Thursday 7 November 2019

Vaccination, compulsion, and paternalism for the lower orders

The National Party has come out in support of encouraging greater vaccination uptake.

But it sure isn't the way I'd do it.

National's suggested docking the benefits of those on benefit whose kids aren't keeping up with their vaccinations. Some in National have suggested extending that to payments under Working for Families, but that appears more controversial.

We can go back to first principles and note that there's a reasonable case for government intervention to encourage vaccination - as I have done previously. There is compulsion all over the place in public health, except where there's an actual market failure case for using compulsion.

I think that case is strongest when it comes to those workers most likely to be in contact with not-yet-vaccinated youths, and with people whose immunity may otherwise be compromised. So, ECE workers and workers in the hospitals and public-facing parts of the health system.

A case for docking benefits as a way of encouraging vaccination you'd think would have to start with data showing far worse vaccination rates among beneficiaries - is there a there there?

Unfortunately, it's hard to find data on anything like that. The closest we've got are the Tier 1 immunisation stats which sort immunisation coverage by DHB area, by deprivation, and by ethnicity. They have those stats for immunisation status as of 6 months, 8 months, 12 months, 18 months, 24 months, and 5 years.

When I look at those stats, differences by DHB are huge as compared to differences by deprivation.

Take immunisation coverage at 8 months for example. Look at the gap between immunisation coverage for the least deprived quartile and the most deprived quartile. On average, the difference is 5.7 percentage points in the most recent data. In MidCentral, the gap is 13.4 percentage points - and it's 38.1 percentage points over on the West Coast, albeit with small sample issues. But in Tairawhiti, the gap is -4.6 percentage points: vaccination coverage rates there are higher for the cohort more likely to be in receipt of benefit. And similarly in Canterbury: vaccination rates among the most deprived are five percentage points higher than for the least deprived.

Why is it that vaccination rates among the most deprived quartile in Canterbury DHB is higher than the vaccination rate among the least deprived in 13 of 20 DHBs? Have they done something there that other DHBs should be replicating? Variability in immunisation rates among the most deprived, across DHBs, is larger than variability in immunisation rates among the least deprived. What on earth is going wrong over on the West Coast, where there's that 38.1 percentage point gap and only 61.9% of the most deprived quartile bother with vaccination?

The standard deviation of immunisation rates across DHBs is 4.1; the standard deviation of vaccination rates across deprivation quartiles is 1.9. There's nasty stuff in some DHBs and in particular in some DHBs for the most deprived quartiles, but it's harder to see this as a generalised poor people problem. National immunisation rates for the most deprived, at 8 months, are 88.3%; for the least deprived, it's 92.6%.

Were I suggesting policy targeting vaccination, rather than playing into other things, I'd be looking at:

  • Compulsory vaccination as employment condition in the state-funded health sector, for both new and existing staff. They impose substantial direct risk. And how many antivaxxers will look at the recent reporting on low sector uptake and take it as reaffirming their beliefs? 
  • Compulsory parental notification of vaccination status of employees at ECE centres, and consider making it a condition of receipt for 30-hours free. Like, the government made it compulsory that piles of workers in ECE have qualifications - even where there's no good justification for it - but we don't even know whether ECE workers are vaccinated? Come on. 
  • Bring back the BPS targets around vaccination, penalise DHBs for vaccination rates less than 90%, reward them for rates above that. The DHB-level vaccination stats are hardly secret, but DHBs have no particular incentive to go and figure out what works or learn from each other. If DHBs faced financial incentives to ensure broad immunisation coverage, they might decide it's worthwhile to send somebody out to see just what Canterbury is getting right - or whatever DHB has population most comparable to theirs but higher immunisation rates. 
    • There are piles of things you can imagine DHBs trying out. Catch-up vaccinations at school for those who missed them. Making sure that all schools get a visit from the nurse with the jabs. Sending a public health nurse along on Plunket visits. Sending public health nurses along to ECEs where vaccination rates are known to be low. How far can you get just by making it really really easy for folks to be vaccinated?
  • Tell the Health Research Council that funding for research in public health, aimed at policy changes or behavioural interventions, should focus on the traditional remit of public health in vaccination and contagious disease rather than noncommunicable disease. I have OIA requests in now with MoH trying to get a handle on whether they've been putting any funding at all into vaccination work. We get piles of HRC grants for stuff like discouraging youth smoking and drinking and advocating for sugar taxes; it's hard to see anything like it for vaccination. It looks like they made a grant to Auckland Uni's immunisation centre. But there just hasn't been much research work there yet on encouraging vaccination uptake. They've done literature reviews, and they have an annual set of charts that come out of the Tier One vaccination stats, but nothing like the research push that HRC makes into noncontagious disease. I suspect that Janet Hoek, all on her own, gets more funding for anti-tobacco work than the government's provided for research into encouraging vaccination. But I'd like to know. 
But National's push does play into my general theory of where we get paternalistic regulation - it's generally targeted at poor people, whether or not it makes sense. And it will be fun to watch people explain why it's okay to make it a condition of benefit, but not okay to make it a condition of WFF. Maybe there's finer-grained data that would let them show that the gap is far larger when you look at beneficiaries compared to other kids in low income quartile households, but I really doubt anybody's even looked at it. 

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