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Mandatory Vaccinations: State of the Union

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By Dr. Jennifer Sedillo
Faculty Member, Public Health at American Public University

Vaccinations are regarded by the scientific community as the single most effective prevention method for infectious diseases.

Vaccines have virtually eliminated diseases such as polio in the United States and smallpox around the world. Developing vaccines for malaria and Ebola is considered to be the best way to eliminate those diseases. Despite the successes of vaccines, anti-vaccination movements thrive.

When the smallpox vaccine was introduced and made mandatory for school-aged children in the 1800s, anti-vaccine campaigns were quick to follow. There was a disbelief of the scientific validity of the vaccine and a belief that the mandate was authoritarian. Similar arguments followed for the diphtheria, tetanus and pertussis (DTP, now DTaP) vaccine in the 1970s and the Hepatitis B vaccine recommendation for infants in the 1990s. In the 1970s, the DTP vaccine was blamed for causing neurological disorders in children. An expert advisory committee investigated those claims and found no scientific evidence for the accusation.

The measles, mumps, and rubella (MMR) vaccine first became the target of an anti-vaccination campaign when a now-retracted Lancet article by Andrew Wakefield and colleagues hit the mainstream media in 1998. The article suggested that the vaccine causes gastrointestinal disorders and may be linked to developmental disorders. Wakefield later lost his medical license due to his misconduct in this research and the link of MMR to autism has been invalidated in numerous studies.

In both the DTP and MMR vaccine predicament, the driving force of the origination of the anti-vaccine campaign was to sustain a lawsuit brought by parents of children with development disorders. The same scientifically unfounded arguments against vaccines have been prevalent within society for hundreds of years.

Infectious diseases that are communicable need to be prevented from spreading and vaccines are the single best way to accomplish this. In the U.S., we have seen outbreaks of vaccine-preventable disease in the past few years. In 2014, 628 measles cases reported to the Centers for Disease Control and Prevention (CDC), representing a more than 300 percent increase compared to 2013. Within the first two months of the current year, 91 cases of measles were reported to the CDC . In 2014, there were 2,088 cases of whooping cough reported and, this year, 1,269 cases have already been reported. In a society where vaccines are readily available, why are we seeing such a high number of cases?

State Vaccination Mandates and Exemptions

Mandatory vaccinations for school-aged children and those entering college exist in all 50 states. These mandates were first established with the implementation of the smallpox vaccine for school-aged children in the 1800s and were upheld as constitutional by a U.S. Supreme Court decision in 1905 and the subsequent refusal to hear a case in 1922.

Currently, all states have mandatory vaccine schedules, although they are not consistent between states and all states allow for medical exemptions to mandatory vaccination. Most also allow for religious or philosophical exemptions but requirements for the exemption fluctuate; some states require a signed note from a physician while others require parents to read educational materials on the disease and sign a consent form.Mandatory Vaccination debate

The epicenter of the most recent outbreak of measles occurred at Disneyland in California, a state which allows for exemptions for religious and philosophical beliefs. In this outbreak, at least 25 percent of those infected were eligible for vaccinations but had not received the vaccine due to philosophical beliefs (43 percent were unknown in vaccination status). Of the 110 infected to date, 15 percent were hospitalized.

Despite the growing number of vaccine-preventable disease outbreaks and epidemics, states are opting to expand philosophical exemptions. As of February 2015, all 50 states allow for religious exemption. This month, the number of states that allow for philosophical exemptions for vaccination will grow to include Montana and New York, bringing the total number of states to 22. Unfortunately, even though the courts have ruled that a philosophical exemption is not necessary; politics have managed to undermine the courts.

HPV: Controversial Vaccine Policy

The human papillomavirus (HPV) vaccine has been shown to be 100 percent effective in preventing cervical cancers caused by HPV strains 16 and 18, which are responsible for 70 percent of all cervical cancer cases. In order for the vaccine to be effective, it must be administered prior to sexual activity so school-aged children are the target population. Administering the vaccine is controversial due to the fact that HPV is a sexually transmitted disease and is not communicable through normal, everyday contact.

Despite the unprecedented efficacy of this vaccine, legislation to require vaccination in children is stalled. In 2007, Rick Perry, the governor of Texas, enacted an executive order that required female students entering the sixth grade to receive the HPV vaccine. This order was quickly overridden by state legislators. Virginia, in the same year, successfully passed a bill to require the vaccination for school attendance which went into effect in 2008. Since the bill passed in 2008, two attempts to repeal the bill have failed.

To date, the District of Columbia and Virginia remain the only jurisdictions with this mandate. Because mandatory vaccination bills are not popular, current state-proposed HPV vaccine legislation focuses on education and access. However, most of the legislation has yet to officially pass.

State courts and the U.S. Supreme Court have ruled that mandatory vaccination is not a violation of the constitution. The therapeutic index of vaccines has been demonstrated by science again and again over hundreds of years.

So, why do anti-vaccination campaigns still exist? Perhaps legislation that increases awareness and availability of vaccines will be enough to once again rid the U.S. of completely preventable infectious diseases.

About the Author
Jennifer Sedillo is an associate professor in the Public Health program at American Public University. She recently received her doctorate from the University of South Florida where she was involved in infectious disease research.  She has been involved in biomedical and environmental microbiology research for the past 12 years.

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