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Should Vaccines Be Compulsory?

In the US children must have proof of vaccination before entering the public school system, although it is becoming easier in many states for parents to gain exemptions from this requirement. In the UK there is no such requirement. This distinction has allowed for a comparison of the impact of scaremongering about the safety of vaccines and the effectiveness of campaigns to improve vaccination rates.

In the UK the scare that the MMR vaccine may be connected to autism (it isn’t) triggered by the bogus study by Andrew Wakefield resulted in a precipitous drop in vaccination rates down to about 78% overall. This is far below what is necessary for herd immunity, when immunity is prevalent enough to prevent a disease from spreading around a population. And the 78% figure is an average – but there are pockets where the number is even lower. This resulted in a surge of measles – from a low of less than 100 cases per year to 1,348 cases in 2008. The surge contniues despite an aggressive campaign to inform the public about the safety of the MMR vaccine.

By contrast the US has seen continued high overall vaccination rates of about 90%. The MMR and other vaccine scare came to the US a bit later than the UK but it is in full swing here, without much effect on overall vaccination rates.  However, we are beginning to see the emergence of low vaccination rates in specific communities, with subsequent outbreaks of measles (131 cases in 2008), mumps, and whooping cough.

It remains to be seen if vaccination rates will suffer as much in the US as they have in the UK. So far it seems that the requirement for vaccination to attend public school has dampened the effects of unwarranted scares over vaccine safety. Further, it is in communities where those laws have been weakened, or there is an anti-vaccine culture that teaches parents how to circumvent the requirements, that we have been seeing a resurgence of vaccine-preventable diseases among the unvaccinated.

It is for this reason that theUK is now contemplating making vaccination compulsory. Sir Sandy Macara, a UK health expert, is quoted by the BBC as saying:

“Our attempts to persuade people have failed. The suggestion is that we ought to consider making a link which in effect would make it compulsory for children to be immunised if they are to receive the benefit of a free education from the state.”

The BBC also reports:

The BBC has learned, however, through a freedom of information request that the strategic health authority in London asked the government if it could introduce compulsory vaccinations.

However, officials respond:

“Our strategy is to maintain a voluntary immunisation system and invest efforts in educating parents about the benefits of vaccination and dispelling ‘myths’ about vaccine safety.”

But how effective is this strategy? It turns out, there isn’t much evidence to support the assumption that educating the public about risks and benefits will actually lead to changes in behavior. It turns out, we humans are not as rational as we like to think we are. This has to do partly with the fact that it is much easier to scare someone than it is to educate them.

Further, there is evidence that campaigns to dispel myths may actually increase belief in those myths. If you tell people that vaccines do not cause autism, many of them will remember “vaccines” and “autism” in the same sentence, and the association will stick.

Therefore, the more public health officials try to fight against the scaremongering surrounding vaccines, the more they feed the fire. This likely explains why vaccination rates are declining despite increasing efforts at educating the public about their safety.

Further, the anti-vaccine lobby has been engaging in an effective pre-emptive strike against public health officials. They are telling the public that doctors and public health officials are all part of a “Big Pharma” conspiracy to hide the awful truth about vaccines. They are sowing distrust in the very people who would correct the myths and misinformation the antivaccinationists are trying to spread.

This strategy also creates a Catch-22 for making vaccines compulsory. The BBC reports:

Professor Adam Finn, a vaccine expert in Bristol, said the media was largely to blame for scaremongering over the MMR jab.

“I think this would be handing a gift to the anti-vaccine lobby, because they would say ‘look they can’t persuade you it is right, so they are going to have to force you’.”

So what is the solution? It seems that the US and UK experiences favor making vaccines compulsory for public school attendance, even if it means taking a PR hit. The PR ramifications should be dealt with a campaign to explain why compulsory vaccinations are necessary.

Public education campaigns also need to be rethought in light of what we know about what works and does not work. For example, we should not be saying that vaccines do not cause autism (because that will likely increase belief in this myth), but rather that vaccines are safe and effective.

There also seems to be no way to avoid the conclusion that we need to fight fire with fire – fear with fear. We have to make parents more scared that their children will contract serious preventable infectious diseases than they are about the false fears surrounding vaccines. And I need to emphasize – parents should be more scared of this. Vaccines prevent many more diseases an ill effects then the rare vaccine reactions cause. That is why professional and public health organizations are pushing vaccines – they work.

Parents have largely lost their fear about these diseases, however, due to the prior success (ironically) of vaccines. Some believe it will take serious outbreaks of these diseases to strike fear back into the public and show them the value of the vaccination program. I hope it does not come to that, but it may.

It is also somewhat controversial whether or not fear campaigns themselves are effective. They don’t seem to dissuade teenagers from drinking, but it is not at all clear if that applies to parental fears over the health of their children. Another strategy is called social norming – essentially exploiting peer-pressure to affect behavior (again, maybe more effective for teens than for parents). The social norming approach would be to tell parents that most parents vaccinate their children – which is true. The implication is that you would be out of step with the normal social behavior of your peers if you do not vaccinate your children.

Therefore a combination of making vaccines compulsory with more thoughtful and effective public education campaigns about vaccines may dampen the effects of anti-vaccine fear mongering. Research and monitoring into the safety of vaccines also needs to continue, and be transparent. And, we need to remind the public often about outbreaks of vaccine-preventable diseases among the unvaccinated.

It may not be rational, but it is a fact of the human condition that talking about the death of 4 week old Dana McCaffery from whooping cough (she contracted the disease due to the loss of herd immunity in her community, which is a center of the anti-vaccine lobby in Australia) is likely to have more of an effect on public perceptions than all the science and statistics we can muster.

Posted in: Science and Medicine, Vaccines

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55 thoughts on “Should Vaccines Be Compulsory?

  1. Jules says:

    I really think parents who’s kids have died or been severely injured (not likely, but there’s probably a few out there) need to step up and say, “This is what happens when you don’t vaccinate. You nutjob, quit telling people how to kill their kids.”

    Well, maybe not the latter, but actually seeing the direct consequences of your (in)actions is quite effective, which is why the autism-vaccine link still persists: people take their kid to the pediatrician, and then two days later the kid “comes down” with autism, never mind that the recommended age of vaccine administration and when autism first becomes apparent are coincidental–well, there’s a “cause and effect” right there! But if you have a parent sobbing that their kid came down with measles and died two days later, or acquired irreversible brain damage and is now a vegetable–well, that’s a pretty powerful message.

    It works with meth: ad campaigns of yore (“this is your brain on drugs” *frying egg*) don’t really work, but pointing out that you’ll get really crappy teeth if you do meth has sent the numbers of users down (at least in Montana; I don’t have the Economist article with me right now, so I can’t tell you by how much). It’ll be more effective than, say, a doctor calmly explaining to a parent that the vaccine is perfectly safe.

  2. sowellfan says:

    How about adjusting the laws so that people who spread diseases because they’re voluntarily un-vaccinated, will be financially responsible for damages caused by their spread of that disease? That takes away the issue of compulsion by the state, and heavily emphasizes the harm that is done by failing to vaccinate.

  3. Scott says:

    sowellfan,

    I don’t think that would work in terms of not being seen as compulsory. If anything, it would be even worse from a PR perspective – “I’m just trying to do what’s best for my kids, but the guvmint is trying to bankrupt me!”

    Fundamentally, I think that it’s pretty open-and-shut that compulsory vaccination is fully justifiable from an ethical perspective. But Dr. Novella unfortunately makes an excellent point about the PR implications. I’d be very worried about it stirring up enough of a public backlash to impair vaccination programs much worse than they already are – or even break them down completely.

  4. overshoot says:

    It may not be rational, but it is a fact of the human condition that talking about the death of 4 week old Dana McCaffery from whooping cough (she contracted the disease due to the loss of herd immunity in her community, which is a center of the anti-vaccine lobby in Australia) is likely to have more of an effect on public perceptions than all the science and statistics we can muster.

    So why don’t we have billboards,milk cartons, PR spots, etc. with the names (and maybe faces) of kids who died of vaccine-preventable diseases?

    That kind of thing is a serious punch to the gut for parents.

  5. megancatgirl says:

    This is a tough question. I don’t know what the answer it, but I still don’t think that vaccination should be more mandatory than it is now. One thing I would love to see is a campaign of parents who didn’t vaccinate their kids, but their kids got autism anyway. Because most kids are vaccinated, it’s much harder to find autistic kids that haven’t been vaccinated than it is to find autistic kids who have been vaccinated.

  6. SF Mom and Scientist says:

    I actually think vaccinations should be mandatory. There are other things we require of parents, such as put their kids in car seats, provide education in some format, not beat their children, etc. When something is important enough, we don’t leave it to people to decide for themselves.

    megancatgirl, I don’t think that would work. Parents who do not vaccinate still believe vaccines are bad, even if their kids still become autistic. It would be impossible to get them to put their kids on an ad for vaccinations.

  7. Joe says:

    @Jules on 03 Jun 2009 at 8:24 am wrote “I really think parents who’s kids have died or been severely injured (not likely, but there’s probably a few out there) need to step up and say, “This is what happens when you don’t vaccinate. You nutjob, quit telling people how to kill their kids.” ”

    The American Academy of Pediatrics did just that a couple years ago. I know one couple who signed-up immediately. The lack of vaccination was an oversight, the result is a lifetime of unimaginable, extreme disability. I suspect the AAP is still interested in finding parents who are willing to come forward.

    Mandatory vaccination is no different than mandatory requirements for sewage disposal. Some children have medical conditions that preclude vaccination. Letting optionally unvaccinated kids join them in public is like allowing your neighbor to flush his toilet on the lawn of property adjacent to yours.

  8. superdave says:

    In a fit of circular reasoning, JB of the aoa blog argues that the vaccine campaigns have failed because the vaccines don’t work and we know vaccines don’t work because parents have not been listening to the ad campaigns.

  9. Joe says:

    From pharyngula, more on why kids should be vaccinated: http://scienceblogs.com/pharyngula/2009/06/roald_dahl_wanted_you_to_immun.php

  10. macleod57 says:

    The phrase “Those who do not remember history are doomed to repeat it” definitely applies to this situation. Sadly it is going to take quite a few deaths before people begin to remember what a medical miracle vaccines really are. A solid and successful wrongful death lawsuit against Jenny McCarthy and her anti-vax propaganda might also go a long way to change the public’s opinion as well.

  11. daedalus2u says:

    I think the way to deal with this is not make vaccines mandatory, but rather to charge parents with child abuse if their children are unvaccinated, take the children into state legal custody for neglect (parents may retain physical custody at the state’s discretion). As legal guardian of the child, the state can then bring a malpractice lawsuit against the pediatrician.

    If a child comes down with a vaccine preventable disease and is not vaccinated, then either the parents were neglectful, or they were the victims of malpractice (unless vaccination was not recommended according to the standard of care). Empowering Children’s Protective Services to bring lawsuits for malpractice against pediatricians who do not vaccinate according to the guidelines will (I think) go a long way in preventing this malpractice.

    This is different than making vaccines mandatory, although the net result may be the same. The focus is on the children receiving proper medical according to the standard of care, and sanctioning pediatricians who do not deliver that standard of care.

    Once the children have received proper medical care, and the malpractice sanctioned, the children could be returned to parental custody.

  12. Sastra says:

    Years ago I read a book by a scientist who had studied conspiracy theories, and tried to evaluate the most effective means against them. His conclusion was that, once people are in a ‘conspiracy’ mindset, it’s almost impossible to change views with reasoned evidence. Instead, he advocated offering them another conspiracy, to counteract the first one.

    Instead of “there is a secret cabal of insiders trying to manipulate the public into believing the lie that vaccines are safe,” go with “there is a secret cabal of insiders trying to manipulate the public into believing the lie that vaccines are dangerous.” And you’re being let in on this hidden knowledge, and getting the inside scoop that they don’t want you to know about …

  13. Danio says:

    Great post. I totally agree, and would advocate strongly for vaccines to be compulsory for any child in public school, camp, daycare, etc., with exceptions *only* for medical contraindications. Period. I would favor abolishing religious exemptions altogether. People genuinely opposed to vaccines on religious grounds would be perfectly free to leave their children unvaccinated, but those children would be banned from attending or participating any of the aforementioned group care scenarios. Yes, there will be public outcry, but the parents still have a clear choice in the matter. The fact that a choice not to vaccinate has community-wide effects needs to be highlighted in as many ways as possible.

  14. sowellfan says:

    @Scott on 03 Jun 2009 at 9:41 am wrote: [regarding civil liability for spreading vaccine preventable diseases]
    “I don’t think that would work in terms of not being seen as compulsory. If anything, it would be even worse from a PR perspective – “I’m just trying to do what’s best for my kids, but the guvmint is trying to bankrupt me!””

    I don’t think that it would be worse from a PR perspective at all. If you push mandatory vaccines, you’re going to have people making commercials showing jack-booted thugs busting their way into people’s homes, and pulling their screaming children out. In no way would that be an accurate representation of what happens, but it’s the image that the other side would try to portray, and to be honest, I think they’re a little better at public relations than we are. If instead, you adjusted the law so that people are civilly liable for their actions, then the ‘guvmint’ isn’t even the one that’s taking their money – instead, it’s another individual. Even better, the individual that is suing is, by the nature of being *involved* in the lawsuit, a victim who has been damaged, or who has had their child damaged, physically and financially. IMHO, that would be a much better PR arena for our side.

  15. grendel says:

    Whenever I see Dana McCaffrey’s name I can’t help but wonder if Meryl Dorey would be willing to pay compensation to any parent who lost a child from a vaccine-preventable disease. After all, Meryl’s view seems to be that vaccines should not be compulsory since they (a) do not work; (b) are dangerous and; (c)the diseases they are supposed to prvent don’t kill children . If she honestly holds those beliefs then I think she can demonstrate her integrity with cash.

    The second thought that usually follows this is: Can anti-vax campaigners who actively agitate against vaccines AND claim success as a result of declining vaccination rates be sued by parents who lose a child to a vaccine preventable disease?

  16. wales says:

    “I think the way to deal with this is not make vaccines mandatory, but rather to charge parents with child abuse if their children are unvaccinated, take the children into state legal custody for neglect.”

    Daedalus, I cannot tell if you are serious or simply vying for the Jonathan Swift “Modest Proposal” award of 2009. Where oh where is the vaunted sbm rationality? Your idea (and several others here) would be a boon to the legal profession. I often wonder if this is a science based blog or a legal blog.

    Twenty states allow for philosophical vaccination exemption for public school entry, all but 2 allow for religious exemption. California law specifically states that vaccination exemption does not constitute child neglect or abuse. It is unlikely that state legislatures are going to reverse course in a country where the vaccine coverage rate is an unprecedented 95% among kindergartners….And where school bus seat belts are not mandatory, and where the supreme court has upheld citizens’ rights to own handguns……public health risks abound. The fact is that vaccines are not risk free. In addition to the “proven” risks, there are myriad uncertainties regarding vaccine safety, such as the fact that NONE of the routine childhood vaccines are tested for carcinogenesis, mutagenesis or impair to fertility. This disclosure appears in every vaccine package insert.

    BTW, on the subject of criminalizing certain types of human behavior, shall we also go back to the days when gay sex was a crime (as recently as 2003 in several states) on the grounds that HIV/AIDS is a public health hazard?

    Aside from the philosophical, legal, ethical and political problems with Daedalus’ proposal, there remain numerous practical hurdles to removing children from their families and placing them within state custody programs. Even staunch vaccine proponents, if they’re honest, would have to question which is fraught with more risks to children: state foster care systems or vaccination refusal. Some sort of research study would have to be conducted on this subject before such draconian measures could be implemented. In this age of state budget deficits, where shall states find funds to pay for this study and legal removal of children from their families and subsequent custodial expenses? From pharmaceutical companies perhaps? They might agree to that if the children were useful as vaccine test subjects. Or perhaps Daedalus would step up to the plate? No? A totalitarian state might not offer any options, perhaps he would be forced to adopt several children. And what about all the runaway children who would try to get back to their loving families because they perceived no abuse in vaccination refusal?

    You get my drift. Outlandish, perhaps. But no more so than the original proposal.

    Another aside: it is very curious to me that purported objective and rational skeptics promote emotion-based behavior modification tactics such as fear and “social norming” as solutions to a perceived compliance problem with a preventive medical intervention.

  17. wales says:

    That should read “impairment” to fertility.

  18. daedalus2u says:

    I am not talking physical custody, only legal custody, and then to file malpractice claims against the MDs who did not recommend vaccination.

    The system would be self-funded from the malpractice claims.

    If the legal profession was given free reign to sue pediatricians for malpractice if they didn’t vaccinate according to the standard of care, then the problem would be solved without government intervention.

    All that is needed to file a suit is”standing”. Only an injured party has “standing”, that is why the state needs legal custody to file the malpractice suits. If “the public” were granted “standing” for the hypothetical risk of unvaccinated individuals decreasing the herd immunity, and allowed to sue for malpractice, then the problem would go away (or at least MDs that didn’t follow the vaccine guidelines would go away).

  19. wales says:

    You are indeed serious, amazing. Are you an attorney? Otherwise that Freudian slip of “free reign” (perhaps you meant “free rein”) for attorneys is pretty humorous. Some would say that the legal profession already has free reign and that it is one of this country’s major problems (I especially hear this from physicians, ironically).

    Your solution could result in even more families going to the “dark side” and using homeopaths and chiropractors for primary care, bypassing pediatric standards of practice. A resulting fallout could be decreasing numbers of pediatricians due to lack of demand. Now how about that for a risk to children’s health? All in the name of forcing preventive medical interventions to preserve “herd immunity”. Consequences, consequences. Usually they are unforeseen.

  20. The Blind Watchmaker says:

    …”it is much easier to scare someone than it is to educate them.”

    Steve, this is a great line. This should be on a billboard with the pictures of the recent kids who died of measles and pertussis.

  21. JustAsItSounds says:

    IIRC vaccination is a pre-requisite for attending state-run schools in France. If your kid does not have the requisite number of vaccinations then she/he cannot attend public school.

    If such a law was to be introduced in the US, with an appropriate public awareness campaign – emphasising the civic duty aspects, and the saftey of your own and other’s children, I can see this being one of the best ways to ensure the highest vaccination rates. Or possibly just an increase in the number of middle-class, Oprah-watching home-schoolers

  22. wales says:

    Again, if the supreme court upholds handgun rights based upon the constitution, it will uphold vaccination exemption rights based upon constitutional religious freedom.

  23. bcorden says:

    Dr. Novella, thanks for keeping this issue before us.

    A friend gave me an old pediatric textbook translated from the German in 1908. (The Diseases of Children; Shaw and LaFetra) At that time, in Europe, approximately 40% of all live births did not make it through the fifth year. The overwhelming majority of these died in the first year (25% of all children). While it is true that most of those deaths were to “gastrointestinal disease” which, I presume, refers to gastroenteritis with dehydration, a significant number were diseases that I, as a pediatrician, have almost never seen except when I was a kid in the pre MMR days. Prominent among these were Diphtheria, Pertussis and Measels. There was also significant pneumonia which, I would guess, included Hemophilus Influenza and Pneumococcus, both recent but wonderful vaccines.

    Furthermore, in the lowest social classes, again in Europe, the death rate was an astonishing 60% by the fifth year. In this day and age when the death of even one child (e.g. Dana McCaffrey) is rightly seen as a tragedy, these kinds of numbers are just not fathomable.

  24. pec says:

    “Because most kids are vaccinated, it’s much harder to find autistic kids that haven’t been vaccinated than it is to find autistic kids who have been vaccinated.”

    Why doesn’t someone compare the autism rates in vaccinated vs. unvaccinated kids in the UK, since there are so many unvaccinated kids there? Instead, they compared autism rates before and after removing mercury and found the rates did not decrease. Of course, there can be several explanations for this.

    It would be much more straightforward to compare vaccinated and unvaccinated children in the UK, maybe correcting for things like SEC. If the rates are about the same, you would have made your pro-vaccination case very clearly. As it is, the data is ambiguous and confusing.

    Since you believe people are basically irrational, you don’t even try to use clear evidence and reason to convince them. You feel that PR is the only way.

    Autism is more frightening than measles because most kids get over measles, but autism is usually permanent. Maybe you could try to understand why parents are so afraid of autism, and maybe you could acknowledge that it seems to be much more common now than previously.

  25. wales says:

    There is a VAST difference between childhood infectious disease morbidity and mortality rates in 1908 and those immediately prior to the vaccine era (1940′s-1960s). The majority of the decrease in infectious disease mortality in the 20th century was due to improved sanitation and antibiotics.

    CDC and other vaccine proponents make statements about the impact of vaccines upon 20th century morbidity and mortality, yet their graphs always start with 1950, omitting the first half of the 20th century, in order to exaggerate the decrease in disease and mortality attributable to vaccines. Truncated graphs are very misleading.

  26. Joe says:

    @wales on 03 Jun 2009 at 8:13 pm wrote “Truncated graphs are very misleading.”

    Not if you know how to interpret them. For example, by showing the morbidity and mortality after the improvements in sanitation, etc., have been established the effect due to vaccines is clearer.

  27. wales says:

    Joe, I disagree. The exaggeration achieved by truncating the graph emphasizes the impact of vaccines for a specific limited time period, and makes their overall impact longer term less clear. My point is that selective data presentation is misleading: i.e. Making a statement that encompasses the entire 20th century, yet showing a graph for only the second half of that time period. Quoting disease mortality rates for the first two decades of the century, then skipping to post-vaccine rates implies that vaccines were responsible for the bulk of the decrease. Only by looking at a graph for the entire century does one get an accurate picture of the situation.

  28. Joe says:

    @ wales on 03 Jun 2009 at 9:20 pm wrote “Joe, I disagree.”

    If one knows how to interpret data, it is not misleading. It seems that you have it figured out.

  29. zayzayem says:

    I think the “social normalising” approach could be quite successful.

    This approach works quite well in African countries I believe.

    It also appears to have been quite successful in Gardasil’s cervical vaccine campaigns.
    “Get your vaccine, everyone else is”

  30. wales says:

    Joe, pardon my obtuseness. I see your point.

  31. Th1Th2 says:

    NO, vaccines shouldn’t be compulsory.

  32. Eric Jackson says:

    Well, there are several points here that that can be made.

    Joe, above posted a link to Pharyngula on Science blogs. One of the earliest comments made was about how rare it is to find vaccine refusal or denial among individuals who lived through the 1940s and onward, the generation that experienced the brunt of Polio in the United States. My own grandmother wrote down a collection of stories about her youth, and one of the things that featured prominently was her time as an RA, or ‘den mother’ in a university in Hawaii during World War II, and how one of her duties was to check with each of the residents every morning to make sure they could still feel and move their feet. That sort of prevalence of an infectious disease, particularly one as ugly as Polio is something that just seems utterly incomprehensible.

    Beyond that, there’s the issue of -which- vaccines should be mandatory? In this case, I think the CDC’s proposed guidelines for mandatory US Immigrant vaccination might be an appropriate starting place:

    “The vaccine must be age-appropriate, as recommended by ACIP for the general U.S. population. This means vaccinations are only required for immigrants within the age group for which a specific vaccine is recommended.
    AND at least one of the following:
    The vaccine must protect against a disease that has the potential to cause an outbreak.
    The vaccine must protect against a disease that has been eliminated from the United States or is in the process of being eliminated in the United States.”

    Note the two lower requirements. Obviously, some of the context applies only to immigrating individuals. Mandatory vaccination should not necessarily be required for, say, Herpes Simplex (yes, the vaccine is still in trials, but it’s a good example here), but diseases that have the ability to rapidly spread and pose major and immediate public health issues? Things like Pertussis, Measles etc. A strong case can be made for these.

    Another possible route, other than legal mandate, that has not been brought up is that of health insurance companies. They have quite a bit of interest in preventative care that lowers the number of larger, later payouts. A financial motive, say in the form of increased premiums for non-vaccinated individuals could have some use. Given that most health insurance companies are quite glad to pay for vaccination, and that refusal is a choice on the part of either an adult or the legal guardian of a child. You want to put yourself, your children and those around you at increased risk? Well, it’s going to cost more for a health insurer to assume the risk of paying for your medical coverage.

    I’m not at all familiar with the internal practices of insurance companies, or many of the laws governing them, but I thought I’d throw it out there.

  33. Kultakutri says:

    I live in a country where vaccination against some eight diseases is compulsory, there’s a schedule and that’s it. The exemptions are only for medical reasons – no religion or other persuasion is permissible.
    I seem to vaguely remember one or two cases when there was the real Rio, with police taking the child to the hospital and parents being charged for neglect but in general, most people just have the kids vaccinated without objections since there are compulsory medical checkups for children under 15 and, well, while being screened for growing up normally, they get the shot. If the parents resist, they are sent to a local public health office which has staff trained to explaining and I hear that these folks manage with almost all people. There’s been some pressure in changing the vaccination schedules because ‘such small babies cannot deal with them ebil toxins’ and ‘parents know better than them ebil doctors’ but it’s a very minor voice.
    Also, there are several vaccines available – I’m not a M.D., just an interested lurker – and insurance covers the cheapest ones (obviously) which causes slightly more adverse reactions and have a more demanding vaccination schedule – more visits to the doc, basically. The other stuff is paid from the insurance if the children have health problems but should parents want, they can pay it from their pockets so that their precious snowflake gets everything in two shots instead of eight (now I’m making things up but it works somehow like this).
    There were minor outbreaks of hepatitis A and pertussis in the last few years and… it was the general public which started to call for mandatory vaccination against hep and mandatory pertussis booster whenever it may be needed in later age.

  34. daedalus2u says:

    Wales, I am not a lawyer. To me the issue is very different than gun rights. The issue is not the rights of the parent, the issue is the rights of the child. Children have a right to be not subjected to abuse by their parents. Medical neglect is child abuse. Parents cannot use religion or philosophy as an excuse to abuse their children.

    You are misinterpreting the data. The mortality rate (deaths per case of the disease) fell prior to vaccination due to non-vaccination effects. The cases of the disease fell to near zero following vaccination resulting in sufficient herd immunity. If there are no cases of the disease, it doesn’t matter what the deaths per case are because with zero cases there are zero deaths. There is no basis what so ever for projecting a decline in deaths per case independent of vaccination. The cause of that decline is not fully understood, the idea that you can project an effect of an unknown cause is preposterous.

    We require people who drive cars on public highways to have insurance. Requiring people who congregate with others in public spaces to be vaccinated is not different (in my opinion). People in public have a right to hold others in public to the “reasonable person” standard of conduct. To me, that “reasonable person” standard includes being vaccinated against communicable diseases.

    I see that personal vaccination against transmissible diseases is an obligation that individuals have to other people to associate with them in public. If you don’t want to be vaccinated, then stay out of public places, stay away from other people and don’t expose them to your non-vaccinated status. If you do go into public and harm others as a consequence of your refusal to be vaccinated, then you should be responsible and bear the cost of the damage you caused. That “damage” includes the cost of public health preparations to prepare for an epidemic in case herd immunity fails, even if there are no outbreaks.

    In my opinion vaccines for communicable diseases for children and adults should be provided by the government at no cost as a public health measure. That is the government should pay the full cost of the program, the cost of the vaccines, the cost to administer them, and the cost of any vaccine related injuries.

    If a disease is non-contagious (i.e. tetanus), then individuals can use a standard different than the “reasonable person” standard for themselves. Children are still entitled to the “reasonable person” standard for health care which includes vaccination according to the “standard of care” which includes vaccination against tetanus.

    My opinions are based on my understanding of ethics and logic, not on how workable or non-workable they are. I don’t understand the mindset of anti-vax wing-nuts. They didn’t arrive at their mindset with facts and logic, facts and logic are not going to change it. I think that denying unvaccinated individuals access to public accommodations would work. If you don’t have up to date vaccinations, you can’t travel by air, you can’t go to school, you can’t attend sporting events, you can’t attend conventions, you can’t go to the theater, you can’t go to the mall, you can’t go to the library, you can’t cross the US border into the US.

  35. wales says:

    Daedalus, you do give me a chuckle. Thankfully your totalitarian yearnings will never be satisfied in this country.

    If vaccination exemption equated to child abuse, state legislatures would not allow it. That definition of abuse is simply your biased and emotional opinion, not a fact. And your plan would never work even though you’ve made a distinction between legal and physical custody. Do you honestly think that if states criminalized vaccine exemption (which they would have to do in your scenario to get legal custody) they would then allow parents to retain physicial custody? Again, a heyday for attorneys.

    “There is no basis what so ever for projecting a decline in deaths per case independent of vaccination. The cause of that decline is not fully understood, the idea that you can project an effect of an unknown cause is preposterous. ”

    Huh???? Let’s go out on a limb here and make a wildly preposterous assumption that the 75-95% decline in infectious disease morbidity and mortality that occurred between roughly 1900 and 1950 is a complete mystery, we have no clue how or why it happened and sanitation and antibiotics had no role. So what? Are you suggesting a woo factor? Was it a spiritual effect? It doesn’t matter. My point is that it is not attributable to vaccines.

  36. Wales – what is your point? Are you saying that vaccines are not effective? Be clear. If you agree that vaccines work, then your point seems to be a non sequitur.

    Sure, understanding of the germ theory led to many interventions, including sanitation, that reduced the spread and morbidity from infectious diseases. So what. We have multiple independent lines of epidemiological evidence that clearly show that vaccines are effective, as is herd immunity. Infectious diseases prevented by vaccines dropped significantly in every country in which the vaccines were instituted. And when pockets of low compliance occur, the illnesses return. The pattern is undeniable.

    We can take as an established premise that vaccines and herd immunity are safe and effective public health measures.

  37. James Fox says:

    For the state to intervene in cases of parental neglect does not require any criminal statutes. These are civil actions and use the same laws utilized in the recent case of the parents/child who refused chemo for cancer. These laws are used all the time to ensure children are adequately cared for and receive necessary medical care when, for what ever reason, the parents are not able or choose not to act in the best interests of their children. It would not seem to me that requiring vaccinations would be a significant change in current laws.

    And considering state laws and policy are driven by federal funding requirements it wold be a simple thing for the federal government to enact legislation that would tie child welfare funding to a requirement that mmandates vaccination .

  38. megancatgirl says:

    Why doesn’t someone compare the autism rates in vaccinated vs. unvaccinated kids in the UK, since there are so many unvaccinated kids there?

    There are many reasons. Parents who don’t vaccinate are much, much less likely to accept a diagnosis of autism. They’re much less likely to even consider the possibility of autism in their children, when they have such a firm belief that their kid can’t get it. It’s common enough for mild cases to fall through the cracks, but even more so when there is the assumption that the kid can’t possibly have autism. This is the exact reason why the best trials have to be double-blind. If someone is expecting a certain result based on their treatment (or lack of it), they are much more likely to observe what they expect to see.

    The two groups of vaccinated and non-vaccinated children are not statistically the same. They’re certainly not random, and there will likely be many confounding factors involved. So instead of comparing just two variables (autism rates and vaccination), you introduce many other variables, making it much harder to determine a causal relationship. Non-vaccinated children tend to be clustered in geographic and socioeconomic groups. Worldwide, non-vaccinated children tend to be poorer and have less access to health care overall.

    There are additional statistical factors that make this type of study less than ideal. If you want to learn more, I suggest that you take an intro statistics class at a local community college.

    However, someone did do a study like this awhile ago, and it showed that children who receive only some vaccines are more likely to have autism than children who receive all recommended vaccines. I don’t remember the source of the study, and I’d be grateful if someone could post a link to it. The conclusion wasn’t that having more vaccines decreases autism risk. Rather, it’s more likely that some children started to get vaccines, were diagnosed with autism, and then their parents stopped vaccinating because of it. IIRC, the autism rates were the same for the unvaccinated and fully vaccinated children.

  39. pec says:

    “There are additional statistical factors that make this type of study less than ideal. If you want to learn more, I suggest that you take an intro statistics class at a local community college.”

    Wonderful idea. Every PhD in an experimental science ought to run out and take that intro course, that would really be a good use of my time. I understand perfectly well that there are other differences between vaccinated and unvaccinated groups. But all the problems you mentioned would not prevent this kind of study from being very useful and informative. If cases of severe autism (which parents are not likely to deny or ignore!) are lower in unvaccinated children in the UK, that would be a hint that vaccines can sometimes contribute to autism. It is certainly worth trying!

    You list all these reasons why the study should not be done, but you have no problem with the even more problematic comparisons that have been done, which pro-vacciners always cite.

    And then you mention a study that was done but you can’t remember much about it. Was it in the UK? Children who are unvaccinated because of extreme poverty should not be included.

    And as I said, certain variables such as SES can be controlled for. Maybe you should take that intro to statistics course.

  40. Jurjen S. says:

    Joe wrote:

    Some children have medical conditions that preclude vaccination. Letting optionally unvaccinated kids join them in public is like allowing your neighbor to flush his toilet on the lawn of property adjacent to yours.

    That’s the first TV ad in the campaign right there! With accompanying visuals.

  41. Jurjen S. says:

    wales wrote:

    Again, if the supreme court upholds handgun rights based upon the constitution, it will uphold vaccination exemption rights based upon constitutional religious freedom.

    The two are not analogous. While the ruling in Heller may have affirmed a constitutional right to keep, possibly even bear, a handgun, it did not find a constitutional right to randomly discharge it in public. And that is a fairly apt analogy for sending an electively unvaccinate child into a place like a public school.

    Much as I would like to make it legally compulsory for all children to be vaccinated (providing for medically based exemptions only), I doubt that could be made to fly. However, I think there is a compelling case to be made that if you opt to not vaccinate your children, you don’t get to place them in an environment where they are likely to present a risk to others. That means ending the religious and philosophical exemptions for the vaccination requirement to attend public schools. No requirement to vaccinate per se, but very real consequences if you don’t.

    And, to be blunt, I think it’s a factor in the increase in refusals to vaccinate on religious or “philosophical” grounds: it’s been too easy because there’s been no price attached to it. We can see how strong those parents’ convictions are if there are immediate negative consequences attached to their decision. Let them home-school, or set up private schools that don’t require vaccination. It’s far from my ideal solution, because there are kids who are going to get hurt if they get ill, but if we can’t treat everybody, we have to perform triage.

  42. daedalus2u says:

    pec, how many dead children is such a study worth? From the very large, whole nation studies that have been done, the number of autism cases “caused” by vaccination must be a small fraction of the total number.

    Let us assume that number is 1% of autism cases. To do a prospective trial to see a difference of 1% in the 1 in 150 incidence of autism, the number of subjects in the trial needs to be large. With 15,000 subjects, a 1% change in the incidence due to vaccination status would be 1 individual. Assume we need 10 individuals to get reasonable statistics, that means 150,000 non-vaccinated children. How many deaths can we expect from 150,000 non-vaccinated children? That will depend on how many come down with the diseases that the vaccines protect against. Using death rates from this paper

    http://jama.ama-assn.org/cgi/content/full/298/18/2155

    If we assume that all 150,000 children do come down with these vaccine preventable diseases, how many would we expect to die?

    Measles 440/530,162 = 0.083% = 124.5 deaths

    Mumps 39/155760 = 0.025% = 37.6 deaths

    Rubella 17/47,734 = 0.035% = 53.4 deaths

    Pertussis 4007/185,120 = 2.16% = 3427 deaths

    Total 3642/150,000 = 2.42%

    In reality, probably not every one would get the disease, and probably the death rate would be lower than historic rates. Because these children are in a clinical trial, they would be monitored pretty carefully. After the first dozen or so children died from vaccine preventable diseases, those monitoring the clinical trial would stop it and vaccinate everyone in the unvaccinated leg of the trial. The trial would be a bust because it was stopped early.

    So pec, what would be your criteria for stopping the trial? What difference between the vaccinated and unvaccinated legs would you monitor and when would you terminate the trial?

    Everyone who has given even a moments thought to the ethics knows that to wait until after children die is to wait too long.

  43. wales says:

    James Fox: The definition “Necessary medical care” with regard to chemo treatment and preventive vaccination are two very different animals.

  44. tmac57 says:

    Wales-”The definition “Necessary medical care” with regard to chemo treatment and preventive vaccination are two very different animals.”
    Yeah, the difference being that it would only be necessary to be vaccinated against lets say…pertussis, if the child were to die or suffer serious medical consequences from it. Oh wait! Damn, you can’t do that because THEN ,it’s too f**king late!

  45. pec says:

    daedalus2u,

    I said they should compare the children in the UK whose parents decided not to vaccinate them, to the children who were vaccinated. They are not going to be vaccinated whether the study is done or not!

    Maybe the reason no one has done it is they’re afraid what the results might be.

  46. daedalus2u says:

    I think you are right, they are afraid of what the results would be from such a study, lots of sick and dead children. Those proposing such studies are the fools running in where angels fear to tread.

  47. Psyche78 says:

    I find this debate both interesting and maddening in many ways. Let me be upfront by stating I am one of those parents who most of the posters here probably sneer at. My two-year-old son is selectively vaxed, and he was vaxed on a somewhat delayed schedule. He is up-to-date on MMR and DTaP, he received the polio vaccine, and he had two doses of HiB before the shortage; he has not received the Hepatitis B vaccine or chicken pox vaccine (as well as rotavirus or Prevnar vaccines), and because of that, I – like many moms I know – filed for a religious exemption in order for him to attend daycare. I chose the vaccines I did because after looking at the risk of the disease and the risk of contracting the disease, I felt the benefit of those vaccines was worth taking the risk of an adverse reaction. I also chose to give no more than one vaccine at a time. Did I do this because of fears over autism? To be honest, no. I did it because of a strong family history of autoimmune disorder (which includes myself) and a personal belief that medical intervention should only be undertaken when necessary. I probably wouldn’t have thought twice about vaccinating on schedule but for the fact that Gardasil came out while I was pregnant with my first son, and the controversy over adding it to the mandatory vaccination schedule for school attendance made me examine the current vaccination schedule more closely.

    From where I sit, the current public health campaign is tilting at windmills. Assuming that Jenny McCarthy and her ilk are the reason for decreasing vaccination compliance is poor science. Has there been a survey to determine why parents are choosing not to vaccinate? Or is it that the establishment has chosen to glom onto the most visible group of vaccine refusers and is spending all its time and resources fighting that group, rather than addressing the concerns of the silent majority of vaccine refusers/selective vaxers.

    Here are my suggestions for increasing compliance with vaccination. First, start over with regards to the schedule and determine what are the true public health priorities when it comes to vaccination. It’s a lot easier to convince people to vaccinate their kids for measles, rubella, and pertussis than it is to vaccinate for rotavirus or the flu. I, personally, think the CDC/state health authorities shoots themselves in the foot every time they try to get another vaccination added to the childhood schedule, because the more shots kids are being made to get, the more parents are going to wonder whether all the shots are necessary. It’s easier to convince parents to get 3 shots for their kids than 10. It’s easier to convince parents of the extreme importance of vaccination when you are not trying to force them to vaccinate their day-old infant for a primarily sexually transmitted disease. Second, there needs to be true informed consent. This is a two-fold point. One, there needs to be longitudinal studies about the effects of giving this many vaccinations to children and there needs to be real studies about the side effects of the preservatives and other ingredients in the vaccines. In my opinion, it is dishonest, in a way, to say that vaccines are safe and the side effects are minimal when you have a vaccine like Prevnar on the schedule. Prevnar was determined to be safe in a trial in which it was compared to an experimental vaccine. It doesn’t take a Ph.D. to realize that it is intellectually (and scientifically) dishonest to claim substance A is safe by comparing its effects to substance B, when substance B has not be tested for safety previously. Two, physicians and the CDC need to be upfront with parents about the possibility of adverse reactions from vaccines and not attempt to sweep them under the rug. MMR may be extremely safe, but the simple fact is there are and will be children who will react negatively to it and will be damaged from it – this is the case with practically any medical intervention. For the doctors and CDC to act as if there are no possible negative impacts from vaccines undermines their authority and trustworthiness when a true vaccine reaction occurs and is publicized. It makes it look like they are hiding things, and the conspiracy theories flourish. Dr. Novella writes that anti-vaccine advocates are sowing distrust in public health officials and the medical establishment – I think the public health officials and medical establishment are doing a fine job of this themselves. Go out and ask a sample of parents how they are treated by pediatricians when they ask about the safety of vaccines. I have not done a scientific study on this, but anecdotally, most parents are given the attitude that they are stupid for even deigning to question vaccination, rather than be given information about the benefits and risks. This is not the way to build trust in the medical establishment, and it is certainly not the way to gain informed consent. Once again, anecdotally, the parents I know who are choosing alternative medicine practitioners over conventional medicine practitioners are the ones who ask the pediatricians and family practice doctors for more information – for studies, for statistics, for data – and instead receive attitude and disparagement.

    This is not the 1950s. Paternalistic edicts from government health officials and from doctors will not be heeded as readily in the age of the Internet. Parents need to be treated more as equal partners in medical decision-making rather than as uneducated rubes.

    Sorry this is so long! I had a lot to say!

  48. daedalus2u says:

    psyche, could you share with us links to the information you used to determine that the risks of those vacines were worse than the risks of those diseases?

  49. Psyche78 says:

    Chicken Pox: http://jama.ama-assn.org/cgi/content/full/284/10/1271

    http://emedicine.medscape.com/article/1131785-treatment

    Dr. Gary S. Goldman, “Universal Varicella Vaccination: Efficacy Trends and Effect on Herpes Zoster,” International Journal of Toxicology 24, no. 4 (July-August 2005): 205-213.

    Dr. Gary S. Goldman, “Cost-benefit Analysis of Universal Varicella Vaccination in the U.S. Taking into Account the Closely Related Herpeszoster Epidemiology,” Vaccine 23, no. 25 (9 May 2005): 3349-3355.

    Hepatitis B: http://www.cdc.gov/hepatitis/HBV/HBVfaq.htm#overview

    http://www.immunizationinfo.org/vaccineInfo/vaccine_detail.cfv?id=4

    Prevnar: http://content.nejm.org/cgi/content/abstract/348/18/1737

    http://jama.ama-assn.org/cgi/content/abstract/295/14/1668

    http://www.wyeth.com/content/showlabeling.asp?id=134

    Rotavirus/RotaTeq:
    http://diarrhea.emedtv.com/rotavirus/rotavirus-statistics.html

    http://www.medicinenet.com/rotavirus/page3.htm

    http://jama.ama-assn.org/cgi/content/abstract/279/17/1371

    http://www.merck.com/product/usa/pi_circulars/r/rotateq/rotateq_pi.pdf

  50. Psyche78 says:

    Don’t know if the post went through – my connection has been wonky:

    Chicken Pox: http://jama.ama-assn.org/cgi/content/full/284/10/1271

    http://emedicine.medscape.com/article/1131785-treatment

    Dr. Gary S. Goldman, “Universal Varicella Vaccination: Efficacy Trends and Effect on Herpes Zoster,” International Journal of Toxicology 24, no. 4 (July-August 2005): 205-213.

    Dr. Gary S. Goldman, “Cost-benefit Analysis of Universal Varicella Vaccination in the U.S. Taking into Account the Closely Related Herpeszoster Epidemiology,” Vaccine 23, no. 25 (9 May 2005): 3349-3355.

    Hepatitis B: http://www.cdc.gov/hepatitis/HBV/HBVfaq.htm#overview

    http://www.immunizationinfo.org/vaccineInfo/vaccine_detail.cfv?id=4

    Prevnar: http://content.nejm.org/cgi/content/abstract/348/18/1737

    http://jama.ama-assn.org/cgi/content/abstract/295/14/1668

    http://www.wyeth.com/content/showlabeling.asp?id=134

    Rotavirus/RotaTeq:
    http://diarrhea.emedtv.com/rotavirus/rotavirus-statistics.html

    http://www.medicinenet.com/rotavirus/page3.htm

    http://jama.ama-assn.org/cgi/content/abstract/279/17/1371

    http://www.merck.com/product/usa/pi_circulars/r/rotateq/rotateq_pi.pdf

  51. weing says:

    I am not a pediatrician but I do, on occasion, give MMR to college kids. They are given a pamphlet issued by the CDC about the risk and benefits of the vaccine to read and they must sign an informed consent before I administer it. When I take my own kids to the pediatrician, I do the same. Is this not the common practice in other states besides Connecticut?

  52. Psyche78 says:

    Weing, my son was born in Virginia and we currently live in North Carolina. When he has gotten his vaccinations at his doctor’s office in either state, I have not received the CDC sheet. At his doctor in Va, I did receive an overview from the practice, but generally after the vaccination was already received. I am sure it is supposed to be standard of care to provide the information prior to vaccination, but from personal experience and anecdotal evidence, this is not the case. There needs to be a much better effort at informed consent.

  53. nickhaas says:

    DON’T MOVE -> Look at the price. http://www.iansvoice.org

  54. nickhaas says:

    This family paid the price; their new baby died. You want compulsory now? http://www.iansvoice.org

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