Following news this week that two children from northern New South Wales have been diagnosed with diphtheria, a disease-fatigued nation is asking: what next? There is also little surprise among many that once again, a region considered the “anti-vax capital of Australia” should be the one incubating a bacteria not seen in Australian children this century.
One of the unvaccinated children, a two-year-old, is being treated in the intensive care unit of a Brisbane hospital, but in the child’s northern rivers community, there is little urgency to vaccinate.
Medical centres in the region contacted by the Guardian say they have not noticed any increase in vaccination bookings or requests for information, while some parents say they are attentive but not worried.
Diphtheria is now extremely rare but was once a leading cause of death among Australian children until the introduction of school vaccinations in 1932. It is just one of 17 vaccine-preventable diseases targeted by the national immunisation program for children and adults.
However, as of March 2022, just 87.3% of children aged five in the Northern NSW health district were up-to-date with their vaccinations, the lowest rate since September 2016 and well below the national average of 94.3%. Within that district, the Byron shire reports 68.2% of one-year-olds are fully immunised, compared with 94.9% across the country.
The Australian Department of Health, in its public information on immunisations, says about 95% vaccination rates are required to achieve herd immunity for many infectious diseases. In the case of pertussis (whooping cough), for example, a much higher proportion of people need to be immunised to get the protective effect of herd immunity compared with many other vaccine preventable diseases.
It was whooping cough that, in 2009, claimed the life of Lennox Head newborn baby Dana McCaffery, sparking a stronger pro-vaccination movement in the northern rivers to counter anti-vax sentiment. In 2017, a critically ill unvaccinated child was transferred from Lismore to Brisbane’s children’s hospital after contracting tetanus. During a worldwide measles outbreak in 2019, a Byron Bay child who had returned from New Zealand was diagnosed with the highly infectious disease. But despite disease on the doorstep and small children at risk, there has been no perceptible increase in vaccination in the region.
Dr Joel Hissink of Bay Centre Medical in Byron Bay has been a GP in the northern rivers for seven years and says there has definitely been an increase in vaccination rates in his experience but agrees there is vaccine hesitancy. Many people are genuinely fearful about vaccines, he says, and about the government encouraging vaccination.
“We do have lower vaccination rates and it’s always highlighted but I think most of the northern rivers area are seeing the importance of vaccinations and are participating in vaccination programs because they know that they’re protective,” he says.
Hissink says over the years he has worked in the area, he has found that with a lot of conversations addressing people’s myths and fears, his patients have developed a greater appreciation of the benefits of vaccination.
“When they have a genuine fear, telling them what to do and getting angry or belittling them or making them feel silly doesn’t help us get the message across and makes matters worse so listening to them and recognising their genuine concerns is really important in addressing vaccine hesitancy and improving vaccination rates in the northern nivers, to protect children and to protect everybody.”
The Covid-19 pandemic brought new grist to the the vaccination mill in the area, as the northern rivers was once again in the spotlight for its vaccination rates. The 2021 government vaccine mandates brought fresh restiveness to the area as many were forced to vaccinate to keep their jobs, enter a venue, or travel. Many locals were not impressed at what they saw as having their freedom to choose taken from them.
The GP connection
However, Hissink says a major roadblock in gaining the trust of vaccine-hesitant patients is the current exodus of GPs, and health workers in general, and the time required to reassure parents.
“GPs are burning out across the country and especially in regional areas,” Hissink says. “They are walking away from the job because its overwhelming but in order to address people’s fears, health professionals require a lot of time – to listen, to address their concerns and build their trust – and that’s very hard to do because we are so time-poor.
“It makes it more difficult by removing telehealth and incredibly difficult to achieve good outcomes when resourcing is being reduced.”
While the 17 diseases on the national immunisation program have not been eradicated, Australia’s high vaccination rate means we see fewer cases of them appear in the community. There have been no cases of respiratory diphtheria in children in Australia since 1992. However, in populations with low vaccination rates, vulnerabilities remain so that diseases possibly not seen for decades are more likely to occur.
“These were terrible diseases that we saw in very high numbers and with very significant consequences,” says Associate Professor Paul Griffin, director of infectious diseases at Brisbane’s Mater hospital.
Diphtheria is a contagious bacterial infection which produces a toxin that causes severe inflammation of membranes in the nose, throat, windpipe and heart. It can also cause nerve damage, life-threatening heart failure and paralysis. It can cause difficulty breathing and can lead to suffocation or heart failure.
“We very rarely see disease when we see high coverage with these vaccines. That’s what’s happened with diphtheria. It’s a bacterium that is around but we see very few invasive infections when we have high vaccination rates.”
The northern rivers region is famously steeped in anti-authoritarian, countercultural values and alternative lifestyles, but it is not only this which has impacted the vaccination of children in the region. Many parents are still traumatised by flooding earlier this year and are trying to rebuild their lives. Arranging catch-up vaccinations, according to one parent spoken to by Guardian Australia, is not a priority in the face of eviction or food affordability.
Outside a Mullumbimby coffee shop, Kate*, a young mum with two small children, admits that while she is concerned about the diphtheria cases, she is also vaccine hesitant. Her older child is fully vaccinated but her younger only partially. After news of the two cases, she booked her youngest for her third diphtheria shot but then cancelled and has not yet rebooked. She says her mothers’ groups are sharing information about diphtheria but generally, they are not worried, especially as they were told by health authorities that the risk of further spread was “almost zero”.
However, as Griffin points out, these diseases are still active, especially in countries where public health initiatives are not as vigorous as those in Australia or where access to vaccines is limited. A fully vaccinated traveller returning from overseas, for example, could unwittingly bring a disease into the community, and an unvaccinated person – a vulnerable person – may catch it from them. As people start travelling internationally again, the risk increases.
“All those diseases that we’ve successfully reduced by vaccination have the potential to return because they haven’t actually been eradicated and probably the main one of significance would be measles,” Griffin says.
“If we don’t have high vaccination rates then we’ll likely see more of that. We’ve seen some cases of tetanus over the recent years, again relating to low vaccination uptake, so all those diseases that haven’t been completely eradicated have the potential to undergo a resurgence if we don’t keep those vaccine rates high.”
Kate says she has “cherry-picked” the vaccines she wants her children to have but even in doing that, she admits she has not followed through with the entire vaccination course. Data from the Australian Institute of Health and Welfare shows this to be a trend across Australia, with lower rates of vaccination in parts of Sydney, Melbourne, Perth and Brisbane as parents neglect to complete vaccination schedules, rendering their child insufficiently protected against disease.
Griffin has seen children seriously ill with diseases that could have been prevented and knows how terribly catastrophic it can be for families to sit beside their child in the intensive care unit.
“Look, I get that it’s a challenging decision [to vaccinate], and perhaps even more so at the moment with the minefield of information and misinformation circulating about Covid vaccines that’s being extrapolated to other vaccines, but I’d encourage people to ask questions and get informed – but from reputable sources, not from YouTube or social media,” he says.
“I’d encourage people to make sure they’re well-informed to make the right decision because it is a tragedy to see vaccine-preventable diseases like this result in severe illness and loss of life.”
*name has been changed
