Can this be enforced?

Due to the anti-vaccination movement that has become more popular in recent years, the number of children who haven’t received immunizations is rising. As a result, there have been outbreaks of diseases that normally aren’t seen. This has led some school districts to want to change their policies regarding allowing these children in school due to their risk. The idea of not allowing children to attend public school because they’re not vaccinated has left many wondering if this could be enforced. If so, where do these kids go to receive an education?

VaccinationOne of the most important public health initiatives in the 20th century is our pediatric immunization programs. The reason for the success is statewide immunization mandates for school and childcare entry. In 2000, the United States had the highest immunization coverage and the lowest rates of vaccine-preventable disease ever recorded. In fact, that year, US public health officials declared that measles had been eliminated from the country. Despite this success, the media, the Internet, and antivaccination groups repeatedly put out unscientific, sensationalized, and biased information linking vaccines to numerous health problems resulting in vaccination laws being questioned as unnecessary.

Skepticism about vaccines isn’t new. During the 1800s, disbelievers and big-government critics waged legal battles against mandatory vaccine laws. The definitive answer on the subject came in Jacobson v. Massachusetts, which was presented before the Supreme Court in 1905. They ruled that the government had the right to protect the common good because people who don’t want to be vaccinated can present a danger to the community. The ruling said that all states have the legal authority to mandate vaccinations for all residents. The Court reinforced the government’s ability to require vaccinations as a condition of school attendance in 1922. Schools were major sites of disease transmission. The evidence showed that states with school immunization laws had rates of measles 40-50% lower than states that didn’t have such laws. However, by 1963, only 20 states had a vaccination mandate. That all changed in the 1970s when a measles outbreak occurred. In the fall of 1976, measles was quickly spreading throughout Alaska after starting in Anchorage. Public health officials discovered that schools weren’t following the vaccine law. So, officials decided to actually enforce the law and set a deadline by which children had to be vaccinated. They said that any student who couldn’t prove they had been immunized against the measles would be sent home. On the first day of enforcement, a little over 8% of all Alaskan students were banned from attending schools. Within a few weeks, nearly all of the unimmunized received their shots. This halted the outbreak and the big public outcry health officials feared never happened. Alaska wasn’t the only area to see positive change from enforcing the vaccination law. Los Angeles responded to its own measles outbreak the same way and had similar results. Encouraged by these successes, a national campaign to expand and enforce vaccination laws ensued. By 1980, all 50 states required kids to get at least some vaccines before entering school. This gave birth to the modern childhood immunization initiatives that we know today.

The success of the vaccination programs against common, deadly illnesses was so great that public health officials started targeting diseases that don’t typically spread among kids, like Hepatitis B. Unfortunately, this turned a lot of parents against the whole vaccine schedule. To encourage most people to get vaccinated, most states enacted policies allowing parents not to vaccinate their children on religious grounds. To qualify for the exemptions, they had to demonstrate that vaccinations violate the teachings of a recognized religion to which they belonged. However, many courts found these policies unconstitutional under the First Amendment since they require the government to determine whether a person’s religious beliefs are valid. To combat this, 19 states either replaced or expanded their existing religious exemptions with broader philosophical ones based on personal, moral, or religious beliefs. The other exemption type is medical, which applies to children at significant risk from the vaccination, such as those with compromised immune systems. The percentage of people seeking nonmedical exemptions has been steadily creeping upward. It was 1.1% in 2009-2010, but by 2017-2018, it was 2.2%.

Vaccines were developed to stop children from getting sick and dying. In the US, we’ve done such a great job vaccinating that we’ve forgotten about the devastation measles, polio, pertussis, diphtheria, and the many other illnesses used to cause that we now prevent. Between 1936 and 1945, every year there were about 21,000 cases and 1,800 deaths from diphtheria, 16,000 cases and 1,900 deaths from paralytic polio, 530,000 cases and 440 deaths from measles, and 200,000 cases and 4,000 deaths from pertussis. Now, those numbers are far less. For instance, in 2014, the number of deaths associated with pertussis was 13. It’s the lack of the illnesses that have made some comfortable with the decision not to vaccinate.

Most parents who are hesitant about vaccines will tell you that they’re concerned about the vaccine’s possible side effects. They worry about everything from fevers and soreness to additives to possible links to autism. No vaccine is 100% safe or effective and as vaccination rates go up, reports of vaccine-associated adverse events increase. This adversely affects public perception of vaccine safety. Given the high-tech age we live in, where anyone can say anything and have it broadcast to the world, there is rampant misinformation about vaccines everywhere. One study done years ago said there was a link between vaccines and autism was later retracted because it wasn’t true. Despite this, the study is still used as “evidence” that vaccines cause harm. The American College of Physicians completed a major study tracking 10 years of data on all children born in Denmark. It concluded that the measles, mumps, and rubella vaccine does not trigger autism or increase a child’s risk of being diagnosed. The Centers for Disease Control and Prevention (CDC) has long said vaccinations are safe and the data shows the US’s current vaccine supply is the “safest in history.” The American Academy of Pediatrics has publicly called on Google, YouTube, Facebook, and other social media sites to slow the misinformation on their platforms. Lawmakers and federal agencies are calling for more research on ways to address antivaccine parents’ concerns, halt misinformation, and improve rates of vaccination in the future.

This isn’t to say that parental autonomy isn’t important. The Supreme Court has upheld it on several occasions. However, it doesn’t mean that parental authority is absolute. Parental autonomy can be limited by a state’s interest in protecting children from harm and neglect. With regards to immunizations, the growing refusal of vaccines creates a serious public policy problem. Vaccination works by enlisting a majority in protecting a minority, which means they only work if enough people in a community receive them. When enough people are vaccinated, viruses have trouble spreading, sparing both the unvaccinated and those in whom the vaccination has not produced immunity. Studies have shown that for vaccines to work, at least 92% of a population must be immunized against the disease to protect the community and for highly contagious viruses, that increases to 95%.

So, if large amounts of people don’t get vaccinated, it results in vulnerable points of disease transmission, making the whole population more susceptible to contagious diseases that could have significant impact on morbidity and mortality. This is already documented in states that allow people to opt-out for personal beliefs. The states with lower childhood-vaccination rates have markedly higher incidences of infectious diseases than states that don’t have these opt-outs. In 2006, the Journal of the American Medical Association (JAMA) released a report regarding the spread of pertussis in Vermont, which has a relatively liberal personal-exemption policy, compared to Nebraska, which doesn’t allow personal exemptions. During the same time period of 1986 to 2004, Vermont had a higher incidence of disease. This is a clear demonstration of when you don’t get vaccinated against an illness, you’re more likely to catch it. In another study published in JAMA, researchers looked at information about recent measles and pertussis outbreaks. They found that unvaccinated people made up most of those who caught measles and a large amount of those who end up with pertussis (waning immunity from the pertussis vaccine plays a role too). Some of those infected weren’t old enough to be vaccinated, but of those who were, most came from families who chose not to vaccinate.

When those who choose not to vaccinate live in the same communities, it forms the perfect environment for a vaccine-preventable illness to spread. One example of this comes from a private Montessori school in Traverse City, Michigan—The Children’s House. The idea behind Montessori schools is that they’re meant to mirror “the real world” where individuals work and socialize with people of all ages. Mixed-age classrooms are common, meaning infants, kindergarteners, and adolescents come into contact throughout the school day. Infants who still aren’t fully vaccinated rely on the rest of the school to shield them from outbreaks that can be life-threatening. In January 2015, The Children’s House revised its admissions policy and refused to accept new students whose parents opted-out of vaccinations for their personal beliefs. This came after a report revealed that 23% of the families at the school were opting out of vaccinations. The lack of vaccinations wasn’t just happening at the school though, between 2008 and 2014, the waiver rates for both medical and personal reasons had risen from 6% to 11% in Grand Traverse County. Michigan health records showed that waiver rates had climbed more sharply among local Montessori students than other public and private schools within the state. Both Grand Traverse County and The Children’s House had dangerously high exemption rates. This happened in part because Michigan made it so easy to get a waiver that nearly 45% of its residents lived in counties that were at risk of disease outbreaks. The threat to Traverse City’s children wasn’t merely theoretical because just a month earlier, 22 confirmed cases of pertussis resulted in temporarily closing one of the K-12 charter schools, Grand Traverse Academy. In response, Michigan recently updated its policy for daycare centers and licensed schools. Now, parents who refuse vaccinations because of personal beliefs must have their waivers certified by the local health department.

Another factor that we have to take into consideration is that we live in a global community. Travel is easy and lots of people do it. So, while we’ve done a great job eradicating vaccine-preventable diseases in the US, they haven’t been eradicated from the world. According to the World Health Organization (WHO), measles cases have been slowly rising in countries around the world, with a 300% increase being seen. Many countries, such as Britain, Greece, Brazil, France, and Germany, where measles had been declared eliminated, have recently lost that status. The US has come close to losing its measles elimination status. This reversal has led other countries to come up with new measures to ensure better vaccination rates. In Italy, the parliament recently passed a law requiring parents to prove their children have their vaccinations before entering school or face a €500 (about $600 USD) non-compliance fine. In Germany, lawmakers passed a law stating that parents need to prove they’ve vaccinated their kids against measles or pay fines up to €2,500 (about $2,750). In addition, unvaccinated children risk losing their places in school. Australia has also implemented fines for schools that let in unvaccinated kids. France’s health ministry made 11 vaccines (an increase from their current three of diphtheria, tetanus, and polio) mandatory for children, although there’s no fine yet.

In the US, New York, where a recent large measles outbreak lasted for nearly a year, the government threatened parents who don’t vaccinate their children with a fine of up to $1,000. Ultimately, in June 2019, New York state ended religious exemptions and passed a law saying children who aren’t vaccinated can’t attend classes. Medical exemptions are still allowed, but a doctor with a New York license must first certify “that such immunization may be detrimental to a child’s health.” There was a 14-day grace period at the start of the next school year, after which school officials barred students from going to class or began removing them from schools to be picked up by their parents. Students could return to school if their parents had them vaccinated. If they don’t follow the law, schools face a fine of up to $2,000 per student. The state’s health department was increasing its audits of schools to assure that the new vaccination rule was being followed.

If more states were to follow New York’s example of limiting personal exemptions for vaccines, it would be a good move, but that could take a very long time. This is why it’s important to know that schools do have the authority to bar unvaccinated students during a health threat. The exemption forms that parents submit to schools include a warning that this may happen. If the schools don’t remove unvaccinated children, they could potentially be held legally accountable for not protecting their community. The issue is how much authority do schools have when disease burdens and risks of infection are low. The American Federation of Teachers encourages parents to vaccinate themselves and their children. For private schools, like The Children’s House, it’s easier to put into place policies. It only took them four months to develop a new admissions policy in the face of the surprising statistics. This exemplifies the degree to which the education system is emerging as a key player in the vaccine debate and how educators, not state legislators or health officials, could ultimately be the ones that resolve the public controversy over immunization requirements.

Some people feel that refusing vaccines on behalf of your children amounts to child abuse and parents who do this should be punished for their decision. The idea of punishing parents for doing things that could harm their kids is not without precedent. For instance, there are laws requiring parents to use car seats or seat belts for their children or pay a fine or be docked driver’s license points. There are similar laws for firearm storage. Instead of going to these drastic measures, lawmakers should look for ways that make it more inconvenient to opt-out, such as requiring a signature from the local health department/doctor licensed to practice in the particular state or having exemptions that require regular renewals.

One thing is for certain, we can’t ignore that vaccines are incredibly effective and have saved thousands of lives. To continue to have successful vaccination programs, we will need to shift the policy balance away from personal autonomy toward social responsibility. We’re all in this together, so we need to make sure the information available about vaccines is reliable and accurate. Doing this should encourage people that vaccines are safe and to vaccinate themselves and their children.