Vaccine sentiments and

under-vaccination: Attitudes and

behaviour around Measles, Mumps, and
Rubella vaccine (MMR) in an Australian
cohort Mathew Toll & Ang Li
Visit to download the full and correct content document:
https://ebookmass.com/product/vaccine-sentiments-and-under-vaccination-attitudes-a
nd-behaviour-around-measles-mumps-and-rubella-vaccine-mmr-in-an-australian-coh
ort-mathew-toll-ang-li/
 Vaccine 39 (2021) 751–759

Contents lists available at ScienceDirect

Vaccine
journal homepage: www.elsevier.com/locate/vaccine

Vaccine sentiments and under-vaccination: Attitudes and behaviour

around Measles, Mumps, and Rubella vaccine (MMR) in an Australian
cohort
Mathew Toll a,b,⇑, Ang Li c,d
a
Department of Sociology and Social Policy, School of Social and Political Science, Faculty of Arts and Social Science, The University of Sydney, Camperdown, NSW, Australia
b
LCT Centre for Knowledge Building, Faculty of Arts and Social Science, The University of Sydney, Camperdown, NSW, Australia
c
Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia
d
Sydney Health Economics, Sydney Local Health District, Camperdown, NSW, Australia

a r t i c l e i n f o a b s t r a c t

Article history: Objective: The study aimed to examine the consistency in factors associated with attitudes towards vac-
Received 5 February 2020 cination and MMR vaccination status.
Received in revised form 12 September Methods: Using the nationally representative Longitudinal Study of Australian Children matched with the
2020
Australian Childhood Immunisation Register, 4,779 children were included from 2004–2005 to 2010–11.
Accepted 6 November 2020
Available online 17 November 2020
Different MMR vaccine dosages and general attitude towards vaccination were modelled individually
with multinomial logit regressions, controlling for demographic, socioeconomic, and health related fac-
tors of the children and their primary carers.
Keywords:
Vaccine hesitancy
Results: The group with non-vaccination and negative attitudes was characterised by more siblings and
Vaccine refusal older parents the group with under-vaccination but positive attitudes was characterised by younger par-
Under-vaccination ental age; and the group with under-vaccination and neutral attitudes was characterised by less socioe-
Vaccine attitudes conomically advantaged areas. The presence of parental medical condition(s), being private or public
Immunisation policy renters, and higher parental education were associated with under-vaccination but not with attitudes
towards vaccination, whilst parental religion was associated with attitudes towards vaccination but
not reflected in the vaccine uptake.
Conclusions: Vaccine attitudes were largely consistent with MRR vaccine outcomes. However, there was
variation in the associations of factors with vaccine attitudes and uptake. The results have implications
for different policy designs that target subgroups with consistent or inconsistent vaccination attitudes
and behaviour. Parents with intentional and unintentional under-vaccination are of policy concern and
require different policy solutions.
Ó 2020 Elsevier Ltd. All rights reserved.

1. Introduction taken [2]. A high level of vaccine coverage is required to ensure

The World Health Organization declared vaccine hesitancy one
of the top ten public health threats and noted that measles, once
near eradicated, was resurgent with a 30% increase of cases glob-
ally [1]. Measles outbreaks have been recently observed in coun-
tries which had effectively eliminated the disease, leading an
editorial from The Lancet to conclude that the chance to control
the disease was ‘‘slipping away” if effective policy action was not
⇑ Corresponding author at: Department of Sociology and Social Policy, School of
Social and Political Science, Faculty of Arts and Social Science A02, The University of
Sydney, Camperdown, NSW 2006, Australia.
E-mail address: Mathew.toll@sydney.edu.au (M. Toll).
community immunity for measles and small declines in the vacci-
nation rate can lead to measles outbreaks [3].
Contemporary public concerns and uncertainty around the
safety of the Measles, Mumps and Rubella (MMR) can be traced
to the publication of the research in 1998 that suggested a causal
link between the vaccine and the development of autism and
bowel disease, which has since been retracted and discredited by
a large number of epidemiological studies. Controversy surround-
ing the MMR vaccine and the adverse effect on public confidence
in vaccination has been termed ‘‘the MMR effect” [4,5]. With the
public controversy around the safety of the MMR, the number of
parents who are unsure, delay or refuse immunization of their
children has increased globally [6]. Many parents in developed

https://doi.org/10.1016/j.vaccine.2020.11.021
0264-410X/Ó 2020 Elsevier Ltd. All rights reserved.
M. Toll and A. Li
countries make conscious decisions not to vaccinate their children
rather than being limited by practical access, though barriers to
access can affect parents in all settings [7,8].
Addressing vaccine hesitancy and refusal among parents is cru-
cial in increasing immunisation coverage and improving disease
control. The behaviour of the vaccine hesitant is heterogeneous,
ranging from non-uptake, partial uptake, and full uptake. The
WHO Strategic Advisory Group of Experts (SAGE) working group
on vaccine hesitancy defined the term as a spectrum from delay
in acceptance to refusal of vaccination despite availability of vacci-
nation services [9]. Recently, vaccine policy experts have revisited
this definition and argued that vaccine hesitancy is more appropri-
ately considered a psychological state, describing people who exhi-
bit indecision and uncertainty around vaccine uptake, while
vaccine refusal is a decision to reject vaccination [10]. This latter
definition clearly distinguishes between attitudes and behaviours
around vaccination that can be consistent or inconsistent.
Research has examined a number of psychological, demo-
graphic, social and contextual factors associated with childhood
vaccine uptake in Australia and other developed countries
[7,8,11–13]. Factors such as parental age, birth parity, family size,
parental education, and area socioeconomics were significant pre-
dictors in the likelihood of incomplete vaccination in children. In
addition, beliefs and social meanings attributed to specific vaccines
have also been found to affect the reception of immunisation [14].
Studies suggest that safety concerns, trust in healthcare system,
inadequate information/knowledge, disease severity perception,
and parenting/social context have typically been linked with vac-
cine uptake rate, although studies addressing the factors associated
with combination vaccines, such as the MMR vaccine, were limited
[8]. Compliance with vaccines also varied according to vaccine
type, dosage and schedules [15].
However, there is lack of investigation into the consistency in
factors associated with attitudes towards vaccination and actual
vaccine uptake [8]. Studies tend to investigate the factors
associated with under-vaccination or vaccine attitudes, without
considering the consistency between factors associated with
under-vaccination and attitudes. Under-vaccination and negative
attitudes towards vaccination leave the community at risk for
measles outbreaks, yet vaccine attitudes and behaviours are not
always consistent and can be associated with different factors.
Understanding the factors associated with attitudes towards vacci-
nes and vaccine uptake, and when vaccine behaviour and attitudes
are consistent, is vital to designing policies to most effectively curb
transmission of vaccine-preventable diseases, especially in the case
of MMR for which parents had poor understanding and particular
concerns compared to other vaccines [4,5,8]. The analysis can help
tease out groups who were unvaccinated or partially vaccinated
despite positive attitudes, which is likely due to pragmatic issues,
and groups who were intentionally under-vaccinated.
The aim of this study was to examine the factors associated
with vaccine attitudes and uptake in accordance with the MMR
vaccine schedule, and the consistency, or lack thereof, between
attitudes and uptake in a nationally representative cohort. The data
is from a cohort sample that is the last nationally representative
survey with combined information on immunisation status and
vaccine attitudes on an individual level that can be matched to
assess the consistency of factors between vaccine attitudes and
behaviour, rather than relying on data from local sites [12]. It
was collected between 2004 and 2010, following the MMR contro-
versy that helped spur the growth of the modern anti-vaccination
movement when conscientious objection was a valid exemption
from immunisation requirements for eligibility of federal govern-
ment payments, prior to the introduction of No Jab No Pay in
2016. The campaign for No Jab No Pay in Australia, launched by
The Daily Telegraph, targeted vaccine hesitant and refusing parents,
752
Vaccine 39 (2021) 751–759
yet these concerns were not informed by a considered understand-
ing of under-vaccination and vaccine attitudes [16].
Coverage rates in Australia have improved in recent years, post
the introduction of No Jab No Pay and other state-level policies,
almost reaching the aspirational target of 95% coverage for one
and five years olds but still lagging behind at 91.68% coverage for
two years olds [17]. No Jab No Pay Act (2015) [18] made receipt
of family support payments and childcare subsidies conditional
on children’s vaccination status1. The design of No Jab No Pay and
other state level policy initiatives have been questioned on the
grounds of equity and the likely effectiveness for various sub-
groups in the population [19,20]. Low-income families that under
vaccinate due to logistical, financial barriers, or vaccine concerns
lose family support payments, while high-income families that
under vaccinate and conscientiously refuse are less likely to be
affected [21,22].
Establishing a baseline analysis of the factors associated with
vaccine attitudes and vaccination status, and the inconsistency
between factors associated attitudes and behaviours, prior to
removal of conscientious objection, can assist understanding how
policies could be more appropriately targeted for groups that both
intentionally and unintentionally under vaccinate. An analysis of
parental attitudes and under-vaccination for a cohort from the per-
iod leading up to the policy shift can help understand the lack of
responsiveness from different groups of parents to the removal
of conscientious objection. The analysis identifies several sub-
groups that have different sets of factors associated with their con-
sistent or inconsistent attitudes and vaccination behaviour. Aus-
tralia’s immunisation coverage is high, though still below the
government target for community protection. In this context poli-
cies need to be well calibrated to close the margin without engen-
dering resistance to policy initiatives and causing an increase in
anti-vaccine sentiment. Therefore, policy should focus on efficient
burdens [23] for each subgroup.
1.1. Data
The data used for the analysis were from The Longitudinal
Study of Australian Children (LSAC), a longitudinal study that
began with a nationally representative sample of over 10,000
children and their families in 2004. The data contained a rich
set of children and family information that are instrumental in
controlling for the decision around vaccination. Participating fam-
ilies have been followed up every two years. Cohort B contains
5,107 children who were born during March 2003-February
2004, and were 0–1 years old in 2004, 2–3 years old in 2006,
4–5 years in 2008 and 6–7 years in 2010. According to the Aus-
tralian Standard Vaccination Schedule, the first dose of MMR is
scheduled at 12 months and the second dose of MMR is sched-
uled at 48 months [24].
The LSAC ID was linked with Medicare databases including the
Australian Childhood Immunisation Register (ACIR) data by The
Australian Institute of Family Studies (AIFS)2. ACIR begins in 1996
and contains immunisation details for all children up to 7 years
old who are enrolled in Medicare. There were 85 children in cohort
B from the LSAC data who were matched to Medicare datasets but
1
The federal government level No Jab No Pay legislation removed the conscientious
objection exemption from immunisation requirements to eligibility for the Child Care
Benefit, Child Care Rebate, and Family Tax Benefit Part A supplement [17]. Only
parents of children who are fully immunised on the childhood schedule, on a
recognised catch-up schedule, or with approved medical exemption (e.g. medical
contraindications and natural immunity) can receive these payments.
2
The Australian Childhood Immunisation (ACIR) recorded immunisation for
children under the age of 7 was reorganised into the Australian Immunisation
Register (AIR) that records immunisation of all ages in September 2016.
M. Toll and A. Li
were missing the ACIR data because they did not have any vaccines
recorded [24]. For these children, the vaccination status was defined
as no vaccines in the analysis. The third dose of MMR vaccine was
not considered in the analysis because it is only recommended for
children who are identified as being at higher risk because of an out-
break [25]. Primary parent, or parent one, was defined as the parent
who knew the study child the best and in most cases was the child’s
biological mother [26].
Since LSAC data was recorded every two years, the vaccination
records in 2004–2005, 2006–2007, 2008–2009 and 2010–2011
were matched with information in LSAC in 2004, 2006, 2008 and
2010 respectively. For children who received one or two doses of
MMR vaccine, the characteristics of children and their primary car-
ers at the time of their last vaccine administration were used for
the analysis; and for those who were not vaccinated, the character-
istics at the national schedule age for the second dose were used,
that is, age 4–5 years (wave 3). Analyses using the characteristics
at wave 1 and 2 for the unvaccinated group were also performed
as robustness checks.
In conjunction with MMR vaccine uptake, the study also inves-
tigated attitudes towards vaccination. An important question in
enhancing vaccination uptake is the consistency of values and
actions and the translation of vaccine beliefs into vaccination out-
comes. Parental attitudes were captured in a general question:
‘‘Overall, how much do you agree with children being immunised, that
is having their needles or injections?” on a scale from 1 (very
strongly disagree) to 5 (very strongly agree).
2. Methods
Attitude towards vaccination and uptake of MMR vaccines
were estimated in separate models considering that attitudes
towards vaccination are endogenous with respect to vaccine
uptake, and the study aimed to identify the association of demo-
graphic, socioeconomic and health-related factors with attitudes
and uptake individually. Multinomial logit regressions were mod-
elled to estimate dosage uptake status and attitudes towards vac-
cination. The MMR dosage uptake status was constructed as not
immunised, partially immunised or fully immunised using the
LSAC-derived antigen-dose indicators. The variable took on the
value of 0 if no doses of MMR vaccine were recorded at any time
for the child, 1 if the first dose was recorded at some point but
the second dose was not recorded at any time, and 2 if both doses
were recorded being received by the child. The five-point attitude
scale that measured the degree of agreement with child being
immunised was collapsed into a three-point scale. Very strongly
and quite strongly disagree were recoded into disagree, neither
agree nor disagree remained unchanged, and very strongly and
quite strongly agree were recoded into agree. Analyses were con-
ducted in Stata 14.0.
Based on a wide range of research studies, field and expert
experience, and survey findings [9], the underlying determinants
of vaccine hesitancy have been grouped into contextual influences
(political, socio-economic, etc), individual and group influences
(perceptions and social norms, etc), and vaccine/vaccination speci-
fic issues (cost, mode of administration, etc). The current study
focused on contextual and individual-level influence to assess the
consistency between attitudes and uptake of vaccination among
parents. The models of MMR vaccine status and attitudes adjusted
for several factors related to demographics, socioeconomics, reli-
gion, geographic location, and medication/medicine history for
children and their primary caregivers.
In particular, covariates included the gender of the child (codes
as 1 if male); residential remoteness (coded as 1 if major cities);
the Socio-Economic Indexes for Areas (SEIFA) quintiles (reference
753
Vaccine 39 (2021) 751–759
category is the most socioeconomic disadvantaged group)3; num-
ber of siblings in the household; parental status (coded as 1 if
single-parent families); medical condition of the child (coded as 1
if any medical conditions); medication use of the child (coded as 1
if using prescribed medicine); the age of the primary parent; her/
his country of birth (coded as 1 if Australian born); her/his housing
tenure (coded as 1 if homeowners); her/his usual weekly income
(reference category is the lowest quintile); her/his employment sta-
tus (employed full-time, employed part-time, employed on mater-
nity leave, and unemployed or not in the labour force as reference
category); her/his highest education qualification (secondary and
below, diploma or certificate, and bachelor degree and above as ref-
erence category); her/his government payment status (coded as 1 if
receiving any government payment); her/his religion (no religion,
other religions, and Christianity as reference category); and her/his
medical condition (coded as 1 if any medication conditions).4 Mone-
tary means were adjusted to 2010 Australian dollars using CPI [27].
Note the Relative Socio-Economic Advantage and Disadvantage
(IRSAD) from the SEIFA index was used, a rank that measures educa-
tion, income, employment, occupation, health and living conditions.
3. Results
The combined sample comprised 4,779 children who were born
in 2003–04 and had information on primary carers. Of those, 4,437
(92.8%) received the second dose of MMR vaccine, 227 (4.75%)
received the first dose, and 115 (2.41%) did not receive any doses.
4,484 (93.9%) quite or very strongly agreed with vaccination, 191
(4.0%) neither agreed nor disagreed, and 99 (2.1%) quite or very
strongly disagreed. The average age for children receiving the first
and the second dose was 44.9 weeks and 198.7 weeks respectively.
Table 1 contains summary statistics of the study children and
their primary parents in the sample, separately for children who
were not immunised, partially immunised with one dose and fully
immunised with two doses. The table shows that children with
more siblings had higher rates of not being immunised, while chil-
dren with medical condition(s) and prescribed medicine use were
more likely to receive full immunisation. Children whose primary
parent was older, achieved bachelor degree or above and had no
religion exhibited higher rates of no vaccination, and children
whose primary parent was unemployed or not in the labour force,
received government payment and had medical condition(s) were
more likely to receive partial immunisation.
Fig. 1 presents the consistency between caregiver’s attitudes
towards vaccination and the behaviour of MMR vaccine uptake
by examining the immunisation status across different degrees of
the parent’s agreement with children receiving vaccines. It shows
that almost all the parents who agree strongly with vaccination
had their children vaccinated two doses, and the uptake rate
decreased with the degree of disagreement of parents with vacci-
nation. In comparison, the proportion of children not immunised
increased with the degree of disagreement with vaccination. The
prevalence of partial immunisation was highest for parents who
neither agreed nor disagreed, followed by those who quite strongly
disagreed with vaccination. The prevalence of non-compliance was
highest for parents who were strongly opposed to vaccines. A Chi
square test for MMR vaccine uptake and attitudes suggests a statis-
tically significant dependence between the two variables with p-
value < 0.000. The observed pattern indicates that positive or neg-
3
Socio-economic indexes for areas (SEIFA) is an Australian Bureau of Statistics
(ABS) product that ranks the relative socio-economic advantage or disadvantage of an
area. Individuals were categorised by SEIFA quintiles based on their residency in an
area.
4
The country of birth for the child was not included in the model due to complete
separation.
M. Toll and A. Li Vaccine 39 (2021) 751–759

Table 1
Summary statistics for children and their primary parents.

Not immunised (no dose) Partially immunised (one dose) Fully immunised (two doses)
n = 115 n = 227 n = 4437
Mean SD Mean SD Mean SD
Child demographics
Male 0.59 0.49 0.55 0.50 0.51 0.50
Australian born 1.00 0.00 0.99 0.12 1.00 0.06
No. siblings in household 1.64 1.07 1.32 1.36 1.33 0.99
Single parent 0.11 0.31 0.11 0.32 0.11 0.31
Child health
Has medical condition(s) 0.04 0.20 0.06 0.24 0.09 0.29
Uses prescribed medicine 0.06 0.24 0.16 0.36 0.13 0.34
Primary carer/child area disadvantage
SEIFA 1st quintile 0.14 0.35 0.21 0.41 0.18 0.38
SEIFA 2nd quintile 0.19 0.39 0.26 0.44 0.16 0.37
SEIFA 3ed quintile 0.16 0.37 0.13 0.34 0.23 0.42
SEIFA 4th quintile 0.29 0.46 0.19 0.40 0.23 0.42
SEIFA 5th quintile 0.22 0.42 0.22 0.41 0.20 0.40
Primary carer demographics
Age 36.75 4.65 31.62 6.00 34.31 5.41
Australian born 0.82 0.39 0.65 0.48 0.80 0.40
Major Cities 0.52 0.50 0.68 0.47 0.59 0.49
Primary carer religion
Christianity 0.65 0.48 0.67 0.47 0.71 0.46
Other religions 0.07 0.26 0.13 0.34 0.07 0.26
No religion 0.27 0.45 0.20 0.40 0.22 0.42
Primary carer income
Weekly income 1st quintile 0.08 0.28 0.20 0.40 0.15 0.35
Weekly income 2nd quintile 0.18 0.39 0.16 0.36 0.17 0.37
Weekly income 3ed quintile 0.24 0.43 0.23 0.42 0.18 0.38
Weekly income 4th quintile 0.22 0.42 0.21 0.41 0.21 0.41
Weekly income 5th quintile 0.27 0.45 0.20 0.40 0.30 0.46
Primary carer employment
Employed full-time 0.19 0.39 0.12 0.33 0.20 0.40
Employed part-time 0.51 0.50 0.26 0.44 0.40 0.49
Employed on maternity leave 0.02 0.14 0.07 0.25 0.03 0.18
Unemployed/Not in labour force 0.28 0.45 0.55 0.50 0.37 0.48
Primary carer education
Bachelor degree and above 0.42 0.50 0.34 0.47 0.35 0.48
Diploma/Certificate 0.37 0.48 0.31 0.47 0.37 0.48
Secondary and below 0.21 0.41 0.35 0.48 0.28 0.45
Primary carer/child homeownership
Homeowner 0.73 0.45 0.56 0.50 0.72 0.45
Primary carer government payment
Yes 0.57 0.50 0.72 0.45 0.63 0.48
Primary carer health
Parent has medical condition(s) 0.05 0.23 0.22 0.41 0.10 0.29

Source: LSAC-ACIR data 2004–2010.

ative attitudes towards vaccination is a crucial factor that hinders
full vaccination.
Results from estimation of multinomial logit models of immu-
nisation status and attitudes are shown in Table 2. The first two
columns present the relative risk ratios (RRR) for partial vaccina-
tion and no vaccination with full immunisation as the base out-
come. The last two columns present the RRR for neither
disagreement nor agreement and disagreement towards child vac-
cination. To explore the change in average marginal effects (AME)
across the range of key socioeconomic variables for each vaccina-
tion outcome and attitude, adjusted predictions at different values
of these predictors were computed and displayed in Fig. 2. All mod-
els included the set of controls shown in Table 1 as well as state/
territory indicators.
was associated with a higher likelihood of no vaccination
(RRR = 1.315, 95% CI = 1.092–1.583) and disagreement with vacci-
nation (RRR = 1.315, 95% CI = 1.080–1.600). Second, the probability
of no MMR dose (RRR = 1.079, 95% CI = 1.033–1.128) and disagree-
ment with vaccine (RRR = 1.073, 95% CI = 1.024–1.124) increased
with age.
Primary carers who practiced other religions (e.g. Islam, Bud-
dhism, Hinduism, Judaism and other religion) (RRR = 2.802, 95%
CI = 1.267–6.196) or no religions (RRR = 1.970, 95% CI = 1.167–3.
326) showed higher tendency to disagree with vaccination than
those who practiced Christianity. The negative attitude was not
translated into partial or non-vaccination as the primary carer’s
religion was not a statistically significant predictor for vaccine
status.

3.1. Factors related to no dosage and negative attitude 3.2. Factors related to partial uptake and neutral attitude

Two factors were found to be consistent with an attitudinal Several factors were significantly and negatively associated
position of disagreement with vaccines and vaccine status with one dosage of MMR being administered. The probability of
of no dosage. First, a higher number of siblings in the household partial immunisation of MMR vaccine was lower among primary
754
M. Toll and A. Li
Fig. 1. Attitudes and uptake for MMR vaccine. Source: LSAC-ACIR data 2004–2010.
carers who were older (RRR = 0.917, 95% CI = 0.890–0.945), lived in
the middle quintile of IRSAD rank (RRR = 0.487, 95% CI = 0.291–0.
815), born in Australia (RRR = 0.442, 95% CI = 0.316–0.617), had
CPI-adjusted usual weekly income in the second lowest quintile
(AU$86.892–209.463) (RRR = 0.593, 95% CI = 0.354–0.993), held a
diploma or certificate (RRR = 0.676, 95% CI = 0.466–0.982), and
lived in an owner-occupied dwelling (RRR = 0.689, 95%CI = 0.49
7–0.956). In contrast, children were more than twice as likely to
be partially vaccinated if their primary carers had any medical con-
dition(s) (RRR = 2.550, 95% CI = 1.769–3.676).
According to Fig. 1, parents who neither agreed nor disagreed
had the highest risk of partial immunisation of the children. Two
factors were found to be associated with neutral attitudes towards
vaccination. Consistent with the results for dosage uptake, primary
carers who lived in the middle quintile of the IRSAD rank
(RRR = 0.570, 95% CI = 0.335–0.969) and had no religion
(RRR = 1.471, 95% CI = 1.016–2.130) were also least likely to be
neutral about child vaccination. Similarly, the influence of religion
on attitudes towards vaccination was not reflected in a reduction
in vaccination uptake.
3.3. Factors related to full uptake and positive attitude
Based on the adjusted predictions, the probability of full immu-
nisation increased with the parent’s age until late 30s, followed by
a decrease for older ages; and the probability of strong agreement
with MMR vaccination decreased with age monotonically (Fig. 2,
panel (a)). The predicted probability of full immunisation and
strong agreement with vaccination was highest among primary
carers who practiced Christianity, followed by those with no reli-
gion and other religions (Fig. 2, panel (b)).
Primary carers residing in areas of middle socioeconomic ranks
had the highest predicted probability of full dosage uptake and
positive attitudes toward vaccination (Fig. 2, panel (c)). The proba-
bility of complete MMR vaccine and parental agreement with vac-
cination decreased with the level of education, with children
whose primary carers had at least a bachelor degree showed low-
est rates of full uptake and agreement with vaccination (Fig. 2,
panel (d)).
755
Vaccine 39 (2021) 751–759
4. Discussion
This study investigated the factors associated with different
dosages of MMR vaccine uptake and attitudes towards vaccination
in a nationally representative cohort of Australian children. The
assessment of associations of demographic, socioeconomic, and
health related factors with vaccination status and attitudes
towards child immunisation furthers the understanding of the cor-
respondence, or lack thereof, between attitudes and vaccination
status among parents with positive, neutral, and negative atti-
tudes. The results are important for informing more effective and
targeted policies that diagnose the causes of under-vaccination
and address the barriers to full vaccination in different groups.
The results show that attitudes and behaviours around child
vaccination were mostly consistent. Positive attitudes towards
vaccination or vaccine acceptance were mostly associated with full
uptake; neutral attitudes were mostly associated with partial
uptake; and negative attitudes or vaccine refusal were mostly asso-
ciated with non-vaccination. However, amongst groups that under
vaccinated, there was variation in the associations of demographic,
socioeconomic, and health related factors with attitudes towards
vaccination. The group with under-vaccination and negative atti-
tudes was characterised by more siblings and older parents; the
group with under-vaccination and neutral attitudes was charac-
terised by less socioeconomically advantaged areas; and the group
with under-vaccination but positive attitudes was characterised by
younger parental age. The presence of parental medical condition
(s), being private or public renters, and higher parental education
were associated with under-vaccination but not with (generically
measured) attitudes towards vaccination, whilst parental religion
was associated with attitudes towards vaccination but not
reflected in the vaccine uptake.
The negative association between family size and vaccination
status has been suggested in previous studies to be related to the
decrease in parental concern and the increase in organizational
work with additional children in the family [24,25]. The negative
relationship between parental education and full vaccination has
also been observed in other Australian studies close to the period
the data was collected, especially in metropolitan areas [22,23],
although some studies found no or a positive relationship of
M. Toll and A. Li Vaccine 39 (2021) 751–759

Table 2
RRR estimates from multinomial logit models of immunisation uptake and attitude.

Immunisation status Immunisation attitudes

One dose (n = 227) No dose (n = 115) Neutral (n = 191) Disagree (n = 99)
(under-vaccination) (hesitancy and refusal)
Child demographics
Male 1.161 1.378 1.305 1.239
(0.169) (0.300) (0.213) (0.287)
No. siblings in household 1.042 1.315*** 1.056 1.315***
(0.078) (0.125) (0.083) (0.132)
Single parent 0.715 1.595 0.891 1.073
(0.191) (0.641) (0.274) (0.509)
Child health
Medicine use 1.300 0.556 0.640 0.637
(0.269) (0.242) (0.183) (0.281)
Medical condition 0.556* 0.595 1.194 0.656
(0.168) (0.313) (0.347) (0.348)
Primary carer/child area disadvantage
SEIFA 2nd quintile 1.305 1.605 0.871 1.036
(0.297) (0.611) (0.236) (0.397)
SEIFA 3rd quintile 0.487*** 0.956 0.570** 0.810
(0.128) (0.383) (0.154) (0.308)
SEIFA 4th quintile 0.762 1.689 0.668 1.101
(0.191) (0.659) (0.184) (0.439)
SEIFA 5th quintile 1.051 1.412 0.712 1.204
(0.282) (0.599) (0.211) (0.509)
Primary carer demographics
Age 0.917*** 1.079*** 1.028* 1.073***
(0.014) (0.024) (0.017) (0.026)
Australian born 0.442*** 1.454 0.790 1.607
(0.075) (0.451) (0.157) (0.541)
Major Cities 1.406* 0.741 1.116 0.613*
(0.274) (0.194) (0.231) (0.170)
Primary carer religion
Other religions 1.081 1.512 1.263 2.802**
(0.264) (0.656) (0.395) (1.135)
No religion 0.840 1.467 1.471** 1.970**
(0.159) (0.377) (0.278) (0.526)
Primary carer income
Income 2nd quintile 0.593** 2.066 1.061 1.227
(0.156) (0.954) (0.332) (0.535)
Income 3rd quintile 1.059 2.285* 1.120 1.400
(0.268) (1.043) (0.354) (0.602)
Income 4th quintile 0.881 1.291 1.020 0.850
(0.241) (0.615) (0.332) (0.390)
Income 5th quintile 0.856 0.857 1.402 0.576
(0.246) (0.415) (0.452) (0.279)
Primary carer education
Diploma/Certificate 0.676** 0.877 0.796 0.724
(0.129) (0.224) (0.157) (0.200)
Secondary and below 0.927 0.703 0.765 0.628
(0.182) (0.211) (0.169) (0.196)
Primary carer/child homeownership
Homeowner 0.689** 0.838 0.752 1.107
(0.115) (0.225) (0.145) (0.327)
Primary carer employment
Maternity leave 1.735* 0.947 0.858 0.000
(0.546) (0.715) (0.418) (0.001)
Part-time 0.677* 1.581 1.206 1.232
(0.138) (0.464) (0.266) (0.372)
Full-time 0.612 1.561 0.562* 1.098
(0.183) (0.634) (0.185) (0.497)
Primary carer government payment
Yes 1.254 0.678 1.033 0.868
(0.242) (0.176) (0.207) (0.246)
Primary carer health
Medical condition 2.550*** 0.617 1.034 1.096
(0.476) (0.290) (0.278) (0.424)
States/Territories Yes Yes Yes Yes
Log-likelihood 1158.699 1158.699 1018.458 1018.458
Pseudo R2 0.106 0.106 0.061 0.061

Notes: Multinomial logit models of immunisation status and attitudes were estimated. Base category for uptake was two doses (n = 4437) and base category for attitude was
strongly agree (n = 4484). Standard errors were in parentheses and estimated using Delta-method. * p < 0.10, ** p < 0.05, *** p < 0.01. Estimates in bold indicate significance at
the 5% level.

756
M. Toll and A. Li Vaccine 39 (2021) 751–759

Fig. 2. AME estimates for immunisation uptake and attitudes by primary carer’s sociodemographics. Notes: Multinomial logit models of immunisation status and attitudes
were estimated. AME estimates were calculated as the average of predicted probability at different values of the predictors across the sample.

757
M. Toll and A. Li
parental education with vaccine uptake [28]. Compared to other
studies that looked at religiosity [26], this study showed religions
other than Christianity were more likely to disagree with child vac-
cination, although the effect the religion had on vaccine attitudes
was not translated into non-uptake.
Importantly, the results have implications for different policy
designs that target subgroups with consistent or inconsistent vac-
cination attitudes and behaviour. For intentional under-
vaccination group characterised by non-vaccination and negativity
about vaccination who were likely to be older and have more chil-
dren, education campaigns, home visits and communication with
health care providers would be more effective and equitable than
No Jab No pay that disproportionally affects lower income families.
For unintentional under-vaccination group characterised by under-
vaccination and positive attitude who tend to be younger, policies
like No Jab No Pay that act like a nudge or incentive to full vaccina-
tion would provide efficient pressure, though equity issues cannot
be neglected. For under-vaccination parents with neutral or
insignificant attitude who were largely from less socioeconomi-
cally advantaged areas, living in rental dwellings and with medical
conditions, removing logistical or financial barriers would bring
more gains as financial sanctions put pressure on them to vacci-
nate although cause unintended hardship. For parents of certain
religious backgrounds who had significant negative attitudes that
did not translate into under-vaccination, general campaigns would
promote vaccine awareness.
Policies that tied welfare benefit to vaccination status, such as
No Jab No Pay, were likely to adversely affect benefit dependent
parents who faced practical barriers to full vaccination, as the poli-
cies did not address pragmatic barriers or the under-vaccination of
socioeconomically advantaged groups who were less welfare
dependent [21]. No Jab No Pay disproportionately affects vaccine
objectors from lower income families, potentially antagonise hesi-
tant parents, and eliminates a chance for contact between vaccine
objectors and health care professionals that can provide opportuni-
ties for mutual understanding [20,21]. The heterogeneous nature
of under-vaccination implied in the results suggests that a combi-
nation of policies that contend with practical barriers, increase
intrinsic demand for vaccination, and impose financial sanctions
for wealthier vaccine objectors would better contribute to reaching
the target coverage rate.
The study has a few limitations. First, similar to other studies
that used the Australian longitudinal data for vaccination research
[11], the current study covered the period from 2004 to 5 to 2010–
11, a period post the MMR controversy and prior to the policy
change in 2016. However, LSAC is the last national survey that con-
tains data on vaccine attitudes and status, and detailed information
of socio-economics and demographics. Second, the study did not
consider the influence of secondary carers, but including such
information would unavoidably reduce sample size. Third, the
matching process in the study led to a slight overrepresentation
of full immunisation of children [24], although many variables
identified as being associated with over-representation were
included in the estimation. Fourth, the focus of the study was on
the completion of doses rather than the timeliness of the vaccine
schedule. Fifth, it should also be acknowledged that while MMR
is one of the most controversial vaccines, the attitudinal question
used in this study was generic and covered a single spectrum from
strongly agreement to strongly disagreement with vaccines rather
than a purpose built instrument. Future studies should also exam-
ine the factors associated with and consistency between attitudes
and behaviours post the introduction of No Jab No Pay, and how
shifts from a permissive mandate with non-medical exemptions
(NMEs) to a restrictive mandate without NMEs have affected the
choices made by objecting parents from lower and higher income
brackets [22].
758
Vaccine 39 (2021) 751–759
The current study complements previous studies on factors
associated with childhood under-vaccination [8,11,28–30]. In par-
ticular, the study contributes to the literature by examining the
relationship between attitudes towards vaccination and MMR vac-
cination status, and differential factors associated with attitudes
and vaccination status. Unlike many studies in childhood vaccina-
tion that have used self-reported vaccine uptake [10], the current
study used an objective measure based on administrative records.
Subjective measures have the issue of potentially overestimating
the uptake rate. Employing a national representative cohort of
age-appropriate children also avoided a dependence on surveys
in a limited setting and alleviated sample selection bias.
Recent clarification of the concept of vaccine hesitancy and vac-
cine refusal has emphasised the importance of making a distinc-
tion between motivational or attitudinal state and vaccine
behaviour [10]. The distinction between vaccination attitudes
and uptake, and the factors associated with each, facilitated teasing
out groups that were intentionally under-vaccinating and those
that were under-vaccinating due to extrinsic factors such as prac-
tical barriers to full vaccination. Strategies that nudge parents
towards action and reduced barriers are likely to be effective for
parents with positive intentions. Whilst strategies intending to
change neutral or negative attitudes of parents remain an area of
active research [31,32], there is some evidence that effective bur-
dens through education programs with health care professionals
can reduce objection [23]. Parents with positive attitudes and
under-vaccination and parents with negative attitudes and
under-vaccination are of policy concerns and require different pol-
icy solutions. Australia’s coverage rate is high and has been
improving in recent years though it is still below the government
target, policies need to address access barriers and nudge parents
towards vaccine uptake without causing undue hardship or resent-
ment that might undermine public health efforts.
Declaration of Competing Interest
The authors declare that they have no known competing finan-
cial interests or personal relationships that could have appeared
to influence the work reported in this paper.
References
[1] World Health Organisation, Ten threats to global health in 2019. WHO, 2019.
[2] Image, T., Measles Eradication: a goal within reach, slipping away. The Lancet,
2019.
[3] World Health Organisation, Report of the SAGE Working Group on vaccine
hesitancy. WHO, 2014.
[4] Kata A. A postmodern Pandora’s box: anti-vaccination misinformation on the
Internet. Vaccine 2010;28(7):1709–16.
[5] Tickner S, Leman PJ, Woodcock A. Factors underlying suboptimal childhood
immunisation. Vaccine 2006;24(49–50):7030–6.
[6] Larson HJ et al. Understanding vaccine hesitancy around vaccines and
vaccination from a global perspective: a systematic review of published
literature, 2007–2012. Vaccine 2014;32(19):2150–9.
[7] Smith LE et al. A systematic review of factors affecting vaccine uptake in young
children. Vaccine 2017;35(45):6059–69.
[8] Brown KF et al. Factors underlying parental decisions about combination
childhood vaccinations including MMR: a systematic review. Vaccine 2010;28
(26):4235–48.
[9] World Health Organisation, Report of the SAGE Working Group on vaccine
hesitancy. 2014.
[10] Bedford H et al. Vaccine hesitancy, refusal and access barriers: The need for
clarity in terminology. Vaccine 2018;36(44):6556–8.
[11] Pearce A et al. Barriers to childhood immunisation: findings from the
longitudinal study of Australian children. Vaccine 2015;33(29):3377–83.
[12] Lim C et al. Identification of the determinants of incomplete vaccination in
Australian children. Vaccine: X 2019;1:100010.
[13] Haynes K, Stone C. Predictors of incomplete immunisation in Victorian
children. Aust N Z J Public Health 2004;28(1):72–9.
[14] Reich JA. Neoliberal parenting, future sexual citizens, and vaccines against
sexual risk. Sexuality Research and Social Policy 2016;13(4):341–55.
M. Toll and A. Li
[15] Falagas ME, Zarkadoulia E. Factors associated with suboptimal compliance to
vaccinations in children in developed countries: a systematic review. Curr Med
Res Opin 2008;24(6):1719–41.
[16] Smith DT, Attwell K, Evers U. Majority acceptance of vaccination and mandates
across the political spectrum in Australia. Politics 2020;40(2):189–206.
[17] Department of Health. Childhood immunisation coverage. Australian
Government: Department of Health; 2020.
[18] Parliament of Australia, Social Services Legislation Amendment (No Jab, No
Pay) Act 2015. Australian Government, 2015.
[19] Beard FH, Leask J, McIntyre PB. No Jab, No Pay and vaccine refusal in Australia:
the jury is out. Med J Aust 2017;206(9):381–3.
[20] Li A, Toll M. Removing Conscientious Objection: The Impact of ‘No Jab No Pay’
and ‘No Jab No Play’ Vaccine Policies in Australia. Prev Med 2021. https://doi.
org/10.1016/j.ypmed.2020.106406.
[21] Leask J, Danchin M. Imposing penalties for vaccine rejection requires strong
scrutiny. J Paediatr Child Health 2017;53(5):439–44.
[22] Attwell, K. and M. C. NAVIN, Childhood Vaccination Mandates: Scope,
Sanctions, Severity, Selectivity, and Salience. The Milbank Quarterly, 2019.
97(4): p. 978-1014.
[23] Navin MC, Largent MA, McCright AM. Efficient burdens decrease nonmedical
exemption rates: A cross-county comparison of Michigan’s vaccination waiver
education efforts. Preventive medicine reports 2020;17:101049.
[24] Homel J, Edwards B. Using Australian Childhood Immunisation Register data in
the Longitudinal Study of Australian Children. Medicine 2016.
759
Vaccine 39 (2021) 751–759
[25] Marin M et al. Recommendation of the Advisory Committee on Immunization
Practices for use of a third dose of mumps virus–containing vaccine in persons
at increased risk for mumps during an outbreak. Morb Mortal Wkly Rep
2018;67(1):33.
[26] Soloff C, Lawrence D, Johnstone R. The longitudinal study of Australian
children: An Australian government initiative. LSAC technical paper 2005;1.
[27] ABS, 6401.0 Consumer Price Index, Australia, Mar 2019. Australian Bureau of
Statistics, 2019.
[28] de Cantuária Tauil M, Sato APS, Waldman EA. Factors associated with
incomplete or delayed vaccination across countries: a systematic review.
Vaccine 2016;34(24):2635–43.
[29] Homel J, Edwards B. Factors associated with delayed infant immunization in a
nationally representative cohort study. Child Care Health Dev 2018;44
(4):583–91.
[30] Pearce A et al. Factors associated with uptake of measles, mumps, and rubella
vaccine (MMR) and use of single antigen vaccines in a contemporary UK
cohort: prospective cohort study. BMJ 2008;336(7647):754–7.
[31] Brewer NT et al. Increasing vaccination: putting psychological science into
action. Psychological Science in the Public Interest 2017;18(3):149–207.
[32] Saint-Victor DS, Omer SB. Vaccine refusal and the endgame: walking the last
mile first. Philosophical Transactions of the Royal Society B: Biological Sciences
2013;368(1623):20120148.
Another random document with
no related content on Scribd:
 In dogs there are the same general symptoms with vomiting. The
vomited material is usually remasticated and swallowed. The
swelling in the pharynx can be felt from without, or seen through the
open mouth. The tonsils are usually enlarged. Pressure on the
pharynx or gullet produces instant regurgitation.
Treatment consists in the removal of the tumor when possible.
Malignant growths and multiple tumors are not favorable for
treatment. Actinomycosis can be treated throughout by iodides, or
these may supplement the surgical measures. In the short-faced
animals an ecraseur, or a wire-snare passed through a tube may be
employed. (See pharyngeal polypi).
 ESOPHAGITIS. INFLAMMATION OF THE
GULLET.

Causes: Alimentary and therapeutic; parasitic and accidental traumatisms;

mechanical irritants; acrids; caustics; parasites—gongylonema, coccidia,
spiroptera. Extension inflammations. Lesions: hyperæmia; epithelial degeneration
and desquamation; erosion; petechiæ; suppuration; fibroid contraction;
sacculation; polypi. Symptoms: dysphagia, difficult deglutition; eructation; cough;
upward wave motion in jugular furrow; colicy pains; probang arrested; fever.
Treatment: liquid or semi-liquid food; for caustics, antidotes; cold water; ice;
antiseptics; derivatives; open abscess; potassium iodide.

Causes. This usually arises from injury to the mucous membrane

and in the milder forms remains confined to this structure. In the
more severe, it extends to the muscular coat and even to the
periœsophagean tissues. The causes may be divided into alimentary
and therapeutic irritants; parasitic or accidental traumatisms; and
extension of inflammation from the pharynx or other adjacent part.
Among irritants taken as food, may be named hot mashes, bolted
by a hungry and gluttonous horse, and temporarily arrested in the
gullet by reason of the resulting irritation of the mucous membrane.
In other cases, coarse fibrous fodder is bolted without previous
mastication, and scratches and abrades the œsophagean mucosa
leading to transient or progressive inflammation. In other instances
diseases of the teeth, jaws, temporo-maxillary joint, or salivary
glands prevent the necessary trituration of the food, and it is
swallowed in a rough, fibrous, or even a dry condition. Again the
impaction of a solid body (turnip, apple, potatoe, egg) or of a
quantity of finely divided grain or fodder so as to obstruct the lumen
of the gullet, is an occasional cause. The density of the epithelium
reduces these dangers to the minimum, yet a too rough morsel, or an
undue detention of the less irritating material will determine
hyperæmia and even inflammation and infective invasion. Acrid and
irritant vegetables in the food are less injurious when thoroughly
insalivated, as their contact with the œsophagean walls is then very
slight and transient.
Irritant and caustic chemical agents given for therapeutic
purposes, attack the mouth, pharynx and stomach, more severely
than the gullet through which they are passed with great rapidity. In
some cases, however, the agent will adhere by reason of its powdery,
gummy or balsamic character and will then act as a direct irritant.
Solutions of caustic alkalies (weak lye) given to correct acid gastric
indigestion in the horse, and ammonia to remedy tympany in cattle,
when insufficiently diluted, will dangerously attack the œsophagean
mucosa.
Parasitic irritation is not so common here as in other parts of the
intestinal canal where the contents are longer delayed and are passed
with less friction, yet certain parasites are found in this region and
may even produce considerable irritation. The gongylonema of the
thoracic œsophagean mucosa of ruminants and swine are apparently
harmless. The psorospermia of the œsophagean muscles of the same
animals are alleged to cause œdema of the glottis, asphyxia and
epilepsy. The spiroptera microstoma of the horse has in one instance
known to us caused extensive denudation of the muscular coat
within a foot of the cardiac end of the gullet. Finally we have found
bots hooked on to the œsophagean mucosa close to the cardia,
causing much irritation and spasm. The spiroptera sanguinolenta is
often present in chambers hollowed in the œsophagean mucosa of
the dog.
Traumatic causes appear in the form of contusions and bruises
from without, but much more frequently from foreign bodies, and
probangs operating from within. The use of a whip or of a rope
without a cup-shaped end for the relief of a choked animal. Short of
the occurrence of laceration this often produces contusion and
abrasion which results in local inflammation. Even the too forcible
dislodgment of a solid body by a probang of approved pattern, may
bruise and scratch the gullet when the seat of violent spasm. Pins,
needles, wire, thorns and other sharp bodies are liable to do serious
damage during their passage in an ordinary bolus and when they
transfix the mucosa violent infective inflammation may ensue.
 Extension inflammations from the throat, and from phlegmous,
abscesses, tumors, etc., in the jugular furrow need only be mentioned
in this connection, as the primary disease will be clearly in evidence.
Lesions. These are usually circumscribed when due to a traumatic
injury and extended when caused by caustics or irritants. The
affected section is swollen, and surrounded by some serous effusion.
When the muscular coat is involved it is often paler than normal, and
microscopically shows extensive granular and fatty degeneration.
The mucosa usually sloughs off its epithelial layer, sometimes over
an extensive area (thoracic portion, Renault; whole gullet, Bertheol),
and the exposed raw surface is of a deep red or violet. When the
epithelium is not shed, it is infiltrated, swollen and friable breaking
down under the slightest manipulation. Petechiæ and slight blood
extravasations are abundant, and diffuse suppuration is not
uncommon. In traumatic injuries necrosed areas are found in the
muscular and mucous coats. Strictures, dilatations, and polypoid
growths are liable to follow as sequelæ.
Symptoms. These usually manifest themselves from two to four
days after the operation of the cause. There is much difficulty in
deglutition, the effort to swallow either solids or liquids causing
acute suffering, with extension of the head on the neck and strained
contraction of the facial muscles. If the liquid succeeds in passing the
pharynx, it is arrested at the seat of inflammation and regurgitated
through the nose and mouth, or in solipeds through the nose only.
This takes the appearance of emesis even if nothing actually comes
from the stomach. The animal shakes the head violently, breathes
hurriedly, and has fits of paroxysmal coughing. A wave extending
from below upward along the jugular furrow and followed by nasal
discharge is a marked symptom, as the violence of the inflammation
increases. Uneasy movements of the limbs, pawing and lying down
and rising, indicate the existence of colic, and this is aggravated by
the administration of anodynes or antispasmodics by the mouth. In
cattle, rumination is arrested, froth accumulates around the lips, the
rumen becomes tympanitic, and colicy movements appear.
Oftentimes a swelling extends upward in the jugular furrow, and
even in its absence, pressure with the fingers along the furrow will
often detect an area of tenderness with or without local swelling.
Fever with more or less elevation of temperature, is a general
symptom. There may be wheezing breathing or loud stertor. The
passage of a probang is arrested by the swelling or spasm at the
diseased part and when withdrawn may be covered with pus or fœtid
debris. In the horse a small probang may be passed through the
nose.
Treatment. In a slight congestion at the seat of a recent
obstruction and which tends to renewed obstruction, little more is
necessary than to restrict the feed for a few days to soft mashes so
that irritation of the sensitive surface, spasm and the arrest of the
morsel may be obviated. Plenty of pure water or of well boiled
linseed or other gruel should be allowed.
In cases in which the obstruction is still present in the gullet, its
removal by probang or looped wire is the first consideration, to be
followed by the measures mentioned above.
In case of the swallowing of a caustic agent, no time should be lost
in giving an antidote. For the mineral or caustic organic acids, lime
water, magnesia, or other bland basic agent is demanded. For caustic
alkalies or basic agents, bland acids, such as vinegar, citric acid, or
even a mineral acid very largely diluted will be in order. In both these
cases and in that of caustic salts, albuminous and mucilaginous
agents, eggs, linseed tea, slippery elm, gums, and well boiled gruels
are indicated. To these may be added small doses of laudanum when
the irritation is great. Iced drinking water, iced milk, or iced gruels
are often soothing to the suffering animal, and cold compresses,
snow or ice applied along the jugular furrow is often valuable. To
counteract the septic developments on the affected mucous
membrane, chlorate of potash, boric acid, salol, naphthalin,
naphthol, pyoktannin, or even weak solutions of phenic acid or
creolin may be used. In the slighter forms of inflammation or when
the acute form threatens to persist, an active counter-irritant of
mustard or cantharides may be applied along the jugular furrow.
In case of abscess, as manifested by fluctuation following a hard,
indurated, painful swelling, a free incision should be followed by
frequent injections of antiseptic lotions or by the packing of the
cavity with such bland antiseptics as salol, boric acid, or iodoform on
cotton.
As inflammation subsides, potassium iodide may be given, both as
an antiseptic and a resolvent, to counteract the tendency to fibroid
contraction and stricture of the gullet.
 SPASM OF THE ŒSOPHAGUS.
ŒSOPHAGISMUS.

Causes: nervous disorders or lesions, pharyngeal, œsophagean, or gastric

disease, œsophagean parasites, choking, tumors, ulcers, cold drinks. Symptoms:
extended drooping head, working jaws, frothing, pawing, attempts at swallowing,
alkaline regurgitation, cries, rigid gullet, tenderness. May be paroxysmal with
intervening dullness. Treatment: by sound; by removal of obstruction; by
antispasmodics. Embrocations. Tonics.

Causes. This has been noticed as a concomitant of certain diseases

of the nervous centres, such as rabies, tetanus, or epilepsy, and those
of the pharynx or stomach. Cadeac has seen it in connection with
stricture, and the present writer has observed it as a result of larvæ of
œstri hooked on to the mucosa above the cardia. It is an important
factor in most cases of choking, and may depend on tumors, ulcers,
or even cold beverages. Animals with a specially nervous
organization are particularly subject to it and it may thus be an
hereditary family trait. It has been especially noticed in solipeds and
calves.
Symptoms. A feeding animal suddenly ceases to eat, extends the
head on the neck, drops the nose toward the ground, moves the jaws
constantly, froths at the mouth or lets the saliva drivel to the ground,
moves the fore feet uneasily pushing the litter under the belly, makes
efforts at deglutition during which, waves may be seen to descend
along the jugular furrow, followed by regurgitation and discharge of
the liquid as by emesis. The act is often followed by a slight cry.
Manipulations of the left jugular furrow detects the gullet as a firm,
rigid cord, unless when liquids are passing as above, and
auscultation reveals a rattling or gurgling noise as if in jerks.
Pressure on the gullet is often very painful, increasing the spasm and
rigidity, and causing the animal to cry out. Wheezing breathing may
attend the discharge of saliva through the nose, and violent
paroxysms of coughing may be caused by the entrance of this liquid
into the larynx.
In the majority of cases no food is swallowed and nothing but
saliva is disgorged, which together with the absence of an acid odor
distinguishes this from true vomiting. In an exceptional case of the
author’s, occurring in a colt, the animal continued to masticate and
swallow green food which gradually filled the whole length of the
gullet, practically paralyzing it. In ordinary cases a small sound can
usually be passed into the stomach. In cases of obstruction, however,
by a solid morsel, or by an accumulation of soft solids, the probang
will enable one to detect the condition. The acute symptoms may
occur in paroxysms of a few minutes in length, between which, the
animal remains dull and disspirited until the new attack supervenes.
Recovery is at times as sudden as the onset, though there remains,
for a length of time, liability to a relapse. Cadeac has seen a
succession of such attacks which extended over a year and a half.
Treatment. In many cases the passage of a probang or sound, will,
by the mere distension of the gullet, overcome the local spasm,
though it may be necessary to repeat the operation several times. In
case the sound causes much pain the end of the instrument may be
well smeared with solid extract of belladonna, and after passing this
as far as the obstruction a short time may be allowed, before its
passage is again attempted. In case obstruction by soft solids has
taken place, the passage of the wire loop will serve to break up the
mass and even to draw it up toward the mouth.
The administration of antispasmodics is the next indication.
Chloroform or ether by inhalation or in solution in water, chloral
hydrate as an enema, morphia or atropia hypodermically may be
used according to convenience. Bromide of potassium and other
antispasmodics given by the mouth, too often fail to pass the
obstruction and thus prove useless, except in the intervals of the
spasms.
Fomentations of the lower border of the neck with warm water,
and frictions over the region of the gullet with camphorated spirit,
essential oils, ammonia, or in calves with oil of turpentine, often
contribute to relieve the spasm.
 Finally after the severity of the attack has passed, a course of bitter
tonics and above all of nux vomica will fortify the system against a
relapse.
 PARALYSIS OF THE ŒSOPHAGUS.

Causes: nervous lesions and disorders; arytenectomy; over distension; stricture;

parasites. Symptoms: dysphagia; regurgitation; cough; dyspnœa; hard packed
gullet. Inhalation pneumonia. Lesions. Treatment: remove cause; liquid food;
dilatation; nerve sedatives and stimulants; electricity; counter-irritants.

Causes. This has been noticed in a number of cases in solipeds,

and attributed to central nervous lesions, cerebral concussion
(Straub), encephalitis (Hering, Bornhauser), paralysis of the fore
extremities (Meier), pharyngeal paralysis (Puschmann). Möller has
seen it several times consequent on arytenectomy, while Dieckerhoff
and Graf have seen it occur without any clearly defined cause. In a
case referred to above, the present writer found it connected with the
attachment of larvæ of œstri in the lower end of the gullet. Stricture
and impaction may be a further cause.
Symptoms and lesions. There is more or less interference with
deglutition, culminating in complete inability to swallow, and the
rejection of morsels of masticated food by the nose. Cough may also
occur from the descent of food toward the lungs, with more or less
dyspnœa and oppression of the breathing. Manipulation along the
left jugular furrow, detects the œsophagus as a prominent hard,
rope-like mass which fills up the groove unduly. When death occurs
rapidly the gullet is found gorged with masticated food throughout
its entire length. In certain instances gangrenous pneumonia is
found, the result of the penetration of food into the bronchia. In
other cases there are lesions of the medulla oblongata, or of the
vagus or glossopharyngeal nerves or their œsophagean branches.
Death usually results from obstruction, inanition, or, in case the
paralysis is partial, from pneumonia or exhaustion.
 Treatment. First remove or correct the existing cause of the
disease. Impaction may be broken up by the use of the wire loop, or
pincer probang; parasites may be expelled by passing a cupped
probang; the impactions following arytenectomy can be obviated by
feeding gruels, milk and other liquid foods only, and from a bucket
set on the ground; stricture may be dilated by the use of graduated
sounds; and nervous diseases may be dealt with according to their
specific nature in each several case. When any definite cause of this
kind has been overcome the persistent use of strychnia, subcutem, or
by the mouth, may be effectual in overcoming the paresis of the
gullet. Hypodermic injections are best made along the left jugular
groove, and frictions, stimulating embrocations, and galvanic
currents may be employed with excellent effect.
 ŒSOPHAGEAN TUMORS.
Forms of neoplasm in gullet of horse, ox, sheep, pig, dog. Symptoms: dysphagia;
eructation; vomiting; bloating; cough; dyspnœa; stertor; fœtor; palpitation.
Treatment.
These have been often noticed in the lower animals. In the horse
have been noticed melanoma (Olivier, Röll, Kopp, Besnard,
Pouleau), fibroma (Dandrieu, Dieckerhoff), Carcinoma (Chouard,
Lorenz, Cadeac, Laurent), epithelioma (Blanc, Lorenz), Leiomyoma
(Lucet, Lothes), cystoma (Caillau, Legrand), mucous cysts (Lucet).
In cattle papilloma is especially common, having been noted by
Johne, Mons, Fessler, Schütz, Lusckar, Gratia, Beck, Cadeac and Kitt.
Tubercles, and fibroid masses with cystic purulent centres are
not uncommon. Actinomycosis is also frequent, sometimes hard
and warty and at others soft and vascular.
In the Sheep, Dandrieu found between the muscular and mucous
coats a hard tumor as large as a hen’s egg, the removal of which put a
stop to a persistent choking. In both cattle and sheep, swellings
from coccidiosis are common; in cattle and swine from
gongylonema, and in sheep from filaria (Harms) or spiroptera
(Zurn).
In pigs, fibroma is met with in the walls of the gullet (Raveski)
and in dogs fibroma, papilloma, and the tumors of spiroptera.
Symptoms. The coccidia and spiroptera usually cause few
symptoms or none, but neoplasms usually develop symptoms of
obstruction, dysphagia, eructation, vomiting, and all the indications
of choking according to their seat. These do not come on suddenly
and recover as in simple choking, but even though there may be
periodic obstructions, spasms and paroxysms, there is a slow,
progressive advance as the neoplasms increase. Stertorous or
mucous breathing, cough, dyspnœa and fœtid exhalations are
common, the symptoms may be aggravated when the head is bent,
and the tumor may even be felt on palpation of the throat or left
jugular furrow. In ruminants tympany occurs after feeding.
 Treatment is surgical and consists in the removal of the tumors by
incision and ecraseur or otherwise. Thoracic œsophagean tumors are
usually inoperable.
 IMPACTION OF THE CROP. INGLUVIAL
INDIGESTION.
Gallinaceæ and Palmipeds. Causes; Overfeeding after privation; fermentation;
lack of water; green food in geese and chickens; food containing paralyzing
element. Symptoms; dull; motionless; erect plumes; drooping wings and head;
gapes; ejects liquid from bill; firm cervical swelling. Treatment; manipulation;
incision; surgical precautions. Convalescent feeding.
The cervical dilatation of the œsophagus known as the crop is well
developed in all granivorous birds, (Gallinaceæ, etc.;) and like the
macerating cavities of the ox (first two stomachs) is subject to
overdistension and paralysis. In the palmipeds (ducks, geese) there is
no distinct crop but in its place the cervical portion of the gullet has a
fusiform dilatation, and under given conditions this may be also the
seat of impaction.
Causes. The impaction may result from overfeeding when the bird
has been starved, or when it suddenly gains access to food of a
specially appetizing kind and to which it has been unaccustomed.
The crop like every other hollow viscus is rendered paretic by
overdistension. Then the food undergoes fermentation still further
distending the cavity, affecting the brain by reflex action, and
paralyzing the vagus and its peripheral branches in the lungs, heart,
stomach, liver, intestines, etc. When the food is dry as in the case of
beans, peas, bran, farinas, it may be a simple firm impaction which
the muscular walls of the crop are unable to break up or move
onward. When green food is taken there is often superadded the
additional evil of active fermentation from the great number and
activity of the bacterial ferments contained in it and the soft aqueous
fermentescible nature of the food (See tympany in ruminants).
Dupont states that young geese led out to fresh spring grass may lose
two-thirds of their number in a few hours from such overloading and
that some species of Carex and cynodon dactylon are particularly
injurious. Chickens also gorge the crop with clover, etc. In all such
cases, plants that contain a paralyzing principle like lolium
temulentum, ripening lolium perenne, chick vetch, etc., are to be
specially dreaded. (See Trichosoma Contortum).
 Symptoms. There are first dullness and sluggish movements,
followed by indisposition to move, the bird standing in one place
with ruffled feathers and drooping wings, and at intervals, projecting
the head forward with open beak and in some cases a little liquid is
rejected. If the bird is now caught and examined the crop is found to
be firmly distended, and more or less compressible or indentable
according to the nature of the food impacted. In most cases and
especially if the food has been green or aqueous, there is a certain
resiliency from the presence of gas outside the solid impacted mass.
Treatment. This must be in the line of seconding the physiological
efforts of regurgitation which is a normal and common act in birds.
The duck which has gulped a mouse half-way down the cervical part
of the œsophagus will readily disgorge it when he finds it impossible
to pass it further. The carnivorous birds often reject by vomiting the
indigestible debris such as feathers and bones, after all the more
soluble parts have been disposed of in the stomach. The pigeon even
feeds its young by disgorging into their open bills, the semi-digested
food and milk from its crop. Following these indications we must
break up the contents of the crop by manipulation and force them in
small masses upward into the bill and downward to the
proventriculus. The rejection by the bill may be further stimulated by
introducing the finger into the fauces to rouse the reflex active
emesis. Usually the crop can be quickly and satisfactorily emptied in
this way.
When this proves impossible there remains the operation of direct
incision through the walls of the crop and the evacuation of its
contents. This can be done by a pocket knife or even a pair of
scissors. The crop is punctured in its lower part and the incision is
continued upward as far as may be necessary to allow the escape of
the contents. Usually half an inch will suffice. Then the crop is
squeezed so as to press the contents through this opening and it is
emptied by a process of enucleation. If the contents are fibrous it
may be necessary to employ forceps to dislodge the material. The
empty crop may be washed out with tepid water, any food attached
to the raw edges of the wound must be removed and the skin stitched
accurately together. The wound rarely fails to heal by first intention.
To avoid stretching it, the food for a day or two should be restricted
to milk, gruels, or a little soft mash.
 Lerein notices jaundice as a sequel of impacted crop, and
recommends treatment by sulphate of soda in the water.
 TYMPANITIC INDIGESTION IN THE
RUMEN. BLOATING.
Definition. Susceptible Genera. Causes; gastric paresis, overloading, cold, fear,
exhaustion, poisons, fermentescible food,—new grain, leguminosæ, frosted
vegetables, ruminitis, foreign bodies in rumen, microbian ferments. Symptoms,
abdominal, general. Gases formed under different aliments—carbon dioxide,
marsh gas, hydrogen sulphide, nitrogen, oxygen. Lesions, rupture of rumen or
diaphragm, compression or rupture of liver or spleen, petechiæ, congestion of
lungs and right heart, of cutaneous and cerebral vessels. Prevention, avoid
indigestible and fermentescible aliments, correct adynamic conditions, tonics,
avoid injurious ferments, make alimentary transitions slowly. Treatment, exercise,
bath or douche of cold water, rubbing and kneading, rope round abdomen spirally,
gag in mouth, dragging on tongue, movement of a rope in fauces, probang,
stimulants, antiseptics, alkalies, ammonia, oil of turpentine, oil of peppermint,
alcohol, ether, pepper, ginger, soda, potash, lime, muriatic acid, carbolic acid,
creosote, creoline, sulphites, kerosene, chloride of lime, chlorine, tar, common salt,
hypochlorite of soda, magnesia, eserine, pilocarpin, barium chloride, colchicum,
lard, trochar, Epsom salts, rumenotomy. Treatment of diseased gullet, mediastinal
glands, stomach or intestines.
Definition. The condition is a combination of paresis of the rumen
and gaseous fermentation of its contents. The initial step may be the
paresis or in the more acute forms the fermentation.
Genera susceptible. While all ruminating animals are subject to
this disorder, it is much more frequent in cattle and sheep than in
goats.
Causes. It commences in paresis of the rumen in the weak,
debilitated, convalescent or starved animals which are suddenly put
on rich, and appetizing food. Hence it is common in animals that
break into a cornbin, a store of potatoes, a field of growing corn or
small grain, or that are turned out on green food in early spring.
Cadeac maintains that paresis of the rumen is the essential cause in
all cases, while the nature of the aliments ingested fills a secondary
and comparatively insignificant rôle. According to this view the
torpid stomach can neither relieve itself through regurgitation for
rumination, nor expel through the œsophagus the constantly
evolving gas which therefore distends the viscus to excess. In support
of this view may be adduced the occurrence of tympany through
fatigue, fear, cold, enlarged (tubercular) mediastinal glands pressing
on the gullet and vagus, obstruction of the œsophagus by a solid
body (choking), impaction of a morsel of solid food in the demicanal
of the calf as noticed by Schauber, and the cessation of the normal
vermicular movements of the rumen in connection with
inflammation of its coats, or extensive inflammation elsewhere or
finally of fever. Even in paralysis of the stomach by poisons like lead,
tympany may be a result. Cadeac attributes tympany following the
ingestion of green food wet with a shower, or drenched with dew, of
frosted potatoes or turnips, or of iced water, to the paralyzing action
of the cold on the rumen. This view is manifestly too extreme, as the
bloating occurs often after a warm summer shower, or after the
consumption of potatoes and other roots and tubers which have been
spoiled by frost but which are no longer at a low temperature when
consumed.
Tympany may also start from the ingestion of certain kinds of
food which are in a very fermentescible condition. Green food,
especially if the animal has been unaccustomed to it, is liable to act
in this way. Clover and especially the white and red varieties, lucern
(alfalfa), sainfoin, cowpea and other specially leafy plants, which
harbor an unusual number of microbian ferments, and which
contain in their substance a large amount of nitrogenous material
favorable to the nourishment of such ferments are particularly
dangerous in this respect. All of these are most dangerous when wet
with dew or when drying after a slight shower, partly no doubt at
times by reason of the chilling of the stomach, but mainly because
the ferments have been stimulated into activity by the presence of
abundance of moisture. Drenching and long continued rains are less
dangerous in this respect than the slight showers and heavy dews,
manifestly because the former wash off a large portion of the
microbes, which under a slight wetting multiply more abundantly.
Frosted articles act in a similar way, partly when still cold by the
chilling and paralyzing of the stomach, but cold or warm, by reason
of the special tendency of all frozen vegetables to undergo rapid
fermentation when thawed out. This is true of green food of all kinds
when covered by hoarfrost, of turnips, beets, potatoes, carrots,
apples, cabbage, etc., which have once been frozen, and of frosted
turnips and potato tops, though, in the case of the latter agent, a
narcotic principle is added.
In the case of Indian corn, the smaller cereal grains, and certain
leguminous plants (vetches, tares, peas, beans) which have the seed
fully formed but not yet quite hardened nor ripened, there is the
double action of a paralyzing constituent and an aliment that is
specially susceptible of fermentation.
Inflammation of the rumen, already quoted as a cause, may be
determined by hot as well as cold food, by irritant drugs and poisons,
and by narcotico-irritant and other acrid plants in fodder or pasture.
In the same way the inflammation caused by the introduction of
foreign bodies into the rumen, such as nails, tacks, needles, pins,
wires, knife blades, and masses of hair or wool may at times cause
tympany.
The two main causative factors, of paresis of the rumen on the one
side and of specially fermentescible food and a multiplicity of
microbian ferments on the other, must be recognized as more or less
operative in different cases, and in many instances their combined
action must be admitted. The tympany is the symptom and
culmination of a great variety of morbid causes and conditions, and
its prevention and treatment must correspondingly vary.
Symptoms. The whole left side of the abdomen being occupied by
the rumen, its distension leads to an uniform swelling of that side,
differing from that caused by simple excess of solid ingesta in being
more prominent high up between the last rib and the outer angle of
the ilium, and in giving out in this region a clear tympanitic or
drumlike resonance on percussion. It has also a tense resiliency, like
that of a distended bladder, easily pressed inward by the finger but
starting out to its rotundity the moment the pressure of the finger is
withdrawn. The distension caused by overloading with solids bulges
out lower down, is not resonant but dull or flat when percussed, and
yields like a mass of dough when pressed retaining the indentation of
the finger for some time. The swelling of tympany, when extreme,
rises above the level of the outer angle of the ilium and even of the
lumbar spines on the left side, and if no relief is obtained the right
side may undergo a similar distension.
Auscultation detects an active crepitation over the whole region of
the rumen, finer in some cases and coarser in others, according to
the activity of evolution and the size of the bubbles of gas. The
crepitation is especially coarse and loud in fermentation of green
food, and of spoiled potatoes or other tubers or roots.
In all acute or severe cases, there is anorexia, suspension of
rumination, and the normal movements of the compressed bowels
seem to be largely impaired, though the anus is protruded and a little
semi-liquid fæces or urine may be expelled at intervals. The
breathing is accelerated, short, and labored. The nostrils are dilated,
the nose extended, the face anxious, the eyes bloodshot and the back
arched. Froth may accumulate around the lips, or the mouth may be
held open with the tongue pendent. Sometimes a quantity of gas may
suddenly escape with a loud noise, but without securing permanent
relief. The heart beats are violent and accelerated, the pulse
increasingly small and finally imperceptible, and the visible mucous
membranes are congested and cyanotic. Pregnant females are very
liable to abort.
When the right flank as well as the left rises to the level of the
lumbar spines death is imminent, and this may take place as early as
fifteen or thirty minutes after the apparent onset of the attack. Death
may result from nervous shock, from suffocation, or from the
absorption of deleterious gases, or from all of these combined.
In the less acute cases the animal may live several hours before the
affection terminates in death or recovery. As a rule he stands as long
as he can and finally drops suddenly, the fall often leading to rupture
of the diaphragm or stomach, to protrusion of the rectum, or the
discharge of ingesta by the mouth and nose.
In still slighter cases relief comes through vomiting or more
commonly through frequent and abundant belching of gas, the
swelling of the flanks subsides, rumbling of the bowels may again be
heard, and usually there is a period of diarrhœa.
Gases present. When the rumen is punctured before or after death
so as to give exit to the gas in a fine stream it proves usually more or
less inflammable, the lighted jet burning with a bluish flame. The
usual inflammable ingredients are carbon monoxide, hydrogen
carbide (marsh gas) and hydrogen sulphide, yet the relative
proportion of the gases varies greatly with the nature of the food and
the amount of gas evolved, carbon dioxide being usually largely in
excess. The following table serves to illustrate the variability: