1.1 This is the introduction to the dissertation Dr Richard Lanigan DC, MSc presented for his masters. "Are parents making an informed choice when they consent to the DTP vaccination" . This vaccine was withdrawn two years ago with many unanswered questions surounding it. (Table of contents)
According to the World Health Organisation (WHO, 2003), the two public health interventions that have had the greatest impact on the world’s health are clean water and vaccines.
Bedford and Elliman (1998) consider that the benefit of immunising is clear, fewer people develop the disease and fewer people suffer from serious illness or die as a result. Diseases such as measles, diphtheria, pertussis, tetanus and polio are now extremely rare in developed countries with vaccination programmes.
Mandatory vaccination programmes were introduced in the United States in the 1960s; persuasion became obligation as vaccination was a condition of school entry. Vaccination is not mandatory in the UK and consent should always be obtained before immunisations are administered (Downie and Calman 1998).
The UK Department of Health (DOH) recommends that routine vaccines are given as detailed in the immunisation schedule presented by health visitors to all newborns. The DOH has set targets for vaccine uptake. The aim is that by the age of two, 95 per cent. of children will be immunised against diphtheria, tetanus, polio, pertussis, Hib, measles, mumps and rubella (Department of Health, 2004). Similar schedules are in operation throughout the world.
Vaccination has been a controversial subject in the UK since the Vaccination Act of 1853 made smallpox vaccination compulsory for all infants in the first three months of life and made defaulting parents liable to a fine or imprisonment. Author Lewis Carroll (1877) was one of the first to question this approach to health care in his letters to the Eastbourne Chronicle, which over the years has spawned mass criticism of a public health policy now considered by many to be the most cost effective part of health care.
Critics of vaccination programmes, Coulter and Fisher (1991), argue that there was already a 90 per cent. decline in the mortality rate from pertussis in the United States and England in the 20 years preceding the introduction of the vaccine and the same decline in mortality rates were occurring with other infectious diseases such as scarlet fever, measles, influenza, tuberculosis and typhoid. These diseases were formerly prevalent and lethal and all declined as causes of death during the same period, while morbidity remained high.
McKeown and Lowe (1974) proposed this was principally due to a vast improvement in living standards in both Western Europe and the United States. Better housing, sanitation, nutrition and health care resulted in a better state of health in the infant population. Coulter and Fisher (1991) also pointed out that the successful use of antibiotics to control secondary infections such as pneumonia and bronchitis gave babies a much better chance of surviving pertussis and other serious illnesses.
Another reason proposed for the decline in morbidity was that the populations of Europe and the United States had acquired a certain degree of natural resistance to these diseases after so many generations of exposure (Scheibner, 2000).
The objective of most of the studies on immunisation is to assess the efficacy of vaccines in relation to preventing the disease and safety issues. In 1974 a study by Kulenkampff (cited by Kassianos, 2001) reported neurological complications related to the pertussis vaccine that greatly damaged confidence in the apparently successful immunisation programme. According to Kassianos, “Doctors started inventing contra-indications to the vaccine” to avoid giving them, uptake dropped dramatically from 80 per cent. coverage to 30 per cent., with the number of cases notified matching the pre-vaccine era. In his opinion, these events provided clear evidence that the benefits of the vaccine far outweighed the possible risks (Kassianos, 2001).
On the other hand no studies have examined whether vaccinated children are healthier than unvaccinated children (McTaggart, 2000) yet governments all over the world promote vaccination policy.
The Ottawa Charter (WHO 1986) identified “Healthy Public Policy” as one of the five key health promotion actions. Milio (1986) argued that public policy should outline a framework within which individuals and communities are empowered to take control of their health and well-being.
According to Kemm (2001), health public policy should be conceived on the basis of how it can influence factors detrimental to optimal well-being such as socio-economic, cultural and environmental conditions, living and working conditions and social and community influences.
Rogers and Pilgrim (1994) noted that the attention paid by public health experts to the risks of, and eradication of, childhood infectious diseases did not reflect their degree of threat compared with other contemporary hazards, particularly in the developed world. In comparison with cardiovascular disease, cancer, AIDs, pollution, violence and accidents in the United Kingdom, the dangers posed by childhood infectious diseases are actually quite small. Despite this, vaccination programmes retain a privileged position in public health policy.
Donaldson (2002) explains how politicians who were formerly preoccupied with illness are becoming increasingly focused on the health and well-being of the population and disease prevention. He states disease prevention is an important part of health promotion through the application of pre-symptomatic screening and vaccination programmes. He claims that frameworks exist to determine whether such interventions are effective, safe and the costs justified in relation to other public health priorities.
According to WHO (2003), the participation of the public and health workers in immunisation takes place within a myriad of complex and varying social settings. Understanding these factors helps health providers offer a better and more acceptable service that is the “foundation of all advocacy messages to increase acceptability of immunisation.”
Farrow (2001) describes the role of school nurses in promoting health and attributes much of the success of the mass measles/rubella campaign to their involvement. In Canada, school nurses play a central role in ascertaining the immunisation status of children. Their role is also important in the UK as the Government strives to meet its target to vaccinate ninety five per cent. of the population against these diseases.
To help people make their decision the quality of information on the procedure is important, yet no published studies have been found in the PubMed database assessing the quality of information available to parents in the UK contemplating the vaccination of their children. UK studies on “informed consent” and vaccination tend to focus on the minority of parents who chose not to vaccinate their children (Sporton and Francis, 2001).
Coulter, Entwistle and Gilbert (1998) was the only UK study assessing the quality of patient information in GP surgeries, it was less than complementary about the information available, unfortunately they did not look at vaccination information.
Hinman (2000) assumes that the parents consenting to the vaccination of their children and parents refusing because of a recognised contraindication are making an informed decision. The “misinformed” opposition to immunisation are those arising from acceptance of unproven allegation about vaccine safety or efficacy. He concludes “that carefully developed and forthright responses to these allegations are needed to assure that people make truly informed immunisation decisions”.
Langkamp and Langhough (1993) found that parents of premature infants were not correctly informed regarding immunisation and recommended that this should be dealt with before the mother leaves hospital.
Health workers involved in immunisation programmes can ensure that parents are able to give informed consent to have their children vaccinated, they can provide information on the nature, prevalence, risks of the disease, the risks of side effects and talk about the role of individual immunity in community well-being (Fulginiti 1984).
North American studies assessing the quality of information provided to parents are not recent. According to Fitzgerald and Glotzer (1995), parents indicated that they wanted information about many aspects of immunisations, and those familiar with the vaccine information pamphlets reported high levels of satisfaction with the pamphlets in the United States.
Clayton, Hickson and Miller (1994) assessed parents’ knowledge and opinions about immunisations and immunisation practices before and after the introduction of vaccine information pamphlets to inform parents about the process. They found vaccine information pamphlets enhanced parents’ knowledge and acceptance of immunisations but concluded “there is room for further improvement.”
Davis, Frederiksen. Arnold Murphy, Herbst, Boccle (1998); and Lieu, Glauber, Fuentes and Lo (1994) found that information pamphlets alone did not adequately inform patients. Dunn, Shenouda, Martin, Abigale, and Shultz (1998) recommended video tapes as a useful addition to the vaccination information statements that must be given to parents before they consent to vaccination in the United States.
The right to choose is the reality of patient autonomy and power. Patient power may mean that large groups of parents have the right to behave in a way that “the authorities” think misguided (Smith, 2002). Parents may chose to ignore the advice of authorities and not vaccinate their children and, according to Smith (2002,) it seems likely that this will continue to happen.
Longstanding anxieties over vaccination, declining folk memory of the complications from the infections being prevented, distrust of the authorities fuelled by Government’s mishandling of salmonella and BSE has resulted in a fall in the number of children being vaccinated in the UK. Government rhetoric on “patient partnership” (Coulter et al, 1998) suggests that it believes patients should be given choices. However, in relation to the Measles, Mumps and Rubella (MMR) vaccination programme the Government has responded by holding fast on its policy on the triple vaccine, when the vast majority of people want single vaccines given separately (Smith, 2002).