In January 2015, the California Department of Public Health received reports of several suspected cases of measles in California and Utah. The connecting links in these, and soon to be many other cases, were visits to Disneyland Resorts in Anaheim.1 By mid-April, when new infections had ceased, 131 measles cases in California were linked to the Disneyland outbreak,2 with at least twelve additional cases in other states.3
As panic swept the nation, many wondered how such a widespread outbreak of measles could have occurred in the United States, a country where measles vaccinations had made this disease seem like a concern of the past. “The problem,” explained Jane Seward, a director of viral diseases at the Centers for Disease Control (CDC), “is that there are these pockets with low vaccination rates. If a [measles] case comes into a population where a lot of people are unvaccinated, that’s where you get the outbreak and where you get the spread.”4
Accordingly, these events brought increased scrutiny to parents who forgo some or all childhood vaccines, whether out of fear of alleged side effects, a desire to have an “all-natural” lifestyle, or religious opposition. Schools in areas with large numbers of vaccine refusers can see vaccination rates fall far below the approximately 95 percent needed to prevent measles outbreaks. This can occur despite school-entry vaccine requirements because of “loopholes” allowing vaccine refusers to send their children to school by obtaining nonmedical or “personal beliefs” exemptions from school vaccination policies.
Typical school rules require vaccines that are jointly recommended by the CDC, the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP). This list of recommended vaccines currently includes tetanus, diphtheria, pertussis, polio, pneumococcus, Haemophilus influenzae type B, measles, mumps, rubella, chickenpox, and rotavirus. Some states provide nonmedical exemptions, enabling parents to send their children to school without receiving these vaccines.5 People who favor such exemptions cite them as a means by which parents can maintain a choice regarding which medical treatments their children receive. Those who oppose nonmedical exemptions see them as posing a risk to public health by increasing the possibility that dangerously contagious children could spread infection in schools.
This controversy gained dramatically more attention when then-presidential-hopeful and New Jersey Governor Chris Christie publicly advocated for finding a middle ground, saying of vaccines, “we think that it’s an important part of being sure we protect [our children’s] health and the public health. I also understand that parents need to have some measure of choice in things as well, so that’s the balance that the government has to decide.”6 A heated nationwide debate ensued, with practically every presidential contender commenting on the issue of vaccines, their effectiveness, their purported side effects, and to what extent they should be mandatory.
The appropriate “balance” of how government schools, which are populated by a substantial majority of American children, should approach the issue of vaccine rules and exemptions is a complex matter. But the most important questions surrounding the issue are: How do vaccines work? Does their use involve a significant risk of neurologic harm? How would a proper, strictly rights-protecting government approach these issues? And how, given our current government, which is not limited to the protection of rights, can we most reasonably apply medical knowledge and principles for the purpose of maximizing public safety and health?
The answers to these questions will provide the context for a proper approach to the issue of vaccine choices and requirements.
How Do Vaccines Work?
Hillary Clinton weighed in on Chris Christie’s 2015 vaccine comments with a succinct same-day reply on Twitter: “The science is clear. The earth is round, the sky is blue, and #vaccineswork. Let’s protect all our kids. #GrandmothersKnowBest.”7
Of course, vaccines do work, as evidenced most conspicuously by the worldwide eradication of smallpox and the Western expulsion of endemic polio. Interestingly, however, the pioneers who developed our earliest vaccines did so with little knowledge of how they work. . . .
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1. Jennifer Zipprich et al., “Measles Outbreak—California, December 2014–February 2015,” Morbidity and Mortality Weekly Report (MMWR), vol. 64, no. 6, February 20, 2015, 153–54, http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6406a5.htm.
2. “Measles Outbreak That Began in December Now Over,” California Department of Public Health, April 17, 2015, https://www.cdph.ca.gov/Pages/NR15-029.aspx.
3. Nakia S. Clemmons et al., “Measles—United States, January 4–April 2, 2015,” Morbidity and Mortality Weekly Report (MMWR), vol. 64, no. 14, April 17, 2015, 373–76, http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6414a1.htm.
4. Adam Nagourney and Abby Goodnough, “Measles Cases Linked to Disneyland Rise, and Debate over Vaccinations Intensifies,” New York Times, January 21, 2015, http://www.nytimes.com/2015/01/22/us/measles-cases-linked-to-disneyland-rise-and-debate-over-vaccinations-intensifies.html?_r=0.
5. Advisory Committee on Immunization Practices, “Recommended Immunization Schedules for Persons Aged 0 through 18 Years,” Centers for Disease Control, January 1, 2016, http://www.cdc.gov/vaccines/schedules/downloads/child/0-18yrs-child-combined-schedule.pdf.
6. Philip Rucker, “Christie Clarifies Comments on Measles Vaccine after Call for ‘Balance’ Causes Stir,” Washington Post, February 2, 2015, https://www.washingtonpost.com/news/post-politics/wp/2015/02/02/christie-breaks-with-obama-over-measles-vaccine-calls-for-balance/.
7. Hillary Clinton, Twitter post, February 2, 2015, 7:45 p.m., https://twitter.com/HillaryClinton/status/562456798020386816?ref_src=twsrc%5Etfw.
8. Susan L. Plotkin and Stanley A. Plotkin, “A Short History of Vaccination,” in Vaccines, 6th ed. (Philadelphia: Saunders, 2012), 1.
9. Plotkin and Plotkin, “A Short History of Vaccination,” 2.
10. Wiliam E. Paul, “The Immune System,” in Fundamental Immunology, 7th ed. (Philadelphia: Lippincott Williams & Wilkins, 2013), 2.
11. Paul, “The Immune System,” 3–8.
12. Claire-Ann Siegrist, “Vaccine Immunology,” in Vaccines, 6th ed. (Philadelphia: Saunders, 2012), 14.
13. Paul E. M. Fine and Kim Mulholland, “Community Immunity,” in Vaccines, 6th ed. (Philadelphia: Saunders, 2012), 1395–96.
14. Fine and Mulholland, Community Immunity,” 1399.
15. “CNN Reagan Library Debate: Later Debate Full Transcript,” CNN Pressroom, September 16, 2015, http://cnnpressroom.blogs.cnn.com/2015/09/16/cnn-reagan-library-debate-later-debate-full-transcript/.
16. Andrew J. Wakefield et al., “Ileal-Lymphoid-Nodular Hyperplasia, Non-Specific Colitis, and Pervasive Developmental Disorder in Children,” Lancet, vol. 351, no. 9103, February 28, 1998, 637–41.
17. Brian Deer, “Focus: MMR—The Truth behind the Crisis,” The Sunday Times (London), February 22, 2004.
18. Paul A. Offit, Deadly Choices: How the Anti-Vaccine Movement Threatens Us All (New York: Basic Books, 2011), 93–94.
19. Cedillo v. Secretary of Health and Human Services, Case No. 98-916V, United States Court of Federal Claims, June 22, 2007, 2281–94, http://www.uscfc.uscourts.gov/cedillo-v-secretary-health-and-human-services-case-no-98916v-concluded-june-26-2007.
20. Luke E. Taylor et al., “Vaccines Are Not Associated with Autism: An Evidence-Based Meta-Analysis of Case-Control and Cohort Studies,” Vaccine, vol. 32, no. 29, June 17, 2014, 3623–29.
21. James D. Cherry, “Pertussis Vaccine Encephalopathy: It Is Time to Recognize It as the Myth That It Is,” JAMA, vol. 63, no. 12, March 23, 1990, 1679–80.
22. A. E. Miller et al., “A Multicenter, Randomized, Double-Blind, Placebo-Controlled Trial of Influenza Immunization in Multiple Sclerosis,” Neurology, vol. 48, no. 2, February 1997, 312–14.
23. Barbara Loe Fisher, “Pencil Pushers Deny Vaccine/Optic Neuritis Link,” Vaccine Awakening, June 14, 2006, http://vaccineawakening.blogspot.com/2006/06/pencil-pushers-deny-vaccineoptic.html.
24. Offit, Deadly Choices, 77–80.
25. Offit, Deadly Choices, 71–73.
26. Offit, Deadly Choices, 106.
27. Offit, Deadly Choices, 107–9.
28. Offit, Deadly Choices, 129.
29. Offit, Deadly Choices, 130.
30. “Measles,” in Epidemiology and Prevention of Vaccine-Preventable Diseases, 13th ed. (Centers for Disease Control and Prevention, 2015), http://www.cdc.gov/vaccines/pubs/pinkbook/meas.html.
31. Offit, Deadly Choices, 136–38.
32. Offit, Deadly Choices, 142.
33. Offit, Deadly Choices, 143.
34. Offit, Deadly Choices, 143.
35. Offit, Deadly Choices, 143.
36. Jeffrey A. Singer, “Seeking Balance in Vaccination Laws,” reason.com, February 7, 2015, http://reason.com/archives/2015/02/07/seeking-balance-in-vaccination-laws.