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To Vaccinate or Not to Vaccinate? That is Not the Question :

March 23, 2020

Dr. Conis describes a series of historical stages that has led to the rise of personal belief vaccine exemptions in the US over the past 200 years (REF). The development of the first human vaccine, smallpox, prompted the first vaccine requirements.

In 2018-9, almost 6% of kindergartners in my home state of Maine had nonmedical exemptions for vaccination, which was an increase of about 1% from the previous year.1 These numbers were heading in the wrong direction, and reading “The History of the Personal Belief Exemption” by Dr. Elena Conis (REF) greatly enhanced my understanding of this troubling trend.

This article is particularly timely as COVID-19 paralyzes our health care systems, and the significance of community immunity has become very relevant to our modern, social lifestyle.  As a member of the Pediatrics editorial board, I was interested in additional perspective on this from one of the most effective vaccine advocates I know, and asked Laura Blaisdell MD, MPH, FAAP to provide comment. Dr. Blaisdell researches vaccine hesitancy, and is the vice president of the Maine chapter of the American Academy of Pediatrics.  Due in large part to her leadership, the Maine legislature passed a bill eliminating nonmedical exemptions in 2019, and an attempted people’s veto of this bill was overwhelmingly defeated several weeks ago. Dr. Blaisdell has emerged as the leading advocate for elimination of nonmedical vaccine exemptions in Maine, and she shares her insight on Dr. Conis’ article below. 

- Michele LaBotz MD, FAAP, Editorial Board Member, Pediatrics

Dr. Conis describes a series of historical stages that has led to the rise of personal belief vaccine exemptions in the US over the past 200 years (10.1542/peds.2019-2551). The development of the first human vaccine, smallpox, prompted the first vaccine requirements. U.S. anti-vaccinationists and their allies lobbied for repeals to these requirements and non-medical exemptions began with success in a handful of states. Next, the deadly polio epidemic was stifled with vaccination—but when declines in disease reversed in poor, urban areas—requirements for this vaccine were put in place. Subsequent political opposition surrounding this vaccine centered around the destruction of freedom of choice and school district autonomy. Another wave of legalized non-medical exemptions came in the 1960s-70s with the requirement for measles vaccination for school enrollment. 

Recently, California, Maine, and New York have repealed non-medical exemptions for all required school vaccines due to diminished community immunity rates and resurgences of measles and pertussis. More states are considering similar legislative action. Other states have trimmed back non-medical vaccine exemptions in other ways, either striking philosophical and leaving religious exemptions for some (e.g. MMR and Washington state) or all vaccines (e.g. Vermont). 

Dr. Conis artfully articulates the “unintended consequences” of compromises reached in legislative efforts to expand vaccine coverage and her article should give us pause when considering these issues.  Vaccine requirements have always inspired anti-vaccinationism in the struggle of liberties and rights. It is important to differentiate mandatory vs. required vaccination for school entry. No state or federal government can or should be able to mandate vaccination—meaning forcibly vaccinate against ones will.  But the government’s singular purpose is to protect the well-being of all of its citizens. As such, we do not have unlimited rights to put others at risk because of our decisions. Seatbelts, car seats, drunk driving and smoking are all examples of this principle of balanced rights.

As modern medicine reduces mortality, more of us are living in communities with medically vulnerable patients. Medical exemptions from vaccines are vitally important to some individuals, as is their reliance on our community immunity. As we socially distance ourselves this spring, may we re-evaluate the privilege of attending schools, riding buses and joining social gatherings. COVID-19 reminds us these activities are not a right when individual and public health stands in the balance.   

Reference

  1. Seither R, Loretan C, Driver K, Mellerson JL, Knighton CL, Black CL. Vaccination Coverage with Selected Vaccines and Exemption Rates Among Children in Kindergarten — United States, 2018–19 School Year. MMWR Morb Mortal Wkly Rep 2019;68:905–912. DOI: http://dx.doi.org/10.15585/mmwr.mm6841e1
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