Is Italy’s introduction of compulsory vaccinations the way forward?

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In March 2019, Italy reintroduced its 2017 compulsory vaccination schedule for children which is comprised of 10 vaccinations. This terminates an intermittent period in which parents’ attestation of vaccination rather than a doctor’s note was proof enough of a child’s vaccination coverage. Now, children under the age of six whose parents cannot provide official documentation are banned from kindergarten. Because education is compulsory for children from the ages of six to 16, parents of insufficiently vaccinated children are fined €500 (£425).

The background to this is a rise in measles cases, which also occurred in the US and Romania. Problematically, the inoculation coverage in Italy had dropped to 80% in 2018 which is far lower than the 95% recommended by the WHO. A vaccination level around 95% (depending on the disease) across a population provides for so-called herd immunity, meaning that the risk of contracting and spreading the disease for those who are not vaccinated is sufficiently reduced. Thus, vaccination happens not only for the benefit of the individual but also in the interest of those who are too young to be vaccinated or suffer medical conditions like a compromised immune system. Following the reinforced vaccination law, Italy’s national coverage level now is close to 95%, albeit with regional variations.

Yet, the ethics and effects of compulsory vaccination are debatable, especially when it is tied to financial and institutional incentives or disincentives (as is also the case in the US and Australia). The acuteness of the current measles outbreak justifies the stark measures. However, the nature of the disease and acuteness of an outbreak should be factored into decisions on binding immunisation. For example, Italy is reviewing the inclusion of the varicella vaccination (against chickenpox) in its compulsory schedule. The disease typically is unproblematic in children and results in immunity.

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While cost benefits have been modeled to arise from a varicella vaccination, more than finances are at stake. Ultimately, a vaccination compromises physical integrity and carries a minimal, but existing, risk of side effects. When it comes to interventions the benefits of which for individuals and society are scientifically proven, choice is more desirable than coercion. In the long run then, the accessibility and desirability of vaccination must be increased. This requires improvements in infrastructure, awareness raising and dialogue.

Poverty and exclusion from health services and advice contribute to low coverage levels in specific populations. This is doubly problematic because even with a national vaccination  coverage of 95%, unvaccinated people cluster due to socioeconomic factors like income, religion and education. The exclusion of unvaccinated children from kindergarten may lead to the establishment of low-quality alternatives where worse education standards reinforce segregation.

Misinformation also keeps vaccination levels low. Internationally, the 1998 Wakefield scandal is cited as the instance provoking the attitude of so-called “anti-vaxxers” whose influence on sinking vaccination levels has been exaggerated. Although the results that postulated an association between vaccinations and autism could not be reproduced, making the study insignificant, it is claimed to have left a lasting fear among vaccination sceptics. In Italy, this was reinforced by the “infamous ruling in 2012 from a Rimini court that established a link between autism and the combined measles, mumps and rubella vaccination, experts say. While the ruling was overturned three years later, it helped anti-vaccination theories to spread in Italy — and globally”.

While such scandals stick, more regular information like that available on the internet also influences attitudes towards vaccination. A study analysing YouTube videos viewed in Italy for positive and negative messages about vaccination found that while “most videos were positive in tone, […] those that disapproved of immunization where most liked and shared”. Given the internet’s accessibility and its increasing impact on health decision-making, monitoring the web to communicate health messages effectively is instructive.

Given the fact that far less than 5% of a population are “anti-vaxxers”, awareness must be raised amongst those who display “vaccine hesitancy”. The European Centre for Disease Prevention and Control (ECDC) distinguishes several responses for different articulations of scepticism. Some are as straightforward as the reduction of costs or improved access. Individual beliefs in risks and effectiveness of vaccinations can be “addressed through discussions, information, and educational interventions. Others, such as mistrust in institutions, require interventions that will build trust in health systems and vaccines”. This applies to the Italian public which displays a general distrust in institutions beyond the health sector. The ECDC states that populations with strong beliefs, among others, of religious or conspiratorial nature, are most difficult to be convinced of the benefits of vaccinations. Cooperation with religious or community leaders may yield limited successes but a way to convince, rather than coerce, these populations is yet to be devised.


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