Vaccine Refusals and Regulations

Mack Thomas Ruffin IV, MD, MPH | Bernice L. Hausman, PhD

Fam Med. 2019;51(9):785-785.

DOI: 10.22454/FamMed.2019.959213

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To the Editor:

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.


  1. Centers for Disease Control and Prevention. Measles Cases and Outbreaks. https://www.cdc.gov/measles/cases-outbreaks.html. Accessed June 21, 2019.
  2. Seehusen DA. Time for family physicians to change strategy against vaccine refusal. Fam Med. 2019;51(6):468-470. https://doi.org/10.22454/FamMed.2019.248359
  3. Hill HA, Elam-Evans LD, Yankey D, et al. Vaccination coverage among children aged 19-35 months—United States, 2017. MMWR 2018;67(40):1123-1128. https://www.cdc.gov/mmwr/volumes/67/wr/mm6740a4.htm. Accessed September 3, 2019.
  4. Mellerson JL, Maxwell CB, Knighton CL, et al. Vaccination coverage for selected vaccines and exemption rates among children in kindergarten—United States, 2017-18 school year [Table 2]. MMWR 2018;67(40):1115-1122. https://www.cdc.gov/mmwr/volumes/67/wr/mm6740a3.htm#T2_down. Accessed September 3, 2019.
  5. Otterman, S. New York confronts its worst measles outbreak in decades. The New York Times. January 17, 2019. https://www.nytimes.com/2019/01/17/nyregion/measles-outbreak-jews-nyc.html. Accessed June 15, 2019.
  6. Tanne, JH. Ultra-Orthodox Jews criticized over circumcision practice. BMJ January 21, 2006;332:137. https://doi.org/10.1136/bmj.332.7534.137
  7. Colgrove J. Immunity for the people: the challenge of achieving high vaccine coverage in American history. Public Health Rep. 2007;122(2):248-257. https://doi.org/10.1177/003335490712200215

Lead Author

Mack Thomas Ruffin IV, MD, MPH

Affiliations: Penn State College of Medicine, Hershey, PA


Bernice L. Hausman, PhD - Penn State College of Medicine, Hershey, PA

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Seehusen DA. Time for Family Physicians to Change Strategy Against Vaccine Refusal. Fam Med. 2019;51(6):468-470. https://doi.org/10.22454/FamMed.2019.248359.


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