can be used on the general population.

It is unsurprising that vaccines are held to higher standards of safety. After all, vaccines would be used on a healthy population – mostly children.  The likes of GlaxoSmithKline and Merck are now testing vaccines on nearly 150,000 subjects. These companies are spending nearly USD400 million to conduct clinical trials, and to detect rare side effects.

Vaccines are only manufactured once it has passed rigorous testing standards. But, it is often expensive, with high risks and low profitability.

Do pharmaceutical companies profit from the manufacture of vaccines? Yes. But, global revenue generated from vaccines only accounts for 3% of total revenue for all their products. When we compare the rising cost of research and development, and the long development time for any new vaccine, it is clear that vaccine research is often at a disadvantage when competing against the more lucrative market for other drugs.

Vaccines are not perfect. It doesn’t work perfectly, for all individuals, at all times. However, the side effects that may occur are often mild, and temporary. Out of billions vaccinated, big events are only occurring in less than 1% of the population.

Are there alternatives?

All vaccine manufacturers have to go through many hoops before their products could be marketed.  It is then incredibly frustrating to see that anti-vaccination parents would rather turn to unproven alternatives.

Andrew Wakefield was attempting to profit from his scare tactics by offering his own alternatives to the MMR vaccine. Large anti-vaccination groups are trying to do the same. In one large group, the leader, Katie Gironda, is also the CEO of an online business, a business that is pushing high doses of Vitamin C as alternatives to its members.

These groups often operate on large social media platforms. These platforms are not taking enough precautions to reduce the amount of inaccurate information being disseminated. Only Pinterest has gone a little further, by crippling the search function on any anti-vaccination content.

Is it halal?

We are also seeing the rise of vaccine refusal in Muslim-majority countries, due to concerns of the presence of the porcine enzyme trypsin in certain vaccines. However, the process of vaccine production often leaves little to no trace amounts of the enzyme in the final product.

If you need more reassurance, European Council of Fatwa and Research (ECFR) has already deliberated on this issue in 2003. More than 100 scholars from all over the world that attended the session, encouraged Muslims to focus on the benefits that vaccines would bring. They agreed that the vaccine is permissible if refusal would cause greater harm.

However, concerns among Muslim parents remain. Despite news of halal vaccines that would be produced in Malaysia in 2018, nothing has materialised beyond the announcement.

It’s okay to ask

You might have doubts if vaccines are really good for your children. It’s okay to have frank discussions with your health providers about your concerns.

But research has clearly shown that the benefits of vaccination far outweigh the risks.

Vaccines save lives.

Vaccine hesitancy has very real and significant impacts on the health of the community. When you don’t vaccinate your children, you might end up not only causing them harm. Too often, the ones who have to pay the price, are the youngest, and the most vulnerable in your community.

Over the past 15 years, Najmin worked as a management consultant, ran a community-supported agriculture (CSA) programme out of an integrated goat farm, and helped manage an equine centre. A biologist by training, this mum of three (5 to 13 years old) now has all her kids in school. She wants to spend more time reading, writing and gardening, and sharing her discovery of fun local places at Mums of Makchic.

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