PROCEDIMIENTO USO DE IMPLEMENTOS DE SEGURIDAD EN EL TRABAJO OBJETIVOS

Fears over the safety of vaccines were raised in a number of focus groups in Ireland, Italy and the UK. Participants made reference to cases and media reports where they believed that children had suffered from serious, and in some cases fatal, side-effects of the vaccination, and others stated their opposition to having their own children immunised:

Ò Right, see, I was, I was for it, I let my son have the first one and then when it all came out and it was all basically, it came out it could cause this, it causes this, and my son is a very bright child. I absolutely flatly refused to let him have the booster, simply because if heÕs come out like that I donÕt want to spoil his intelligence by giving him something.Ó

Participants were divided in how they weighed the perceived risks. Some argued that the link with autism had not been proven and even if it existed the risk of developing autism from the vaccine would be less than the risks associated with contracting a vaccine-preventable disease. Others argued that, partly owing to the risk of side-effects, immunisation should be a matter of parental choice.

Focus group participants in Ireland and the UK expressed concern over the concept of

immune-overload, both by questioning the safety of multiple vaccines, in particular the MMR triple-vaccine, and by discussing their perceptions of the relative merits of single antigen vaccines for measles, mumps and rubella:

Ò- It is 3 completely different injections and they are trying to put, trying to make it into one thing and that one chemical, whatever it is that they are using, and itÕs wrong, itÕs totally wrong.

- It should be available in 3 separate vaccines. - I think there should be a choice.

- You should have the choice, I mean why do you have to pay for separate injections É why should you have to pay for it when you, if one is free and one is not they are forcing some people into it.

- Right. So you are saying that single vaccines should be available?... ThatÕs a compromise position?

- Yeah.Ó

UK/male/20-30/married/children/further education

In countries where the safety of the MMR vaccine was not debated (Germany, Finland), participants may have been unaware of the high-profile scare surrounding the vaccine or they had been successfully reassured by the State or relevant health agencies.

7.6.8 Discussion

Childhood immunisation is an effective means of eradicating or significantly reducing the prevalence of particular infectious diseases. However, in recent years rates of immunisation coverage have fallen, in some cases below the level required for herd immunity, thus raising the threat of outbreaks of vaccine-preventable diseases. One factor in this decline is the immunisation paradox, a phenomenon where the success of previous public health measures, mass immunisation and consequent herd immunity have reduced the prevalence of particular diseases leading parents to believe that the current threat of infection from such diseases is minimal. Some parents refuse to have their children immunised on the grounds that the risks associated with immunisation, though small, are perceived to outweigh the benefits.231 Paradoxically, the success of immunisation programmes may ultimately reduce take-up rates with the potential for future epidemics of preventable diseases. 232 233 234 A second factor in the decline of immunisation rates has been a number of recent vaccine scares. 235 One of the most high profile scares, linking the measles, mumps and rubella (MMR) triple-vaccine with autism and bowel disease236 has an ongoing impact on immunisation uptake rates despite being shown to be groundless.237238239240241

The State has an interest in encouraging immunisation, both to provide protection for individuals and to protect the public health via herd immunity. The regulation of immunisation varies across Europe. In the countries in this study, certain immunisations are

compulsory in Belgium, Greece, Italy and Poland, with non-compliance theoretically punishable by fines or temporary imprisonment for the parents and refusal of school enrolment for children. In other countries financial and non-financial incentives may exist to encourage parents to have their children immunised and/or to encourage health professionals to increase immunisation coverage.

A systematic review of qualitative studies looking at parental attitudes and beliefs toward immunisation found that in more than half of all the studies reviewed barriers to childhood immunisation included concerns over the risk of adverse side-effects, distrust of those advocating the vaccines, poor communication with health-care staff and a lack of awareness of the immunisation schedule.242 Fears of side-effects and concerns over the safety of particular vaccines have been reported as factors associated with low immunisation coverage in numerous other studies 243 244 245 and were common themes in the focus group discussions. Such fears need to be addressed by health professionals giving good quality information to parents and giving parents the opportunity to discuss their concerns around (particular) immunisations. Studies also suggest that parents fear overloading the childÕs immune system with multiple vaccines.246, 247 Discussions about immune overload within the focus groups were more prominent in countries where the MMR scare received a lot of negative media coverage and where immunisation rates have fallen, most notably in Ireland and the UK. However, not all studies support the notion of a correlation between the health beliefs of parents and the immunisation status of their children.248 Instead, some studies report that immunisation status is more closely related to socio-demographic characteristics.249 A study from the Netherlands found that parents with the most negative attitudes to further expansion of the Dutch vaccination programme were more likely to be highly educated, health care workers, non religious, and to perceive vaccinations to be at best ineffective and at worst the cause of asthma and allergies.250 A study from the USA found that the parents of under- immunised children were more likely to be low earners, not have a consistent health care provider, to have four or more children, and to see vaccines as relatively unsafe.251 This suggests that interventions may need to target particular socio-demographic groups. However, the only discernable socio-demographic difference in attitudes toward immunisation noted in the current study was that focus group participants who were also parents tended to have stronger views on immunisation. Whether this was an opinion for or against immunisation depended more upon the intensity of recent vaccine scares and trust in the reassurances of family doctors and State public health authorities. The other main pattern apparent in the focus groups was the correlation between support for State compulsion and the over-riding of parental choice amongst those countries where certain immunisations are already compulsory. This could suggest a degree of normalisation where laws on compulsory immunisation gradually become part of a cultural norm.

In some countries, a small number of participants spoke of the foreign threat whereby immunisation was deemed necessary to combat diseases being brought in from abroad. Where this foreign threat was raised as an issue, participants tended to refer to neighbouring countries. The Austrians and Finns spoke of the threat of disease entering from Russia, while the Greeks blamed the Albanians. However, this was very much a minority voice, with generally only one or two participants from each listed country making reference to a foreign threat. It is worth noting that the timing of the focus groups coincided with the global panic over Severe Acute Respiratory Syndrome (SARS), a disease spread between countries largely through foreign travel.

Access to information regarding immunisation was also raised in the focus groups. A number of participants commented that they would like to have more information, particularly around the MMR vaccine, in order to make an informed decision. This reflects findings from other studies, where parents who felt they did not have enough information were less confident in the safety of vaccines and had more negative attitudes toward their health care providers.252 Such findings suggest that parental confidence in immunisation could be increased if trusted healthcare providers provide more information about the relative risks and benefits of immunisation versus non-immunisation.

A key finding in this study is the positive relationship between parental trust in health professionals and their decision to immunise. This finding has been supported by a German internet survey on parental attitudes to immunisation which found that 95.0% of respondents (5722 respondents) perceived their paediatrician as Òthe most important source of information regarding immunizationÓ.246 253 254 This has significant implications for the role of physicians in increasing immunisation coverage. Studies from across Europe and the United States have shown that physicians who were concerned about the safety of particular vaccines were less likely to vaccinate or recommend certain vaccinations and this correlated with low levels of childhood immunisation.255 256 257 Similarly, parents within the focus groups who did not trust the advice of health professionals were less likely to consent to their children being immunised, particularly with the MMR vaccination. A UK study found that parents who were aware of the financial incentives offered to family doctors for reaching immunisation targets had less confidence in the recommendations of their health care providers 258, however this issue of incentives was not raised in the focus groups.

In countries where the potential risks or side-effects, however small, of immunisation were not debated, one may assume that participants had no significant fears over the safety of vaccines and thus they trusted the advice of the State and any reassurances they had received following vaccine scares. By contrast, where participants spent most of their time debating the relative risks of immunisation versus non-immunisation or where they opposed immunisation on the grounds of safety concerns, then one may assume that participants lacked trust in the advice and reassurances of their governments and public health agencies. In addition to a lack of parental trust in the efficacy of vaccines and/or in the health advice of governments or family doctors, other factors associated with low rates of immunisation may include the perception that building natural immunity to infectious diseases is preferable to immunisation and/or that vaccine-preventable diseases are not particularly serious.259 260 Each of these perceptions was raised in the focus group discussions. Ways of increasing immunisation coverage may therefore include improving physiciansÕ attitudes, beliefs and commitment toward immunisation 261 262 and increasing parental confidence in the vaccines and in the assurances given by family doctors and the State.