Running head: THE VACCINE WAR

The Vaccine War: A Battle Between Public Health and Personal Liberty

Jennifer R. Fries

First Colonial High School

THE VACCINE WAR

Abstract

This paper evaluates the individual and public health risks that accompany vaccine refusal, and

considers the conflict between personal liberties and the welfare of the public. The author begins

by briefly introducing the history of vaccination in the United States. The author then describes

how vaccines work with the immune system and evaluates vaccine safety. The anti-vaccination

movement is briefly mentioned to explain the sources of the increasing opposition to vaccination.

Finally, the author evaluates the constitutional basis of vaccine exemptions and compulsory

vaccination legislation to determine the role of individual liberties in the grand scheme of public

health.
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Vaccines: A Battle Between Public Health and Personal Liberties

In 1796, Edward Jenner demonstrated that an individual deliberately exposed to the

infectious material of a cowpox lesion would be protected against subsequent exposure to

smallpox. The introduction of Jenner’s vaccine in the United States sparked the beginning of the

vaccine era, in which many new vaccines were developed and introduced to the public (Malone

and Hinman, n.d.). Widespread implementation of vaccination programs contributed to the

global eradication of smallpox, and the near elimination of certain vaccine-preventable diseases

like polio. Despite continuing to exist in other countries, measles was declared by the Centers for

Disease Control and Prevention to have been completely eliminated from the Western

Hemisphere in 2000 (World Health Organization, 2016).

In recent years, the perpetuation of misinformation and false claims, along with the belief

that vaccination is no longer necessary for diseases that are uncommon or non-existent in the

United States has contributed to significantly low vaccination rates. As a result,

vaccine-preventable diseases like measles are making a comeback. In 2014, the United States

experienced nearly seven hundred cases of measles across twenty-seven states; the greatest

number of measles cases since the elimination of measles in 2000. A study conducted by the

Journal of the American Medical Association attributed the measles outbreak to vaccine refusal

(Davis, 2016).

Unvaccinated individuals are at an increased risk for highly infectious diseases that

endangers the health of those around them. Vaccination is an essential aspect of public health

that should be regarded as a civil obligation instead of a personal choice.

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The Necessity of Vaccines

The immune system is a network of specialized cells, tissues, and organs that work in

conjunction to protect the body from infection by identifying and destroying the harmful

pathogens it comes into contact with. The surface of every pathogen consists of antigens, which

alert the body to an infection and stimulate an immune response. When exposed to an antigen for

the first time, immune cells produce antibodies that are specific to the antigen. Each antibody has

an antigen-specific binding site that allows the antibody to bind onto and destroy the antigen.

The immune response continues until all antigens have been destroyed. After the immune

response has successfully eliminated the infection, antigen-specific antibodies continue to

circulate in the body, and memory immunity against the pathogen has been established. The next

time the body is exposed to the same pathogen, the immune cells will remember its antigens and

rapidly produce the correct antibodies that will eliminate the pathogen before it becomes harmful

to the body.

Vaccines contain a version of a pathogen that has been weakened or inactivated so that it

is unable to cause infection. The antigens in the vaccine are the same as the antigens on the

surface of the infectious pathogen, which prompts the immune system to produce antibodies that

are the same as those that would be produced in response to a natural infection with the

pathogen. Just like a normal immune response, the antibodies produced by a vaccine remain in

the body. If an individual ever comes into contact with the disease-causing pathogen to which

they were vaccinated against, their immune system will recognize the infectious antigens to

which it must produce antigens against. The immune memory developed through vaccination
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allows the immune system to produce antibodies at a faster and more effective rate (Centers for

Disease Control and Prevention, 2018).

Natural infection with any disease can have severe and potentially fatal complications.

While the overall incidence of vaccine-preventable disease in the United States has made it

possible that some individuals may never encounter a vaccine-preventable disease in their

lifetime, vaccination is the only way to prevent disease. Until the global eradication of all

vaccine-preventable diseases, it is better to be proactive than reactive, even if that means the

immunity developed through vaccination is never utilized.

Protecting the Herd

Perhaps the most important characteristic of vaccines is the protection they provide for

both the individual and the community. Herd immunity occurs when a significantly large number

of individuals in a community have been vaccinated. Their high vaccination rates act as a

protective barrier against the acquisition and transmission of disease within the community. If an

individual contracts a vaccine-preventable disease, the chance of an outbreak occurring within

their community is significantly lower if vaccination rates are high enough to sustain herd

immunity, since there are very few susceptible individuals within that community to spread the

disease (Feemster, 2018).

Not everyone is able to receive vaccines safely. A small portion of a community benefits

directly from herd immunity: newborn babies who are too young to be vaccinated against certain

diseases, the elderly whose immune systems are unable to produce a sufficient response to

vaccines, and individuals with compromised immune systems. Since they are unable to be

vaccinated, these individuals experience a greater vulnerability to disease, and therefore rely on
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herd immunity to protect them in the event that their community is exposed to a

vaccine-preventable disease (Meissner, 2015).

While the number of vaccinated individuals required to prevent the transmission of a

particular disease within a community varies according to the infectiousness of the disease, only

a small portion of a community can be left unvaccinated in order for herd immunity to remain

effective. The benefits of herd immunity are reserved solely for those who are more susceptible

to disease, but are unable to receive vaccines. However, as a community reaches a high level of

vaccination, some may decide to refuse vaccination because they believe they will be protected

by that of others. When a large number of individuals refuse vaccination, the protection levels in

their community will decline and the effect of herd immunity will disappear, which will

consequently cause the risk of disease transmission to increase (Malone and Hinman, n.d.).

Despite the protection herd immunity provides for a community, it does not provide the

same level of individual protection that vaccination does. While herd immunity decreases the

risk of transmission within a community, the only way to effectively prevent a disease is through

vaccination (Vaccine Knowledge Project, 2018). Healthy individuals that choose to rely on herd

immunity as an alternative to vaccination selfishly endanger the lives of individuals whose health

relies completely on the vaccination of others, and are directly contributing to outbreaks of

vaccine-preventable diseases.

Vaccine Safety

As a result of rigorous development and approval processes, the current vaccine supply in

the United States is the safest and most effective it has ever been. In order for a vaccine to be
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approved by the Food and Drug Administration (FDA) for public administration, the vaccine

undergo years of intensive laboratory research and testing, followed by clinical development.

All available information about the vaccine is then evaluated by FDA scientists and medical

professionals to determine its safety and effectiveness. If the benefits of the vaccine clearly

outweighs potential risks, the vaccine will receive a license from the FDA certifying it for public

administration. As the vaccine is made available to the public, it is closely monitored by the

Centers for Disease Control and Prevention for side effects that may not have been observed

during clinical trials (Centers for Disease Control and Prevention, 2015).

Vaccine additives.​ In addition to antigens, vaccines contain a variety of additives that

serve a different and specific purpose: to enhance the immune response, ensure the safety and

effectiveness of the vaccine over a long period of time, or to actually produce the vaccine. All

additives currently in vaccines have been intensively studied by the FDA to ensure they are

one-hundred percent safe for human consumption. However, some additives include substances,

such as thimerosal and formaldehyde, that have been associated with toxicity in high amounts. In

this case, it is important to remember that it is the dose that makes the poison, and that many of

these substances are naturally present in the environment and the body.

Thimerosal is an mercury based preservative that prevents the vaccine from being

contaminated by bacteria in the environment in which it is produced, stored, and administered. In

1999, public concern over the exposure to mercury in vaccines containing thimerosal ensued

after the realization that the cumulative amount of mercury in the childhood vaccine schedule

potentially surpassed the recommended threshold for methylmercury. However, the type of

mercury found in thimerosal is ethylmercury, not methylmercury (World Health Organization,

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2006). While both compounds contain a form of mercury, ethylmercury is completely different

than methylmercury. Due to the tendency of methylmercury to accumulate in the body, exposure

to high, constant amounts of methylmercury can have significant harm on the nervous system,

and impair the development and functioning of the brain. Conversely, the rapid rate at which

ethylmercury is excreted from the body prevents it from accumulating to harmful levels, making

it highly unlikely that the small amounts of ethylmercury contained in thimerosal will cause

bodily harm. Despite extensive research that was unable to prove thimerosal to be dangerous, the

United States Public Health Service decided to remove thimerosal from all vaccines as a

precautionary measure (Centers for Disease Control and Prevention, 2013).

Formaldehyde is used during the production of a vaccine to inactivate the virus of a

pathogen so that it is unable to cause infection. Once the pathogen has been inactivated, the

formaldehyde is removed from the vaccine. It is possible for residual amounts of formaldehyde

to remain in the vaccine even after its removal; however, the residual amount allowed by the

FDA is much lower than the amount of formaldehyde that is produced within the body.

Formaldehyde is essential in many biological processes, and is therefore always present in the

body. When the body breaks down formaldehyde, it is unable to differentiate between the

formaldehyde that has been produced naturally and the residual formaldehyde found in vaccines.

While excessive, long-term exposure to formaldehyde may cause cancer, the potential for harm

depends on the amount. No research thus far has found an association between cancer and the

miniscule amount of formaldehyde exposed to the body during vaccination (U.S. Food and Drug

Administration, 2018).
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Side effects.​ The side effects that often follow vaccination are an imitation of the

symptoms experienced during a real infection. The pathogens in vaccines are not infectious, so

side effects typically disappear within a day or so, since the immune system does not need as

strong of a response to produce antigen-specific antibodies that will eliminate the imitation

infection from the body. Experiencing mild side effects is an indication that the immune system

is successfully developing immunity to the vaccine.

Very rarely will an individual experience a severe reaction to a vaccine. The infrequency

of severe reactions makes it difficult for researchers to determine if it was a result of the vaccine

or a completely unrelated factor. Regardless, the Centers for Disease Control and Prevention

attempts to convey all potential risks of vaccination, even if researchers are not entirely certain

that vaccines are the cause (Public Broadcasting Service, 2010). While severe reactions to

vaccination are viewed by researchers as hypothetical until substantial evidence can prove

otherwise, severe reactions are feared by the public, and are sometimes the reason individuals

refuse vaccination. Whether or not they are related to vaccination, the possibility that an

individual will experience a severe reaction is so miniscule that it is easily outweighed by the

benefits vaccination provides. Experiencing a side effect of a vaccine is significantly safer than

experiencing the effects of a vaccine-preventable disease, and is therefore worth the risk.

The Anti-Vaccination Movement

In 1998, former Dr. Andrew Wakefield published a study in a British medical journal that

claimed to have discovered an association between the Mumps, Measles, Rubella (MMR)

vaccine and the diagnosis of autism. According to the study, all twelve children that participated

in the study experienced some form of developmental delay within one month after receiving the
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MMR vaccine, while eight of those children developed autism. Wakefield contended that giving

a child a vaccine that contains three weakened viruses harmed their cognitive development, and

recommended that the MMR vaccine should instead be given in three separate doses (Lee, 2010).

Almost a decade after the study’s publication, it was revealed that Wakefield was hired

by a group of lawyers to produce results that would support a class action lawsuit against a

vaccine manufacturer for alleged injury caused by the MMR vaccine. Several of the parents

filing the lawsuit had their children participate in the study, while the remainder of children were

selected through anti-vaccination groups. A small number of the children participants had noted

developmental delays in their medical records, before ever receiving the MMR vaccine. To

fabricate results that validated the association between the MMR vaccine and autism, Wakefield

manipulated research data and falsified information about the children’s medical histories.

The possible link between the MMR vaccine and autism was studied intensively for

twelve years following the initial study. No study could confirm Wakefield’s study, which was

eventually retracted in 2010. In sensationalizing the controversial allegation that a vaccine

received by millions of children each year contributes to cognitive defect, the media has

contributed to a distrust of science by concentrating on anecdotal evidence from self-proclaimed

experts instead of hard scientific evidence produced by reputable researchers. When anecdotes

and false claims are presented as scientific evidence, the media creates its own science that

contributes to vaccine hesitancy and confusion (White, 2012).

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The Freedom of Health

As vaccine-preventable diseases have become less visible within the United States over

recent decades, many individuals have become more concerned by the supposed risks posed by

vaccines than by the diseases vaccines prevent. This has resulted in the notion that vaccine policy

is no longer an essential aspect of maintaining public health, and that such policies would expend

a significant amount of resources only to protect the public from what are perceived to be

nonexistent threats. The failure to accurately evaluate the risk of vaccine-preventable disease has

left public health officials with challenges in conveying the importance of vaccines without

causing unreasonable fear. The dualistic nature of vaccines as being both a personal choice and a

matter of public health places vaccination in the gray area of public health policy. The conflict of

finding a balance between the rights of the individual and the interest of public health has

endured since the advent of the vaccine in the eighteenth century (Feemster, 2018).

Current vaccine policy aims to obtain vaccination rates that are sufficient enough to

sustain herd immunity and protect public health, even in the absence of vaccine-preventable

diseases. Although vaccines have decreased or even eliminated some diseases from the United

States, the infectious agents that cause them continue to persist in other countries. Resultant of

our increasingly global society, these agents can cross geographical borders with ease and

agility, and subsequently infect any unprotected individual (World Health Organization, 2018).

If a community’s herd immunity falls below the threshold required for protection, one infected

individual is will it take for an outbreak to ensue.

Such was the case in a 2008 measles outbreak in San Diego, which began after a young

child returned to the United States after unknowingly contracting measles while in Switzerland.
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The child consequently infected two of their siblings, where they collectively exposed their

schoolmates to the disease. The infection spread to four more children who were exposed to the

disease during a visit to the pediatrician. Two hundred and fifty more individuals were exposed

to the disease after an infected child flew on a plane to Hawaii, where, upon their arrival, the

child was intercepted and placed in quarantine. Although this marked the end of the outbreak,

public health officials have estimated a total of one thousand people were exposed to the disease,

and attribute the entry of measles to undervaccination within the San Diego community (Public

Broadcasting Service, 2010).

To prevent future outbreaks from occurring, it is important to maintain high vaccination

rates that will sustain herd immunity, even in the absence of disease. If vaccination is decreased

or even stopped, protection against vaccine-preventable disease will no longer be available. Herd

immunity is only effective when vaccination rates are consistently high. Until all vaccine

preventable diseases have been globally eradicated, decreasing vaccination coverage poses a

serious health risk.

Vaccination Exemptions

State vaccination requirements for school aged children who seek entry into state funded

schools are intended to maintain high vaccination coverage and low rates of vaccine-preventable

diseases among one of the most vulnerable age groups. However, the benefits of vaccination

requirements are often devalued by the ability to claim a non-medical exemption on the grounds

of a religious or personal objection to vaccination. Forty-seven states allow religious exemptions

while twenty allow personal belief exemptions. States with lenient exemption policies had a

higher number of non-medical exemptions and an overall increased incidence of

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vaccine-preventable diseases than states with strict exemption policies or no non-medical

exemptions. Over the past decade, non-medical exemption rates have increased in two-thirds of

the states that allow such exemptions to be claimed (Devitt, 2018). Non-medical exemptions tend

to cluster in communities that hold similar values and beliefs, which results in insufficient

vaccination rates to sustain the community’s herd immunity. Communities with higher rates of

non-medical exemptions also tend to have a higher incidence of vaccine-preventable disease and

an increased number of outbreaks.

The Supreme Court addressed the constitutionality of religious exemptions in ​Prince v.

Massachusetts​. The Court established that the religious exemptions offered by states are elective,

and that no constitutional right exists to religious exemption to vaccination. The decision to

allow or deny religious exemptions was left to state legislatures, rather than mandated by the

First Amendment right to freely exercise religion. Under the Equal Protection Clause, the Court

determined that states could require vaccination despite religious objection, and that a parent’s

right to freely exercise religion does not automatically give them the right to expose their

community to infectious diseases that have harmful and potentially fatal effects (Beltz, 2015).

Similarly, no constitutional right exists to personal belief exemptions. Vaccination is not

centered around belief and opinion. It is based upon evidence and data that has been provided by

thousands of research studies that support the safety and effectiveness of vaccines. A social

contract exists between all members of a community to receive vaccines that will not only

provide individual protection, but contribute to the protection of those who rely on herd

immunity. An individual’s unwillingness to accept evidence and data that conflicts with their

opinions does not give them the right to put their community at danger (Offit, 2012).
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To mitigate the effects of non-medical exemptions on vaccination rates and public health,

increased effort should be made by state legislatures to enact effective administrative and

legislative controls over the provision of non-medical exemptions. It is imperative that states

regard public health above personal liberty when considering the types of allowable exemptions

and the means by which exemption policies will be implemented and enforced. The American

Academy of Pediatrics urges states to use their authority in creating public health policy to

eliminate all non-medical exemptions to reduce the unnecessary risk they create for individuals

and communities (American Academy of Pediatrics, 2016).

Compulsory Vaccination

The constitutional basis of compulsory vaccination rests within the police power reserved

to the state by the Tenth Amendment. Police power is the capacity of the state to establish and

enforce legislation in the interest of protecting and promoting the welfare, safety, and health of

the public. In ​Jacobson v. Massachusetts,​ the Supreme Court established that a state may use

their police power to suspend certain personal liberties in that the freedom to act according to

one’s religious beliefs is subject to reasonable legislation if the exercise of such beliefs poses a

considerable threat to the overall welfare of the public (Pace Law School Library, 2018).

On the Horizon

Vaccination is an essential aspect of public health that should be regarded as a civil

obligation rather than a personal choice. A social contract exists between all members of a

community to receive vaccines that will not only provide individual protection, but contribute to

the protection of those who rely on herd immunity. Legal precedent has determined that no

constitutional right exists to a religious or personal exemption to vaccination, while application

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of the Equal Protection Clause has established that the right to freely practice religion does not

apply when the health of others is endangered. To prevent further outbreaks of

vaccine-preventable diseases, state policy should encourage high vaccination rates that are

sufficient enough to sustain herd immunity by exercising their right to police power to enforce

mandatory vaccination by prohibiting all non-medical exemptions to vaccination. Until all

vaccine preventable diseases have been globally eradicated, decreasing vaccination coverage

poses a serious health risk. Vaccination is the best shot at preventing disease.
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