Friday, January 30, 2015

Measles (or worse) for your child?

An outbreak of measles in California has now spread to several other states and the number of infected people will soon pass 100 if it has not already.  Reporting on the outbreak has largely focused on Disneyland as a common site of infection rather than more important substantive issues.

Proactive engagement and action by parents and grandparents of school age children is needed to ensure that children are protected from highly contagious and potentially deadly diseases.   Immunizing your own child is not enough.  Relying on government and school officials is not enough.

Children entering K-12 in most states are required to have immunizations for Hepatitis B, Polio, MMR (measles, mumps, and rubella), Diphtheria, Tetanus, Pertussis (whooping cough), and Varicella (chicken pox).  Children entering pre-school or in child care are also required to have Hib (Haemophilus influenzae type b) immunization.

Vaccines protect in two ways.  The first is the direct protection of the individual through immune system response to the vaccine.  But that protection is not absolute.  For a small percentage of those who are immunized the immune system does not respond and they lack protection.  In the current California outbreak about seven percent of those with the measles were immunized but still contracted the disease.

The larger public health protection comes from “herd immunity.”  Herd immunity protects both those who have immunity and those who do not by immunizing a very high percentage of the population.  In general, the immunized population must be 92 to 97 percent depending on the disease to achieve herd immunity.  There are increasing numbers of communities where the immunized population falls below these required percentages.  This places everyone at risk.

Why are parents not immunizing their children?   First, there are exemptions to immunizing a child entering school.  A medical exemption exists in all states for a child who medical authorities believe the immunization would be medically harmful due to another medical condition.  A religious exemption exists in 29 states for those who have a religious belief protected by the First Amendment.  For example, Christian Scientists object to immunization as inconsistent with their religious beliefs.   A relatively new philosophical exemption exists in 20 states for parents who have a “personal objection” to immunization.

Each state has its own procedures for declaring and receiving an exemption.  Some are more difficult than others.  But generally, if the exemption is available and is claimed it is received.

On a more practical level some people are simply ignorant of the importance of immunization and when informed by the school that their child must be immunized prior to enrollment will claim a religious or personal exemption.  Word of mouth in some districts provides the knowledge to just declare an exemption to avoid the “hassle” of getting a child immunized.

School front offices often enable this behavior to avoid expending time confronting the parent and enforcing the requirement.

A large number of parents have rejected immunization because they fear it is causing autism and other auto immune diseases.  Despite a lack of evidence to support the position it is strongly held in some communities.   Some communities have less than 90 percent immunization rates that can be directly tied to this belief.

Another segment believes that immunization is a violation of individual liberty.  Individual liberty legitimately  subordinated to the power of the government for public health.  In 1905 in the Supreme Court case of Jacobson versus Massachusetts, and later in 1922 in Zucht versus King this issue was settled.   It is within the police power of the state to provide for compulsory vaccination.

Subordinating individual liberties to a police power of the state for the public health is acceptable. Protection from potentially deadly and highly contagious airborne diseases is only achieved through mass immunization.  But the government also has an obligation to demonstrate competence and effectiveness when it calls for subordination of liberty for the public good.

By creating and expanding exceptions to immunization laws or enforcing those laws capriciously the government creates an environment in which the herd immunity it seeks to achieve by subordinating liberty is no longer attainable.

Exceptions are made understandably for medical reasons or for a very strongly held religious belief. Herd immunity can accommodate those few exceptions. But in our society exceptions too often are the seeds of expansion and abuse.  In the case of immunization the risk of accommodation is potentially life threatening to those who follow the rules and sit idly by.

It is in the interest of every parent to know what exemptions (medical, religious, and personal objection) their state allows; how the exemptions are administered within their child’s school district to include the specific procedure for approval of an exemption; what percentage of your child’s school population is immunized; and to demand that statistics related to immunization rates and exemptions be posted on the school web site prior to the start of each school year.

State legislators should be contacted to request that laws related to immunization be updated to reflect the concerns of the community.   Most legislation introduced in state legislatures in recent years has largely reflected a greater leniency toward immunization with expanded exemptions.  The current outbreak of measles should be a wake-up call for reduction of exemptions and greater scrutiny of immunization program implementation, enforcement, and oversight in school districts.


  1. A few of the more interesting sources related to this topic are listed below:


    Individual Rights vs. Public Health: The Vaccination Debate, by Mahesh Vidula, MIT ANGLES 2010,

    Massachusetts School Immunization Requirements for School Year 2014-2015,


  2. The Harvard Law Review article listed in a previous comment was very interesting. The article points out the need to update law related to immunization. For over 100 years the Jacobson decision has been relied upon to impose the power of the state. Present and future immunization technology is creating opportunities to immunize for diseases beyond those that gravely threaten the public safety and have no other method of treatment or prevention outside of vaccines. They describe “medically necessary” immunizations as those that are the only known viable defenses against diseases taking hold in a community. “Practically necessary” immunizations may be good public policy but the diseases they “combat are not airborne and from which individuals have some other recourse to protect themselves.” Airborne, highly contagious, and potentially deadly diseases such as small pox, polio, measles, and pertussis are considered medically necessary. Hepatitis B and human papillomavirus (HPV) are considered practically necessary. Imposing the sanction of the state upon individual liberty for medically necessary immunizations was the intent of the Jacobson decision. It is being used now to authorize mandatory practically necessary immunizations such as HPV. This issue needs to be addressed by state legislatures across the country. Parents must have adequate knowledge about the topic to make the distinction between medically necessary and practically necessary immunizations.

  3. One off-line comment received by the author was specifically about the requirement in his state for HPV immunization series to begin in 7th grade for both boys and girls. The parent is not opposed to immunization and has had his child immunized against all other medically necessary diseases. This is an example of the state imposing its power on the liberty of its citizens for a practically, but not medically necessary public health issue. The support of the citizenry for immunizations in general is diminished when the state begins using its power to mandate and impose sanction for diseases for which there are alternative methods of avoidance. HPV is spread through sexual contact. It is different than diseases that are spread and contracted by breathing or touching a surface. Make no doubt that contracting HPV can have serious health consequences later in life. In particular, cervical cancer in women is caused by HPV. The question is not whether to immunize, but whether the state should require it. About 20 states now offer, appropriately, education and/or funding for HPV immunization. Only Virginia and Washington D.C. mandate HPV vaccination with Rhode Island joining with them in 2015. See these links for information about HPV in your state: /

  4. A newspaper version was published in the Cape Cod Times on February 7, 2015 and can be obtained here:

  5. Parents can look up immunization rates at the following links. Though they are for kindergarten only they will give a sense of where your child's school stands. Any school that has an exemption rate greater than 2% has a problem:

    USA Today has a searchable tool for 13 states

    Massachusetts has a list published by DPH for Kindergarten classes of 2013-2014 at:


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