Opinion: Finding the ‘right’ solution in the German vaccine debate

by Maeve Cook-Deegan, (MSc. Health Science student at TUM)

Germany has made global headlines after a recent legislative proposal by the German health minister, Jens Spahn. The proposed law aims to increase the rate of measles vaccinations by threatening parents with fines of up to 2500 EUR and by keeping children who have not been vaccinated for measles out of kindergarten. This comes amidst widespread measles outbreaks and a 300% global increase compared to 2018, according to unofficial reports from the World Health Organization. This trend is startling, and as the media are quick to point out, can be partially attributed to the rising voice of so-called ‘anti-vaxxers’. However, this is not the only, or even necessarily the major, reason for suboptimal vaccination rates. Vaccines are effective, safe and are among the greatest achievements of medicine. Debating the details is not the goal here.

What interests me, as a student of health sciences with political leanings, is whether this proposed legislation is really the best approach for increasing vaccinations across Germany in the short- and long- term. This means aiming for ‘herd immunity’– achieving a 95% vaccination rate– while maintaining public trust in the government. This requires us to take a step back and to get a touch philosophical.  The duty of a government, as Gostin (2018) aptly summarizes, is to protect its citizens. Major threats to health, including the spread of infectious diseases, thus fall within a government’s power. But this power has its limits. Government can be expected to employ minimally invasive strategies to reach public health goals. So we must ask, does the recent legislative proposal balance these two objectives? Let’s first take a look at the situation in Germany.

Germany does not have mandatory vaccinations and yet, according to a report from the Federal Health Journal (Bundesgesundheitsblatt), over the past 10 years the vaccination rates of children and adolescents have generally risen (Poethko-Müller et al., 2019). The same report notes that 97.1% of German adolescents received their first measles vaccination. However, only 93.8% received the required second one, leaving the country short of its 95% goal in this population. There is a widespread perception, spurred by recent headlines and global trends, to assume that cases of measles are on the rise. However, the numbers do not support this assertion. As is seen in Figure 1, the rates this year are high, but they are not unprecedented.

Figure 1: Cases of measles among children and adults from the first 10 weeks of the calendar year. Numbers gathered from the Robert Koch Institute, taken from ARD-faktenfinder (2019).

Health decisions are deeply personal and since the end of WWII Germany has been particularly careful to avoid infringing on these rights when possible. That said, the current legislative proposal is not the first of its kind. After the vaccination against smallpox was introduced, children between one and twelve were obliged to be vaccinated; this was deemed compatible with ‘Basic Law’ by the Federal Court in 1959 (Eichinger & Hollstein, 2019). Smallpox was globally devastating as it was incredibly contagious and could stay in the air even two hours after an infected person left a room. The legislation seemed justified and succeeded in its goal – smallpox was eventually eradicated in Germany. Again, in extreme cases the government has both the duty and power to protect its citizens, but strong-armed actions can have unintended repercussions.

The campaign against smallpox, one of two infections to have ever been eradicated (the other being rinderpest, a deadly disease for cattle), was brilliant. In addition to reaching its ambitious goal, the operation also reminds us of some practices to be wary of. Despite its success, it has been demonstrated that some of the coercion and strong-arming that was used by doctors in the final stages of smallpox eradication in South-Asia caused long-term damage and led to an enduring mistrust of health authorities. This has posed challenges for subsequent vaccination campaigns (Greenbough, 1995).

This sentiment is echoed by Prof. Lothar Wieler, the president of the Robert Koch Institute. Based on evidence from a study out of Aachen and Erfurt, he asserts that mandatory vaccination might have adverse effects and reduce the willingness of parents to vaccinate their children for the remaining voluntary vaccinations. Limiting their freedom of choice may lead them to assert it elsewhere. This is a situation everyone wants to avoid. Further, Wieler contends that mandatory vaccinations could tie up staff that are needed elsewhere, such as in community outreach programs, and that the focus on children could distract from increasing vaccination rates in adults, which are just as important (see numbers above for 2019 in particular).

This is not an argument against mandatory vaccination, but rather a discussion about how best to ensure effective and widespread vaccination. Any infection or death due to measles today is unnecessary and should be prevented. If the proposed legislation would protect more citizens today and in the future, then it should be fully supported. However, perhaps we should take a closer look at what the numbers are telling us—97% of children receive their first vaccination. What is the reason for the subsequent drop? Also, the outbreaks tend to occur in regional clusters Germany. The lowest vaccinations rates have been reported in Nordrhein-Westfalen while states like Mecklenburg-Vorpommern report very little resistance (Berres, 2019). This is illustrated in Figure 2. Would vaccination rates be better improved by focusing health resources and education programs on these two populations rather than a federal act that might cause unnecessary resentment and may redirect essential resources?

Figure 2: Cases of measles across Germany in 2017, taken from the latest country report by the WHO (2019)

All health legislation needs to be made delicately with all of the facts, and I hope this one will be no exception. It is clear that action is necessary, but thoughtful efforts need to be made to ensure it is the right kind of action.

Berres, I. (2019) Wo die Masernkranken wohnen. Der Spiegel. Available at https://www.spiegel.de/gesundheit/diagnose/deutschland-wo-die-masernkranken-wohnen-a-1261859.html [Accessed May 12, 2019]

Eichinger, R. & Hollstein, M. (2019). Neues Impfgesetz So will Spahn die Masern ausrotten. Bild am Sonntag, 66(18).

Gensing, P. Immer mehr Kinder an Masern erkrankt? ARD-faktenfinder. Available at https://faktenfinder.tagesschau.de/inland/spahn-masern-impfung-101.html [Accessed May 13, 2019]

Gostin, L. O. (2018). Mandatory vaccination: understanding the common good in the midst of the global polio eradication campaign. Israel journal of health policy research, 7(1), 4.

Greenough, P. (1995). Intimidation, coercion and resistance in the final stages of the South Asian smallpox eradication campaign, 1973–1975. Social science & medicine, 41(5), 633-645.

Poethko-Müller, C., Kuhnert, R., Lassen, S. G., & Siedler, A. (2019). Durchimpfung von Kindern und Jugendlichen in Deutschland: Aktuelle Daten aus KiGGS Welle 2 und Trends aus der KiGGS-Studie. Bundesgesundheitsblatt-Gesundheitsforschung-Gesundheitsschutz, 62(4), 410-421.

Wieler, L. H. (2017). Impfpflicht würder Masernproblem nicht lösen. ÄrzteZeitung. Available at https://www.aerztezeitung.de/medizin/krankheiten/infektionskrankheiten/masern/article/943821/eher-kontraproduktiv-impfpflicht-wuerde-masernproblem-nicht-loesen.html [Accessed May 12, 2019]

World Health Organization (2019). Measles and rubella elimination country profile Germany. WHO Regional Office Europe. Available at http://www.euro.who.int/__data/assets/pdf_file/0011/401105/DEU.pdf?ua=1 [Accessed May 12, 2019]

World Health Organization (2019). New measles surveillance data for 2019. WHO. Available at https://www.who.int/immunization/newsroom/measles-data-2019/en/ [Accessed May 12, 2019]

This blog post reflects the views and opinions of the author(s) based on their research and experience in their respective fields. The content does not represent the official position of the Center for Global Health.

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