Eradication with vaccination? It’s worth a shot

My stomach sank as I read the following email from my residency program: “Four measles cases confirmed in Harris County. Please reference the attached triage algorithm if you encounter a patient with symptoms of measles.”

I wondered if Texas could be facing a largescale outbreak similar to Washington state and New York. As a pediatrician-in-training, it distressed me to think that I could encounter patients with diseases that are entirely preventable thanks to the most simple yet effective public health intervention: vaccination.

In order to establish herd immunity and protect the public, the majority of our population must be vaccinated. However, fear of government infringement on individual autonomy has long been sewn into the fabric of American culture. To some individuals, mandatory vaccination is not seen as a necessary public good but a threat to decisional rights.

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More recently, the anti-vaccination movement has been further stoked by the rapid spread of misinformation online and a mounting sense of distrust towards both physicians and the pharmaceutical industry. While all states mandate childhood vaccination for school entry, most states do not make it so burdensome as to prohibit motivated families from obtaining vaccine exemptions.

As a result, childhood vaccine exemptions have been on the rise for over a decade now, with the rate of exemptions for kindergarten-aged children in Texas rising from 0.3% in 2005-06 to 2.2% in 2018-19. These increasing exemptions create gaps in herd immunity that have now produced substantial consequences in the form of disease outbreaks, particularly measles.

In response to these outbreaks, several states have decided to ban nonmedical (i.e., personal belief and/or religious) vaccine exemptions. After the Disneyland measles outbreak in 2014, California passed legislation eliminating nonmedical vaccine exemptions the following year. New York has removed all nonmedical vaccine exemptions and Washington state has eliminated all personal belief exemptions.

Although the outright elimination of vaccine exemptions may become necessary to prevent disease outbreaks in the future, policymakers have proposed a number of other vaccination policies that could help reduce the dangers of an outbreak while still granting families the autonomy to choose whether to vaccinate their children.

One such policy is transparent school vaccination reporting, a topic that Dr. Mary Majumder and I cover in detail in an American Journal of Public Health article. Currently, the public’s ability to find detailed information regarding school vaccination rates is limited if a state’s health department is not obligated to publish that information. To date, four states have passed legislation mandating that school-specific exemption rates be shared with the public.

For Colorado, you can find easy-to-read online infographics and maps illustrating immunization and exemption rates at individual schools. In contrast, Texas has not passed such legislation so the information available is limited to county-specific exemption rates.

One of the primary ethical arguments in favor of passing this legislation is that it gives families of children with compromised immune systems the ability to identify safe school choices. Training in the Texas Medical Center, I see children who are immunocompromised on a daily basis. These children are unable to receive certain vaccinations due to their medical conditions.

If a disease outbreak such as measles were to occur in Texas, these children would be at high risk of serious illness and even death. Advocates of this type of policy have tried passing legislation that mandates transparent school vaccine reporting in Texas, most recently with Senate Bill 329 in the 2019 legislative session. This legislation has failed to pass due to parents’ concerns about privacy and discrimination.

While these are important points to consider, a number of measures are available to minimize any potential harms, including ways to de-identify the data and community engagement in sensitive, non-discriminatory conversations about vaccination.

As a future pediatrician, my foremost priority is the health of all children, and as such I believe we may reach a point where compulsory childhood vaccination becomes necessary. However, I also think it’s important to consider the potential consequences of forced vaccination, which, as some of the experts in the field of vaccination ethics have pointed out, could result in the loss of public trust in the healthcare institution.

For this reason, physicians and other vaccine advocates should first focus our energy into efforts to increase public education on the merits of vaccination. Our ability to protect children from vaccine-preventable illness relies not only on physicians and politicians, but also on parents.

-By Caitlin Rose Cardenas-Comfort, M.D., pediatrics resident at Baylor College of Medicine and graduate of the Medical Ethics Pathway

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