Towards an extension of mandatory vaccination in Italy?

Immunization rates in Italy are decreasing at a worrying trend: international targets for measles eradication and safety thresholds in childhood vaccination are vanishing. Authorities, doctors and families are concerned that a coverage below 86% for MPR (measles, parotitis and rubella) vaccine can impair herd immunity, putting younger babies, immunocompromised people and not-responders at risk. Polio and diphtheria immunization rates at about 93%, with even lower coverage in some areas, could let these terrible diseases reappear in a country that had managed to forget them. Newborns’ deaths for pertussis have already hit the headlines.

In such a situation, closer and closer to become an emergency, some Italian local authorities, looking for a quick solution to protect the weaker ones, thought that the swiftest and easiest way of intervening was preventing unvaccinated children from entering childcare centres or nursery schools.

It must be pointed out that in Italy, at the moment, only four vaccination are legally mandatory: polio, diphtheria, tetanus and hepatitis B. They are administered in one shot, together with those against pertussis and a baby meningitis cause by Hemophilus influenzae, both of which are not compulsory, though strongly recommended.

Emilia-Romagna region, where vaccine hesitancy is quite diffuse, stated that children could not enter day-care centres without having received, at least, these four legally compulsory vaccinations. This decision, which has the credit of reaffirming the relevance of vaccination for public health, ignited a debate.

One objection is about the range of vaccination included in the norm. Considering only “compulsory vaccines” should make the measure legally more acceptable, but it could also open the way to many lawsuits, since families could ask for single shots and refuse those that are “only” recommended, even if lifesaving. These distinct preparations are not easily available and the request might create trouble in vaccination centres. Moreover, the measure could confirm the false idea that “compulsory” vaccinations are the most relevant for children’s health, which is not. These four are only those introduced in the past, when a more paternalistic vision of medicine was prevailing. The difference between “mandatory” and “recommended” vaccinations just mirrors a changing attitude by public health authorities, which are trying to make people more aware and engage them in their own health choices.

Moreover, in Italy, childcare centres, for children younger than three years, are not so popular: they are available for less than one child out of four under the age of three; they are attended by less than 12% of children younger than two. The profile of families refusing vaccination, or hesitating about it, includes other attitudes, such as long-term breastfeeding, attention to eat only organic food, educational personal beliefs, for which they are probably underrepresented in this small sample of people attending childcare centres. In other words, a measure aimed at this population could miss the target, since most children in these premises are already vaccinated.

The case is different when nursery schools and kindergarten for 3-5 years-old children are taken into account, as Tuscany Region is now doing, by extending the compulsoriness to all recommended vaccines included in the new National Vaccination Plan. Most children attend these schools, so that to be excluded could be a hurdle for many families, even if those strongly motivated against vaccination could easily find the way to look after their children in other, informal contexts.

In any case, when the time comes for school, no law can prevent kids from attending, since Italian jurisprudence has already affirmed that the right to education prevails on the obligation about vaccines.  

National authorities also showed their interest in this approach, which seems to go back to the past but is supposed to provide easy, quick and effective results.

Lombardy Region and some experts across the Country do not agree with this enthusiastic confidence. Is it possible that such a simple solution alone will solve the issue of hesitancy, on which the World Health Organization, scholars and public health authorities all over the world have been working for years?

A systematic review of strategies for addressing vaccine hesitancy, published by SAGE working group on Vaccine in 2015, “showed that multicomponent and dialogue-based interventions were most effective. However, given the complexity of vaccine hesitancy and the limited evidence available on how it can be addressed, identified strategies should be carefully tailored according to the target population, their reasons for hesitancy, and the specific context”.

What do we know about the target population and reasons for hesitancy in Italy? Some clues come from a survey made in Veneto Region, where, starting from 2008, the compulsoriness was suspended for all vaccinations. Its results were surprising: the so-called “antivaxx”, strongly and ideologically opposing vaccinations, whom could hardly be convinced to change their mind, are no more than 1% of parents. A very low rate that could not menace herd immunity, and consequently other peoples’ safety.

Instead, more than 60% of parents that had not vaccinated their children declared that they could reconsider their choice. Even more surprising (and concerning), about 15% of those parents that did have vaccinate their children were hesitant on doing the same in the future.

In 2011, when the survey took place, hesitancy was already spreading, crossing different target groups, and it is supposed to have further outreach nowadays.

When talking to parents, independently of their socioeconomic state, political leanings or education, it is common to hear of fears about the risk of autism or other possible damages caused by vaccines. One cannot get rid of these concerns just labelling them as hoaxes and parents, sometimes highly educated, as fools or criminals, accusing them of menacing their children and others’ lives. Nobody, who would have doubts about a danger regarding his/her child, would accept to be addressed that way.

It is not the same as making fastening seat belts compulsory. Injecting into a healthy baby a substance, somehow related to terrible diseases, on which some companies make profit, which one could not 100% exclude to give any side effect, it is not just an annoying procedure, but something that can be really frightening for parents. Can we force them to do that? Wouldn’t it be better to convince them that it is a great opportunity, much more than a risk, for their kid?

What else can be done for this purpose, then?

An important target for intervention are healthcare workers. Last summer, the Italian Federation of Medical Associations (FNOMCeO) issued a document supporting vaccination and menacing consequences for those who do not vaccinate, against any scientific evidence. In the same period, nevertheless, 120 Italian doctors signed a letter addressed to the president of the National Institute of Health, criticizing the National Vaccination Plan. Much more are those who spread disinformation or discourage immunization “on the field”, when talking with parents, as a TV report has recently show. Most unvaccinated children are followed by the same paediatricians, so that it should not be too difficult to recognize them. When they are payed by the National Health System, this agreement could be broken, since they do not pursue the same objectives.

Many doctors, then, if they have not attended classes after graduation, are not updated with the great advancement made by vaccinology in the last decades. Specific courses should be introduced in medical schools and continuous medical education programmes. Such an issue does not regard only doctors, but nurses and midwives too, since expectant and new mothers trust them a lot.

Another relevant point is the immunization rate among these professional groups. A low coverage, as it is in Italy, is not a good example, since healthcare workers should be the first testimonials for vaccination. A practical consequence of this scarce attitude to vaccination is also the risk of transmitting dangerous infections to debilitated or fragile patients. Talking of compulsory vaccination, one should start from doctors and nurses working in intensive care units or oncology wards, more than from children in nursery schools.

In Italy, a weak point in the vaccination process is also the funding to local public centres where vaccines are administered. In the last years, cuts in budget have reduced staff and resources. Trained personnel and availability of time is crucial for getting in touch with reluctant parents, person to person or by phone, trying to resolve their doubts and reassuring their fears. Such a work needs time and funding, without which even enormous amount of money spent for buying vaccines could be wasted. 

Finally, let’s talk about addressing parents. They should start hearing about the safety of vaccines during the courses they attend before delivery, but having a talk on the subject just after birth could also be useful. It could be useful to introduce an encounter with trained staff before registering to childcare or kindergarten, instead of simply going directly to vaccinations without a word; this would allow parents to listen to clear and effective explanations and find answers about their own doubts.

All of this would require clear and transparent factsheets and other educational materials, which could provide information to concerned parents without denying possible side effects of vaccines, but showing how they compare to benefits. A vaccination point could also be set at school, to make it easier for families to get access when they enrol their children.

There is a lot of measures authorities can take to fight against vaccine hesitancy. All of them can improve the situation, but this will be true only if they remember that parents are not fanatic, stubborn, irrational people, but anxious, worried mothers and fathers, who care for their children as much as those who choose to vaccinate do. You should help them to make the best choice for their beloved, not force them to do something that they think can seriously damage them.