Richard Di Natale (Victoria, Australian Greens) Share this | Hansard source

I rise today to speak to the Social Services Legislation Amendment (No Jab, No Pay) Bill 2015. The Australian Greens are very strong supporters of vaccination as an evidence-based approach to preventing disease, but we have some concerns about this specific legislation.

Immunisation is one of the great success stories of modern medicine and public health. Vaccinating against illness and disease is the easiest way a GP can protect people of all ages from vaccine-preventable disease. It is a proven method of reducing the incidence of deaths from causes such as measles, tetanus, diphtheria and Haemophilus influenzae type B. Measles, we know, can be fatal in young children. Tetanus is something that is almost nonexistent now, but people died from tetanus regularly. Diphtheria is another disease that led to the deaths of people, and Haemophilus influenzae is a cause of meningitis and pneumonia, a very serious cause of morbidity. We know that, since the introduction only recently of the vaccine against Haemophilus influenzae, we are seeing a reduction in the incidence of meningitis and pneumonia from that specific condition. And let's not forget, of course, polio. It was not that long ago that polio caused death and serious disease—a disease that resulted in muscle paralysis and ongoing problems with mobility and so on.

So we know that vaccines work and that they are effective, but of course they are only effective if we are able to immunise large numbers of the population, and vaccination rates over the last 20 years demonstrate that Australia has done a pretty good job of it. We have an excellent record of achievement in the prevention of vaccine-preventable diseases. It is a critical message for the community, though, where there is patchy immunisation coverage in places like the Northern Rivers in New South Wales and the Sunshine Coast in Queensland. It is very critical that this message be able to penetrate those communities, because we know that when immunisation rates fall below a particular level, in the 90 to 95 per cent range for a number of conditions, we lose that critical principle of what is called herd immunity.

Herd immunity is absolutely critical. What it means is that, when immunisation rates are low, illnesses like measles and whooping cough or pertussis can be much more easily spread. So, if we have a population where a large number of people are immune as a result of vaccine, the chain of infection can be disrupted or effectively stopped. The greater the number of people who are immune, the smaller the probability that those who are not immune will come into contact with the infection. So, once you reach that critical threshold and achieve herd immunity, you see the gradual elimination of a disease from a population, so you can actually eradicate the existence of that disease altogether.

What we saw with, for example, the eradication of smallpox in 1977 was exactly that. We were able to reach herd immunity and get a critical level of immunity across the population, and people now no longer die from smallpox, a hugely successful public health intervention. We are on the verge of eliminating polio altogether from the planet. What a wonderful thing that would be, and that is because of the huge investment that we are making across polio eradication in some of those very hard-to-reach populations. Of course, the final yards are the most difficult. The law of diminishing returns means you have to throw a lot at it to eliminate those final cases, but once we do that—and I am confident that we will—polio, much like smallpox, will be a thing of the past.

It is partly because of the success of immunisation that we are having the problems that we have with some communities deciding no longer to vaccinate children. Vaccination has been a victim of its own success in many ways. Because people are not exposed to these life-threatening illnesses, we do not have the level of knowledge and understanding that exists with exposure to diseases like polio and, of course, measles, diphtheria and so on. What that means is that people make the decision not to vaccinate their children because they are not aware of the consequences of those illnesses. Of course, it is a rational decision in some ways, because there is a very small risk associated with having a vaccine and, if we are talking about a population where herd immunity exists, you do not expose your child to the incredibly small risk of the vaccine and you get the benefit of herd immunity within that population. Those people are so-called free riders, and they benefit from the decision that other people make.

Now let's look specifically at the bill, which requires that families be up to date with the National Immunisation Program. They need to be up to date in order for either parents or guardians to be eligible for the family tax benefit part A, for the supplement and for childcare benefit and the childcare rebate. The rules that this bill—basically, the No Jab, No Pay bill—seeks to implement would remove the immunisation exemption categories for access to childcare benefit, childcare rebate and the family tax benefit part A supplement.

One of the positive things the government did as part of this initiative was provide a $26 million funding boost to the Immunise Australia Program to ensure that we saw doctors and immunisation providers identify and vaccinate kids in their practices who were overdue for their vaccinations. That is really important. It is a positive initiative and, if we can do more in boosting those programs that encourage doctors and other immunisation providers to identify kids who are not currently vaccinated, that is a positive thing.

The bill, as Senator Moore just said, does not remove the right to make a conscientious decision not to immunise. People will continue to have that choice. What it does is put a financial cost to that decision. The government's proposition is this: the disincentive of no longer being eligible for Centrelink payments may result in parents reassessing their conscientious objection or antivaccination stance. It is important to understand why people do not vaccinate. It is worth exploring that, because it really goes to the substance of whether this policy proposal is the right one. We know that there are people who do not vaccinate for all sorts of reasons. Interestingly, the majority of these families are not conscientious objectors. In fact, Professor Julie Leask told the inquiry into this legislation that the majority of families who do not vaccinate are not conscientious objectors. Of the eight per cent of people who are not vaccinating, only 1.5 per cent register as conscientious objectors. In her opinion, the remaining 6.5 per cent could benefit from other measures, and the best way to tackle those people is through supporting health professionals and, of course, ongoing education. That is one of the concerns we have with the bill: it does not focus enough on that large group of people who are not conscientious objectors but are not vaccinating their children for other reasons.

Professor Leask also told the inquiry that there need to be strategies to tackle those people who at present do not have fully vaccinated kids. She said that, when it comes to the issue of conscientious objectors, there are a number of what she called hesitant parents—people who are fence sitters and who are on the margins of vaccine acceptance. What we need to do with that group is ensure that there are community-based interventions and that there are provider-based interventions—things that we are working on the moment—and that we actually incentivise the interactions between those parents and the healthcare system. Under the current model, for someone to register as a conscientious objector they actually need to interact with the health system and get their forms signed by a health provider. That is the area in which we should be working. The real concern we have is that this is a very blunt measure. It limits the opportunities for engagement with people who might be at the margins of vaccine acceptance and their interaction with the healthcare provider.

I think it is important to note that the government's provision of $26 million in funding for Immunise Australia does include incentive payments to GPs who identify undervaccinated kids and initiate catch-up schedules. That is a good thing. Also, it improves public vaccination records, reminder systems and communication strategies to promote the benefit of vaccines. We welcome this recognition of the importance of reminder and recall strategies, and we look forward to seeing evidence of how these measures have led to an increase in the numbers of children who are vaccinated. That evaluation process is important. We also look forward to looking at how the reliability of the immunisation register, and their capacity to target Aboriginal and Torres Strait Island communities, has improved.

The bill provides that a child meets the immunisation requirements if a GP has certified, in writing, that the immunisation of the child would be medically contraindicated under the specifications set out in The Australian Immunisation Handbook. That is good; we think that is important. But we also think it is important also to recognise that the legislation says that if in the opinion of a GP a person has contracted a disease or diseases and that as a result has developed natural immunity, that that also is a factor. Importantly, GPs need to be able to use their clinical judgement in assessing children who are eligible for a medical exemption. As Dr Kidd testified to the inquiry, medical exemptions are rare, but with the guidance provided by the handbook and by using their own clinical judgement, GPs are the people who are best equipped to identify the small number of children who should not receive a vaccination.

Again, let's stress that point: that a GP can use their clinical judgement to determine whether somebody should receive a vaccination. But simply going to a GP and saying that you believe a vaccine is dangerous—that a vaccine will cause conditions such as autism—is not good enough. That will no longer qualify.

We do agree with the AMA's view:

All children have the right to be protected from vaccine preventable diseases. This includes infants who are too young to be immunised as well as those infants and children who are medically unable to receive immunisations. Immunising as many infants and children as possible affords these vulnerable infants and children the protection they deserve.

We do, however, as I said, have a concern that in order to register as a vaccine refuser under the current system you need to discuss that decision with a health professional. Often what we hear from health professionals is that sometimes it is a discussion that ends with the person changing their mind. It might not be about all vaccines, it might only be about some of them—but that interaction does create possibilities to influence somebody who is at the margins. We have concerns that removing that incentive for that encounter does deprive health professionals of the opportunity to encourage parents to reconsider that decision.

We also heard evidence from Dr Richard Kidd of the AMA, who said that there are occasionally severe reactions to vaccines. Depending on the degree of severity—we are talking about the extreme end—we are talking about cases that are close to one in a million. So, yes, there are minor reactions—I think that most parents will have had the experience of taking their child along to an immunisation provider and the child having a red, sore arm from the vaccine or, indeed, a little bit of a temperature overnight, but they recover reasonably quickly. But when we talk about serious vaccine injuries, we talk about in the order of one in a million or so. So we can expect a handful of serious vaccine complications to occur each year.

It is the Greens' view that it is a serious problem, and that in order to encourage greater acceptance of vaccines there should be a vaccine injury compensation scheme. We think that is really important. We heard evidence through the inquiry that the United States requires a compulsory levy on the manufacturers of vaccines that goes towards such a vaccine injury compensation scheme for those vanishingly small but very real and severe impacts associated with vaccines. We think that would lead to greater acceptance. Of course, that is at the opposite end of what some of the people who do not support vaccination claim is the consequence of vaccines. They cite links to autism, other mental health conditions and a range of conditions where there is absolutely no evidence of a connection between vaccines and those conditions.

We know that the AMA provided more detail about the Australian Immunisation Handbook and how that provides guidance about exemptions to immunisation. It also provides information on a range of contraindications and precautions for specific groups—those people who are at risk of anaphylaxis, those who are immunocompromised, those who are receiving particular blood products and so on.

One of the other things that we are concerned about is the accuracy and the quality of the data upon which the requirements for immunisation are enforced and, of course, the association with the removal of those particular benefits. The policy uses the Australian Childhood Immunisation Register as the primary data source. It is true that the ANAO did a performance audit of the register, and it reported that overall the administration of the register has been effective and that it has met or exceeded performance targets. That is a good thing. But we also acknowledge that there were concerns expressed through the hearing. Indeed, some were expressed by the Public Health Association of Australia, who documented some of the flaws in the register, which was developed in the 1990s. In evidence submitted on notice, the Department of Human Services wrote that:

In accordance with the phased expansion of the ACIR into a Whole of Life Australian Immunisation Register (AIR)—

and that is a good thing; to have a register that covers people right through their life—

a range of improvements will be implemented to the Register's functions and operations. This includes new functionality to enable providers to correct errors online through the AIR secure site, such as correction of an incorrect dose number or incorrect vaccine recorded. This will begin to be implemented in September 2017.

That is especially concerning. It is concerning because we have a scheme that is relying on data to remove payments from people, but we know that the system they are relying on will not be fully operational and accurate—in the way that we want to see it—until September 2017. That is why we think that if you are going to introduce this sort of legislation, you should at least do it once your data system is up to date. And that is why we are moving an amendment to delay the start date of this legislation until 1 January 2018, along with other specific amendments.

The Public Health Association of Australia told the committee that the government should seek to address the structural and practical barriers that exist, including socioeconomic reasons, and that explain why some children are not fully vaccinated. We absolutely agree with that, and we think that vaccination will be enhanced by supportive systems—reducing barriers to access, improving the reliability of the register, and further strategies that are specific to Aboriginal and Torres Strait Islander communities. We absolutely look forward to seeing the impact of reminder and recall strategies, through a thorough evaluation. These strategies should include a national immunisation reminder system, catch-up campaigns, and local initiatives to improve coverage, as well as home-visiting programs and other actions to address some of the barriers to health care.

Finally, there is some confusion in the information that has been provided on the departmental websites. The Department of Human Services and the Department of Health websites actually differ in terms of information about which vaccinations that are required for people to be able to access family assistance payments. That needs to be clarified as a matter of urgency. We need to know absolutely clearly what is and what is not mandatory for eligibility for family assistance payments.

In conclusion, I move the Australian Greens second reading amendment on sheet 7798:

At the end of the motion, add:

", but the Senate:

(1) recognises that it is of critical importance that GPs remain able to use their clinical judgement in assessing children who are eligible for medical exemption; and

(2) calls on the Government to clarify which vaccinations are mandatory to meet the immunisation requirements and make this clear on all their relevant websites and publicly available material.".