Vaccine Refusal and Delay

by Jeffrey Bomze



Should all children be required to have all recommended vaccines/some vaccines for school entry, Day Care, college?

Do parents who refuse or delay vaccines for their children have a responsibility to other children and the community? Liability for not doing so?

Vaccines have been one of the most effective preventive health measures in medical history. A study by the CDC(Centers for Disease Control) found that among children born between 1994 and 2013, full vaccination would have prevented 732,000 deaths. Scientific studies have shown that unvaccinated children (primarily for nonmedical reasons) have a 9-fold increased risk of varicella (chickenpox), up to a 35-fold increased risk of measles and a 6-28-fold increase in pertussis (whooping cough) compared to vaccinated peers. Delay in receiving vaccines at the recommended times generally results in more severe disease in infants and younger children who contract vaccine-preventable diseases. In addition, there is a risk of community outbreaks of these diseases.

Vaccine refusal and delay is a complex problem influenced by several factors, including convenience, confidence, and complacency. Convenience relates to availability, affordability, and accessibility of vaccines. Vaccines are widely available and covered by almost all insurers, including Medicaid. In addition, there is a program in our state that provides free vaccines to children without insurance. Health departments also provide free vaccines to those in need.

Confidence in vaccine effectiveness and safety has declined in recent years because of lower trust in our government, vaccine manufacturers, and health professionals. Complacency has occurred because of a widely held belief by parents who have not seen vaccine-preventable diseases that these diseases are not serious and do not pose a risk to their children or other children. Because vaccines have been so effective in nearly eliminating many diseases, many parents have not seen these diseases and don’t know about the potentially serious complications and effects of the diseases covered by the vaccines.

Immunization laws are state-regulated and vary among states. Vaccines are required for all children attending Day Care and school, but states vary as to which vaccines are required. Exemptions are granted for three reasons-medical, religious and philosophical.

Pennsylvania allows all of these exemptions. The most controversial and nonspecific exemption is philosophical, interpreted as personal, moral or philosophical belief against some/all vaccines. States with religious and philosophical exemptions have higher rates of vaccine-preventable diseases. Nonmedical exemptions are the primary reason for vaccine refusal or delay, which occurs in up to 6.2% of children.

Parents primarily refuse vaccines because of safety concerns and studies indicate that 60-70% of all exemptions are due to safety concerns. These concerns vary and include many alleged side effects such as autism(not shown), neurological damage(not shown), overload of the immune system(not shown), autoimmune diseases(not shown), Guillain-Barre syndrome(rare), susceptibility to infection(not shown) and intussusception (coiling of intestine within itself requiring emergency treatment-rare). Some of the concerns relate to rare, but serious or potentially serious side effects. Most vaccine side effects are minor, self-limited and modifiable, consisting of low-grade fever, injection site redness and tenderness.

The Institute of Medicine has systematically reviewed well over 200 studies regarding potential side effects and found a true causal relationship between vaccines and only a small number of significant side effects. They concluded that vaccines do not cause autism, neurological/developmental problems or Diabetes. There has been a great deal of scientifically unfounded public attention regarding thimerosal, used as a preservative in multiple-dose vaccines, and neurological side effects. There are also several misperceived concerns resulting in vaccine delay or refusal, including low-grade fever, minor illnesses, prior mild injection site reactions, antibiotic use at the time of immunizations, recent exposure to infections and penicillin or non-vaccine allergies.

The true medical reasons to withhold or delay vaccines include potential allergic reactions to the vaccines or one of its components. The other main category relates to risk in children who have certain types of deficiencies in their immune systems. The potential allergic reaction of most concern is anaphylaxis, a life-threatening multi-system allergic reaction. The actual incidence of this problem has been shown to be very small, 5 cases/7.5 million doses in one large study. In many cases, the vaccines can be administered as long as the staff can manage a potential allergic reaction. The concerns for children with certain specific immune deficits is primarily with live vaccines, and many of these conditions are temporary (chemotherapy, HIV, certain medications) and vaccines can be resumed when conditions improve.

Regarding religious exemptions for vaccines, there are some specific concerns expressed by certain religions and groups. Some vaccines use cells from aborted fetuses to grow the specific virus and manufacture the vaccine. These fetuses were aborted for other reasons and the Catholic Church has endorsed vaccines because of the overriding public health benefit of vaccines. Jewish and Islamic people do not consume pork and some vaccines use pork-derived gelatin as a stabilizer. However, Jewish and Muslim scholars endorse vaccines because vaccines are not ingested as food.

Vaccine effectiveness varies and no vaccine is 100 percent effective or can be expected to be so. Most are highly effective and protect 95 percent or more of those immunized according to the recommended schedule. They provide a great benefit to individuals as well as the community because of a key public health concept of herd immunity. This relates to the protection of those who cannot safely receive certain vaccines being dependent on the complete vaccination of the rest of the community(90-95% of community needs to be immunized). There have been several outbreaks of highly contagious and potentially dangerous diseases like measles, mumps, and pertussis because of vaccine refusal and delay.

Ethical concerns have been raised and are a consideration in vaccine requirements. The key issues relating to the balance of parental rights and personal liberty and the societal rights to protect children and the community. Most believe that the public health value of vaccines and allowing nonmedical exemptions are not equal alternatives. Nonmedical exemptions have resulted in increased outbreaks of vaccine-preventable infections along with their complications.

In summary, the effectiveness of vaccines balanced against the common minor side effects and rare more serious side effects strongly supports their use in all children other than those who truly cannot receive certain vaccines because of medical reasons. The science and many decades of successful vaccine implementation, as well as the continued improvement in the technology with the development of new vaccines, have a profound benefit for the health of children and communities.

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