No Jab, No Pay and vaccine refusal in Australia: the jury is out

While vaccine refusal is but one contributor among several to failures of vaccine-preventable disease control, as stated by Beard and colleagues,1 there are important ethical aspects of vaccine refusal. Intentionally opting out of vaccination imposes risks on others, and policies allowing some to opt out weigh their freedom to do so against the rights of others not to be harmed by vaccine-preventable diseases.2 In particular, people who cannot be safely vaccinated (eg, infants) or maintain immunity (eg, the immunosuppressed) are at increased risk of severe disease — including death — and depend on the immunity of others.2 It is true that herd immunity has no “magic threshold”:1 even with high population vaccination levels, severe harm may be caused when just one unvaccinated person has contact with an infectious person and then a vulnerable person. The death of an immunosuppressed woman from measles pneumonitis in the state of Washington, United States, in 2015 is a case in point.3

Tighter legislation on universal vaccination does not unfairly target vaccine refusal. Indeed, Victorian No Jab, No Play legislation has a general objective: “to increase immunisation rates for young children,”4 which applies equally to people who have unintentionally failed to vaccinate and those who intentionally opt out due to hesitancy or refusal. Policy should make vaccination the norm and aim for the highest possible coverage. Moreover, while we should revise financial penalties if they unfairly burden poor families (while the wealthy may pay to opt out), policy should, in some way, recognise that conscientious objection to vaccination has consequences for others.5

Measles outbreaks are correlated with vaccine refusal6 and lead to significant social costs, which Australia may avoid if high levels of vaccination are maintained. Though the true epidemiology is certainly more complex, if measles vaccination leads to immunity in 99% of vaccine recipients, and 95% of people are vaccinated,1 the population level of immunity would be 94.05%. Threshold concepts have limitations, but whether this is “comfortably exceeding” 94%,1 or perilously close to recurrent measles outbreaks — which impose avoidable risks of harm on others — is a matter for debate.