This year's debate over Senate Bill 276 (Pan) has generated significant controversy in an area where there should be none – the importance of vaccinating all children from often deadly or debilitating communicable diseases.
This debate comes as infectious diseases that used to claim the lives of one in six children before their fifth year are making an alarming comeback in California and nationwide. The culprits are parents who should know better – and the politicians who accommodate them.
Parents of small children today no longer know the fear of deadly childhood diseases. It wasn't so long ago that diphtheria, measles, and whooping cough epidemics regularly killed large numbers of children and left others with permanent disabilities. As a child in the 1950s, I was prevented by my parents from going to public swimming pools during the summer because of the threat of polio.
But thanks to the miracle of vaccines, these outbreaks became rare. However, a kind of amnesia about the threat of infectious diseases, combined with a fraudulent scare that supposedly linked autism to vaccines, and a small but vocal anti-vaccine movement – as shown by the loud opposition to SB 276 – have diminished compliance with vaccination schedules. The result has been the resurgence of certain diseases. The World Health Organization now includes "vaccine hesitancy" on its list of the ten greatest threats to global health.
Measles is one almost-extinct viral illness that has returned. Between 2001 and 2008, a median of fifty-six measles cases were reported each year to the U.S. Centers for Disease Control and Prevention (CDC). So far in 2019, 1,109 individual cases have been confirmed in 28 states. This is the greatest number of U.S. cases reported since measles was declared eliminated in 2000.
Such infections not only cause unnecessary morbidity and mortality but exact significant health care costs. A measles outbreak in Arizona among only fourteen patients cost the two hospitals involved $800,000.
Measles is highly contagious, and the CDC cites several factors that facilitate its spread: (1) The majority who got measles were unvaccinated; (2) the disease is still common in many parts of the world; (3) travelers bring the disease into the U.S.; and (4) measles can spread quickly in U.S. communities where many are unvaccinated.
Pertussis, or whooping cough, is also making a comeback. Twenty years ago, vaccines had reduced the incidence to about seven to eight thousand cases annually in the U.S., but there were more than 48,000 cases in 2012 and just under half that each year since.
All 50 states have legislation requiring specified vaccines for students, but there are some exceptions to the requirement. Although exemptions vary state by state, all school immunization laws grant exemptions to children for medical reasons, such as a vaccine allergy (which is quite rare). Forty-five states and Washington D.C. grant religious exemptions, while 15 states allow "personal belief exemptions" for those who object because of moral or other beliefs. In states that permit them, parents need only sign a form stating their wish to exempt their children from the vaccination requirement, with no specific reason required.
Given the resurgence of almost-extinct illnesses, permitting non-medical vaccine exemptions is a threat to individual children and to the community at large. Although adults should be permitted to make decisions about their own medical care-however unwise they may be-the capricious rejection of vaccines for children is tantamount to withholding a needed blood transfusion or operation.
Putting a single child at risk also puts the community at risk. Some of the recent outbreaks occurred when unimmunized or under-immunized travelers abroad returned home, became ill, and gave rise to other cases that swept through communities, infecting the unprotected.
The higher the community's vaccination rate, the less likely an epidemic will spread. An important determinant of spread is whether there is "herd immunity," an immunological barrier to an infectious disease that appears when a large portion of the population (about 75-94 percent, depending on the infectious agent) is vaccinated. The spread of the pathogen is blocked in person-to-person transmission when it confronts immunized, resistant individuals. When community-level protection falls below a certain level, infection rates rise precipitously. Thus, a high rate of immunization is essential to protect everyone, including those few who legitimately cannot be vaccinated or who have a sub-optimal immune response, such as the elderly.
Another confounding factor is Russian agit-prop intended to create concerns and confusion about vaccination in the U.S. A study by academics published last year in the American Journal of Public Health found that thousands of Russian social media accounts spread anti-vaccine messaging.
The underuse of vaccines should be approached in several ways:
- Public health agencies should more aggressively educate the public about the importance of vaccination. The U.S. Surgeon General, Dr. Jerome Adams, has been largely AWOL on this issue; inexplicably, promoting vaccination is missing from the priorities listed on his official webpage.
- Health care workers should be required to be vaccinated against flu and other common infectious diseases; in the absence of a confirmed allergy to a vaccine, any who refuse it should be removed from patient contact or have their employment terminated.
- Physicians who care for children should decline to treat families who refuse vaccination, to protect other children and their families who might be exposed to virus-shedding in the doctor's office.
- Philosophical exemptions from immunizations should be eliminated, and we should reconsider whether "religious exemptions" are legitimate, particularly for children. Although beliefs should be respected, we cannot jeopardize public health by compromising herd immunity.
- Social media outlets should consider carefully whether anti-vaccine messages are anti-social and should be rejected.
There is no way to immunize against adults' ignorance and bad judgment, but we can at least demand that children not be endangered.
Henry I. Miller is a physician, molecular biologist, and senior fellow at the Pacific Research Institute. The co-discoverer of an enzyme that is critical in the replication of influenza virus, he was the founding director of the FDA's Office of Biotechnology.