Danger Zones of Parental Vaccine Refusal

Back in 2009 I wrote a story entitled, “The New Plague”, about my experiences as a pediatrician with the frightening trend of parental vaccine refusal in New York City. In that post I discussed some of the complex social factors contributing to this phenomenon, and some of the common vaccine myths to which many parents fall prey. I recommend that you read that post, as it is (unfortunately) as timely today as it was then. Now I’m a pediatrician in Amherst, Massachusetts, and I find it necessary to revisit this dangerous trend in parenting.

As I described in my previous post on the subject, my old practice was at an interesting crossroads of several communities that seemed to perfectly embody the socioeconomic and cultural characteristics commonly found in communities with high rates of parental vaccine refusal. Ironically, these tend to include people who are educated and socially privileged; those empowered to question authority. In 2010, I left New York City and moved to Western Massachusetts to take a job at Baystate Children’s Hospital in Springfield. There I was in charge of the teaching clinic where pediatric residents are trained in the outpatient care of children. The children we took care of in Springfield comprised a very high-risk, underprivileged population. Our patients were significantly below the poverty level, with high rates of developmental and educational disability, a high teen pregnancy rate, and high rates of domestic violence, drug use, and gang involvement. Children who were not up to date with their vaccinations were behind because of poor continuity of care, with many missed appointments and gaps in follow-up. I now work at a private practice further north in the Pioneer Valley of Central Massachusetts. Here, my experiences with vaccine lapses are starkly different. Now, when I encounter a child who is not fully vaccinated or is completely unvaccinated, it is the result of a parental decision. A very flawed, dangerous, and misinformed parental decision.

My new practice is comprised of children from an interesting, rich diversity of sociocultural and socioeconomic backgrounds. Its South Amherst location draws patients from many of the local, rural farming communities, and its close proximity to five colleges and universities (The University of Massachusetts, and Amherst, Smith, Hampshire, and Mount Holyoke Colleges), draws a unique mix of highly educated academics. On any given day it is typical for me to see the children of farmers, mechanics, refugees, and university professors, and children who live in Victorian homes, as well as those living in cohousing communes and public housing units. But the proportion of parents in my new practice who are challenging the recommended schedule of vaccines is much greater than what I experienced in my NYC practice. Again, these parents tend to be highly educated, economically privileged, and part of the cultural trend toward self-empowerment and the questioning of authority. While it’s a great thing to be a self-empowered and questioning individual, that can and is being taken to irrational extremes. It is irrational to resist or ignore scientific experts and science itself under the belief that one can be one’s own expert in all matters. It is not uncommon for parents who choose a so-called “alternative” vaccine schedule to state emphatically that, “no one is going to tell me how to vaccinate my child”. The absolute absurdity of that proclamation should be plain as day. Why wouldn’t you take the science-based recommendations of the world’s leading experts on infectious disease and epidemiology when making the most important decision regarding the health of your child? And if not from them, than on whose recommendations will you base these decisions? A quack website such as Natural News, your friends, yourself?

Why are parents so afraid to vaccinate their children? First of all, every parent that comes to me with an alternate vaccine schedule is making a decision that is meant to be in the child’s best interest. These are well-intentioned parents, who want to do the right thing. One of the main issues at play here is the fact that vaccines are a preventative measure, and not a treatment for a visible, tangible disease state. This right away makes it a harder sell. That wasn’t the case when these diseases were commonplace and an ever-present specter looming over every parent’s head. Then, the thought of not vaccinating was inconceivable to most people (though not all, and that’s a different topic altogether). The infections we are trying to prevent with vaccines are now a mere abstraction for most parents. Because vaccines have been so successful at reducing the incidence of these horrific diseases, there are few parents who have ever seen or even heard of them. Add to this the rampant and ever-snowballing avalanche of vaccine myths and misinformation propagated by social circles, the mass media, social media, and the Internet, and you have the conditions for our current decline in vaccination rates.

Concerns about vaccines tend to fall into several different categories including, but not limited to:

  • Vaccines cause diseases, including autism and autoimmune diseases.
  • Vaccines contain toxins, which can harm the body in unknown ways.
  • Too many vaccines given together can overwhelm the immune system.
  • Vaccines are unnecessary, and/or do not work.

These myths have been addressed at length many times on SBM and elsewhere, so I will not discuss them further here. While some parents buy into the more extreme forms of anti-vaccine propaganda, most understand that vaccines are responsible for the dramatic decline in the incidence of horrible diseases and that they are generally safe. However, they may falsely conclude that because these diseases are now so rare, they no longer need to be as vigilant about vaccinating their children. This makes it easier for parents, who don’t necessarily buy into the full anti-vaccine mythology, to take a “play it safe” approach and accept some form of alternate vaccination strategy. It is difficult to explain to these parents that until the diseases are truly eradicated from the planet, we must keep vaccinating everyone; that everyone needs to be vaccinated to maintain herd immunity for those too young to be vaccinated, for those who cannot be vaccinated due to health reasons, and for those for whom the vaccines do not work.

On a single day recently, I saw five families who had children that were, by choice, not being vaccinated according to the recommended schedule of childhood vaccines. Two of these families had a child that had received no vaccines at all – a 9 month old and an 11 year old. The parents of these children, out of misguided fear and with the belief that they were making the correct, “educated” decision for their children, chose to ignore the recommendations of some of the world’s leading experts on infectious disease, immunology, and epidemiology. They chose to ignore science over the advice of their social network, the popular media, and the pseudo-religious anti-vaccine propaganda mill. The rate with which parents are making such decisions for their children in similar communities around the country is truly frightening. It is a movement away from science and reason that warrants much more attention than it has received so far. That includes attention and action from the media, from science and health organizations, physicians groups, and from parents as well. A new effort from the University of Iowa Computational Epidemiology Group is hoping to use an iPhone app to track data on vaccine refusals submitted by pediatric providers throughout the country. Efforts like this, intended to shine a light on the problem of vaccine refusal and denialism, are necessary if we are to stem the tide of this dangerous epidemic.

Vaccine Refused

The University of Iowa, Computational Epidemiology Group

The very dangerous, very bad vaccine exemption decision

In the US, 48 states currently allow parents to claim religious exemptions from the vaccines their children are required to receive to attend daycare and school. Eighteen of these states allow personal belief exemptions, which include religious, philosophical, and any other unspecified non-medical exemption. Only 2 states (Mississippi and West Virginia) allow only medical exemptions.

The aggregate data for vaccine exemptions in the United States as a whole isn’t bad. But that can be misleading as it hides the wide variability in vaccination rates due to local pockets of vaccine under-immunization. For the 2011-12 school year, the aggregate rate for vaccine exemption claims was 1.2%. In Oregon, the rate was 6.4%. This was mostly due to the high prevalence of dangerous vaccine beliefs in a handful of communities throughout the state. In my state of Massachusetts, the Department of Public Health recently released its analysis of kindergarten vaccine exemption rates throughout the Commonwealth. Similar to trends in some other states, the Massachusetts data reveals a worrisome increase in medical and religious exemptions claimed by the parents of kindergarteners to one or more required vaccines over the past several years. Throughout Massachusetts, the exemption rate for 2012-2013 was 1.5 percent, a 0.4 percent increase since 2010. For the two counties represented by my practice, Franklin and Hampshire Counties, the exemption rate reached 6.0 and 4.2 percent respectively. These were the highest rates in the state. These numbers may not sound high, but it is important to point out that the herd immunity threshold (the vaccination rate required to prevent outbreaks of disease) is quite high, and that even a small dip in the vaccination rate can bring back disease. For example, the herd immunity threshold for measles is approximately 94%. That means if less than 94% of a community is vaccinated against measles, outbreaks of the disease can begin to spread easily among susceptible members of the community. In other words, we can expect to see outbreaks of a disease as the vaccination drops below the herd immunity threshold for that disease. In my community, we are close to this threshold already. In other communities around the country the situation is even worse, and outbreaks of disease are already being seen. Around the world, the situation is truly dire. In the UK, where the MMR-autism myth was created, outbreaks of measles are still prevalent a full 15 years after Andrew Wakefield published his fraudulent report.

The ease with which vaccine exemptions can be claimed varies by state, but it typically requires little more effort than filling out an annual form. In Massachusetts, a parent must present a physician’s written certification for any medical vaccine exemption. However, a parent may exempt his or her own child quite easily. General Law for the Commonwealth of Massachusetts states:

In the absence of an emergency or epidemic of disease declared by the department of public health, no child whose parent or guardian states in writing that vaccination or immunization conflicts with his sincere religious beliefs shall be required to present said physician’s certificate in order to be admitted to school.

In Oregon, the state with the highest rate of vaccine exemptions, a new law was recently passed that will require parents seeking a non-medical exemption for their children to:

document either a signature from a health care practitioner verifying discussion of the risks and benefits of immunization, or a certificate of completion of an interactive online educational video about the risks and benefits of immunization.

A model school immunization exemption law, which would make it much more difficult for a child to obtain a school vaccine exemption, has been proposed for the State of Arkansas by the Institute for Vaccine Safety, the Johns Hopkins Center for Law and the Public’s Health, and the Arkansas Medical Society. Although no law this restrictive has yet to be passed, such laws may become necessary if outbreaks resulting from increased rates of under-immuization continue to occur. Many healthcare providers and public health experts (myself included) believe that time has already come.


In 1991, I was a senior medical student completing my sub-internship in internal medicine. I was working on a locked drug-rehabilitation ward, where one of my patients was a man with AIDS. He was sick from his disease and from his drug addiction, but what sickened him most, and in the end what killed him, was measles. Ten days later I was in Seattle, having just returned from an interview for a residency position at the children’s hospital there, when I became ill. I had a high fever and a bad cough. I felt something gritty inside my cheek and looked in the mirror to find tiny, sand like particles. I turned to my friend, on whose floor I was sleeping during my visit, and said, “in a few days I will be the sickest person you have ever seen”. I knew right away that I had contracted measles from my patient in New York. For the next 10 days I lay on my friend’s floor coughing uncontrollably, hallucinating, dehydrated, with fever spikes to 105 degrees. In retrospect, I know that I had pneumonia and encephalitis, dangerous complications of measles infection. I have never been sicker in my life, and I could easily have died. I had also potentially infected a lot of people during my tour of the children’s hospital when I was at my most contagious point in the illness. The Department of Health had to be called in to trace my steps and try to protect all of my potential contacts. I, and anyone I may have infected, was a victim of the 1989-1991 US measles epidemic. This was before Wakefield’s paper and the ensuing media frenzy hyping the claim about a potential link between the MMR vaccine and autism. It was before people began, en masse, to choose not to vaccine their children against measles. But this epidemic, which sickened over 55,000 people, was still a result of under-immunization. In this case it was due to low vaccination rates in preschool children as a result of unacceptably poor access to health care. Whatever the reason, the failure to fully vaccinate our children is extremely dangerous. Parental decisions about whether or how to vaccinate their children that are based on misinformation have already resulted in outbreaks of deadly disease.

While many parents who claim exemptions for their children do so on the grounds that it is their right to make such decisions for their children, there is ample legal precedent for the mandatory vaccination of children to protect the public. According to the Supreme Court, “the very concept of ordered liberty precludes allowing every person to make his own standards on matters of conduct in which the society as a whole has important interests.” If the trend toward increasing rates of vaccine refusal and vaccine exemptions continues, enlarging pockets of under-immunization (and non-immunization) guarantees the re-emergence of deadly, entirely vaccine-preventable disease. We are already beginning to see this happen on a small scale. Hopefully it won’t take large-scale outbreaks or epidemics, which will kill and permanently injure untold numbers of children, to get the pendulum to swing back again toward science and reason.

Posted in: Public Health, Vaccines

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