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Feature Communicable Disease

Compulsory vaccination and growing measles threat

BMJ 2017; 358 doi: (Published 20 July 2017) Cite this as: BMJ 2017;358:j3429

Re: Compulsory vaccination and growing measles threat

As the author of the article points out, the beginning of 2017 was marked by a sudden desire of politicians, generally individuals, to make vaccination compulsory in many European countries. These countries are high income countries. Sweden must be added to the list since it has rejected a motion for making vaccines compulsory on May 10. This motion was part of different vaccination motions [1].

Two questions arise from these initiatives: why and for what purpose? A third question is: are these initiatives justified on scientific and public health grounds since they restrict strongly the freedom of choice of parents? The last point is an ethical and political issue that can’t be separated from the questions above but that has larger implications than for immunization alone.

First question, why? We can’t identify any particular event that puts public health at risk in European countries which are targeted by these measures. So the question hasn’t any clear answer.
For what purpose?

The answer given by the promoters of these measures is: “in order to increase vaccine coverage and reach herd immunity and to avoid an unacceptable public health threat”.

These arguments are based on arbitrary and unproven assumptions. And it can be proven.

So, will compulsory vaccination increase vaccine coverage?

The ASSET project, funded by the European Union, says “no”. In a study it shows that vaccine coverage in Europe is not related to compulsory vaccination [2].

Are we threatened by epidemics putting at risk public health if a higher vaccination coverage is not met?

Many vaccines included in national vaccination programmes have been introduced in recent years. The diseases targeted such as invasive pneumococcal disease, meningococcal disease can be characterized as endemic but not epidemic. Other diseases targeted such as varicella, rotavirus infections are epidemic but not threatening. They can hardly be compared with cholera in the nineteenth century.

In France most infectious diseases targeted by vaccination accounted for 0 to 20 deaths in children and adolescents under 18 every year BEFORE the introduction of the most recent vaccines. Many of these deaths occur in children and adolescents with severe conditions.

In France, it was stated that there were 10 deaths in recent years from measles. But most of these deaths were in adults, not children.

It’s worth remembering that approximately 3000 infant deaths occurred in under 1 year infants every year in France during the 2000s. 99% of those deaths are not caused by vaccine preventable diseases. The figures are substantially the same in other European high income countries.

But we can also ask: in the event of high and sustained immunization coverage, would this allow herd immunity and would herd immunity reduce the public health burden significantly for all the diseases targeted by these measures?

Herd immunity means trying to protect a small proportion of unvaccinated individuals by vaccinating the majority to prevent the circulation of an infectious agent.

Herd immunity is not a panacea and requires a number of conditions to be met.

Herd immunity won’t be reached if there are reservoirs of the agent other than in humans, or if the vaccine exerts a selection pressure that mutates the infectious agent, or if there are multiple strains of an agent and then the pressure of the vaccine causes replacement of vaccine strains by others. In the last two cases, increasing vaccination coverage would be counterproductive by hastening the replacement or the mutation.

It is the case with pneumococcal vaccine. In France the introduction of the Prevenar 7 vaccine has led to an increase of the total cases of invasive pneumococcal disease of about 20% with respect to the prevaccination period. During the 9 year period from 2003 to 2011 (Prevenar 13 was introduced in 2010 in France) there were 8000 more cases of bacteraemia and 230 more cases of meningitis as compared to the prevaccination period from 1999 to 2000 [3]. Moreover 19 A serotype, a more virulent multidrug resistant serotype, has emerged in all countries that had implemented pneumococcal vaccination [4].

Another example, somewhat different, is vaccination for whooping cough caused by Bordetella pertussis and para-pertussis. After the introduction of an acellular vaccine in the 1990s the current strain was totally replaced by a pertactine negative strain under vaccine pressure in the United States [5]. Fully vaccinated individuals have an OR of 2,7 (95% CI, 1.2–6.1) for having pertactine negative bordetella pertussis infections [6].

Moreover, the notification of cases does not allow a correct estimate of the real number of cases. A study conducted at GP surgeries in Paris in 2009 recruiting patients with persistent cough allowed the incidence to be estimated as 145 per 100 000 cases of whooping cough. This figure would represent at the national level 100 000 cases [7]. Many other international studies using this methodology have shown the same results. That simply means that, despite or due to very high immunization coverage, there are still many cases of whooping cough that are being underdiagnosed and under reported.

So science and public health benefits can’t be invoked and used in such a simplistic manner to justify a restriction in patients and doctors choices and freedom.

Immunization is a complicated topic that needs more reflection and less coercion.

It’s time to realize that vaccines, like medicines, are not a mystic panacea and that they are subject to the commercial and political pressure and also to the influence of conflicts of interest.

3- INVS, Données Epibac 2014, 20/11/2015, PDF.

Competing interests: No competing interests

24 July 2017
Preventive care, MD
Lyon, France