Mandatory vaccines: this is how mandatory vaccines work

Fonte: shutterstock
The law on compulsory vaccinations - law 119 of 31 July 2022 - is definitively in force, and Asl, kindergartens and schools are organizing themselves to meet the required obligations. But how exactly do things work? This is clarified by an operational circular issued by the Ministry of Health on August 16 last year. Let's see all the details.

Compulsory vaccines, what are they

The compulsory vaccinations for children from zero to 16 years have been increased to ten. The obligation concerns both first doses and reminders and also affects unaccompanied foreign minors. The ten mandatory vaccines are: • polio polio; • anti-diphtheria; • anti-tetanus; • antihepatitis B; • pertussis; • anti Haemophilus influenzae type b; • anti-measles; • anti-mumps; • antirosolia; • antivaricella. Those born from 2022 onwards will have to do them all, according to the schedule set out in the National Vaccine Prevention Plan 2022-2022. Those born between 2001 and 2022, on the other hand, are in fact exempt from the varicella vaccine, because at the time they were (or should have) been vaccinated, this vaccine was not foreseen by the calendar then in force. For vaccines against measles, mumps, rubella and chicken pox, the law provides that the provision of the obligation must be reviewed every three years: compatibly with the data on the spread of diseases and vaccination coverage, in fact, the obligation could be abolished.

What happens if you don't get mandatory vaccines

If a child does not comply with the vaccinations required by law - and if his parents refuse to bring him into compliance even after being summoned by the ASL for a detailed information interview - first of all a fine is triggered: from 100 to 500 euros. In case of conjugated vaccinations, the fine is only one: the child's family who, at three months, should have the six vaccinations foreseen by the calendar (against polio, diphtheria, tetanus, pertussis, Haemophilus and hepatitis) and does not see them administer a single fine, you are not, and if he sees it administered only once, after which the obligation towards those vaccinations is considered extinct. The same family, however, may be given a new fine if they also miss subsequent vaccinations (measles, mumps, rubella and chicken pox, at 13-15 months). Even if the fine has been paid, the child without the required vaccinations will not be able to access kindergartens and preschools. Instead, he will be able to access compulsory school.

Vaccines: why they have become mandatory

The Ministry circular opens with a long paragraph dedicated to explaining why, at a certain point, it was decided to introduce a law that imposes the obligation of certain vaccinations and which therefore goes against the trend of the dominant attitude in public health in the last 15 years. Up to now, in fact, a path that aimed at "conscious and voluntary" compliance with vaccinations, whether mandatory or recommended, had been favored. On the other hand, failure to vaccinate compulsory vaccines did not entail particular sanctions, nor did not refuse admission to school. So why have things changed today?

Because - explains the circular - starting from 2022 there has been a progressive downward trend in the use of vaccinations, both mandatory and recommended. In other words, people are being vaccinated less and less, which, for some diseases, has led to a drop in vaccination coverage below the threshold of 95% of the population, indicated by the World Health Organization as the minimum threshold for achieving the group (or herd) immunity. Only above this threshold, for some diseases, it is guaranteed that the responsible microorganism actually stops circulating, protecting even those who cannot be vaccinated or who do not respond to vaccination.
The circular proposes in particular the example of vaccines against measles and rubella, whose coverage increased, from 2022 to 2022, from 90,4% to 85,3%.

Recommended vaccines, what are they

The circular reminds that, by law, other vaccinations must be offered actively and free of charge to the parents of the new born: • meningococcal B; • antimengingococcal C (in the first years of life), or tetravalent antimeningococcal ACWY in adolescence; • antipneumococcal; • antirotavirus. The Ministry justifies the non-mandatory nature of these vaccinations with the fact that they prevent less frequent diseases in our country, or not particularly contagious. Furthermore, vaccination against Hpv is foreseen in adolescence, both in males and females.

Exemptions: when the child has already had the disease

There are two possible cases in which vaccination can be avoided:

1. If the child has already had the disease against which he had to be vaccinated, as witnessed either by the specific notification made to the ASL by his doctor or by a declaration from the doctor himself, to which a blood test certifying the presence of protective antibodies. The test is not free, but charged to those who request it. The law instead provides that the issue of the certificate by the treating pediatrician is free for the family (a provision that many pediatricians do not like).

If the vaccine against the disease in question is contained in multicomponent formulations, the family may request that the child be vaccinated only for the other diseases, either with single-component vaccines or combination vaccines, but without the antigen in question.

It should be noted, however, that these vaccines are not necessarily available - at the moment, for example, single-component vaccines against diphtheria, pertussis, measles, rubella and mumps are not authorized in the country. And even if they were, it's not always possible to get them. On the one hand, considering that single-component products cost more, it is not certain that the Regions intend to purchase them. "On the other hand, it is also necessary to verify the real willingness on the part of the companies to supply them" explains Pier Luigi Lopalco, professor of hygiene at the University of Pisa. "Many of these vaccines are actually either discontinued or produced in small quantities for special reasons, so it is not certain that even if the regions competed to buy them, the companies would show up." The circular therefore specifies that if the "particular" formulations are not available, the prophylaxis will be completed with the existing combined vaccines, underlining that there are no contraindications to vaccinating who has already had the disease. Moreover, combined vaccines should not worry too much: not only is the child's immune system perfectly capable of receiving more "active ingredients" (vaccine antigens) at the same time, but they also contain fewer excipients than the sum of the monovalents. "In addition, they reduce the number of adverse events, such as febrile seizures or severe allergic events, which is related to the number of administrations," says Lopalco.

Exemptions: when the vaccine is a hazard

The other possibility of exemption occurs when the vaccine itself poses a danger to the health of the child. In general, it is an absolute contraindication to vaccination if the child has had a severe allergic reaction (anaphylactic shock) after the administration of a previous dose, or to a component of the vaccine (Guide to contraindications to vaccinations, Higher Institute of Health). The presence of a severe or moderate disease, with or without fever, is not in itself an absolute contraindication: the risk-benefit ratio must be assessed case by case to decide whether to vaccinate or not.

The documentation to be presented

But who is concerned with verifying that the child who has to attend the nursery, kindergarten or school is in compliance with the obligations? For the upcoming school year, parents should submit the necessary documentation - certifications such as vaccination records or ASL certificates, or self-certifications - to the institutions the children are enrolled in, who will then forward it to the ASL. Certifications or self-certifications must be submitted by 10 September for infant-toddler centers and preschools and by 31 October 2022 for compulsory schools. In case of self-certification, the documentation certifying the vaccination must be submitted by 10 March 2022. A model for self-declaration is available at the end of the circular "Some ASL, however, are organizing directly with the schools, in order to avoid parents in good standing do not bother, "says Lopalco. "For example, schools send lists of ASL members, who carry out the necessary checks and send the names of the children back to the schools with the vaccinations, while the families of the defaulters will be called to check the vaccination status of the child". By law, however, this mechanism should still be fully operational, for all regions and all local health authorities, in 2022, that is, with the next school year.

Teachers and health professionals: for them a questionnaire on the vaccination status

The new vaccine prevention law has been hotly contested, for various reasons. Among these, the fact that it provides for the obligation of vaccinations only for children and not, for example, for teachers and health workers, ie professional categories that can play an important role in the spread of infectious diseases. The operational circular, however, seems to take a first step forward at least in taking these categories into consideration and showing that they are under observation. In fact, it provides that, within three months of the entry into force of the law, all school and health workers must submit a self-declaration on their vaccination status at their workplaces. For now, however, this certificate has a pure meaning of data collection.

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