Vaccinations, The Law in Costa Rica
With the number of foreigners moving to Costa Rica, some of them wonder what the rules are in Costa Rica when it comes to vaccinations, particularly if they have children. Earlier in the year, there was a significant discussion about this topic due to the measles outbreak in the US. By February 6th, there were 121 confirmed cases over 17 states across the US. 108 of those cases were traced to Disneyland.
I decided to write about this topic since have some friends and know some people here in Costa Rica who do not vaccinate their children. Thus, the question: What is Costa Rica’s position on vaccinations? I hope not to step on anybody’s toes and not to lose some friends. I really like the friends I currently have. Although, the purpose of the essay is to share the legal situation of the country regarding this issue, unavoidably, the text will also contain some of my personal views, which I try to pose from an objective perspective, which is the wellbeing of the population at large.
VIRUSES BY NUMBERS
Measles: It has been estimated that measles killed 200 million people in the last 150 years
Rubella: Although rubella does not cause death to the host, it can lead to complications in pregnant women that can cause miscarriages, therapeutic abortions and congenital diseases in the fetuses. Between 1964–65, the United States had an estimated 12.5 million rubella cases. This led to 11,000 miscarriages or therapeutic abortions and 20,000 cases of congenital rubella syndrome. Of these, 2,100 died as neonates, 12,000 were deaf, 3,580 were blind, and 1,800 were mentally affected. In New York alone, CRS affected 1% of all births.
Mumps: Similar to rubella, mumps is not a direct cause of death, but can certainly affect the person infected with the disease: it can cause infertility, hearing loss, and meningitis, which can cause death.
Smallpox: In the 20th century, between 300 and 500 million people died of smallpox. As late as 1967 the WHO estimated that 15 million died that year by smallpox. After vaccination campaigns throughout the 19th and 20th centuries, the WHO certified the eradication of smallpox in 1979.
Influenza: Influenza spreads around the world in a yearly outbreak, resulting in about three to five million cases of severe illness and about 250,000 to 500,000 deaths. Death occurs mostly in the young, the old and those with other health problems. the 20th century three influenza pandemics occurred: Spanish influenza in 1918, Asian influenza in 1958, and Hong Kong influenza in 1968, each resulting in more than a million deaths.
Polio: The World Health Organization estimates that there are 10 to 20 million polio survivors worldwide. In 1977 there were 254,000 persons living in the United States who had been paralyzed by polio. According to doctors and local polio support groups, some 40,000 polio survivors with varying degrees of paralysis live in Germany, 30,000 in Japan, 24,000 in France, 16,000 in Australia, 12,000 in Canada and 12,000 in the United Kingdom.
Diphtheria is fatal in between 5% and 10% of cases. In children under five years and adults over 40 years, the fatality rate may be as much as 20%. In 2010 it caused about 2,900 deaths.
I make reference to this list of diseases as they all can be prevented through vaccinations. Different pandemics and outbreaks throughout history has prompted different governments to enact vaccinations policies with the intent to protect the populations at large from death or crippling diseases.
THE COSTS OF NON VACCINATION
A number of outbreaks have occurred similar to the one in Disneyland, due to not following vaccination policies. Here is a list of outbreaks and the effects in the communities where they occurred.
Stockholm, smallpox (1873–1874). An anti-vaccination campaign motivated by religious objections, concerns about effectiveness, and concerns about individual rights led to the vaccination rate in Stockholm dropping to just over 40%, compared to about 90% elsewhere in Sweden.
UK, pertussis (1970s–80s). Vaccine uptake in the UK decreased from 81% to 31%, and pertussis epidemics followed, leading to the deaths of children.
Sweden, pertussis (1979–1996). Sweden suspended vaccination against whooping cough (pertussis) from 1979 to 1996. 60% of the country’s children contracted the potentially fatal disease before the age of 10; the death rate was about one per year. Pertussis remains a major health problem in developing countries. WHO estimates it caused 294,000 deaths in 2002.
Netherlands, measles (1999–2000). An outbreak at a religious community and school in the Netherlands illustrates the effect of measles in an unvaccinated population. The population in the several provinces affected had a high level of immunization, with the exception of one of the religious denominations, which traditionally does not accept vaccination. The three measles-related deaths and 68 hospitalizations that occurred among 2,961 cases in the Netherlands demonstrate that measles can be severe and may result in death, even in industrialized countries.
UK and Ireland, measles (2000). As a result of the MMR vaccine controversy, vaccination compliance dropped sharply in the United Kingdom after 1996. From late 1999 until the summer of 2000, there was a measles outbreak in North Dublin, Ireland. At the time, the national immunization level had fallen below 80%, and in part of North Dublin the level was around 60%. There were more than 100 hospital admissions from over 300 cases. Three children died and several more were gravely ill, some requiring mechanical ventilation to recover.
Nigeria, polio, measles, diphtheria (2001-Present). Due to religious opposition to vaccines, polio reappeared in a dozen formerly polio-free neighbors of Nigeria which reported nearly 20,000 measles cases and nearly 600 deaths from measles from January through March 2005. In 2006, Nigeria accounted for over half of all new polio cases worldwide. Outbreaks continued thereafter; for example, at least 200 children died in a late-2007 measles outbreak in Borno State.
Indiana, United States, measles (2005). A 2005 measles outbreak in the US state of Indiana was attributed to parents who had refused to have their children vaccinated. Most cases of pediatric tetanus in the US occur in children whose parents objected to their vaccination.
Multiple states, United States, measles (2013-Present). In 2000, measles was declared eliminated from the United States; remaining reported cases were due to importation. The CDC reported that the three biggest outbreaks of measles in 2013 were attributed to clusters of people who were unvaccinated due to their philosophical or religious beliefs. As of August 2013, three pockets of outbreak—New York City, North Carolina, and Texas—contributed to 64% of the 159 cases of measles reported in 16 states.
Philadelphia, United States, measles (1990-1991). Between October 1990 and June 1991, more than 1,400 people living in Philadelphia were infected with measles, and nine children died. Children had not been vaccinated, and when they became ill, their parents prayed instead of taking them to the hospital to receive the intravenous fluids or oxygen that could have saved the lives of those with the worst cases.
UK, Swansea, measles (2013). In 2013, an outbreak of measles occurred in the Welsh city of Swansea. One death was reported. Some estimates indicate that while in 1995, MMR uptake for two-year-olds was at 94% in Wales, it fell to as low as 67.5% in Swansea in 2003, meaning the region had a “vulnerable” age group. This has been linked to the MMR vaccine controversy, which caused a significant number of parents to fear allowing their children to receive the MMR vaccine.
VACCINATIONS IN COSTA RICA
Vaccinations in Costa Rica are mandatory by law.
There are three relevant bodies of law when it comes to vaccinations in Costa Rica. First of all, there is the Law 5395 (Ley General de Salud) and the National Vaccination Law 8111, which is a mirror of law 5395. And second, the Vaccination Regulation (Norma Nacional de Vacunación).
Law 5395 lays out the vaccination policy, and the Regulation gets into the specifics about the implementation of the policy. Let’s start with the law, as readers (particularly expats) may find out the content to be very interesting.
Section 150 estates that all vaccinations, as determined by the Department of Health (Ministerio de Salud or MS), are mandatory. There are two important elements here: first, vaccination is not an option; second, the law delegates to the MS the determination of what vaccines should be required for the population at large.
Section 151 delegates the responsibility on the parents and guardians to complete the vaccinations for children. This does not mean that parents have the right to decide whether to vaccinate, it means that parents are responsible to take the children to vaccinate. It is not the responsibility of the MS to go door to door.
Section 152 requires every person to furnish the Vaccination Certificate (VC) when required. Which means that people need to keep records of the vaccination, which will become relevant for travel and school enrollment.
Section 153 requires parents or guardians to produce the VC for school enrollment every year. In addition, it delegates the responsibility to School Principals to enforce this policy. Lastly, it is applicable to both public and private schools. What this means is that all children attending school must be vaccinated. Once again, it is not up to the parent.
Section 154 states that valid VC can only be issued by health professionals, whether from a public or private practice. In addition, the VCs must contain legitimate information. Forging is prohibited.
The foregoing sections set forth some basics about the mandatory nature of the vaccines, as well as establishing the Vaccination Certificate as a method to enforce the policy.
VACCINATIONS FOR FOREIGNERS
Regarding foreigners, the law also sets some mandatory requirements whether the foreigner intends to be in the country as a tourist or as a resident.
Section 172 requires all foreigners to produce their Vaccination Certificate along with the application to the Immigration Department.
Section 173 requires all people when entering the country at a port of entry, to furnish a vaccination certificate indicating that they have received all of the required vaccinations. This is applicable to all foreigners whether they are intending to enter Costa Rica as a tourist or a resident. Furthermore, this section states that if the person cannot provide proof of vaccination, the corresponding authority will proceed to vaccinate the person at the port of entry. If the person refuses, they should be put in quarantine.
Well, we all know how good Costa Rican authorities are about enforcing the law. But it may just be a matter of time for someone to file a complaint for non enforcement of these provisions should an outbreak reach Costa Rica.
Now the question is: what vaccinations are mandatory?
The Vaccination Regulation sets forth the following list of mandatory vaccinations for children prior to entering school at age 6.
WHAT TO DO?
Well, this blog is mainly targeted to expats. So let’s analyze this from that premise. If you are an expat and do not have vaccinations and have not vaccinated your children, you basically have three options:
- If you are a law abiding person, so, go ahead and get vaccinated and vaccinate your children.
- If you are loyal to your beliefs and do not want to vaccinate your children and do not want comply with the law, then leave the country and move to a place where the legal system is more in tune with your belief system.
- If you are loyal to your beliefs and want to remain in Costa Rica but not abide with existing regulations, then challenge the law. Bring your case to court and force them to allow you to have the option to decide what to do with vaccinations.
When analyzing these three options, you need to keep in mind that Costa Rica has a socialized system, and certain laws are put in place for the protection of the population at large, not for the protection of an individual. When you decide not to vaccinate, it is indeed a personal decision that affects you at a personal level, but it also affects the population at large as noted previously in the section narrating the Costs of Non Vaccination.
THE AUTISM CONTROVERSY – WHO ANALYSIS
Concerns about a possible link between vaccination with MMR and autism were raised in the late 1990s. The WHO, on the recommendation of GACVS (Global Advisory Committee on Vaccine Safety), commissioned a literature review by an independent researcher of the risk of autism associated with MMR vaccine.
Autistic spectrum disorder represents a continuum of cognitive and neurobehavioral disorders including autism. The prevalence of autism varies considerably with case ascertainment, ranging from 0.7 – 21.1 per 10 000 children (median 5.2 per 10 000) while the prevalence of autistic spectrum disorder is estimated to be 1 – 6 per 1000. Eleven epidemiological studies (representing the most recent studies, mostly in the last 4 years) were reviewed in detail, taking into consideration study design (including ecologic, case control, case-crossover and cohort studies) and limitations. The review concluded that existing studies do not show evidence of an association between the risk of autism or autistic disorders and MMR vaccine. Three laboratory studies were also reviewed. It was concluded that the alleged persistence of measles vaccine virus in the gastrointestinal tract of children with autism and inflammatory bowel disease requires further investigation through independent studies before the laboratory findings of the published studies, which have serious limitations, can be considered confirmed.
Based on the extensive review presented, GACVS concluded that no evidence exists of a causal association between MMR vaccine and autism or autistic disorders. The Committee believes the matter is likely to be clarified by a better understanding of the causes of autism. GACVS also concluded that there is no evidence to support the routine use of monovalent measles, mumps and rubella vaccines over the combined vaccine, a strategy which would put children at increased risk of incomplete immunization. Thus, GACVS recommends that there should be no change in current vaccination practices with MMR. Read the WHO report here.
In Costa Rica, the Department of Health has not addressed any issues about autism. Currently, there are no statistics about this issue. The Costa Rican Association of Parents and Friends of Autistic Persons have tried to obtain assistance from the government at least with legislation that acknowledges the problem, to no avail.
MY PERSONAL DECISION
I love this quote by Ortega y Gasset: “I am myself plus my circumstances”. Therefore, I base my decisions according to my circumstances. I lost my daughter last year. As a parent, I cannot get over the feeling of hopelessness of trying to do everything possible but failing to save my daughter’s life. My wife and I are trying to get pregnant again, and we will do everything in our power to protect our children’s lives. I would try not to expose them to diseases that may have been eradicated, thus we will vaccinate. We decided that at a personal level. But from an objective perspective, according to the WHO 16 people die per hour due to measles. Not vaccinating your children not only puts them at risk, but also puts other children at risk.
I am sure that all parents, regardless of whether you support vaccinations or are against them; make that decision with the best interest of your children in mind. I remember having this conversation with a friend from Europe who weighted the risks vs. the benefits and decided not to vaccinate their children. I do not blame him for that, as I hope he would not blame me for vaccinating mine.