Eliminate Vaccine Exemptions
Kristen A. Feemster is a pediatric infectious diseases physician and health services researcher at the Children’s Hospital of Philadelphia and University of Pennsylvania School of Medicine.
UPDATED MARCH 23, 2014, 7:01 PM
At the crux of this question is whether individual choice can be subverted for public good. Vaccines work by protecting individuals, but their strength really lies in the ability to protect one’s neighbors. When there are not enough people within a community who are immunized, we are all at risk.
Vaccines protect our neighbors — like following traffic laws, drug tests at work, paying taxes — they are a shared responsibility.
Personal and religious belief exemptions should be curtailed because some people, whether because of age or compromised immune systems, cannot receive vaccines. They depend on those around them to be protected. Vaccines aren’t the only situation in which we are asked to care about our neighbors. Following traffic laws, drug tests at work, paying taxes — these may go against our beliefs and make us bristle, but we ascribe to them because without this shared responsibility, civil society doesn’t work.
Public health is no different.
To justify the subversion of individual choice to public good, there are some conditions that need to be met. The behavior or intervention needs to be safe and effective, and the risk of not participating in the behavior needs to outweigh any risk from the behavior. The currently recommended vaccine schedule meets those criteria. Vaccines are safe and effective. The significant reduction in illness and death from vaccine-preventable diseases is testimony to how well they work. Yet this success likely contributes to the reason requests for personal belief exemptions have proliferated.
We are fortunate to live in an era when we rarely see many vaccine-preventable diseases — the risk of these diseases seems minimal while the perceived risk of vaccination becomes larger. This is compounded by the proliferation of misinformation, readily available from the news media and other sources. This has resulted in what many describe as the “vaccine confidence gap.” There is no doubt that this gap needs to be addressed. It is the responsibility of the scientific and public health community to ensure that vaccines are safe. It is that community’s responsibility to listen to concerns and provide accurate and clear information.
However, it is also the scientific and public health community’s responsibility to support the health of patients and ensure the health of the communities in which they live. As more people choose not to vaccinate based on personal belief, our communities are at risk — we have seen recent outbreaks of diseases like measles, mumps and whooping cough throughout the U.S. It is prudent policy to limit such exemptions to protect our own and the public’s health.
In the early 20th century, the childhood mortality rate before age five was 20 percent in the United States. Immunizations changed the equation. Today, many parents choose not to vaccinate their children based on the thoroughly debunked myth that it causes autism or, worse, figuring that vaccines are no longer necessary. And when parents choose not to vaccinate their children, it puts other lives at risk.
A certain level of the population must be immunized in order to fully protect the community, known as “herd immunity.” When enough people are vaccinated, then it’s more difficult for a disease to spread. Specifically, it protects the most vulnerable who cannot be vaccinated, such as infants, those with immune-system disorders, or even cancer patients.
In recent years, herd immunity has been compromised as parents choose not to immunize. One strategy to boost the immunization rate is to require proof of immunization for children to enter public schools. Today, 18 states allow parents to apply for an exemption based on religious or personal beliefs, and Washington has one of the highest rates of exemptions. In Snohomish County, 5.9 percent of K-12 children were granted exemptions for the 2012-2013 school year (higher than King County which came in at 5.2 percent.)
In 2011, Gov. Chris Gregoire signed a law that requires a physician’s signature to verify that exemption-requesting parents have been given the facts on immunization. Currently Colorado’s legislature, a state with an even higher immunization-exemption rate than Washington, is considering a bill that would require parents to participate in an online education seminar. The political response was sparked by Colorado’s whooping cough outbreak, an outbreak that also hit the Pacific Northwest. In August 2011, a 27-day old infant died from whooping cough in Lake Stevens, exposed to a carrier but sadly too young to be immunized.
Vaccinations are designed not only to protect every child, but the community as a whole. That’s why Washington lawmakers must make immunization exemptions as strict and infrequent as possible.
Parents Deserve to Have a Choice
UPDATED MARCH 23, 2014, 7:01 PM
This January lawmakers in the United Arab Emirates mandated that women breastfeed for two years, announcing that breastfeeding is a “duty, not an option.”
Officials should encourage childhood vaccinations, but they shouldn’t have the right to force parents to vaccinate their children.
Should public health officials do everything they can to encourage, inform and facilitate breastfeeding? Yes. Do they have the right to force women to breastfeed? Not in a country that believes in freedom of choice.
There is tremendous evidence showing vaccinations prevent childhood diseases. Should public health officials do everything they can to encourage, inform and facilitate childhood vaccinations? Yes. Do they have the right to force parents to vaccinate their children? Absolutely not.
An American parent could reasonably decide not to follow the C.D.C.’s current vaccination schedule by choosing to vaccinate on the schedule they use in Norway, which has one of the lowest infant mortality rates in the world. In Norway no childhood vaccinations are routinely given in the first three months of life whereas a 2-month-old American infant has been vaccinated against at least four diseases. At the same time, 99 percent of Norwegian infants are breastfed when they leave the hospital and generous family leave policies facilitate successful (and exclusive) breastfeeding. For an American mom who is exclusively breastfeeding and not putting her child in daycare, following the Norwegian schedule would be a philosophical, evidence-based, demonstrably better choice.
It is a news media-driven misperception that parents who claim philosophical or religious exemptions are uneducated or misinformed. Most parents who individualize the vaccine schedule are actively educating themselves, continually assessing their family’s specific health needs, and doing everything they can to keep their children safe and healthy.
Unlike in the United Arab Emirates, in America we believe parents are capable of making their own decisions about their children’s health. We believe in freedom of choice. This freedom of choice extends to when — and even whether— parents vaccinate their kids.