Mandatory Childhood Vaccines: The Debate

If most medical experts had their way, people would treat getting vaccines as routinely as making a trip to the grocery store. And, generally, most Americans do. Millions of adults get annual influenza shots and vaccines for shingles and a variety of other ailments. And the majority of parents comply with the Centers for Disease Control and Prevention (CDC) recommended immunization schedule for their children. But news stories about a measles outbreak originating in Disneyland late last year have rekindled the debate about the risks of children getting — or not getting — the recommended vaccines, and whether they should be mandated.

The American Academy of Pediatrics, the American Academy of Family Physicians, CDC and other organizations all urge protecting children with recommended vaccinations. Why? The statistical benefits of vaccines are indisputable. Between 1994 and 2014, for example, an estimated 732,000 American children were saved from death and 322 million cases of childhood illnesses were prevented due to vaccination, according to CDC. In addition, hospitalizations avoided and lives saved through vaccination will save nearly $295 billion in direct costs and $1.38 trillion in total societal costs.¹

History of Vaccines

While vaccines are at the forefront of modern medicine, their creation dates back more than 10 centuries. There is evidence that the Chinese used a smallpox inoculation as early as 1000 A.D., and inoculations were later used in Turkey and parts of Africa.²

The first use of vaccine promotion in the United States occurred in 1721, when a Puritan minister named Cotton Mather promoted vaccination as a response to smallpox.³ Vaccination, as practiced today, came into being when Edward Jenner, an English physician and scientist, created the first smallpox vaccine using cowpox (a bovine disease similar to smallpox) and vaccinated an 8-year-old boy in 1796. Jenner’s innovation was tweaked over the next 200 years and eventually led to the eradication of smallpox.^2,3

Louis Pasteur’s 1885 rabies vaccine was the next to make an impact on human disease. And as bacteriology grew, new developments followed, including vaccines against anthrax, diphtheria, cholera, plague, tetanus, tuberculosis and typhoid. By the mid-20th century, through the use of viruses grown in laboratories, there was a rapid increase in discoveries and innovations, including the creation of vaccines for polio. Researchers also targeted common childhood diseases such as measles, mumps and rubella. Today, innovative techniques drive vaccine research, with recombinant DNA technology and delivery techniques leading scientists in new directions. In addition, disease targets have expanded, and some vaccine research is focusing on noninfectious conditions such as addiction and allergies.²

Herd Immunity

Ideally, a population must reach so-called “herd immunity” (or community immunity) for vaccines to be most effective. When a “critical portion” of a population is vaccinated against a contagious disease such as influenza, measles, mumps, rotavirus and pneumococcal disease, an outbreak is unlikely to occur, and most members of the community will be protected. Even those not eligible for certain vaccines — infants, pregnant women or immunocompromised individuals — get some protection because the spread of contagious disease is contained.⁴

Eventually, herd immunity can lead to the eradication of diseases. For instance, today, there is no evidence of naturally occurring smallpox transmission anywhere in the world, which eliminated the need for children to be vaccinated against it. The last case of smallpox in the United States was in 1948, and the last case in the world was reported in 1977 in Somalia.⁵

Without herd immunity, though, it is possible for the incidences of diseases to rise. Measles is an excellent example. Until measles vaccines became common in the early 1960s, as many as four million Americans each year were diagnosed with the disease, and as many as 500 died. For the past four years, the reported incidence of measles in the U.S. has been less than one case per million, with only 86 cases reported to CDC in 2000. Last year, however, there were a total of 644 measles cases in 27 states — the largest number since 2000.⁶

Healthy People 2020, an initiative of the U.S. Department of Health and Human Services, has set a national baseline goal of 90 percent for preschooler MMR (measles, mumps and rubella) vaccinations. According to the initiative, reaching a national immunization rate above 91 percent has helped reduce measles rates by 99 percent. Achieving even higher vaccination rates would protect even more individuals and increase herd immunity protection for the wider community.

Mandating Vaccinations

Today, the CDC recommendation is that children receive 10 vaccines in 28 doses between birth and age 6. There is no federal mandate requiring that children get vaccinations, but all 50 states require children to receive them before they attend public schools (although the required vaccinations vary). Of those, all except Mississippi and West Virginia allow parents to request religious exemptions. Other states allow medical, religious and philosophical/personal belief exemptions.⁷

The first school vaccination requirement was enacted in the 1850s in Massachusetts to prevent smallpox transmission. By the beginning of the 20th century, nearly half of the states had requirements for children to be vaccinated before they entered school. By 1963, 20 states, the District of Columbia and Puerto Rico had such laws, with a variety of vaccines mandated. However, enforcement was uneven.⁸

The constitutional foundation for requiring vaccinations stems from a 1905 ruling by the U.S. Supreme Court in a case called Jacobson v. Massachusetts that upheld the right of states to compel vaccinations. The high court ruled that requiring smallpox vaccinations was a “reasonable” exercise of Massachusetts’ police power and did not violate the liberty rights of individuals under the Fourteenth Amendment to the U.S. Constitution. Specifically, the court stated that “the police power of a state must be held to embrace, at least, such reasonable regulations established directly by legislative enactment as will protect the public health and the public safety.”⁹

R. Alta Charo, a Warren P. Knowles professor of law and bioethics at the University of Wisconsin Law School, said that, as an ethical matter, vaccination policy represents a form of “social contract” in which “our individual well-being is enhanced when everyone gives up just a little bit of autonomy.… This is done all the time. Every time you follow the traffic rules, you are participating in a social contract. And from the earliest days of our country, the role of government to protect public health has been recognized as a legitimate exercise of its powers, even when this intrudes to some extent on personal choices.” Not allowing unvaccinated children to attend school, Charo said, is an attempt “to balance parental autonomy — to forgo vaccinating their kids — with the public health risks created by having too many unvaccinated children in the group, children who may contract an illness and then pass it along — either to those medically contraindicated to the vaccine, too young for the vaccine or previously vaccinated but without complete immune response.… The number of medically contraindicated kids is very low, so having just those children unvaccinated poses much less risk, but if you add all the kids whose parents have medical/philosophical objections, the numbers can get very high, and herd immunity is lost.”

Fears

Vaccine opponents argue that vaccines can cause serious and sometimes fatal side effects. Indeed, CDC says all vaccines carry a risk of a life-threatening allergic reaction (anaphylaxis) in about one child per million. The rotavirus vaccination, for example, can cause intussusception (bowel blockage that can require hospitalization) in about one out of 20,000 children. The DTaP (diphtheria, tetanus and pertussis) and MMR vaccines can be associated with long-term seizures, coma, lowered consciousness and permanent brain damage — though the agency says such reaction is so rare that it is difficult to determine causation.¹⁰

Vaccination foes also have often said that vaccines cause autism. But despite much controversy on the topic, researchers haven’t found a connection between autism and childhood vaccines. In fact, the original study that ignited the debate years ago has been debunked and retracted. Although signs of autism may appear at about the same time children receive certain vaccines such as the MMR vaccine, this is simply a coincidence.¹¹

In addition to the fear of side effects from vaccines, needle phobia is a serious issue that affects about 50 million Americans and is a disorder recognized by the Americans with Disabilities Act. At least 20 percent of those suffering from needle phobia don’t seek medical treatment as a result, said Heather Potters, vice chairman and chief business development officer at PharmaJet, which has developed a needle-free injector for adults ages 18 years to 64 years to get an annual vaccination against the flu. “It is estimated that over 35 percent of Americans, or 71 million people, could be positively influenced by a needle-free option due to their aversion to needles, many of whom do not get a flu shot as a result,” Potters said. “Also, needle-free delivery provides a safer workplace environment. Since there is no needle, there is no chance of needlestick injuries or needle reuse when administering the flu shot. It also offers an option for healthcare workers who have an aversion or fear of needles.” On another front, vaccination opponents also counter that the immune systems of children can handle most infections. The Mayo Clinic says that natural infection “often provides more complete immunity than a series of vaccinations — but there’s a price to pay for natural immunity. For example, a natural chickenpox (varicella) infection could lead to pneumonia. A natural polio infection could cause permanent paralysis. A natural mumps infection could lead to deafness. A natural Hib infection could result in permanent brain damage. Vaccination can help prevent these diseases and their potentially serious complications.”¹¹

Vaccination Gap

Parental concerns over possible adverse effects of vaccinations have resulted in decreases in the number of children who have had their recommended vaccines, including MMR. Although health officials have not identified who brought measles to Disneyland, the outbreak — which spread to some 117 people from 21 states and the District of Columbia12 — “shines a glaring spotlight on our nation’s growing antivaccination movement and the prevalence of vaccination-hesitant parents,” according to a study published in The Journal of the American Medical Association.¹³

Nationwide, 91.9 percent of children ages 19 months to 35 months have received their MMR shot, according to CDC’s latest National Immunization Survey. While that is an increase from 2000, when 90.5 percent had been immunized, it is down from 2006, when the rate was 92.3 percent.¹⁴ However, an analysis released in February by the Trust for America’s Health (TFAH), using data from the National Immunization Survey, found that fewer than 90 percent of U.S. children ages 19 months to 35 months have received the recommended MMR vaccination in 17 states. New Hampshire has the highest MMR vaccination rate for preschoolers at 96.3 percent. Colorado, Ohio and West Virginia have the lowest at 86 percent. No state in the Northeast was below 90 percent, while eight states in the South, five in the West and four in the Midwest had rates below 90 percent. “It is so important that communities maintain high levels of MMR vaccination because measles is so infectious, and especially when outbreaks are occurring around them,” said Litjen (L.J) Tan, MS, PhD, chief strategy officer of the Immunization Action Coalition. “To have pockets where community immunity is below 90 percent is worrisome, as they will be the ones most vulnerable to a case of measles exploding into an outbreak.”¹⁵

“Sadly, there is a persistent preschooler vaccination gap in the United States. We’re seeing now how leaving children unnecessarily vulnerable to threats like the measles can have a tragic result,” said Jeffrey Levi, PhD, executive director of TFAH. “We need to redouble our national commitment to improving vaccination rates.”¹⁶

The Public Debate

The vaccination debate has stirred emotions and even spilled over into the race for the 2016 presidential nomination. In February, Sen. Rand Paul (R-Ky.) said in interviews that most vaccines should be voluntary, adding that “many tragic cases of walking, talking, normal children … wound up with profound mental disorders after vaccines.” Then, in an interview on CNBC, Paul stated: “The state doesn’t own your children. Parents own the children. And it is an issue of freedom and public health.”

Professor Charo stressed that requiring vaccinations is not an example of government telling people what to do solely to protect them from their own behaviors such as with motorcycle helmet laws. “The vaccine policies are about protecting the community from the individual objectors who have made themselves potential vectors of disease,” she said, which is why the laws mandating vaccination are not just about protecting the children of the objecting parents. “Rather, they are about protecting all children.”

Dr. Tim Jacks, an Arizona pediatrician, has spoken publicly about the need for childhood vaccines after his two children were exposed to measles — presumably by someone who was infected via the Disneyland outbreak — during a visit to Phoenix Children’s Hospital. Jacks’ 3-year-old daughter, Maggie, has acute lymphoblastic leukemia and a compromised immune system. In addition, his then-10-month-old son, Eli, was too young to have received his recommended first dose vaccination for MMR.

Jacks wrote an open letter first published on his family blog for Maggie: “To the parent of the unvaccinated child who exposed my family to measles: I have a number of strong feelings surging through my body right now. Towards my family, I am feeling extra protective like a papa bear. Towards you, unvaccinating parent, I feel anger and frustration at your choices … I assume you love your child just like I love mine. I assume that you are trying to make good choices regarding their care. Please realize that your child does not live in a bubble. When your child gets sick, other children are exposed. My children. Why would you knowingly expose anyone to your sick, unvaccinated child after recently visiting Disneyland? That was a boneheaded move.” According to Jacks, since then, “the kids finished quarantine without incident. Eli is back to his toddler ways. Maggie has resumed her chemotherapy treatments, has lost her hair again, and is doing pretty well overall.”

It’s Professor Charo’s opinion that a parent who refuses to vaccinate a child — without good reason — is attempting to cash in on the benefits of herd immunity provided by all the other children who endured the discomfort and minimal risk of the vaccine, but without participating in that same sacrifice of discomfort and minimal risk. “One might call this ‘free-riding,’” said Charo.

Jennifer Margulis, PhD, author of Your Baby, Your Way: Taking Charge of Your Pregnancy, Childbirth, and Parenting Decisions for a Happier, Healthier Family, said childhood vaccinations are necessary and useful. But there is a “but,” she said. “My research has revealed that the problem is not vaccines in general; it is the current American childhood vaccine schedule. Our American vaccine schedule is overpacked with vaccines, several of which are not necessary.” She pointed out that the birth dose of hepatitis B is not given in Europe unless the child’s mother or father is hepatitis B positive, a prostitute or an intravenous drug user. “Yet we give this unnecessary vaccine to every newborn in America,” she stressed.

Margulis said vaccines should not be mandated: “Vaccines are a pharmaceutical product that carry some risk and that the consumer is required to pay for. It is not the state or federal government’s place to mandate medical products. The decision about how and when a child — or an adult — should receive a medical treatment or a medical prevention should be made in the privacy of a doctor’s office.” According to Margulis, she has interviewed hundreds of families who have chosen to delay or forgo some vaccines — and those choices were not made lightly. “Forgoing some vaccines is a difficult choice that sometimes opens you up to ridicule, anger and hate,” Margulis explained. “It is very difficult to choose not to vaccinate your children and not something American parents are doing thoughtlessly. Most parents who are referred to as ‘antivaxxers’ actually began by vaccinating their child on the recommended schedule, but their child had some kind of bad reaction to the vaccines, or some other devastating health problem that the doctors could not explain. In these cases, it was the current vaccine schedule that ended up being more harmful to their child’s health than not vaccinating.”

Dr. Gregory Poland, chief of the Mayo Clinic Vaccine Research Group and American editor of the journal Vaccine, said that “research has repeatedly demonstrated the value of vaccines in reducing the risks and complications of infectious diseases across the population. Vaccines have improved longevity and quality of life in a safe and cost-effective manner.”

The Legal Debate

Since the beginning of this year, 29 states have introduced vaccine bills, many of which would make it harder for parents to opt out of immunizing their kids based on personal or religious beliefs.¹⁷ While many of these bills are still being considered, others have been withdrawn due to increasing opposition among individuals and organizations that are instructing members how to fight them.

Whether vaccines should be mandated is a hotly debated topic. A host of expert arguments on both sides can be read at ProCon.org (vaccines.procon.org), a nonpartisan vaccines website. In addition to expert statements, the site includes a chart of religious, medical and philosophical exemptions for vaccinations by state; a state-by-state listing of vaccinations required for public school; and an article on how deaths from measles, chickenpox, influenza and other diseases were impacted when the vaccines became available.

With strongly held views driving both sides of the debate over mandating vaccines, this issue is far from resolved. And, in fact, it is a controversy dating back to the 1800s in this country that continues today among a variety of individuals with opposing personal beliefs. Proponents focus on the statistics of disease prevention and the common good, while opponents are more interested in preserving individual freedoms and personal choices. Not surprisingly, the collision between these factions is bound to continue with uncertain results.