Compulsory School Vaccination: Governmental Authority vs Personal Autonomy

Dr Seehusen in his commentary in the June 2019 issue of Family Medicine succinctly summarized the current challenges facing family physicians and vaccine refusal.¹ He was prescient in observing that the United States was on track to achieve a record number of measles cases. From January 1 to December 31, 2019, 1,282 individual cases of measles were confirmed in 31 states, more than tripling the 372 cases reported in 2018.² Of these cases, 128 were hospitalized and 61 reported having complications, including pneumonia and encephalitis. The majority of these measles cases were among unvaccinated individuals.

All 50 US states require that children be vaccinated in order to attend public school, and the constitutional authority to enforce mandatory vaccination laws has repeatedly been affirmed by the Supreme Court. However, 45 states and the District of Columbia provide exemptions based on religious beliefs, and 15 states also permit exemptions on the basis of philosophical beliefs.³ Requests for these exemptions are increasing resulting in a substantial number of unvaccinated students in our public schools. A recent study has demonstrated that over the past decade the number of nonmedical exemptions to vaccination increased in 12 of the (then) 18 states allowing philosophical exemption to vaccination.⁴ There is a demonstrable association between vaccine refusal and vaccine-preventable diseases. A study evaluating 1,416 measles cases revealed about 57% of afflicted individuals had no history of measles vaccination. Of this total, 970 cases had detailed vaccination data and, of these, 574 cases (59%) were unvaccinated despite being vaccine eligible. Almost 71% of those unvaccinated (405 cases) had nonmedical exemptions. This same study reviewed nine reports describing 12 outbreaks of pertussis for which detailed vaccination data on unimmunized cases was available, and among eight of these outbreaks 59% to 93% of individuals were intentionally unvaccinated.⁵

A model for states to put teeth into their existing compulsory school vaccination laws has been provided by California. In response to the 2014 Disneyland measles outbreak, in June, 2015 the governor of California signed SB 277 into law, removing the personal belief exception to school immunization requirements thus making medical exemption the only legitimate reason to send an unvaccinated child to school. Recently, due to increasing rates of measles cases, the law has been strengthened to give state public health officials authority to decide which unvaccinated children are allowed to attend school. Under the new laws, the state will issue a standardized medical exemption certification form for doctors to complete and send to a child’s school. The form outlines the details of the exemption and includes information about the medical basis for the exemption. In addition to reviewing doctors who grant five or more exemptions in a year, the California Department of Public Health would also investigate schools with an overall immunization rate of less than 95%. Additionally, the legislation gives the California Department of Public Health the authority to revoke a medical exemption deemed inappropriate by a state physician or public health officer.^6,7

To reverse the trend of declining vaccination rates, both medical and civil authorities must begin to take a stand. California has demonstrated it is possible for civil authorities to do so. For us as family physicians, it is preferable to work within the parameters of the physician-patient relationship to counter the misinformation widely disseminated on social media and in popular culture.

A significant percentage of parents are vaccination-hesitant rather than vaccination refusers, and thus are open to changing their mind if their concerns are addressed. Family physicians will have the greatest impact on increasing vaccination rates by identifying and focusing efforts on this target group. Practical measures for family physicians to utilize in counseling these parents include starting the conversation early by talking about vaccination in the prenatal and first several postnatal visits; presenting vaccination as the default option (ie, assuming parents will immunize the child); building trust with parents by showing respect, empathy, and tailoring information to individual needs; honestly addressing questions about possible adverse side effects of vaccination and providing reassurance on a robust vaccine safety system; addressing possible (usually mild and transient) pain associated with vaccination and explaining comfort measures to use if necessary; focusing the discussion on both the community and the child’s protection; and supplementing the factual information provided with stories (eg, personal statements about vaccinating their own children or personal experience with vaccine safety among their patients).⁸