B (A Child: Immunisation)

B is a 5-year-old girl. She is an only child. Her parents separated in 2015. Since their separation disagreements have arisen concerning B’s care. In 2017 the mother issued an application seeking a child arrangements order to determine the living and contact arrangements for B, a specific issue order concerning nursery provision for B and a specific issue order to permit the mother to arrange for B to be immunised. Only the last issue remains contested. This judgment deals with that issue.

The issue is properly categorised as an issue of preventative health care rather than medical treatment. In the UK the vaccination of children is not compulsory. The vaccination of very young children, though strongly recommended, is a decision which the State entrusts to parents to determine as part of their parental responsibility. Such a decision would not be brought to court if the parents were agreed that the vaccination should not be given.

When B’s parents were living together B had all of the immunisations recommended for a child of her age. The recommendations are set out in The routine immunisation schedule (‘the schedule’) which is to be found in the Green Book: Immunisation against Infectious Diseases (‘the Green Book’) published by Public Health England. Both parents consented to those immunisations taking place.

At her present age, the schedule recommends that B should now have three further vaccinations: a single dose of the combined diphtheria/tetanus/whooping cough/polio immunisation, by injection; a single dose of the combined measles/mumps/rubella immunisation (‘MMR’), by injection; and a single dose of influenza vaccine by nasal spray. The first two are overdue. The third should be given at the beginning of the influenza season (September/October).

The court granted permission to the parties jointly to instruct a medical expert witness, Dr David Elliman. Dr Elliman has assisted the court by providing both written and oral evidence. Both parents have filed written statements. Neither has given oral evidence. B has been joined as a party to these proceedings and an officer of Cafcass appointed as her

Dr David Elliman has devoted a large part of his career to the study of immunology. His curriculum vitae is very impressive. From 1989 to 2003 he held the post of Consultant in Community Child Health in Wandsworth and District Immunisation Coordinator. For many years he was a member of the British Paediatric Association (now the Royal College of Paediatrics and Child Health) Standing Committee on Immunisation. He has written a large number of articles on immunisation in childhood. Hs is one of the editors of the Manual of Childhood Infections first published in 1995 and now in its fourth edition. He is the co-author of Childhood Immunisation. The Facts, a guide for parents. He currently works half time for Great Ormond Street Hospital from where he is seconded to Public Health England. He does not have an immunisation role for Public Health England. However, he is also an honorary consultant with Whittington Health and North Central London NHS Trusts where he provides clinical advice and teaching in relation to immunisation. Dr Elliman is exceptionally well qualified to provide the court with an expert opinion in this case.

Dr Elliman has reviewed B’s GP records. B was born at term. She had a normal birthweight. No neonatal problems were recorded. Her 6-week physical examination is recorded as normal. She has had a number of minor illnesses, a minor head injury and injuries to her left elbow. Dr Elliman is satisfied that there is nothing in B’s medical history that contraindicates the appropriateness of her having the vaccinations proposed. The viruses and infections and their incidence

The detail which follows concerning the nature of the viruses and infections against which immunisation is sought for B and the incidence of those viruses and infections in the general population, is taken from Dr Elliman’s report.

Diphtheria is a highly contagious and potentially fatal infection. The infection is spread by respiratory droplets from an infected person, but can also be passed on by contact with the germ. The infected person may not have any symptoms. Amongst the effects is the production of a membrane across the back of the throat, which can lead to suffocation if not treated. The toxin can also cause paralysis of the muscles of the limbs or of the heart.

Prior to the introduction of the vaccine, between 2,500 and 3,000 children died each year from diphtheria in England and Wales. Between 2000 and 2015, there were four deaths due to diphtheria and 16 cases of classical diphtheria. Two of the deaths occurred in unimmunised children, one of whom had not been abroad. In England in 2016 and 2017,

Tetanus is a serious but rare condition caused by bacteria getting into a wound. The wound itself may be of a minor nature, barely noticed and not requiring medical treatment. The organism multiplies in the wound and produces the toxin. The toxin causes the muscles to go into spasm with the most minor of stimuli.

Between 2000 and 2015 there were 110 cases of tetanus and nine deaths from tetanus in England and Wales. In England there were 9 cases and no deaths to the end of 2017.

Whooping cough is a highly contagious bacterial infection of the lungs and airways. The typical illness begins with what can appear to be a cold. A cough develops, which may occur in bouts accompanied by vomiting. The whole illness often lasts for a matter of months and can be very debilitating, at whatever age it occurs. The disease may be complicated by weight loss due to vomiting, chest infection and brain damage due to lack of oxygen. Complications and death are most likely in young children, particularly in those less than six months old.

The incidence of whooping cough follows a cyclical pattern with peaks every four years. In the 1940s, prior to the introduction of the vaccine, in most years there were over 100,000 cases notified and, in some years, over 160,000. Each year there were, on average, over 900 deaths, although this was falling. Since the introduction of the vaccine, the number of reported cases has fallen as have the numbers of deaths.

Polio is caused by a virus of which there are three strains (1, 2 & 3). Most people who are infected by the virus do not develop the disease. However, in industrialised countries about 1 in 1000 children and 1 in 75 adults who are infected go on to develop the disease. The disease may take the form of paralysis of the muscles. This can be severe enough to require mechanical support with ventilation. Some patients die, others may recover but with a residual paralysis and others recover totally. Some survivors develop ‘post-polio syndrome’ some decades after they had polio. There are a variety of symptoms, but it can

Wild polio virus types 2 and 3 have been eradicated. Wild polio infections due to type 1 still occur in Pakistan and Afghanistan.

Measles is caused by a virus that is spread by respiratory droplets. It is highly infectious. It is predominantly a disease of childhood and results in rash, temperature and malaise. Complications are common – otitis media (7-9%), pneumonia (1-6%), convulsions (one in 200), and encephalitis (one in 1000). Between one in 1000 and one in 5000 people who develop measles will die from it. Before the introduction of immunisation against measles, almost all children would have had the disease by their tenth birthday and 100 people would die from measles each year.

Following the introduction of vaccines, the number of deaths due to measles has fallen.

Mumps is a contagious viral infection that is spread by respiratory droplets. Some infected people have no symptoms whereas others have swelling of the parotid glands (one of the pairs of salivary glands, situated at the angle of the jaw on each side). Complications include meningitis (the commonest form of viral meningitis before the vaccine was introduced), inflammation of the pancreas and permanent (usually one sided) hearing loss.

Prior to the introduction of the MMR vaccine there were up to five deaths a year and most children would have had the disease by the time they reached ten years old. Since

Rubella (also known as German measles) is caused by a virus that is spread by respiratory droplets. Many people may be infected without ever being aware of it. In most people who have symptomatic disease it takes the form of a rash and little else. However, if a susceptible woman in early pregnancy is infected with rubella, the unborn baby may become infected and this infection can severely damage the baby. This damage can affect the ears, eyes, heart and almost any other part of the body.

The number of confirmed cases of rubella in 2012 and 2013 were 65 and 12 respectively. In 2017, this had fallen to 4. In recent years there have usually been one or two cases each year of babies damaged by maternal rubella. There were none in 2016 and 2017.

Influenza-like illness is caused by a number of different viruses including influenza virus A, B. C and D. Influenza virus C is of little importance and influenza virus D does not infect humans. The A and B strains often change in their composition year on year. Every so often the circulating virus undergoes a major change and pandemics occur. Including that of 1918/19, there have been four pandemics in the last 100 years. Infection is by respiratory droplets and is easily spread. The disease usually takes the form of a fever, with chills, muscular aches and pains, headache and general malaise. There may be other symptoms of an upper respiratory tract infection. One of the main dangers is the development of a bacterial infection, eg pneumonia.

The disease is worse at either extreme of age and in those with underlying medical problems. The actual burden of influenza disease varies year on year, even in nonpandemic years. It has been estimated that between 2000/1 and 2007/8, 176 (95% C.I. +/-5) per 100,000 otherwise healthy children aged 6 months to 4 years and 10 (95% C.I.+/-0.8) per 100,000 aged 5 to 14 years were admitted to hospital each year with influenza. As important, young children are a major source of infection for the rest of the population, including vulnerable adults and the elderly, such as their grandparents. They have been referred to as “super-spreaders”.

Dr Elliman describes the vaccines which the schedule proposes that B should have and their efficacy.

These are produced by taking the toxin produced by the germs and chemically treating them so that they can no longer cause disease, but the immune system is tricked into thinking it is the toxin and producing a protective immune response. These vaccines were produced before randomised controlled trials were widespread and relied on the observation that the vaccines produced high levels of antibodies. The introduction of the vaccines was followed by falls in the incidence of the diseases. To maintain immunity throughout life, a total of five doses of each vaccine is necessary.

Both vaccines have been in use around the world for many decades and have a very good safety record. Local reactions, such as redness and tenderness at the site of the injection are common, as is a mild rise in temperature. More serious side effects are extremely uncommon. WHO describes diphtheria vaccine as “one of the safest vaccines available” and states that “severe reactions are rare”. Tetanus vaccine, likewise, has an excellent safety record. WHO states that it is “considered very safe” and while “mild local reactions are common”, “more serious reactions are rare”.

The pertussis vaccines now in use in the UK and most industrialised countries are known as acellular pertussis vaccines (aP). Those used in the UK are prepared from three or five components of the pertussis germ. These are much more highly purified than the previously used whole cell vaccines. Because pertussis is more difficult to diagnose than many other diseases, it is difficult to estimate the efficacy of the vaccines accurately. A recent review of the literature concluded that the efficacy of the vaccine against severe disease was 84-85% and against mild disease was 71-78%. The protection does wear off, as is the case following the disease, and one or more boosters are needed.

The old whooping cough vaccine gave rise to significant side effects, although it was never proven that it caused any lasting harm. The current acellular vaccines cause fewer side effects. Adding the new acellular vaccines to combinations of diphtheria and tetanus vaccines does not appear to give rise to any increase in reactions.

The vaccines in current use in the UK, and most well-resourced countries, contain the three wild viruses that have been inactivated. Prior to the introduction of inactivated (Salk) vaccine, a large trial in the 1950s demonstrated an efficacy of 80-90% against paralytic polio and 60-70% against any form of polio. Experience in Canada recorded an efficacy of 96% for the inactivated vaccine. The currently used enhanced IPV has even greater efficacy.

Adverse reactions apart from local reactions are very uncommon. As the vaccines are inactivated, they cannot cause the disease.

Dr Elliman makes the point that it is not appropriate to assume that a combined vaccine will act in a way that just takes on the properties of the separate vaccine. There have been examples where this has been shown to be untrue. However, these do appear to be exceptions to the general pattern which is that combined vaccines tend to work just as well as separate vaccines and do not cause greater side effects. The evidence is that their safety and effectiveness profile is no different from when the vaccines are given separately.

The MMR is the only vaccine available on the NHS to protect against the constituent diseases. The individual vaccines are not available separately on the NHS. MMR consists of the wild viruses that have been toned down (attenuated), but not killed.

In 2012 a systematic review for the Cochrane Collaboration concluded that a single dose of MMR vaccination “was at least 95% effective in preventing clinical measles” and using the vaccine containing the mumps vaccine virus used in the UK, was between 69% and 81% effective against clinical mumps. They found no studies showing how effective the combined vaccine was against rubella. There is evidence that the protection against mumps falls with time. A slightly more up to date review found the effectiveness of the MMR vaccine to be about 99% against rubella. The effectiveness of two doses of MMR against measles was 97% and against mumps was 88%.

The main side effect of the vaccine is the development of a mild form of one or more of the illnesses. One in ten develops mild measles at 7-10 days after the vaccine and one in fifty develops mild mumps. Mild rubella is less common and often unnoticed. Between 1 in 1000 and 1 in 2000 children receiving their first dose of vaccine in the second year of life will have a febrile convulsion – this is about a tenth of the risk from the disease. About 1 in 30,000 children develop a temporary lowering of platelets making them more likely to bleed. This is about a tenth to twentieth the risk from the diseases and is usually milder than the non-vaccine related condition. The Cochrane review (mentioned above) reported that “Exposure to the MMR vaccine was unlikely to be associated with autism, asthma, leukaemia, hay fever, type 1 diabetes, gait disturbance, Crohn's disease, demyelinating diseases, bacterial or viral infections”. The review stated that mumps meningitis has been reported with vaccines containing particular strains of mumps virus. These were used in UK, but withdrawn in 1992. There is no good evidence that this left any permanent harm.

There are two forms of influenza vaccine – a live attenuated vaccine and many forms of inactivated vaccine, containing all or parts of the virus. The live vaccine is the variety recommended for children of B’s age. It contains four strains of virus and is administered nasally.

Preschool children are much more likely to suffer the complications of influenza, thus requiring hospital admission. There is also a substantial reservoir of disease from which spread occurs to other members of the population. Pre-school have been called ‘superspreaders’. It has been shown that immunising primary school children not only reduces the incidence of infection in the recipients, but it also reduces the incidence of influenza in the local general population. For these reasons, the Joint Committee on Vaccine and Immunisation has recommended that all children between 2 and 16 years old inclusive should ultimately receive the live attenuated inactivated vaccine (LAIV). This vaccine was chosen because it seemed to be the most effective in children.

In England in 2015/16, the effectiveness of LAIV in reducing the frequency of hospital admission in two to six-year olds was about 55%. Data from the 2016/17 season showed that the LAIV used in 2-17 year old children and young people had an effectiveness against influenza disease of approximately 66% against all circulating influenza viruses.

Data from the 2015/16 season in England confirmed that, when the vaccine was given to all primary school children in an area, there was indeed a reduction in many measures of influenza in the local adult population, although most of this did not reach statistical significance because of the small numbers involved.

The vaccines can cause minor local reactions in the nose after the LAIV nasal spray and at the site of injection of the inactivated vaccines. The vaccines can also cause fever and malaise. No major side effects have been associated with LAIV.

Having set out the landscape I now turn to consider the father’s objections.

Though he has no relevant medical or scientific training or expertise, the father has clearly undertaken an immense amount of research. He has exhibited to his statements more than 300 pages of material comprising, for the most part, academic articles and statistical information. He says,

Dr Elliman accepts that most peer reviewed studies in medicine, and in many other fields, are published in academic journals to which one has to subscribe, though he notes that an increasing number of journals are providing free access to some articles and even, in some cases, to all articles they publish. It is, though, his opinion that conducting research by obtaining information from individuals “facing similar issues” is likely to lead to bias and is no replacement for examination of the original research.

The father’s key points appear to be that:

The father has considered the expert evidence of Dr Elliman. His position remains unchanged.

Point (i): Dr Elliman does not accept the father’s proposition that some children may develop immunity without taking the full course of vaccine. It would be unusual for someone to have immunity against a particular disease without being vaccinated against that disease. Dr Elliman found it difficult to conceive that this was a realistic possibility.

Dr Elliman also does not accept that children should routinely be screened before being given a second dose of the same vaccine. In his report he says that,

Dr Elliman also makes the point that screening is not reliable. In the past it had been common to test for rubella during pregnancy but it came to be recognised that the test was not reliable and so it was stopped.

There is evidence to suggest that over time the effectiveness of a vaccine wears off and a booster is required. With respect to mumps, in particular, there is a lot of doubt about how long immunity lasts. 10% of those who contract measles have had the MMR vaccine. This is why a second dose is recommended.

Point (ii): Dr Elliman does not accept that the proposed vaccinations would put B’s health at greater risk than is necessary. It is clear from B’s GP records that she is a healthy child. That reduces the risk of her developing serious side effects.

The vaccines which it is proposed B should have contain neomycin (the MMR vaccine); aluminium phosphate, formaldehyde, neomycin, polymyxin B, phenoxyethanol and aluminium hydroxide (the combined diphtheria/tetanus/whooping cough/polio vaccine) and egg protein (ovalbumin) and porcine gelatin (influenza vaccine). Three of these are live attenuated vaccines and the fourth (the combined diphtheria/tetanus/whooping cough/polio vaccine) is inactivated. Although there has been anxiety about the inclusion in vaccines of, for example, aluminium (a recent paper has suggested that levels of aluminium are set too high) no published study has provided evidence of harm. The amount of formaldehyde in vaccines is less than that which occurs naturally in the body. The levels of neomycin, polymyxin B and phenoxyethanol used in vaccines are much too small to give rise to a risk of harm.

Dr Elliman does not share the father’s view that these factors give rise to a level of risk that cannot be justified and which should be avoided. Vaccines are always trialled before they go into general use. Such trials enable the nature and frequency of side effects to be ascertained. Adverse events must be reported to the Medicines and Healthcare Products Regulatory Agency. Such reports are a signal that there may be a problem. Carefully structured research would need to take place before making a decision as to whether a suspected side effect of a vaccine is indeed related or whether it is simply coincidental.

With respect to the father’s general point concerning the toxicity of vaccines, Dr Elliman noted that there are substances which are widely acknowledged to be beneficial in small doses, such as vitamin D, but which when taken in large quantities are poisonous. Vaccines do not contain toxins at a level that could be poisonous.

Point (iii): Dr Elliman accepts that some vaccines have been withdrawn from use because of concerns relating to risk. For example, he says that

It could be said that the fact that some vaccines have been withdrawn from use because of concerns relating to risk is an indication that the systems in place for the continuous monitoring of efficacy and safety of vaccines is effective.

I note in passing that the Green Book is available online. It is regularly updated. It is possible to sign up to receive vaccine updates. So far in 2018 eight vaccine updates have been published. The website provides updating safety information.

Point (iv): Dr Elliman did not accept the father’s contention that vaccines should not be used because there is no absolute certainty that a vaccine will not give rise to side effects. It is a matter of balancing risk. The risks to health of not having a particular vaccine and developing the disease are greater than the risk of suffering a serious adverse reaction to the vaccine. The father’s contention requires the proof of a negative. Dr Elliman made the point that it is impossible to prove a scientific negative.

Dr Elliman also does not accept the father’s submission that the introduction and use of vaccines are motivated by financial gain more than by scientifically proven efficacy. He says that,

Point (v): Dr Elliman agrees that there are many factors that are important in reducing illness and susceptibility to illness including sanitation, nutrition and reducing overcrowding and underlying illness. However, he makes the point that repeated studies comparing unimmunised and immunised groups of children, who are otherwise similar, have shown that unimmunised children are more likely to be infected with organism(s) targeted by the vaccine and suffer the effects of the infection.

Point (vi): The father’s proposition appears to be that if two parents are unable to agree whether their child should have a particular vaccination, the status quo should be preserved and the views of the objecting parent should hold sway. I do not accept that proposition. It is wrong in law. In Re Z [1996] 1 FLR 191 at p. 217, Sir Thomas Bingham MR analysed the function of the court in the following passage:

Although that analysis was formulated in a wardship case, it has been held that it equally defines the function of the court deciding an application for a specific issue order advanced by one parent and resisted by another, each holding parental responsibility in relation to the child (see Re B (A Child) [2003] EWCA Civ 1148 per Thorpe LJ at §20). Why vaccinate?

Given the concerns expressed by the father and the acknowledgment by Dr Elliman that no vaccination is 100% risk-free, the question arises: why vaccinate? Dr Elliman says that the answer is to be found in a risk/benefit analysis which needs to be undertaken not in a generalised way but in a specific way in respect of each and every vaccine which is considered for general use. He explains this approach in some detail. He says that,

A Bulletin published by the World Health Organisation in 2008 began by making the point that, ‘Vaccination has greatly reduced the burden of infectious diseases. Only clean water…performs better.’

The question I have to determine relates to the upbringing of a child. Section 1(1) of the Children Act 1989 therefore requires that B’s welfare must be the court’s paramount consideration. In determining what is in B’s best interests the court must have regard to the factors set out in the welfare checklist in s.1(3). Section 1(2) sets out the general principle that any delay in determining the questions before the court is likely to prejudice

Section1(5) requires that the court shall not make any order unless it considers making an order is better for B than making no order at all. In this case, given that the parents’ views are polarised, I am in no doubt that it is appropriate that the court should make the decision for them.

As I noted earlier, decisions relating to the vaccination of children are a function of a parent’s parental responsibility. For the court to determine the issue because the parents are unable to make that decision for themselves is an interference with their right to respect for their private and family life. Article 8 of the European Convention is therefore engaged. Interference with that right is only permissible if it is,

Although it is only rarely that the court is called upon to determine whether a child should have the vaccinations recommended by the schedule, over the last fifteen years there have been five published decisions in which the court has had to consider this issue.

The first reported decision is that of Sumner J in Re C and F (Children) [2003] EWHC 1376 (Fam) in June 2003. There were two applications before him relating to two girls, one aged 4 and the other aged 10. The applications were not connected. They were heard together because they raised the same issue and had other points in common. In both cases the fathers wished their daughters to receive immunisation appropriate to their age. The mothers opposed the applications. There was, therefore, a dispute between the parents involving the welfare of their children. The judge made the point that,

The judge was assisted by expert evidence. He heard from three doctors, one instructed on behalf of the fathers, one instructed on behalf of the mothers and one instructed by Cafcass Legal. The judge was highly critical of the expert instructed on behalf of the mothers. He said that he was

The judge was therefore left with the opinions of two experts, broadly in agreement with each other, whose evidence he accepted. He ordered that both children should receive most of the vaccinations proposed by the fathers. The mothers appealed. The appeal was unsuccessful.

One matter that has been a particular subject of public concern in the relatively recent past is the safety and the potential side effects of the MMR triple vaccine. It is appropriate to set out Sumner J’s conclusions on this vaccine in full. He said:

Next in time is the decision of Theis J in LCC v A, B, C & D (Minors by their Children’s Guardian) K,S [2011] EWHC 4033 (Fam). This case concerned an application by a local authority to invoke the inherent jurisdiction seeking declarations regarding the immunisation of children in its care. The local authority’s application was opposed by the birth parents but supported by the Children’s Guardian.

As in the case of Re C and F (Children) [2003] EWHC 1376 (Fam), the judge was assisted by expert evidence, in this case by a single expert, a Consultant Paediatrician, whose evidence she accepted.

Once again it was the MMR triple vaccine that gave rise to particular concern on the part of the parents. In setting out her conclusions at §17 of her judgment, Theis J came to the following conclusions concerning the MMR vaccine:

The third published decision, also a decision of Theis J, is that of F v F [2013] EWHC 2683 (Fam). In this case a father applied to the court for an order that his daughters, aged 15 and 11, should receive the MMR vaccination. The mother objected. The children were old enough to express their wishes and feelings. They, too, objected. No expert evidence was relied upon. As in the other two cases to which I have referred, concerns related to the safety of this vaccine and in particular to the risk of side effects.

Theis J concluded that both children should receive the MMR vaccination. I highlight two of the reasons the judge gave for arriving at her decision. At §22, she said,

The fourth decision is Re M and N (Parental Responsibility: Immunisations) [2016]

The judge went on to set out the approach he was required to take in determining the father’s application, referring to the provisions of s.1 of the Children Act 1989 and to Article 8 of the European Convention. He then went on to say:

The judge accepted the evidence of the medical expert, Dr Mittal, saying that he preferred

The fifth and most recent decision is that of MacDonald J in London Borough of Barnet v SL [2017] EWHC 125(Fam). A local authority issued care proceedings in respect of four children. One of those children, SL, was 7 months old and was the subject of an interim care order. The local authority sought permission to arrange for the child to receive the Haemophilus Influenza Type b vaccine and the pneumococcal conjugate. The mother objected.

The mother was ordered to file a statement in support of her objections. She did not comply. I assume the basis of the mother’s objections to be reflected in her counsel’s submissions. These include a reference to a claim by the mother that there had been three previous instances of her older children attending hospital for what she contended were adverse reactions to immunisation. There was no evidence to support that claim.

The judge gave permission to the parties jointly to instruct an expert. In light of the expert’s evidence (and also, no doubt in light of the lack of any evidence from the mother) the judge granted the declaration sought by the local authority. He reaffirmed the approach set out in the other authorities to which I have referred. His final paragraph bears repetition. He said,

The mother (supported by the Children’s Guardian) wishes B to have three vaccines: the combined diphtheria/tetanus/pertussis/polio vaccine, the MMR vaccine and the influenza vaccine. The father objects to B having any of those vaccines. As the judge, my role is not to evaluate the reasonableness of the positions taken by each of these parents but to come to my own conclusion on what is in B’s best welfare interests.

In determining what is in B’s best welfare interests the views of the parents should be carefully considered. They retain considerable importance in the balancing exercise. But they are not necessarily determinative. They are simply to be taken into account as part of the overall evaluative exercise.

Another important aspect of the evaluative exercise is the expert evidence of Dr Elliman. The views expressed by Dr Elliman appear to be in broad agreement with the evidence of other experts who have given evidence on similar issues in the previous cases to which I have referred. Dr Elliman considers his opinions to be ‘mainstream’. I am satisfied they are. In contrast, and for the reasons given by Dr Elliman, I consider the father’s views to be biased and unreliable. The fruits of the father’s untutored, amateur research are at odds with the expert medical evidence of Dr Elliman. In my judgment, where there is disagreement between the father and Dr Elliman the expert opinions of Dr Elliman are to be preferred.

In determining what is in B’s best interests I have in mind, of course, all of the factors set out in the welfare checklist in s.1(3) of the Children Act 1989. In this case, one of those factors is of particular importance. Section 1(3)(e) requires the court to consider

With the consent of both parents, B has already received some vaccinations. At the time those vaccinations took place there was nothing in B’s known medical history to suggest that having those vaccinations was contra-indicated. There was no reason to believe that

That being the case, is there anything known about B’s health today (i.e. has there been any change in her medical history since the date when the parents agreed to her having the vaccinations she has already had) to suggest that she is at greater risk today than when she was previously vaccinated? The answer, plainly, is ‘no’.

Is there anything known about these vaccines today that gives rise to a risk that if B took them she would be exposed to a risk which any well-informed and reasonable carer might properly regard as unwise or inappropriate? Again, in my judgment, in light of the expert evidence of Dr Elliman, the answer, plainly, is ‘no’.

Dr Elliman acknowledges that all vaccinations carry risks. There is a very wide body of research evidence – international and not just British – concerning the risks of individual vaccines and, on the other side of the balance, the risks that arise from contracting the diseases concerned. As a consequence, the known risks of particular vaccines can, with confidence, be balanced against the known risks of not being immunised with those vaccines. Rational, balanced, informed decisions can be made.

Research is ongoing. The frontiers of knowledge are being continuously rolled back. The science in this area does not stand still. With respect to any of the vaccines I am concerned with the possibility that in the future new risks may be identified cannot be ruled out. However, decision-making takes place today in the light of what is known today about risks and in the light of what is known today about B.

I am satisfied that it is in B’s best welfare interests that she should receive the vaccines recommended by The routine immunisation schedule for a child of her age. There will be a declaration to that effect and a specific issue order. I invite the parties to prepare a draft for my approval.

In making that order, like MacDonald J, I make it clear that my judgment is not a commentary on whether immunisation is a good thing or a bad thing generally. I am not saying anything about the merits of vaccination more widely. I do not in any way seek to dictate how this issue should be approached in other situations. I am concerned only to determine what is in B’s best welfare interests.

That said, it is, in my judgment, appropriate to make the point that this is now the sixth occasion when the court has had to determine whether a child should be vaccinated in circumstances where a birth parent objects. On each occasion the court has concluded