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The Vaccine Debate

A public health expert explains why some children remain unvaccinated — and why that puts all children's health at risk.
 

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Here's some alarming news: The number of young children who are not fully vaccinated for preventable diseases has been steadily increasing over the last decade. More and more, parents are claiming nonmedical exemptions from routine vaccinations — leaving their children, their children's classmates, and other children in their communities vulnerable to diseases.

To find out what's behind this troubling shift, Daniel A. Salmon, Ph.D., M.P.H., of the Institute for Vaccine Safety at Johns Hopkins Bloomberg School of Public Health in Baltimore, surveyed parents of both vaccinated and unvaccinated children. He and his colleagues found that parents who avoided vaccines most often did so because of fears that the vaccine itself might be harmful. What is driving this fear? "Not enough public education about vaccines," Dr. Salmon says. The irony is that many people are afraid of immunizations developed to prevent the very diseases their parents and grandparents feared. The editors of Scholastic's Parent & Child magazine talked to Dr. Salmon to get some perspective.
 

Parent & Child: Please give us some background. Have people always been wary of vaccines?
Dr. Salmon: There's always been some controversy surrounding vaccines, but in the past that was usually overridden by fear of the disease itself. Take the polio vaccine, for instance. When it was first tested, families lined up for the trials. These were people who had no idea if the vaccine itself would cause polio. They didn't even know if they'd receive a vaccine or a placebo. But they were so terrified of polio that they were willing to try anything. Ordinary people were also willing to pay for the development of the vaccine. That's what got the March of Dimes started; it was an effort to pay for the research privately since the government wasn't willing to fund it with public money. The point is that when people are terrified of a disease, they are far more willing to take risks.

P&C: And the general public is no longer afraid of these diseases?
Dr. Salmon: Exactly. Back when polio was a big threat, every family was touched by it. Everyone knew someone who had been stricken. Parents weren't letting their kids go swimming for fear they'd contract polio. But now that we rarely see polio, parents don't fear it. And once people aren't afraid of the disease, attention shifts to the vaccines themselves, and the fear that they may not be safe.

P&C: Was that what happened a few years ago with the MMR (measles, mumps, rubella) vaccine? Parents heard that the vaccine may cause autism.
Dr. Salmon: Yes. A British doctor, Andrew Wakefield, observed that, of the 12 children he was treating for bowel disease, 6 were also autistic. And those same six had had the MMR vaccine. So he made the conclusion that the vaccine was a cause of the autism. It's important to note that his conclusion was based on an observation, not a scientific study. However, he published his findings in a respected British medical journal, The Lancet, and it got a lot of media attention. Once people heard this news they became alarmed, and even after later studies confirmed that the MMR is not linked to autism, the suspicion persists. But parents should feel comforted knowing that both the Institute of Medicine and the American Academy of Pediatrics have concluded that the MMR vaccine doesn't cause autism.

P&C: So why does that suspicion, or fear, persist?
Dr. Salmon: You have to look at it from a parent's perspective. If you have an autistic child, you naturally want to know what caused it. And even if your child is not affected by autism, you may be seeing the number of cases on the rise. This is what parents are afraid of now, not polio or measles or pertussis, because those diseases are so rare you may never have known anyone who had them. But you probably do know someone who has an autistic child. The media also is to blame — it was a story that was easy to hype. Not only that, but there is a lot of misinformation on the Internet. Plenty of sites look authoritative, but they are not based on good, scientific studies or information.

P&C: What are the risks of not having your child vaccinated?
Dr. Salmon: PTA There is always a risk of the unvaccinated child contracting the disease, depending on the type of disease, how easily transmissible it is, and its prevalence in the area. Parents should be aware that there is a definite risk of their child getting sick. Unvaccinated children are, for example, 22% to 35% more likely to contract measles than those kids who are vaccinated against it. Thus, a group of unvaccinated children with measles can put all other children they come into contact with at risk for contracting the disease. Although vaccines work extremely well, nothing is 100% effective. One child may have gotten all her immunizations, but perhaps she didn't get the full immune protection from every dose. Another might be too young to be vaccinated, or might have received her latest dose a bit late. On a community level, schools with higher numbers of exempt children have higher rates of disease. We've seen it in some religious communities. An example is an island off the coast of Seattle, Washington, where many children are unvaccinated; there, outbreaks of pertussis occur.

P&C: Are there accepted medical exemptions to some vaccines?
Dr. Salmon: Yes. A child who has had an organ transplant, has HIV, or for some other reason has a compromised immune system, should not get a live vaccine. There are also some immunizations that are made with egg whites, so children who have egg allergies should avoid those. But that covers a very small number of children.

P&C: How easy is it for parents to claim nonmedical exemptions?
Dr. Salmon: In some states — vaccination laws are state, not federal — it's surprisingly simple. You may live in a state — California is one example — where you are given an immunization form when you enroll your child in school. You're supposed to get it filled out and signed by your child's doctor. That often means you have to drop off the form at the doctor's office, and either wait or come back later for it, and even pay a small fee if the doctor requires it. But if you turn the form over, you can check off the "exempt" box and be done with it. No one asks why.

Two things can happen here. One, the parent may not have had the child immunized at all, for whatever reason, and does not have to explain him or herself. And two, the parent may have had the child immunized and think, "Well, I know my kid's up to date with his shots, but checking this box means I save the extra step of going to my doctor and getting the form signed." The problem with that is many parents overestimate their children's coverage; a child may not be fully immunized, and having the doctor check the records would reveal that.

P&C: What can be done to change these practices?
Dr. Salmon: I believe that some state laws should be rewritten so it isn't so easy to avoid vaccinations on nonmedical grounds. And we need to do a much better job of educating parents, particularly those about to have their first child, who are really a captive audience for this kind of information about the safety, efficacy, and importance of routine vaccinations. Vaccines are very safe. While it is true, as I've said, that nothing is 100% perfect, vaccines have to go through very rigorous clinical trials, then the approval process of the FDA, which is stringent. By the time a vaccine makes its way from the lab to the market, a lot is known about how safe it is. Even after licensure, there's a reporting system for any potential problems, and further testing takes place.

Our study revealed that even parents who have gotten their children properly immunized have some concerns about safety, but those fears can be eased with good education. Parents with any questions about vaccines should first consult their child's pediatrician and other health care providers for reliable information. Additional information is also available from the Centers for Disease Control and Prevention and the Institute for Vaccine Safety.

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