2015. Current Climate

Schools should have the right to ban unvaccinated children. One kid’s civil liberty cannot trump another’s health and safety.

–Robin Abcarian, Los Angeles Times

1900s: Disease Eradication

1980s: Paradigm Shift

2000: Measles Elimination

2014: Disneyland Outbreak

2015: California SB 277

2015: Current Climate

 

SB277 and Mandatory Vaccination: Evaluating the Ethical Implications

Paternalism

The discussion around mandatory vaccination is often framed in regard to personal liberty versus public health. Under the main arguments is the question of whether or not the government has the ‘right’  to ‘infringe upon’ the personal liberties of individuals, especially in matters related to their health. Health decisions, of course, are accepted as deeply personal decisions in which the government should not intrude.

But why is the discussion so provocative? This is because under the notion of government ‘intrusion’ is the connotation of unjust paternalism. Paternalism in the context of government involves the establishment of coercive laws–that is, laws that restrict the actions of individuals–in the name of the individuals’ best interests. The government essentially takes a ‘fatherly’ role (to invoke the root of the word) to help protect the (ignorant) ‘children’ of society from themselves. Some modern laws, such as seatbelt laws and helmet laws, can be thought of as paternalistic, designed to protect people from themselves.

Paternalism is problematic for two main reasons: (1)  it suggests that the government actually knows what is in the best interest of an individual, and (2) because it places people in an unfairly passive role in their own lives, often with intimate decisions like health. In the case of vaccination of children, a parent might be distraught with the idea of the State knowing what is best for her child’s health and at the same time feeling disempowered with the notion that she cannot control her very own healthcare decisions.

This is why seatbelt laws usually aren’t justified with paternalism. Rather, seatbelt laws are justified with a compelling public health interest that, in its implementation, poses little or no harm to the individual. This is to say that it isn’t the government taking a role in the individual’s best interests, but rather the government taking a role in what is the society’s best interests–namely, maintaing a society in which the health decisions of some don’t translate into negative repercussions for others. In the case of vaccination, the argument for a mandate is made stronger because it isn’t simply about positively advancing the health of society, but rather about mitigating the harm of illness in those who can’t get vaccinated–very young children, some elderly individuals and some individuals with medical exemptions.

A similar parallel can be drawn in terms of alcohol consumption:  the government will tend to avoid regulating how much individuals drink, but it will step in when the story involves the lives of third parties, such as through regulations of driving under the influence.

Rights of Children

In an April Los Angeles Times Opinion piece on SB 277 entitled “Vaccine legislation properly puts public health above personal beliefs,” George Skelton explains that “relatively few people today remember the frightening polio epidemics before the Salk vaccine was introduced in 1955.” In the early 1950s, more than 10,000 Americans were affected by paralytic polio–including Skelton, who ends his piece with a chilling remark about his mother, who helped him through the disease: “But if there had been a polio vaccine that she had prevented me from receiving, I never would have forgiven her.”

Children are a difficult subject in the MMR vaccine debate because they are often placed in the domain of their parents. But what if their parents are wrong? Dr. Paul Offit, a staunch supporter of vaccination and author of Bad Faith, argues that parents refusing to vaccinate their children is akin to child sacrifice. Though arguably an extreme example, Offit’s analogy highlights the notion of misplaced priorities in putting personal beliefs above science and the health of children.

Feasibility of Compulsory Vaccination: The Plausibility of Implementing Mass Immunization Programs

Public Education

Public education about vaccination is important for fruitful discussion to take place, especially when vaccination is compulsory. First of all, it is important that the public understands the nature of the disease–in this case, measles. We find that the public may often downplay the effects of a disease, forgetting the scope if its impact, while at the same time overplaying the dangers of vaccines. A 2015 study in the journal Vaccine found that 43 percent of people believe the flu vaccine can give you the flu (it can’t); at the same time, the study found that correcting myths about vaccines actually reduced the intent to vaccinate in those who have high concerns about vaccine side effects. This might be for a number of reasons, including distrust of a scientific community or government authority that may seem to offer conflicting prescriptions about vaccination. Thus it is important to be conscious of who the target of the education is and how to translate public education into public action.

An article in the BMJ that argued mandatory vaccination of healthcare workers is unethical suggested that people approach vaccines with the method of ‘persuasion not coercion.’ The article concludes that mandatory vaccination should only occur if the “hearts and minds” of individuals cannot be won over to vaccinate–and even then, it should be limited to those caring for young children or the elderly. The article discussed mandatory influenza vaccination at the Virginia Mason Medical Center in 2004, noting that the ordeal took a toll on overall morale. This suggests that even when vaccinations are made mandatory, education is still crucial to maintaining a sense of morale and commitment to the compulsion.

Spending or Saving: The Costs of Vaccination Versus Treatment

Vaccination is seen as a great public health asset, saving the country large amounts of money in healthcare costs due to deaths from preventable diseases. A Johns Hopkins School of Public Health study estimated that increasing vaccination in three disease areas (pneumococcal disease, meningitis and rotavirus) would be valued at $63 billion. The Centers for Disease Control and Prevention estimates that for every dollar spent on vaccination, $10.20 is saved in treatment costs.

But what about measles? A 2008 measles outbreak in San Diego (noted for having a “highly vaccinated population”) exposed 839 people to the disease with 11 infected–all who were unvaccinated children. An infant, too young to be vaccinated, was hospitalized. The outbreak cost over $150,000 to stop. In contrast, the cost of a single MMR vaccine, according to the CDC, falls between $20 and $60, depending whether bought publicly or privately. The study ultimately concluded that despite San Diego having a high vaccination rates, “pockets” of unvaccinated individuals could spur outbreaks.

In 2004, a measles outbreak in Iowa racked up an estimated $140,000 in costs for local and state health departments. The burden of disease reflected the need to “investigate, contain and treat just three patients with confirmed cases and their more than 1000 identified contacts.” That estimate left out outside resources used on the outbreak, such as airlines who tracked air travel, or the federal government.

CDC date compiled by the Washington Post (below) shows the resurgence of a disease that was declared eliminated in 2000, suggesting a large future burden of costs.

The Washington Post
The Washington Post

 

Traditionally, California offers both medical and philosophical exemptions to vaccination–but not religious. California requires the MMR vaccine at or after age 1. SB 277 would eliminate the philosophical exemption, meaning only medical exemptions can be granted.

Under the Affordable Care Act, health care plans are required to cover preventative services such as vaccines. Uninsured or underinsured children under 19 years of age can received vaccines at no cost through the Vaccines for Children (VFC) program: they must be Medicaid-eligible, be American Indian or Alaska Native, or have no health insurance.

Where Are We Now: Current Status of SB277

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On May 14, 2015, SB 277 overwhelming passed (25-10) in the California State Senate, increasing confidence that the bill would pass the Assembly and be signed into law. This came after a variety of changes were made to SB 277, limiting its reach. The number of vaccinations listed on the bill were limited to 10, for example, and a grandfather clause addressing parents who’ve opted out of vaccines may be included.

In response, anti-vaccine advocates compared California to Nazi Germany, many threatening to leave the state before complying.

Only skimmed those last pages? Here’s the quick and simple take home message.

References

1. “CDC—Immunization and Respiratory Diseases.” Centers for Disease Control and Prevention. Retrieved from http://www.cdc.gov/fmo/topic/budget%20information/factsheets/IRD_Factsheet.pdf

2. “How to Pay.” Vaccines.gov. Retrieved from http://www.vaccines.gov/getting/pay/index.html#kids

3. Ingraham, Christopher (2015). “The devastating impact of vaccine deniers, in one measles chart.” The Washington Post. Retrieved from http://www.washingtonpost.com/blogs/wonkblog/wp/2015/01/22/the-devastating-impact-of-vaccine-deniers-in-one-measles-chart/

4. Isaacs, D. and Leask, J. (2008). “Should influenze immunization be mandatory for healthcare workers? No.” The BMJ. doi: http://dx.doi.org/10.1136/bmj.a2140

5. Nyhan, B. and Reifler, J. (2015). “Does correcting myths about the flu vaccine work? An experimental evaluation of the effects of corrective information.” Vaccine 33: 3. 459-464. doi:10.1016/j.vaccine.2014.11.017

6. Orenstein, W. and Seib, K. (2014). “Mounting a Good Offense against Measles.” The New England Journal of Medicine 371: 1661-1663. DOI: 10.1056/NEJMp1408696

7. “School Vaccination Requirements, Exemptions and Web Links.” Centers for Disease Control and Prevention. Retrieved from http://www2a.cdc.gov/nip/schoolsurv/schImmRqmtReport.asp?s=grantee&d=4&w=WHERE%20a.gradeID=1%20AND%20a.vaccineID=8

8. Skelton, George (2015). “Vaccine legislation properly puts public health above personal beliefs.” Los Angeles Times. Retrieved from http://www.latimes.com/local/politics/la-me-cap-vaccine-20150423-column.html

9. Stone, Rachel Marie (2015). “What one of the anti-vaccination movement’s least favorite doctors discovered about Jesus.” The Washington Post. Retrieved from http://www.washingtonpost.com/news/acts-of-faith/wp/2015/04/13/what-one-of-the-anti-vaccination-movements-least-favorite-doctors-discovered-about-jesus/?tid=sm_fb

10. Sugarman, D. E. et al. (2010). “Measles Outbreak in a Highly Vaccinated Population, San Diego, 2008: Role of the Intentionally Undervaccinated.” Pediatrics 125: 4. doi: 10.1542/peds.2009-1653

11. Swanson, Ana (2015). “A horrifying reminder of what life without vaccines was really like.” The Washington Post. Retrieved from http://www.washingtonpost.com/blogs/wonkblog/wp/2015/05/04/a-horrifying-reminder-of-what-life-without-vaccines-was-really-like/?tid=sm_fb

12. “The Value of Vaccines in Disease Prevention.” Pfizer. Retrieved from http://www.pfizer.com/files/health/VOMPaper_Vaccines_R7.pdf

13. “Vaccines for Children Program (VFC).” Centers for Disease Control and Prevention. Retrieved from http://www.cdc.gov/vaccines/programs/vfc/awardees/vaccine-management/price-list/index.html

14. “2014-2015 Child Care Immunization Assessment Results.” California Department of Public Health, Immunization Branch. Retrieved from https://www.cdph.ca.gov/programs/immunize/Documents/2014-15%20CA%20Child%20Care%20Immunization%20Assessment.pdf

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