Abstract
A legal perspective on the risks and benefits of vaccines: Should there be legal enforcement?
When I was a bar student studying Contract law in 1968/1969, I am afraid our class felt rather patronisingly towards the naivety of people who believed the health claims made for the Carbolic Smoke Ball in the late 19th century. How different from us – we the sophisticated intelligentsia living in the White Heat of Technology and Science. The advertisement claimed that using the smoke ball would prevent influenza – £100 reward if you did catch it and to show we mean it £1000 is deposited with our bank. Mrs Carlill purchased and used several smoke balls in the correct manner but notwithstanding succumbed to influenza and sued for the promised £100. She won in the Court of Appeal ([1893] 1 QB 256, CA). The case developed a new line in the making of unilateral contracts – but the issue of contract is not the point I make now! Fake claims when they are what people want to believe seem as readily swallowed as they were in Victorian times.
The scientific data and facts are available now at the touch of a keyboard (but so are the myriad of fake claims) and it is very difficult (nigh impossible) to prove a negative. The Times investigation of 4 May 2015 runs the headlines ‘Baseless beliefs that fly in the face of science’ and ‘How homeopaths push useless alternatives to critical vaccines’. Homeopathy was finally blacklisted from NHS England last year as at best a placebo and ‘a misuse of NHS funds’. Children are supposed to have 16 vaccinations by the age of five to protect them from diseases such as diphtheria, rota virus, measles and polio. Numerous studies suggest that vaccines are safe and effective, and while serious side effects can occur, they are very unusual. The effects of the disease itself are likely to be far worse.
Government statistics and figures may help to persuade people, but in my experience, most people unconnected to medicine and science and maths find statistical risks and the logic deducted very difficult, especially statistics that go beyond 10s or 100. Diagrams showing impacts may help people to visualise these effects if they are limited to manageable numbers, namely 100 or less as a working base. Short and simple messages are the best route if they can be accurately stated. Prof. Zeitlin argues below that what is needed is a clear, succinct, reliable and readily accessible guide for parents. Yes, I absolutely agree with him – but this should be written along the lines of a patient information leaflet with a reading age of about 10 years. It should be available and visible in all GP surgeries and paediatric departments in hospitals. But will this message be enough? Unfortunately, with a number of health scandals, e.g. giving people flu vaccine for the wrong strain of flu a few years back and the shocking deaths and illnesses resulting from contaminated blood that are still being discovered and investigated nearly 50 years on, people are understandably sceptical of medical ‘authority’.
How best do we ensure that children and ‘society’ are protected? The vaccination of children and others is vital to reduce the outbreaks of potentially serious preventable illnesses and ultimately to eradicate them completely. Figures from many countries show that there are worrying rises of measles outbreaks linked to the failure to vaccinate – apparently most often by middle-class parents. In the USA, there have been more than 700 cases of measles in this year alone. Falling vaccination rates in Italy and France (with more than 2400 cases each last year) have resulted in measles being added to mandatory immunisation for children. Greece had more than 1400 cases and Britain more than 900. In The Times of 6 May 2019, there is a report of draft legislation in Germany which if implemented will fine parents up to €2500 if they do not vaccinate their children against measles and which also threatens exclusion from crèches, nurseries and schools. Should we go down the legal route in the UK? Should non-vaccinated children be banned from all nurseries and schools and holiday destinations? In Holland, Berend Botje, a major day care group, has announced that all children not inoculated by 1 July would be sent home. Most day care groups already refuse new entrants who are not vaccinated.
Is it time for Britain to introduce legal requirements for vaccination on all children going to crèches, kindergartens and schools?
Diana Brahams
Increasing problems around vaccination
A number of issues concerning vaccination are again in the news. There are reports of rising numbers of people getting measles in Europe and in the USA (see e.g. Mahase 1 ). There are also proposals to make vaccination compulsory (see e.g. Times newspaper leading article 2 ) and reports of protest groups against compulsory vaccination (see e.g. Independent newspaper 3 ).
Much of the arguments relate to the efficacy of vaccination and whether the risks from adverse effects outweigh the benefits. There is at the same time concern over whether the usual vaccinations remain beneficial and also whether some of the advertised herbal/alternative medicine/nutritional factors said to reduce risk of infections have any validity.
It is not for an editorial to write a review of the subject but to look at the issues and consider how the scientific literature can help both those involved in the relevant science but also people in the general population, all of whom are likely to be affected.
There is a document that considers the relevant issues: The organisation and delivery of vaccination services in the European Union, prepared for the European Commission, a report of 200 pages prepared by national experts of 28 EU countries. However, there does not appear to be a readily accessible, regular update on the situation with regard to vaccinations, which is readily available and easy to follow by a member of the general public. It will be of interest to know if any such regular publication actually exists. The executive summary of that document is possibly the nearest to this though not that easy to read.
Some of the issues appear to become mixed or muddled. Probably the most significant is confusion over understanding the figures concerning risk and benefit. For the most part vaccinations relate to conditions which affect a large proportion of the population and which have potentially serious consequences. It is possible to consider the effects of vaccinations in two ways. Firstly, it reduces the likelihood of an individual becoming infected by a given organism, but also in so doing it reduces the spread of the organism in the community and hence the transmissibility. Some of the confusions relate to whether adverse effects from vaccines outweigh the benefits. The difficulty in considering this may be at least considered on the following model. Considering a sample of 500 people, if an infection is likely to spread to say half of the population with a serious consequence for 20% of those infected, it means that 10% of the whole population will have a serious consequence, that is 50 of the 500 people would be seriously ill. If vaccination of the population reduces the incidence of that infection to 1% of the population, then 5 of the 500 will get ill from the infection, and just one of those five will have a serious consequence. That is a 1 in 500 rather than as before 50. However, even if the incidence of an unpleasant side effect of the vaccine is just 1%, then 5 of the 500 population will have a bad side effect of the vaccine and 1 in 500 a serious effect of the infection. That would at first glance look unreasonable that five times as many people are adversely affected by the vaccine compared with the illness. However, as given above, without the vaccine it would be 50 people per 500 rather than 6 people; almost 10 times the number would become seriously unwell. Nonetheless, people tend not to look at what would have been without the vaccine, but at the current risk of serious effects of the illness or the vaccine.
So, yes, it is possible to understand why increasing the proportion of the population taking up vaccines is also likely to be associated with increasing anxiety about unwanted effects. We still return to the problem of how the population is best informed. NICE (National Institute for Health and Care Excellence) have produced a consultation, last updated in 2017, called Immunisations: Reducing Differences in Uptakes in Under 19s, but which would be difficult reading for much of the population.
Perhaps what is needed is a new clear review of the subject, written in plain language and agreed on by both NHS and patient organisations as being correct and understandable by most people. If that is available then if a parent objects to their child being vaccinated, the law should require them to read that document and to risk legal action if they then still refuse without clear reason.
Prof. Harry Zeitlin, Emeritus UCL