Perspectives on the Acute Care Continuum


Time to End Personal Exemptions for Vaccinations?

3/10/2015 4:53:49 AM | 3 comments

Last month, California state senators introduced a bill that would end personal exemptions to the state's vaccination program. If the law passes, California will have some of the strictest vaccination laws in the country, allowing exemptions solely for medical reasons.
Vaccination is, of course, an incredibly emotional topic that raises questions about individual liberty on one hand and public health on the other. Citizens have been resisting mandatory vaccination since Britain passed the first such laws in the 1850s. In recent years, celebrities like Jenny McCarthy, Jim Carrey, and Robert F. Kennedy Jr. have publicly questioned the safety of vaccines and asserted that parents should have the right to refuse them. And while none of them are scientists, their views have stoked the public’s paranoia.
Unfortunately, public fear and confusion have caused inoculation rates to plummet. Vaccination rates at some California schools are now on par with those in desperately poor South Sudan. The consequence has been the resurgence of infectious diseases like measles and pertussis that, as recently as the 1980s, had been virtually eliminated in our country.
On one hand, I can comprehend the position of non-vaccinating parents. Vaccines have real costs in terms of side effects and frequent doctors appointments. The media and celebrities bombard us with misguided suggestions that vaccines trigger autism and other health problems. And while correlation doesn't imply causality, autism is often diagnosed in early childhood when kids also happen to be getting a lot of shots. So it's natural that despite massive scientific evidence to the contrary, parents still wonder if danger might be lurking.
On the other hand, as a physician who has treated young patients who are suffering horribly from the effects of preventable illnesses, I feel that the benefits of vaccines far outweigh the risks. In my opinion, here are five good reasons to mandate vaccination:

1. Vaccines Save Lives

In some ways, vaccines are victims of their own success. They’re so effective that most of us have never witnessed the devastating effects of polio, tetanus, or diphtheria. Just a few years ago, measles and pertussis were so rare that many of my emergency department (ED) colleagues had never seen a case firsthand. Unfortunately, diseases that previously existed only in textbooks and developing nations are now everyday realities in our hospitals.
The latest example is the ongoing Disneyland measles outbreak, which directly infected 39 people and may be responsible for over a hundred cases. Most people who get measles in the developing world recover completely. But it’s not a trifling illness. One in 20 children with measles develops pneumonia, a potentially life threatening complication. Ten percent develop ear infections, which can result in permanent hearing loss. For pregnant women, the disease can cause miscarriage or low birth weight.

2. Herd Immunity

When a sufficient number of individuals are vaccinated against a disease, it's unlikely to spread within that population. This "herd immunity" protects a small percentage of unvaccinated individuals, including babies who haven’t had their shots yet, kids who can’t be vaccinated because they’re immunocompromised and adults whose immunity has lessened with time. The herd immunity threshold for highly contagious diseases like measles and pertussis is above 90 percent.

3. Burden on Healthcare Resources

Widespread fear of deadly infectious diseases puts a real strain on our country’s overworked EDs. During the recent measles outbreak, our California ED treated a small number of measles patients. However, much like the recent Ebola panic, we’ve spent much more time ruling out suspected cases and alleviating the public’s fears. This increased patient volume exacerbates crowding and decreases EDs' capacity to provide life-saving care for people with stroke, heart attack, and trauma.

4. Safety

Vaccines in development undergo far more rigorous efficacy and safety testing than other medications. This hasn’t stopped concerned citizens and fringe scientists from linking them to autism, multiple sclerosis, autoimmune diseases, or sudden infant death syndrome (SIDS), despite a lack of sound scientific evidence.
Perhaps the most devastating vaccine scare stemmed from a fraudulent 1998 study led by British researcher Andrew Wakefield. His paper, which was published in The Lancet, outlined preliminary evidence linking the MMR vaccination with bowel disease and autism in 12 children. Over the next few years, it emerged that Wakefield had falsified data and that his research was beset by serious conflicts of interest. In 2010, The Lancet formally retracted Wakefield’s 1998 paper, and most of the original authors publicly distanced themselves from the study.
Massive epidemiological studies involving millions of children worldwide have found no evidence linking vaccines to autism. While all medications have potential side effects, the vaccine injury is extremely low — especially when weighed against the risk of a life-threatening illness.

5. Undervaccination

Even when parents wish to vaccinate their children, systemic barriers may prevent them from keeping up with the recommended schedule. This is especially true in medically underserved communities, where parents and children must travel long distances to see a pediatrician. Other barriers include lack of transportation, difficulty getting time off work, and long waits for physician appointments. As a result, 13 percent of kindergarteners in the Los Angeles public schools are behind on their recommended vaccinations.
Healthcare reform and a growing emphasis on prevention will hopefully address some of these barriers in coming years. For example, the Los Angeles schools have hired nurses to help document kids’ immunization statuses and catch up those who are behind. But until the problem is corrected, undervaccination remains a threat to public health — and another good reason to vaccinate on time when possible.

The Needs of the Many

The vaccine controversy raises strong emotions because it pits individual liberty against public safety. This is not an unusual situation in our society, and in almost all cases where these values are in conflict, public safety wins out.
Consider traffic laws. Living in Southern California, there are certainly days when I’m tempted to thwart a bottleneck by veering onto the sidewalk or passing on the shoulder. But such acts would cause considerable risk to pedestrians, property, and fellow motorists — especially if all drivers engaged in them willy-nilly. The threat of a traffic ticket might affront my individual freedom, but it arguably deters me from reckless behavior, keeping my neighbors safer.
Likewise, parents who choose not to vaccinate for personal or religious reasons need to understand the risks they are taking — for their own children and for babies, immunocompromised individuals, and others who rely on herd immunity. Some pediatricians are already taking a stand by refusing to see unvaccinated patients. (This makes even more sense when you consider the potential for disease transmission in their waiting rooms.)
While physicians can do much to educate parents about vaccines, it’s foolhardy to believe they can sway all parents. History has taught us that some people will always resist vaccination (and other public health efforts) even in the face of considerable social and legal pressure.
That’s why I believe laws ending personal vaccine exemptions are our best hope to stave off a serious public health threat. While we can't choose for parents, it seems fair to increase the "cost" of going unvaccinated to bring it more into proportion with the potential risk it creates for others.

shoulder pain Melbourne
"Vaccines Save Lives" agree.
4/6/2015 9:14:47 AM

Kevin Riggs
Thank you for the post! This is an issue that should be addressed so that we do not repeat history. In our time of resistance and superbugs, we should try to control those things we can and limit the amount of harm caused to the most people.
3/11/2015 2:19:59 PM

Modern Physician
What do you suppose is causing the skyrocketing autism rates in the US? Not saying it's vaccines... just that there is something going on there...
3/10/2015 6:38:14 AM