Vaccination Scandal: A Policy Proposal

Emma Price
If scientists were to create a perfect situation in which to study the spread of
infectious disease, (measles, for example) the setting would look a lot like Disney Land
in California. Visitors mix with an enormous amount of people, both natives from this
country, and travelers from other countries; before they go back to their resorts,
interacting with another large amount of people; and they return home to spend time with
yet another group of individuals. It really is the perfect place to start a nationwide public
health epidemic.
This is an example of just how important it is to maintain a high percentage of the
population that is vaccinated. As more diseases are discovered and pose a threat to
society, scientists continue to devote their entire lives to coming up with a vaccination to
prevent people from suffering at the hands of a potentially preventable disease. At
present, each state is able to determine the vaccination mandates for their population.
Generally speaking, this has shown to be a relatively effective way to maintain that
fraction; however, there are a few loopholes that allow diseases, such as measles, to go
from being eradicated to causing a new epidemic. For this reason, the policy mandating
vaccinations should still allow for medical and religious exemptions; however, the
personal belief exemptions that are allowed in many states should be discontinued.

Measles Outbreak, California: A Case Study

At the end of last year, the CDC confirmed a measles outbreak that originated
from the Disney Land Parks in California. The outbreak was discovered when visitors,

who had been to the park between December 15th and December 20th, began
complaining of symptoms that were consistent with measles. To date, the CDC has on
record that there have been 159 cases over 18 states, most of which included individuals
who were unvaccinated. The CDC issued a statement explaining that the strain they were
looking at was identical to the strain found in an outbreak in the Philippines in 2014.
After some research into the situation, patient zero for this particular outbreak was likely
a traveler who, after being infected overseas, visited the park while still being infectious.
Measles is a highly infectious respiratory disease that is caused by a virus and can
be spread through the air by coughing, sneezing or close contact. Symptoms include
fever, runny nose, cough, red eyes, sore throat, and a rash all over the body. This disease
is so infectious that an infected individual can walk into a room, and, two hours later, the
airborne virus is still able to infect unprotected individuals. The Measles and Rubella
Initiative, sponsored by the Red Cross, explains that, When one person has measles, 90
percent of the people they come into close contact with will become infected, if they are
not already immune. While measles is one of the most infectious diseases known, the
problems that are seen with this infection are simply an extreme of a widespread
vaccination problem.
Measles vaccines are typically administered at 12 months, and a second dose
around 4 years old. However, there are certain aspects of the vaccination that are
common allergies among the population. These individuals, along with those who choose
not to be vaccinated for religious reasons, pose as susceptible individuals that are able to
spread the disease. Only after a person is infected and cured, are they considered to be
immune, and cannot spread the disease.

A CNN article focusing on the most recent measles outbreak pointed out:
Measles was declared eliminated in the United States in 2000, which means it is no
longer native to the United States but continues to be brought in by international
travelers. The reason an isolated case such as the one that started this outbreak, can
spread is that individuals choosing not to be vaccinated depleted the herd immunity. In
the study of infectious diseases, there is a critical fraction of individuals that must be
vaccinated, in order for a disease to be unable to spread. If the fraction of vaccinated
individuals is above the critical number, then individuals that have been affected by the
disease still wont cause an outbreak, because there are enough vaccinated individuals to
quell the issue. This fraction is dependent on the rate of infection of the specific disease,
or the Basic Reproductive Ratio, R0; which in this case, is around 18. The fraction can be
calculated according to the following equation:
= 1

1
!

The Basic Reproductive Threshold for measles is around 94.4%. However, according to
the California Department of Public Health records, the fraction of children in
kindergarten for the 2014-2015 school year, who received the MMR vaccine, is only
92.6%, which is 1.8% less than the critical threshold needed to keep the disease from
spreading. That same assessment reported that 0.19% of the children were exempted
because of medical reasons, and 2.54% of children were exempted because of personal
beliefs. These numbers differ from the 2002-2003 school year data from the same source,
where the percent vaccinated was 95.7% and the personal exemption fraction was only
1.11%.

In the past, measles outbreaks were isolated occurrences, in which one or few
individuals were infected due to outside effects. There is an increasing amount of people
claiming personal beliefs for exemptions in California, as shown, as well as across the
nation in states like Colorado and Minnesota. If this number continues to rise, measles
could become endemic in the United States, meaning that it is a chronically occurring
disease. The measles outbreak in California is just the most recent example of the
problem personal belief exemptions pose in regards to the prevention of all diseases, not
just measles.

Policy Proposal
The first state law mandating vaccinations was in Massachusetts in 1809. In a
U.S. Supreme Court case, Jacobson vs. Massachusetts, the court held that the health
regulation to mandate the smallpox vaccine was within the states police power and
didnt violate individual rights. A report sponsored by the CDC described police power
as, the authority reserved to the states by the Constitution and embraces such
reasonable regulations established directly by legislative enactment as will protect the
public health and the public safety (Measles Cases and Outbreaks). In other words,
the government can mandate something, if it is for the protection of the health of the
general public. This case decided that the liberty given to all citizens under the
Constitution is not without exceptions and limitations, especially in times of risk to the
public.
While vaccinations are tested extensively and are safe and effective, there cannot
be a guarantee that they are perfectly safe or perfectly effective. There will always be a

small risk of adverse effects, no matter the effectiveness of the vaccine. There are some
people who have conditions that may increase the risk of these adverse effects; so all
states have exemption procedures available. There is a fraction of people who see
vaccinations for less common diseases as an unnecessary risk, or are against vaccinations
for religious reasons. According to the National Vaccine Information Center (NVIC), all
50 states allow medical exemptions, 48 states allow religious exemptions, and 17 states
allow for a philosophical, conscientious or personal belief exemption (Vaccine
Laws).
Medical exemptions generally require a doctors signature. However, according to
that same source, A medical exemption to vaccination is very difficult to obtain because
almost all medical reasons for delaying or withholding vaccines have been eliminated by
government and medical trade officials. While 48 states allow religious exemptions,
Mississippi and West Virginia do not allow exemptions due to religious reasons. Of the
48 states, some require a written affirmation from a priest or spiritual leader, and some
require for the individual to defend their beliefs in order to be excused. In the case of
those 17 states that allow for personal exemptions: In order to be allowed to exercise the
philosophical, conscientious or personal belief exemption in some states, parents or
children old enough to give consent (usually age 12 or older) must object to all vaccines
and not just one vaccine (Vaccine Laws). Many times, parents exercising this right
must obtain a signature from a medical professional accepting the risk of not vaccinating
their children.
The idea of vaccination exemptions based in religious ideals stems from the basic
right of all people under the Constitution to religious freedom. This ideal is something

close to the heart of many Americans and remains a priority to lawmakers when deciding
whether a law should be enacted or not. There are some religions that argue that
vaccinations are against their religious beliefs, and that the government cannot require
something that violates these beliefs. And this it true, to an extent. Under the constitution,
the individual has a right to religious freedom, as long as their practices do not endanger
the public. In terms of the California numbers, only 0.52% of the population was
unvaccinated due to religious beliefs.
Because of the religious rights individuals have, the updated policy should still
allow religious exemptions, but with a strict exemption application. A parent choosing
not to vaccinate their child based on religious views should be required to provide some
sort of evidence that the administration of vaccinations hinders their ability to practice
their religion freely. Otherwise, the exemption application should be placed in the
category of personal beliefs.
The other fraction of the 2.54% unvaccinated for reasons other than religion and
medical reasons accounts for 2.02% of the population. Had all those children been
mandated to be vaccinated the total fraction vaccinated would have increased to 94.62%,
which is larger than the basic reproductive threshold needed to maintain herd immunity
in measles. Under the updated vaccination mandate policy, exemptions based on anything
other than medical reasons and acceptable religious reasons, would not be valid.
Looking at the case study in California, this updated policy would ensure that the
fraction of the kindergarteners would be high enough, so that an isolated occurrence
wouldnt be able to spread into a full outbreak, as was seen in the most recent outbreak in

California. The similar situations in other states, with a variety of diseases (not just
measles), would also be resolved with this updated version of the current population.

Conclusion
Even with all of the negative publicity vaccines have gotten in the past, the impact
vaccines have had on public health cannot be ignored. Schools are a breeding pool for
infectious diseases, and would cause a significantly higher infection rate without the
vaccination requirements that are in place. While the vaccination mandates presently are
fairly successful in keeping the population vaccinated, there is room for improvement if
diseases are to be eliminated from and maintained in the United States. The negative
views people have regarding vaccines encourages more people to choose to remain
unvaccinated, something that causes problems such as the outbreak in California.
Vaccines throughout history have had profound effects on infectious diseases that
were not able to spread throughout the population. Upon development of the smallpox
vaccine, smallpox was eradicated from the world. For a long time, measles was
eradicated from the United States, until the most recent measles outbreak. This shows the
importance of the vaccination of the general population for the sake of those who cannot
vaccinate.
In 1968, Garrett Hardin wrote an article introducing his idea of the Tragedy of
the Commons. He told the story of neighboring farmers tending their herd. Eventually,
one farmer will want to increase his herd, using more resources than originally afforded
to him. Other farmers may follow, depleting the land. The end result is detrimental to all,
and all suffer. The vaccination debate follows the same principle, in which an individual

neglects the well being of the society as a whole for personal gain, and ultimately creates
problems for everyone. Mandates are in place for a reason: to protect the herd from
individuals vying for personal gain. A strengthened vaccination mandate policy is needed
to protect society as a whole from the spread of preventable diseases.

Works Cited
"2006-2007 Kindergarten Immunization Assessment Results." California Department of
Health Services, Immunization Branch. State of California, 2007. Web. 6 Apr.
2015.
"2014-2015 Kindergarten Immunization Assessment Results." California Department of
Public Health, Immunization Branch. State of California, 2015. Web. 6 Apr.
2015.
CNN Staff. "CDC: 102 Measles Case in January." CNN. Cable News Network, 2 Feb.
2015. Web. 06 Apr. 2015.
Malone, Kevin, and Alan Hinman. "Vaccination Mandates: The Public Health Imperative
and Individual Rights." Law and Public Health Practice. Oxford University
Press, 2003. Web. 06 Apr. 2015.
"Measles Cases and Outbreaks." Centers for Disease Control and Prevention. CDC, 09
Feb. 2015. Web. 06 Apr. 2015.
"The Problem - Measles & Rubella Initiative." Measles Rubella Initiative. American Red
Cross, 2015. Web. 06 Apr. 2015.
"Vaccine Laws." National Vaccine Information Center. 201f5. Web. 06 Apr. 2015.