Mandatory Childhood Vaccinations            

While childhood vaccination rates have remained relatively stable, the Centers for Disease Control and Prevention (CDC) reported in 2017 that the percentage of children with no vaccines by 24 months old increased from 0.9% for those born in 2011 to 1.3% in 2015.¹ Yet, the CDC advises children receive 14 vaccinations by the age of 24 months.¹ Vaccines are a safe and effective way to protect individuals and society from life-threatening diseases however the rates continue to decline in the United States.¹ Factors ranging from religious exemptions to false information, creating a culture of “anti-vaxxers”, have led to outbreaks of diseases such as the measles. Not only does this put those unvaccinated children at risk, but it is also a public health issue as a lack of vaccination leaves multiple vulnerable populations, who cannot be vaccinated, at risk as well.  

            In 2016 there were only 86 reported cases of the measles.² By 2017, there was an increase to 120 cases and then 375 and 1,282 cases in 2018 and 2019 respectively.²  A majority of these affected individuals were unvaccinated.² Two separate outbreaks during this period, one in Minnesota and multiple in New York, effectively reveal the concern regarding both misinformation about vaccinations and religious exemption. Prior to a 2017 outbreak, a Somali-American community in Minnesota had high vaccination rates, but rates declined from over 90% in 2004 to approximately 45% in 2014.³ This was after members of the community read about Andrew Wakefield’s study and other false information suggesting a link between autism and measles, mumps, rubella (MMR) vaccinations.³ The result was a 65 case measles outbreak, with 95% of those affected unvaccinated and 85% of those affected to be Somali-American children.³ In New York, largely in Orthodox Jewish communities, there were 649 confirmed cases of the measles between September 2018 and August 2019.⁴ Of those cases, approximately 73% of the individuals were unvaccinated.⁴ Similarly, in Rockland County between October 2018 and April 2019, there were 206 confirmed cases of the measles, with most cases within Orthodox communities.⁵ The measles vaccination rates for the previous year in the schools located in outbreak communities was 77% in comparison to the 98% vaccination rate from the New York State School Immunization Survey.⁵ 

            However, this is not just a small community problem confined within Somali-American or Orthodox Jewish populations. Research from a large retrospective cohort study of specific Florida Medicaid individuals found that nine people with one-dose MMR vaccinations were diagnosed with the measles from 1990 to 2009.⁶ This was in comparison to seventy-six diagnosed individuals from the unvaccinated cohort, further emphasizing the efficacy of vaccination.⁶ Furthermore, there were no cases of measles in either cohort from 2004 to 2009 in this study, most likely due herd immunity which is the protection of a population from a disease when the population is vaccinated.⁶ Additionally, MMR coverage varies widely between states from 85.8% in Missouri to 98.3% in Massachusetts in 2017, thus identifying that factors other than religious exemption and misunderstanding of data may be involved.¹ The implications of such exhibit that those unvaccinated are both expansive throughout the country and results in a greater risk to diseases such as measles infection and its transmission.

            Myths in regard to vaccinations and religious exemptions to vaccinations still remain in many states. In addition, disease rates for many diseases with vaccines are low due to high vaccination rates. These factors result in individuals not realizing the severity of such preventable diseases, despite recent outbreaks. According to the CDC, prior to the measles vaccine hundreds would die each year.⁸ Thousands of Americans died of diphtheria prior to vaccinations while only two cases were reported between 2004 and 2014.⁸ Also, as noted above when healthy individuals get vaccinated, the spread of disease can be contained. This is displayed through 2016 estimates in the decline of morbidity of vaccine-preventable diseases, such as a 99.9% reduction in measles, 100% reduction of smallpox and 99.9% reduction in rubella.⁹ In comparison, when healthy individuals are unvaccinated a disease can spread and become commonplace as almost all diseases are not eliminated from the country or world, revealing the potential devastation that can occur.⁸ With such public health implications, it is startling that 44 states in the US continue to allow for religious exemption, 15 states allow for personal and religious exemption and one state, Minnesota, allows for personal exemption that does not mention religion.¹⁰ The evidence provided raises the question: How should the United States mitigate further vaccine-preventable outbreaks? 

            There are several solutions to prevent the further decline of vaccination rates and protect Americans from preventable diseases, such as vaccination education programs to parents. However, mandatory childhood vaccination is the securest solution to this problem. Such a policy would remove the state exemptions of religious or personal reasons to vaccines and would be implemented regardless of if the child will be or is enrolled in a public school. The only exemption to this would be children who cannot get the vaccines due to medical reasons such as being immunocompromised or having a severe allergy. Additionally, the mandate would not force a specific timeline on vaccinations, rather the recommended timeline would remain, with the exception that by a certain age the vaccines must be administered. These vaccines would include but are not limited to MMR, Polio, Hepatitis B, DTaP, Hib and Varicella. All of these vaccines prevent against diseases that can be life-threatening and have been heavily studied in their efficacy and safety. This solution removes outbreaks from low vaccination rates due to personal choice or religion, ultimately providing further protection for the public and vulnerable populations. With a vaccination mandate beginning with a specific birth cohort and continuing thereafter, herd immunity would continue to increase within the country. Both the short- and long-term goals ultimately results in a decrease in preventable-diseases within the United States by mandating childhood vaccinations with minimal applicable exemptions. 

            The above proposal has both strengths and weaknesses that must be addressed in order to successfully understand its effectiveness. Mandating childhood vaccinations, as stated above, will eventually provide efficient herd immunity throughout the entire country. This will afford protection to vulnerable populations that are unable to be vaccinated and will essentially help reduce the risk of diseases spreading. Requirement can also provide a financial benefit to the country, as there will be a decrease in expenditure for vaccine-preventable diseases such as the measles. Furthermore, outbreaks will be nearly eliminated and only limited to individuals, or communities afflicted by the same vulnerabilities that do not allow them to receive the vaccination in the first place. Essentially, mandated vaccinations provides the country with increased immunity to diseases and decreases the likelihood of outbreak, morbidity and mortality. However, there are weaknesses and limitations to this proposal. Mandating vaccinations is controversial and questions biomedical ethics principles such as autonomy. Complete vaccination for those eligible does not equate to elimination of disease, as vulnerable individuals are still susceptible, vaccination effectiveness is not 100% and foreign individuals can still bring imported cases to the country. Additionally, the government may need to increase spending to enhance population understanding of the safety, efficacy and importance of this solution. Regardless, the childhood vaccination rate is a concern in the United States that must be addressed. While a mandatory vaccination proposal has both strengths and limitations, it can provide a substantial benefit to public health.

Sources:

1. https://www.cdc.gov/mmwr/volumes/67/wr/mm6740a4.htm?s_cid=mm6740a4_w
2. https://www.cdc.gov/measles/cases-outbreaks.html
3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5687591/pdf/mm6627a1.pdf
4. https://www1.nyc.gov/site/doh/health/health-topics/measles.page
5. https://www.cdc.gov/mmwr/volumes/68/wr/pdfs/mm6819a4-H.pdf
6. https://link.springer.com/content/pdf/10.1186/s12887-019-1710-5.pdf
7. https://www.cdc.gov/vaccines/vac-gen/whatifstop.htm
8. https://www.cdc.gov/vaccines/vac-gen/whatifstop.htm
9. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4927017/pdf/ptj4107426.pdf
10. https://www.pewresearch.org/fact-tank/2019/06/28/nearly-all-states-allow-religious-exemptions-for-vaccinations/