Published online by Cambridge University Press: 28 May 2010
The ethical tension in childhood vaccination policies is often framed as one of balancing the value of choice with the duty to protect. Because infectious diseases spread from person to person, unvaccinated children are usually described as putting others around them at risk, violating a perceived right to be protected from harm. Editors of Lancet Infectious Diseases recently argued against mandatory vaccination, reminding us that the resort to mandatory vaccination as a means of achieving high vaccination rates is still very much a topic of Western vaccine debates. The nation of Japan offers an interesting case study in childhood vaccination policy, as it has an entirely voluntary (opt-in) system that achieves high vaccination rates. In this paper, we offer an overview of Japanese childhood vaccine policy, suggest some ways to contextualize and understand how a voluntary system achieves high vaccination rates, and speculate on what the future of Japanese vaccination policymaking and government–public relations may hold.
1. Compulsory childhood vaccination. Lancet Infectious Diseases 2009;9(7):393CrossRefGoogle Scholar.
2. “High” is admittedly a subjective term. Here we are referring to vaccination rates in excess of 95% for the first dose of recommended vaccines (2006 data). Japan Ministry of Health, Labour and Welfare (MHLW). Teiki no yobou-sesshu jisshi-sha suu [Number of scheduled vaccines administered]; available at: http://www.mhlw.go.jp/topics/bcg/other/5.html (last accessed 17 Nov 2009).
3. Seasonal influenza vaccine is not recommended for children, but rather the elderly (all adults above 65 years of age and those above 60 with a high-risk condition).
4. In some situations, a vaccine may be introduced in a third category, “special/temporary vaccines” (rinji sesshu), such as during emergencies. This third category was discussed (but eventually not adopted) as a way to fill the expected shortage of novel H1N1 influenza vaccines in 2009 by importing vaccines unlicensed in Japan.
5. The Ministry of Health, Labour and Welfare says that decisionmaking regarding elective vaccines is “the responsibility of the recipient and their doctor. The government does not [specifically] recommend them.” Foundation of Vaccination Research Center. Vaccination Guidelines. 2005; available at: http://www.mhlw.go.jp/topics/bcg/guideline/1.html (last accessed 17 Nov 2009). That said, the National Institutes of Infectious Diseases (NIID), a national institution belonging to the MHLW, does produce vaccination schedules that suggest possible vaccine administration timings of elective as well as scheduled vaccinations. Infectious Disease Surveillance Center, National Institute of Infectious Diseases (NIID). Yobou-sesshu sukejyuuru: nihon no shouni ni okeru yobou sesshu sukejyuuru [Recommended immunization schedule for children]. 2009; available at: http://idsc.nih.go.jp/vaccine/dschedule.html (last accessed 15 Nov 2009).
6. The mother–child handbook system was established in 1942, during World War II, when poverty was widespread. In its early years, the handbook was used to record wartime food rationing (e.g., of rice, meat, and sugar) provided to pregnant women. Today, it is an approximately 100-page booklet, of which around half is meant to be completed by parents and healthcare providers as the child grows and half is filled with explanatory text on childrearing, particularly for new parents, as well as pointers to various social support services available to parents. Descriptions and citations from the mother–child health handbook that appear in this article are from the version distributed by the Chuo-ku, Tokyo government in late 2009.
7. The mother–child health handbook states, “Protective vaccinations are given when the body is healthy. … Please carefully read through the information [you received in the mail concerning your child’s vaccination]” (p. 73). The handbook also indicates that fever is grounds for delaying vaccination: “When the body is not in a normal state of health, you may not be able to receive a vaccine. If any abnormalities are present, the vaccination may worsen a sick child, or adverse events may worsen. Therefore your child may not be able to get the vaccine [on that day] if the following type of conditions exist: (1) fever or an acute illness (2) if any abnormality occurred after receiving a previous dose of the same vaccine. In addition to this, because there may be other reasons why a vaccine may be contraindicated, or on the other hand, why it may be appropriate to be vaccinated even if your child has a sickness (or is sick), please consult with a physician closely acquainted with your child (your primary physician)” (p. 74). Some of the questions included in one sample vaccination questionnaire that must be filled out prior to receiving the vaccine are: “Do you have any concerns about your child’s health today?” “Has your child been ill within the past month?” “Has your child received any immunization within the past month?” “Has your child been or is your child currently being treated for any of the following medical conditions …” “Has your child ever had convulsions?” “Did he/she have a fever at that time?” “Has your child ever felt ill after receiving an inoculation?” “Has anyone in your immediate family ever felt ill after receiving an inoculation?” “After hearing the above recommendation by the doctor, would you like to let your child received the immunization today?” These quotations are from http://www.pref.saitama.lg.jp/A04/BU00/yosiki/yobou%28pdf%29/yousiki2.pdf.
8. Boshi Kenkou Techou [Mother-Child Health Handbook]. Chuo ward, Tokyo, Japan. 2009.
9. The mother–child health handbook contains 3 pages where the administration of vaccines is to be recorded. Two pages are preformatted for recording the scheduled vaccinations. A third page has blank lines to record the type of vaccine, date, vaccine manufacturer and lot number, name of the physician or clinic where the vaccine was administered, and brief additional remarks.
10. Here we are counting a single shot of combined vaccines such as the MR vaccination as two vaccines, as it contains antigens against two diseases.
11. U.S. Centers for Disease Control and Prevention (CDC). Recommended Immunization Schedule for Persons Aged 0 through 6 Years—United States, 2009, 2009; available at: http://www.cdc.gov/vaccines/recs/schedules/downloads/child/2009/09_0-6yrs_schedule_pr.pdf (last accessed 15 Nov 2009).
13. We have deliberately avoided the term “informed consent” because the degree to which most people are fully aware of all the risks and benefits associated with vaccination is unclear, but it is clear that the decision to vaccinate or not is ultimately up to the individual (or parent/guardian in the case of children).
14. Nakatani, H, Sano, T, Iuchi, T. Development of vaccination policy in Japan: Current issues and policy directions. Japanese Journal of Infectious Diseases 2002;55(4):101–11Google ScholarPubMed.
15. Kimura, M, Hirayama, M, Sakai, H. Vaccination Handbook, 11th ed. Tokyo: Kindai Shuppan; 2006Google Scholar.
16. Sesshu he no gimon, toikake tsuzuku [Doubts about vaccines—questions continue]. Asahi Shinbun 2009 Sep 28;29.
17. Infectious Disease Surveillance Center, National Institute of Infectious Diseases, Japan. Hyakunichi-zeki 1982-1996 [Pertussis 1982–1986]. Infectious Agents Surveillance Report, 1997; available at: http://idsc.nih.go.jp/iasr/18/207/tpc207-j.html (last accessed 17 Nov 2009).
18. Today Japan only offers a combined MR vaccine. The MMR vaccine has not been reintroduced since its termination in April, 1993.
19. Gomi, H, Takahashi, H. Why is measles still endemic in Japan? Lancet 2004;364(9431):328–9CrossRefGoogle ScholarPubMed.
20. Feudtner, C, Marcuse, EK. Ethics and immunization policy: Promoting dialogue to sustain consensus. Pediatrics 2001;107(5):1158–64CrossRefGoogle ScholarPubMed.
21. Kamiya, S, Fukue, N. Did media go too far on swine flu? The Japan Times 2009 Jun 5; available at: http://search.japantimes.co.jp/cgi-bin/nn20090605f1.html (last accessed 15 Jun 2009)Google Scholar.
22. UT-CBEL. Yobou sesshu ni kan suru zenkoku ishiki chousa: 2009 nen no infuruenza no ryuukou ga teiki suru mondai (2) [Nationwide opinion survey on vaccination: Questions arising from the 2009 H1N1 influenza epidemic]. Policy Issues 2009(6); available at: http://www.cbel.jp/data/temp/M9DXS/policyissues.no6.pdf (last accessed 17 Nov 2009).