Vaccine Refusals and Regulations

As of this writing (June 21, 2019), 1,044 cases of measles have been reported in the United States—a dramatic increase over last year’s total (372) and the most cases since 1992.1 There is obvious concern about the number of cases and their spread across the country. Dr Seehusen’s commentary “Time for Family Physicians to Change Strategy Against Vaccine Refusal” exhorted family physicians to advocate for laws enforcing immunization.2 However, restricting exemptions from school-entry mandates will not ameliorate the current situation, and may make it worse.

Four states make up the vast majority of current cases: New York (871 cases in Rockland County, Brooklyn, and Queens), California (53), Pennsylvania (5) and Washington (81).1 This fact demonstrates two things: (1) the outbreaks, while continuing, are being contained, and (2) a high national measles vaccination rate among children is successful.

In New York state, the vaccination rate for MMR among toddlers is 92.4% (91.9% NYC, 93.1% rest of state); the rate for kindergartners is 97.2% in the state and 97.8% for the city.3,4 While rates among the ultraorthodox population in which the outbreaks are occurring appear to be lower, it is not clear that vaccine resistance is the only, or primary, reason why. Sources have documented disrupted relationships between this population and public health, due in part to disputes over traditional circumcision practices as well as purposeful cultural isolation.5,6 Restricting exemptions to school-entry vaccine mandates may not improve rates of MMR vaccination in a state with already very high rates.

Historically, exemptions provide a “safety valve” that “prevent[s] backlash against the use of law to achieve compliance with vaccine recommendations.”7 Political activity around vaccination and vaccine mandates is growing. Restricting exemptions to school-entry mandates creates a social climate that is threatening to those who are hesitant, providing motivation for more vocal ideological dissent and doing nothing to ameliorate a highly charged political climate within which parents make medical choices for their children.

Additionally, school-entry mandates do not affect children not in school or organized childcare. To determine the most effective, humane, and ethical approach to diminishing susceptibility to measles outbreaks in the United States—outbreaks that are fueled by tens of thousands of cases abroad—we need more context, data, and deliberation about what makes people dissent from vaccination recommendations, as well as more historical, culturally relevant, and scientifically sound understanding of the current situation. We advocate that family physicians continue to engage families in positive conversations about vaccinations without negative perceptions about parents who raise questions and concerns.