Last week, the wife of an NRL footballer made national headlines after posting on Instagram that the couple did not plan to vaccinate their children.
Indeed, there’s rarely a time vaccination isn’t a hot topic of public debate. What’s important to note is that anyone can use evidence-based communication techniques to be an advocate for vaccination – you don’t need to be an expert in the field.
Conversations between peers can be very influential, because our behaviours are shaped by social norms, or what other people in our network value and do.
While the current measles outbreaks in the United States and Europe are concerning, much of the reporting has over-simplified the issue, with sensationalised headlines placing the blame almost solely on “anti-vax” parents.
In reality, the vast majority of people whose children are missing some or all doses of the recommended vaccines are not “anti-vaxxers”, and labelling them as such is unhelpful.
The ability to register for vaccination exemption based on conscientious objection was removed in 2016, but it was last recorded in December 2015 as affecting only 1.34% of eligible children.
Current childhood vaccination coverage in Australia is between 90.75-94.67%, depending on age.
This suggests that missed opportunities and access barriers, such as parents being unable to get to the GP or a council immunisation session, are much more substantial contributors to under-vaccination.
Communication about vaccines is unlikely to impact the behaviour of firm refusers and those facing access barriers. However, communication has enormous influence when it comes to the 43% of parents who have some questions or concerns about vaccines.
Aggressive or dismissive language can make people less likely to vaccinate, while open, respectful discussion with a trusted individual can encourage hesitant parents towards vaccination.
Instead, these are some tips everyone can use when talking about vaccines, drawing from evidence-based communication techniques. Studies in the United States and Canada have trained healthcare providers to use techniques like these to increase uptake of adolescent HPV vaccination and infant vaccines, and more studies are currently underway.
Ask about, and listen to, people’s concerns: not everyone is driven by the same issues or experiences. Find out what specifically is concerning the person. Is it safety? Effectiveness? Side effects?
Acknowledge their concerns: remember, everyone loves their children. No one is refusing to vaccinate because they want their child to get sick, or because they wilfully hope other children will get sick. Acknowledging that you see where someone is coming from can go a long way in establishing trust.
Provide information to respond to their concerns: share what you know, and try to provide reliable sources for your information. Be careful not to debunk myths too aggressively, as this can actually backfire.
Share personal stories: emotive stories tend to have more impact than facts. This is one reason stories of rare vaccine adverse events can seem to carry more weight than overwhelming safety figures. Share your own stories of positive experiences with vaccines, or better yet, discuss your experience with the diseases they prevent.
Don’t pass judgment: people may discuss vaccination many times with many different people before they decide to vaccinate, especially if they are very hesitant. Your goal should be to establish yourself as a trusted, non-judgmental person with whom they can share their questions and concerns. Berating them won’t convince them to vaccinate, but it will convince them never to speak to you about vaccines again.
These communication tips can help support discussions about vaccines with someone who is hesitant, but open to discussing their position. If, however, you find yourself publicly debating a “vocal vaccine denier”, the WHO has developed a toolkit to help guide your responses.
In such a situation, your intended audience is not the vaccine denier themselves, but the public who may be watching or reading your debate.
The techniques used by a vaccine denier could include referring to conspiracies, fake experts, selective or misrepresented evidence, or impossible expectations (such as 100% safety). The WHO recommends you identify the techniques the denier uses and then correct their content.
If you’re a strong supporter of vaccination, you can become a powerful ally in the effort to sustain high coverage rates in your community. Listen and share your views respectfully, build and maintain open and trusting relationships, and yours may be the words that encourage another person to vaccinate.
Winter has started, and with it, flu season. Inevitably, all of us (young, old and sick) have been implored to be immunised against influenza, with some eligible for a subsidised vaccine. And people are heeding the message, to the point that there is now a shortage of available vaccines.
At the same time, findings from three important Cochrane reviews on the effectiveness of the influenza vaccination aren’t consistent with the advice we’re been given.
Cochrane reviews are independent systematic reviews, which are comprehensive analyses of most of the literature relevant to a research topic. Cochrane reviews summarise the results in a multitude of studies, and are regularly updated to absorb new research.
These three Cochrane reviews have been recently updated, as well as stabilised, which is what happens when it looks as if it seems unlikely new research would be published that would change the conclusions.
What the reviews found
The first Cochrane review looked at the effects of the influenza vaccine in healthy adults from 25 studies conducted over single influenza seasons in North America, South America, and Europe between 1969 and 2009. It found the vaccine reduced the chance of getting laboratory confirmed influenza from 23 cases out of 1,000 to 9 cases out of 1,000.
While this seems to be a reduction of more than 50%, that seems less optimistic expressed in absolute terms.
The infection rate in adults drops from 2% per year to 1%. You could say that’s halved, but it effectively only drops by 1%. So this means that out of every 100 healthy adults vaccinated, 99 get no benefit against laboratory confirmed influenza.
The second Cochrane review – which looked at trials in children over single influenza seasons in the US, Western Europe, Russia, and Bangladesh between 1984 and 2013 – found similar results.
The third Cochrane review looked at vaccines for the elderly in nursing homes. It found much less good evidence, with only one randomised trial – considered the gold standard in clinical trials as it establishes causation rather than correlation.
While observational studies (that draw inferences from a population to establish associations) have been done to show benefits of the vaccines, bias means we cannot rely on their results.
There are also potential harms from influenza vaccines noted in the reviews. They range from serious (a neurological disease called Guillain Barre) through to moderate (fevers, in children especially – some of which will cause febrile convulsions), and trivial (a sore arm for a couple of days).
Why are we so scared of the flu?
There is a special concern about influenza from a public health point of view. This comes about from its potential to cause pandemics. The first in modern history was the Spanish influenza pandemic of 1918-19, when tens of millions of people died worldwide.
There have also been been several, less severe pandemics. These include the most recent swine flu that, although while affecting some (unexpected) groups of people (including pregnant women, those who were obese, and had asthma), caused little more effect on the overall population than the usual seasonal influenza.
Public health experts worry about another pandemic that can be more harmful and contagious, which could be devastating. But it’s important to note the vast majority of deaths from Spanish influenza were from secondary bacterial infections and predated the antibiotic era.
The reasons influenza virus has this ability to cause new pandemics comes from its instability – it changes genetically easily, making it more difficult for our immune systems to recognise newer strains. The effect is that new vaccines must be prepared every year for a best-guess at next year’s virus, and we need vaccination every year.
Influenza can also undergo a more radical change, such as when a new form of the virus emerges from an animal host (wild or domesticated birds or pigs, for example). This moving target makes it more difficult to vaccinate against – especially with the genetic shifts of pandemics. Just when we need protection most, vaccines can provide it least.
So what, if not the vaccine?
There are physical barriers that can prevent the spread of influenza. These are the masks (to reduce the spread of aerosol-borne virus particles), hand washing (to reduce the spread if virus from hands onto shared surfaces), and quarantine measures (isolating infected people to reduce their infectivity).
There is now reasonable evidence such measures reduce infections considerably. It might take a bit of effort to change the psyche of Australians to make wearing a facemask acceptable if you have an acute respiratory infection. Even the heroic “soldiering on to work” (or school) with your virus needs to be reversed as a public health act.
On June 1, health workers in New South Wales will be required to have a flu vaccination if they work in high-risk clinical areas, such as wards for neonatal care, transplants and cancer. Otherwise staff are required to wear surgical masks during the flu season or risk being redeployed.
The most effective way to improve vaccination rates among health workers is to make it mandatory. State, territory and Commonwealth governments should consider making the flu shot mandatory for all health workers in high-risk clinical areas and aged care facilities.
Why health workers need to be vaccinated
For most of us, vaccination is for individual protection. In the case of those caring for sick and vulnerable people such as children and the elderly, vaccination protects others from devastating illness, complications and even death.
Hospitals and aged care facilities can experience explosive outbreaks of influenza.
Aged care facilities may have to close their doors to new admissions, which can also have a significant economic impact. It’s also important that staff absenteeism in hospitals is kept low, especially in areas with limited specialist expertise.
Some argue vaccination of health workers is a moral duty, while others state individual freedom of choice is more important than protection of patients.
The use of immunisation mandates for health-care workers is not new in Australia. In most states and territories, staff are required to have vaccines for (or show evidence of protection against) measles, mumps, rubella, diphtheria, tetanus, pertussis, hepatitis B, and varicella (chicken pox).
NSW, for example, introduced mandatory vaccination of health care workers for several vaccines (but not the flu) in 2007. NSW health workers generally accepted this change in policy, with only 4% objecting.
Making the flu shot mandatory, as NSW has done this year, would simply add the the list of vaccinations health workers are required to have.
The evidence suggests it’s worth it; a five-year study in one hospital in the United States showed mandatory hospital policies can raise coverage rates to close to 100%.
Institutions that have implemented a mandatory policy have dramatically reduced employee sick days as well as flu in hospitals, thereby improving patient safety and reducing health care costs.
Staff vaccination programs
Most workplaces run intensive vaccination programs, which may include mass immunisation clinics, mobile carts, posters and email reminders. But in most cases, these programs aren’t successful at boosting vaccination levels above 60%.
Some hospitals have been able to achieve higher vaccination rates in the short term through easy access to vaccines, education, reminders and multiple opportunities for vaccination. But these initiatives require ongoing resources and continual efforts – a one-off vaccination day is not enough.
The Victorian health system used a slightly different approach in 2014 when it made high rates of flu vaccination a hospital performance target. The government also provided the vaccine free to all Victorian hospitals.
This raised vaccination rates among Victorian hospital staff from 60% to 75% overall (higher in some hospitals). But higher rates may be achieved through mandatory flu vaccination.
But it’s not always the best policy
For each situation, we need to consider the overall risks and benefits of mandatory vaccination, as well as the gains in protection and vaccination coverage.
For infant vaccination, for example, vaccination rates are already at a high baseline of more than 93%. So, the risk of coercive policies may be greater than the relatively small gains achieved by coercive methods. Similar results may be achieved through other methods.
In the case of health and aged-care workers, however, we start with a lower base of vaccine coverage, of 16-60%. Adding financial incentives or disincentives, or making it mandatory, would result in much larger gains in vaccination rates.
Vaccinating health-care workers also has benefits beyond their individual protection: it reduces the risk of their patients contracting influenza and maintains the health workforce capacity. This shifts the balance in favour of mandatory vaccination.
Given large potential gains and low resource requirements, mandatory flu vaccination for all health workers in high-risk areas is a good idea. Governments should consider this and other strategies to improve flu vaccination rates health and aged care workers.
If you are an adult in Australia, the kinds of vaccines you need to get will depend on several factors, including whether you missed out on childhood vaccines, if you are Aboriginal or Torres Strait Islander, your occupation, how old you are and whether you intend to go travelling.
For those born in Australia
Children up to four years and aged 10-15 receive vaccines under the National Immunisation Schedule. These are for hepatitis B, whooping cough, diphtheria, tetanus, measles, mumps, rubella, polio, haemophilus influenzae B, rotavirus, pneumococcal and meningococcal disease, chickenpox and the human papillomavirus (HPV).
Immunity following vaccination varies depending on the vaccine. For example, the measles vaccine protects for a long duration, possibly a lifetime, whereas immunity wanes for pertussis (whooping cough). Boosters are given for many vaccines to improve immunity.
Measles, mumps, rubella, chickenpox, diphtheria and tetanus
People born in Australia before 1966 likely have natural immunity to measles as the viruses were circulating widely prior to the vaccination program. People born after 1965 should have received two doses of a measles vaccine. Those who haven’t, or aren’t sure, can safely receive a vaccine to avoid infection and prevent transmission to babies too young to be vaccinated.
Measles vaccine can be given as MMR (measles-mumps-rubella) or MMRV, which includes varicella (chickenpox). The varicella vaccine on its own (not combined in MMRV) is advised for people aged 14 and over who have not had chickenpox, especially women of childbearing age.
Booster doses of diphtheria, tetanus and whooping cough vaccines, are available free at age 10-15, and recommended at 50 years old and also at 65 years and over if not received in the previous ten years. Anyone unsure of their tetanus vaccination status who sustains a tetanus-prone wound (generally a deep puncture or wound) should get vaccinated. While tetanus is rare in Australia, most cases we see are in older adults.
Pregnant women are recommended to get the diphtheria-tetanus-acellular pertussis vaccine in the third trimester to protect the vulnerable infant after it is born, and influenza vaccine at any stage of the pregnancy (see below under influenza).
Pertussis (whooping cough) is a contagious respiratory infection dangerous for babies. One in every 200 babies who contract whooping cough will die.
It is particularly important for women from 28 weeks gestation to ensure they are vaccinated, as well as the partners of these women and anyone else who is taking care of a child younger than six months old. Deaths from pertussis are also documented in elderly Australians.
The pneumococcal vaccine is funded for everyone aged 65 and over, and recommended for anyone under 65 with risk factors such as chronic lung disease.
Anyone from the age of six months can get the flu (influenza) vaccine. The vaccine can be given to any adult who requests it, but is only funded if they fall into defined risk groups such as pregnant women, Indigenous Australians, peopled aged 65 and over, or those with a medical condition such as chronic lung, cardiac or kidney disease.
Flu vaccine is matched every year to the anticipated circulating flu viruses and is quite effective. The vaccine covers four strains of influenza. Pregnant women are at increased risk of the flu and recommended for influenza vaccine any time during pregnancy.
Health workers, childcare workers and aged-care workers are a priority for vaccination because they care for sick or vulnerable people in institutions at risk of outbreaks. Influenza is the most important vaccine for these occupational groups, and some organisations provide free staff vaccinations. Otherwise, you can ask your doctor for a vaccination.
Any person whose immune system is weakened through medication or illness (such as HIV) is at increased risk of infections. However, live viral or bacterial vaccines must not be given to immunosuppressed people. They must seek medical advice on which vaccines can be safely given.
Australian-born children receive four shots of the hepatitis B vaccine, but some adults are advised to get vaccinations for hepatitis A or B. Those recommended to receive the hepatitis A vaccine are: travellers to hepatitis A endemic areas; people whose jobs put them at risk of acquiring hepatitis A including childcare workers and plumbers; men who have sex with men; injecting drug users; people with developmental disabilities; those with chronic liver disease, liver organ transplant recipients or those chronically infected with hepatitis B or hepatitis C.
Those recommended to get the hepatitis B vaccine are: people who live in a household with someone infected with hepatitis B; those having sexual contact with someone infected with hepatitis B; sex workers; men who have sex with men; injecting drug users; migrants from hepatitis B endemic countries; healthcare workers; Aboriginal and Torres Strait Islanders; and some others at high risk at their workplace or due to a medical condition.
The human papillomavirus (HPV) vaccine protects against cervical, anal, head and neck cancers, as well as some others. It is available for boys and girls and delivered in high school, usually in year seven. There is benefit for older girls and women to be vaccinated, at least up to their mid-to-late 20s.
With ageing comes a progressive decline in the immune system and a corresponding increase in risk of infections. Vaccination is the low-hanging fruit for healthy ageing. The elderly are advised to receive the influenza, pneumococcal and shingles vaccines.
Influenza and pneumonia are major preventable causes of illness and death in older people. The flu causes deaths in children and the elderly during severe seasons.
The most common cause of pneumonia is streptococcus pneumonia, which can be prevented with the pneumococcal vaccine. There are two types of pneumococcal vaccines: pneumococcal conjugate vaccine (PCV) and pneumococcal polysaccharide vaccine (PPV). Both protect against invasive pneumococcal disease (such as meningitis and the blood infection referred to as septicemia), and the conjugate vaccine is proven to reduce the risk of pneumonia.
The government funds influenza (annually) and pneumococcal vaccines for people aged 65 and over.
Shingles is a reactivation of the chickenpox virus. It causes a high burden of disease in older people (who have had chickenpox before) and can lead to debilitating and chronic pain. The shingles vaccine is recommended for people aged 60 and over. The government funds it for people aged 70 to 79.
Travel is a major vector for transmission of infections around the world, and travellers are at high risk of preventable infections. Most epidemics of measles, for example, are imported through travel. People may be under-vaccinated for measles if they missed a dose in childhood.
Anyone travelling should discuss vaccines with their doctor. If unsure of measles vaccination status, vaccination is recommended. This will depend on where people are travelling, and may include vaccination for yellow fever, Japanese encephalitis, cholera, typhoid, hepatitis A or influenza.
Travellers who are visiting friends and relatives overseas often fail to take precautions such as vaccination and do not perceive themselves as being at risk. In fact, they are at higher risk of preventable infections because they may be staying in traditional communities rather than hotels, and can be exposed to risks such as contaminated water, food or mosquitoes.
Aboriginal Australians and Torres Strait Islanders
Indigenous Australians are at increased risk of infections and have access to funded vaccines against influenza (anyone over six months old) and pneumococcal disease (for infants, everyone over 50 years and those aged 15-49 with chronic diseases).
They are also advised to get hepatitis B vaccine if they haven’t already received it. Unfortunately, overall vaccine coverage for these groups is low – between 13% and 50%, representing a real lost opportunity.
Migrants and refugees are at risk of vaccine-preventable infections because they may be under-vaccinated and come from countries with a high incidence of infection. There is no systematic means for GPs to identify people at risk of under-vaccination, but the new Australian Immunisation Register will help if GPs can check the immunisation status of their patients.
The funding of catch-up vaccination has also been a major obstacle until now. In July 2017 the government announced free catch-up vaccinations for children aged 10-19 and for all newly arrived refugees. This covers any childhood vaccine on the National Immunisation Schedule that has been missed.
While this does not cover all under-vaccinated refugees, it is a welcome development. If you are not newly arrived but a migrant or refugee, check with your doctor about catch-up vaccination.
Accepting Islamic law in exchange for peace leaves many uncertain, fearful.
ISTANBUL, March 27 (Compass Direct News) – Just over a month since Pakistan’s fertile Swat Valley turned into a Taliban stronghold where sharia (Islamic law) rules, the fate of the remaining Christians in the area is uncertain.
Last month, in an effort to end a bloody two-year battle, the Islamabad administration struck a deal with Taliban forces surrendering all governance of Swat Valley in the North West Frontier Province (NWFP). Sources told Compass that after the violence that has killed and displaced hundreds, an estimated 500 Christians remain in the area. Traditionally these have been low-skilled workers, but younger, more educated Christians work as nurses, teachers and in various other professions.
The sole Church of Pakistan congregation in Swat, consisting of 40 families, has been renting space for nearly 100 years. The government has never given them permission to buy land in order to build a church building.
An associate pastor of the church in central Swat told Yousaf Benjamin of the National Commission for Justice and Peace that with the bombing of girls schools at the end of last year, all Christian families migrated to nearby districts. After the peace deal and with guarded hope for normalcy and continued education for their children, most of the families have returned to their homes but are reluctant to attend church.
The associate pastor, who requested anonymity, today told sources that “people don’t come to the church as they used to come before.” He said that although the Taliban has made promises of peace, the Christian community has yet to believe the Muslim extremists will hold to them.
“The people don’t rely on Taliban assurances,” said Benjamin.
Last week the associate pastor met with the third in command of the main Taliban militant umbrella group in Pakistan, Tehrik-i-Taliban Pakistan, Kari Abdullah, and requested land in order to build a church. Abdullah reportedly agreed, saying that Islam is a religion of peace and equality, and that his group intended to provide equal opportunities to the religious communities of Swat.
The Catholic Church in Swat is located in a school compound that was bombed late last year. Run by nuns and operated under the Catholic Church Peshawar Diocese, the church has been closed for the last two years since insurgents have been fighting government led forces, source said.
Parliamentarian Shahbaz Bhatti said Christians and the few Hindus in Swat valley have lived under terror and harassment by the Taliban since insurgents began efforts to seize control of the region. He met with a delegation of Christians from Swat last month who said they were concerned about their future, but Bhatti said only time will tell how the changes will affect Christians.
“The Christian delegation told me that they favor the peace pact if indeed it can bring peace, stability and security to the people living there,” he said. “But they also shared their concern that if there is enforcement of sharia, what will be their future? But we will see how it will be implemented.”
Although there have been no direct threats against Christians since the establishment of the peace accord, some advocates fear that it may only be a matter of time.
“These days, there are no reports of persecution in Swat,” Lahore-based reporter Felix Qaiser of Asia News told Compass by phone, noting the previous two years of threatening letters, kidnappings and aggression against Christians by Islamic extremists. “But even though since the implementation of sharia there have been no such reports, we are expecting them. We’re expecting this because other faiths won’t be tolerated.”
Qaiser also expressed concern about the treatment of women.
“They won’t be allowed to move freely and without veils,” he said. “And we’re very much concerned about their education there.”
In the past year, more than 200 girls schools in Swat were reported to have been burned down or bombed by Islamic extremists.
Remaining girls schools were closed down in January but have been re-opened since the peace agreement in mid-February. Girls under the age of 13 are allowed to attend.
Since the deal was struck, seven new sharia judges have been installed, and earlier this month lawyers were trained in the nuances of Islamic law. Those not trained are not permitted to exercise their profession. As of this week, Non-Governmental Organizations are no longer permitted in the area and vaccinations have been banned.
“These are the first fruits of Islamic law, and we’re expecting worse things – Islamic punishment such as cutting off hands, because no one can dictate to them,” Qaiser said. Everything is according to their will and their own interpretation of Islamic law.”
Launch Point for Taliban
Analysts and sources on the ground have expressed skepticism in the peace deal brokered by pro-Taliban religious leader Maulana Sufi Muhammad, who is also the leader of Tehrik-e-Nifaz-e-Shariat-e-Mohammadi. The insurgent, who has long fought for implementation of sharia in the region, has also fought alongside the Taliban against U.S. troops in Afghanistan.
He was imprisoned and released under a peace deal in April 2008 in an effort to restore normalcy in the Swat Valley. Taliban militants in the Swat area are under the leadership of his son-in-law, Maulana Fazlullah.
The agreement to implement sharia triggered alarm around the world that militants will be emboldened in the northwest of Pakistan, a hotbed for Taliban and Al-Qaeda extremists fighting Western forces in Afghanistan and bent on overthrowing its government.
Joe Grieboski of the Institute on Religion and Public Policy said the peace deal makes Talibanization guaranteed by law, rendering it impossible to return to a liberal democracy or any guarantee of fundamental rights.
“The government in essence ceded the region to the Taliban,” said Grieboski. “Clerical rule over the region will fulfill the desires of the extremists, and we’ll see the region become a copy of what Afghanistan looked like under Taliban rule.”
This can only mean, he added, that the Taliban will have more power to promulgate their ideology and power even as the Pakistani administration continues to weaken.
“Unfortunately, this also creates a safe launching off point for Taliban forces to advance politically, militarily and ideologically into other areas of the country,” said Grieboski. “The peace deal further demonstrates the impotence of [Asif Ali] Zardari as president.”
Grieboski said the peace deal further demonstrates that Pakistani elites – and President Zardari in particular – are less concerned about fundamental rights, freedom and democracy than about establishing a false sense of security in the country.
“This peace deal will not last, as the extremists will demand more and more, and Zardari and the government have placed themselves in a weakened position and will once again have to give in,” said Grieboski.
Sohail Johnson, chief coordinator of advocacy group Sharing Life Ministry Pakistan, said he fears that militants in Swat will now be able to freely create training centers and continue to attack the rest of Pakistan.
“They will become stronger, and this will be the greatest threat for Christians living in Pakistan,” said Johnson.
Thus far the government has not completely bowed to Taliban demands for establishment of full sharia courts, and it is feared that the insurgents may re-launch violent attacks on civilians until they have full judicial control.
“The question of the mode of implementation has not yet been decided, because the Taliban want their own qazis [sharia judges] and that the government appointed ones should quit,” said lawyer Khalid Mahmood, who practices in the NWFP.
Mahmood called the judiciary system in Swat “collapsed” and echoed the fear that violence would spread in the rest of the country.
“They will certainly attack on the neighboring districts,” he said.
Earlier today, close to the Swat Valley in Khyber, a suicide bomber demolished a mosque in Jamrud, killing at least 48 people and injuring more than 150 others during Friday prayers. Pakistani security officials reportedly said they suspected the attack was retaliation for attempts to get NATO supplies into Afghanistan to use against Taliban fighters and other Islamist militants.