As I have been quite involved in the struggle to reform our vaccination exemption laws here in California, I’ve been spending a lot of time reading about childhood vaccination lately. While this is only tangentially related to my usual veterinary focus, I thought I would share an interesting document I found.
Assessing the State of Vaccine Confidence in the United States: Recommendations from the National Vaccine Advisory Committee, DHSS. Draft Report
The purpose of this report was to evaluate the degree of confidence parents in the U.S. have in the recommended vaccination protocols, how this is assessed, and what we might be able to do to increase confidence and improve vaccination rates. There weren’t a lot of surprises in the report, but it’s a concise summary of the situation.
The Good News
One persistent problem with media coverage of most issues, including vaccination, is that it is easy for small numbers of vocal, passionate people to be disproportionally represented and to thereby create an inaccurate impression of how widespread their views are. In the case of vaccine confidence, the vast majority of parents trust and follow the recommendations of the medical community, and this level of adherence has been stable for many years. 80-90% of parents have their children fully vaccinated, which is far more of a consensus than on just about any other hot-button political issue. The emphasis on the exceptions, and the desire to improve vaccine compliance is not a reflection of a widespread resistance to vaccination but a function of the need to have very high rates, generally well over 90%, in order to reap the benefits of herd immunity and protect those who cannot have vaccines for medical reasons or for whom vaccination is not 100% protective.
It is important to remind ourselves that vaccinating your children is not only a good idea for their health and the health of others, it is also a normative social behavior. While people should, ideally, make rational and evidence-based decisions independent of the beliefs of others, the reality is that people are influenced strongly by what they perceive to be the beliefs of other members of their community. If parents mistakenly believe that vaccine-refusal is mainstream, they may take it more seriously despite the misguided and mistaken foundations of anti-vaccine attitudes. However, if people understand that vaccination is not, in fact, controversial but accepted by the overwhelming majority of American parents, they may be more comfortable rejecting the scare tactics and specious arguments of vaccine opponents.
This study also found that there is a high degree of confidence in reliable sources of information about vaccines, especially healthcare providers. Most parents trust their pediatrician’s advice, and many who have reservations about vaccines but ultimately decide to follow the guidelines do so because of information and counseling given by their children’s doctor.
Vaccination has been the most successful preventative healthcare intervention in history, and the high rates of vaccine acceptance in the U.S. have allowed more than one generation to grow up ignorant of the dangers of many infectious diseases that routinely injured and killed children for millennia before the development of vaccines. Even though the number of people who have firsthand experiences with these diseases is few and dwindling in the developed world, most parents still understand the importance of vaccinating their children to prevent the resurgence of these infections.
The Bad News
Despite the overall high and stable levels of acceptance of science-based vaccination guidelines, confidence in vaccination varies dramatically by region. The problem today is not widespread rejection of vaccines but high levels of rejection in localized communities. These communities have proven to be sources of outbreaks of otherwise well-controlled infectious diseases. Regional and demographic factors which are partially but not completely understood have led to such pockets of vaccine rejection in which vaccination rates are low enough to undermine herd immunity and facilitate outbreaks. I know because, sadly, my own child goes to school in such a pocket, with vaccination rates well below the average for the state and the other schools in the district.
As mentioned earlier, the formation of such pockets of mistrust in vaccines are facilitated by the impression they create that suspicion of vaccination is common and mainstream. Even in my community, 84% of children are fully vaccinated, yet the remaining 16% of families are able to sustain misguided beliefs about vaccines within a supportive echo chamber that helps insulate them from the information and arguments that the rest of the community offers in support of vaccination.
Though the report does not address this, I have the subjective impression that there is a strong correlation between vaccine refusal and more general pseudoscientific attitudes and beliefs. Most of the individuals arguing against the scientific consensus on vaccines in my community, for example, also proclaim homeopathy and other alternative therapies to be safer and more effective alternatives. And the organized voice for chiropractors in California, the California Chiropractic Association, has come out in opposition to reforming the state’s vaccine exemption laws and recently gave a hero’s welcome to disgraced physician Andrew Wakefield, who launched the modern anti-vaccine movement:
The California Chiropractic Association is actively lobbying against California Senate Bill 277, which would end the state’s “personal belief” exemption against ten types of vaccinations now required to begin school. [Mason M. Chiropractors lobby against bill ending belief exemptions for vaccines. Los Angeles Times, March 5, 2015] CCA’s Web site advises members to say that they are “NOT anti-vaccine we are pro-inform consent and choice.”
Life Chiropractic College West sponsored a talk by Andrew Wakefield, who lost his British medical license for unprofessional conduct related to vaccine scaremongering. The San Francisco Chronicle has reported that he received standing ovations after he advised hundred of students that SB 277 was a step toward mandatory vaccination that could have dire consequences. The paper also noted that the school’s president was considering hiring buses and canceling classes so students could attend a Senate hearing. consent and choice.”
The importance of legislation like SB277, the initiative to eliminate non-medical exemptions to school vaccination requirements in California, is also emphasized in the report. Such exemptions, particularly those that require only a “philosophical” objection and are easy to get, have increased significantly, and they are directly associated with the growth of local clusters of vaccine refusal, and the subsequent outbreak of vaccine-preventable disease. Such exemptions serve no legitimate purpose because they essentially eliminate vaccination requirements altogether and undermine the public health value of immunization. The legal and scientific legitimacy of such mandates has been settled for over a century, and recent efforts to undermine them by extending vaccine exemptions is supported only by misinformation and fear.
Conclusions & Recommendations
The report concludes that while overall confidence in vaccination and trust in doctors and public health officials is high, there are communities in which misinformation and misguided distrust have taken root, and this represents a real threat to public health. The committee made a number of recommendations for monitoring and improving confidence in vaccination:
- Objective and standardized measures of vaccine confidence should be developed and ongoing surveillance of these should be conducted by public health agencies
- Doctors, public health officials, and parents who support vaccination should continue to communicate the benefits of vaccination and reinforce that it is a social norm accepted by the vast majority of Americans. These communication efforts should be supported with evidence-based materials and training.
- Vaccine exemptions for non-medical reasons should only be available if parents are adequately informed about the safety and efficacy of vaccination and the risks of not vaccinating.
Personally, I don’t believe this final recommendation goes far enough. Given the evidence that accurate information rarely changes entrenched anti-vaccine beliefs, I think the degree to which education requirements will reduce vaccine exemptions is too small to be effective. Such exemptions should not be allowed without sound medical justification. People may have the right to choose not to vaccinate their children, even if the choice is based on inaccurate beliefs and fears, however they do not have the right to then endanger others by sending their children to schools and daycare centers with other people’s children