Consequences of the No Jab No Pay legislation in Victoria: Through the Eye of the Needle

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The debate around vaccination is a matter of constant concern in Australia. Government has intensified its measures over the last few years in order to reach herd immunity, a situation in which a disease can no longer be spread. To provide optimal herd immunity vaccine coverage above 90% is generally required for most diseases, but for diseases as measles, 95% is optimal.

Victoria has the strictest policies in Australia, requiring full immunisation for attending child care. Not only has the State Government passed legislation that made it impossible for unvaccinated children to enroll in child care, this legislation also leads to a tax cut for anti-vax parents. Starting 1 January 2016, only parents of fully vaccinated children will receive the Family Tax Benefit part A, the Child Care Benefit and the Child Care Rebate. This legislation is also known as ‘No Jab No Pay/Play’.

Major news outlets as ABC-news a.o. posted on march 8 that one in six children was turned away for medical treatment because their immunisation was not up-to-date. But after further research this could be toned down. The survey by Melbourne’s Royal Children’s Hospital was the outcome of the Australian Child Health Poll, with only 1.945 parents (of 3.492 children) participating. 5% of these children wasn’t up-to-date with their immunisation, and 17% of this 5% was on these grounds refused care by their health care provider. The research was relatively small and therefore not illustrative for Victoria, or Australia as a whole. It does however gives an idea of the ongoing movement, by which unvaccinated children are more and more restricted.

A similar movement can be seen in the United States, where a national survey among members of the American Academy of Pediatrics showed that almost 40% of respondents said they would not provide care to a family that refused all vaccines. 28% said they would not provide care to families that refused some vaccines. The Academy’s Committee on Bioethics however advises strongly against discontinuing care, and says clinicians should address vaccine refusal by respectfully listening to parental concern and explaining the risk of non-immunisation, which is similar to the Australian approach.

Prime-Minister Malcolm Turnbull lately announced a ban on unvaccinated children from preschools across the country, as an extension to the No Jab No Pay legislation. Currently only Victoria, NSW and Queensland require children to be fully immunised to enroll in pre-school. Under the proposed legislation the immunisation rates of preschools and daycare centers would be made publicly available to all parents. His proposal can count on strong support, both from parents and health care professionals, but there’s also some criticism. Since the kids are too young to decide whether they want to be vaccinated or not, they are depending on their parents. It’s no longer only the parents who are punished by means of a tax cut, but also the children who miss out on education. Although the legislation started as a means of exerting pressure on parents, with the prohibition to enroll in preschool it is the kids who suffer.

Furthermore, No Jab No Pay doesn’t only affect families. It’s also health care professionals as GP’s, nurses and child-cares who have to deal with the new legislation. In order to help GP’s, the Royal Australian College of General Practitioners (RACGP) published a guideline to enable effective communication with parents who have concerns about vaccines. Building a strong relationship between the health care provider and the parents seems to be the key, since parents’ trust in the source of information may be more important than the information itself. In case of vaccine hesitant parents, building trust is essential and this can be done through a respectful and non-judgmental approach to their concerns. For parents known as refusing, the aim is to keep the door open for further discussion and provide appropriate resources if wanted.

Dr Andy Psaradellis, working at the Wynlorel Clinic for General Practice, is in favour of the legislation and says it is necessary to be forceful in the situation nowadays with the group of conscientious objectors growing. And although the new legislation doesn’t change the opinion of conscientious objectors, it at least changes the ‘apathetic people in the middle’. People who will rather choose to get their kids vaccinated as soon as the Government takes money from them. He admits the program isn’t perfect, but at least it will help eliminate disease and come one step closer to herd immunity.

In Australia, the number of conscientious objectors registered at AIR has risen from 0.23% in 1999 to 1.34% in 2015, comprising 30,092 children (AIR, 2016). Most parental concerns are about vaccine safety issues, such as the association between vaccines and autism, although this is not supported by any scientific evidence. The amount of compulsory vaccinations increased, and so did the amount of selective vaccinators. Study showed that a reduction of the vaccine-preventable diseases often leads to the perception that the severity of the disease also has decreased. At the same time, more and more information is available to the public, but so is false information. Only a few weeks ago, One Nation-leader Pauline Hanson ended up in an awkward position by calling the Government’s No Jab No Pay legislation ‘dictatorship’, suggesting vaccines weren’t safe and claiming incorrectly that parents could conduct their own test to evaluate vaccination safety. After a storm of criticism and a lack of evidence, she had to take back her words.

Science aside, the legislation has had great impact on the family lives of anti-vaxxers. Being disqualified for the Family Tax Benefit Part A and not able to enroll their kids in child-care, parents are forced to stay at home. The legislation seems to be particularly hard on single-parent-families, who don’t have the possibility of one partner supporting the family while the other takes care of the children.

In Facebook-groups, anti-vaxx parents discuss the consequences of the legislation and the trouble it brings them. Single-mum Lysa (full name known to autor) says she “feels like she’s going to cave”, since she isn’t able to enroll her 3 years old son in kindy and can’t take care of him at home fulltime for 2 more years. Getting him on a catch up schedule in order to claim the Child Care Benefit seems like the only option to send him to childcare, because she doesn’t want him to go to school without any preparation.

In a follow-up-conversation, Lysa tells me she found a local occasional care facility where vaccination hasn’t been an issue, as a temporary option since it’s only once a week. Her main concern now is to enrol her son in kindy to make sure he doesn’t miss out on basic skills before entering school. At the moment Lysa doesn’t think about ‘caving’ anymore, but she fears possible further changes in legislation that might lead to unvaccinated kids being unable to enroll in schools. Homeschooling is not an option and for personal reasons, neither is getting him on a catch-up-schedule.

Same goes for Noori (full name known to autor), who had to quit her part-time job in order to take care of her kid now she’s not able to enroll him in childcare. She says she struggles with the same problems as Lysa: being a single-mum, not wanting her son to miss out on social interaction and arts & crafts activities, or go to school unprepared.

In an article published in the latest issue of the Medical Journal of Australia, Sydney researchers warn that No Jab No Pay might not be the appropriate response to vaccine refusal. They say most parents of not fully immunised children don’t disagree with immunisation, but have simply been unable to overcome a range of logistic and access barriers. Cutting their tax benefits would be an unfair punishment, and they rather see the Government focussing on measures to improve access to the services and assist those families challenged by logistic issues. And already a year ago, immunisation experts from Melbourne warned in the same journal that No Jab No Pay was disadvantaging migrant children.
Paediatrician and co-author of the paper Dr. Margie Danchin told The Conversation that there were barriers for migrant families in accessing health providers and that No Jab No Pay was introduced with little thought for the complexities of minority groups.

The Government however doesn’t seem too concerned with those consequences, with Minister of Social Services Christian Porter telling ABC that although it wasn’t ideal to threaten parents to withhold family welfare payments, it was clear that the policy was working.

And after a few (smaller) studies on the topic, we may indeed carefully conclude that the legislation seems to accomplish its goal. As the federal legislation has only been implemented in 2016, it hasn’t been formally evaluated yet. But Christian Porter published a press release at 31 July 2016 that the immunisation rates had been lifted, only half a year after the legislation went into force.

Regardless the fact that the legislation hasn’t been evaluated federally, it has been locally. La Trobe University worked together with the City of Darebin to research the influence of the legislation in Darebin, a study presented at the recently held World Public Health Conference in Melbourne. Outcome of the studies was that the amount of fully vaccinated children in Darebin increased from 89,86% in the beginning of 2015 (which was below the WHO recommendation) to 93,32% in the middle of 2016. The city in the northern suburbs of Melbourne is now amply meeting the WHO recommendation of 90%.

Although children in Australia in general now amply meet the WHO recommendation, the Turnbell Government announced at the 1st of May to further strengthen it’s No Jab No Pay policy, believing “there is no excuse for parents who not choose to immunise their children.” Starting 1st of July next year, the fortnightly Family Tax Benefit Part A will be reduced by $28 per fortnight for each child that doesn’t meet the immunisation requirements, meant as a constant reminder for parents to keep the vaccination up-to-date.

Apparently a lot of parents got that message, since over 5.700 of them got their children vaccinated since the campaign started, in order to secure their child care benefits. With the new changes to No Jab No Pay, the Federal Government expects it to become even more. But what it will mean in practice for the children and doctors remains unclear. Representative medical agencies don’t have clear-cut guidelines and doctors don’t receive training specifically aimed at dealing with vaccine objectors. At the same time, children won’t be able to enroll in child care meaning they will start school unprepared, with a potential backlog in social skills. Next to that we shouldn’t forget the large group of parents that are pro-vaccination but simply struggle with the access to immunisation, and who now have to deal with the consequences of the legislation.

The No Jab No Pay legislation is obviously a measure that has consequences on a lot of different people, from parents to health care professionals. For now it’s safe to say that the legislation seems to have reached its target by lifting the immunisation rates, but its side-effects should be carefully evaluated over the next few years.

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