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Policy Brief

Siddharth Sant
Health and Social Policy Dr. Sarah


Executive Summary

While national vaccination rates remain high in the United States, regional and local
health landscapes appear vastly different. Statewide immunization disparities have been
created because nonmedical vaccine exemptions have been on the rise, leading to heightened
disease outbreak risk. Exemptors tend to congregate geographically, resulting in vaccinepreventable disease hotspots. Although consequent epidemics are typically localized, they do
possess the potential to increase in scale as more people refuse vaccinations. The increasing
propensity for vaccine exemption poses a significant threat to maintaining herd immunity,
and empirics have proven resurgence of disease following decline in vaccine use.
In response, public agencies and non-profit organizations have attempted to
disseminate educational information and reduce the risk of vaccines, but little action is being
taken to target high-risk areas and improve immunization. Legislators are exploring tort law,
vaccine exemption criteria, and national exemption policy reform to reduce the number of
vaccine exemptors.



The United States has experienced near-record lows in vaccine-preventable disease

outbreaks in recent years (CDC, 2011). The US currently administers childhood
immunizations through a state mandate, a policy that has been highly effective in ensuring
high vaccination rates among
children. (Baden, 2007). When
assessing the success of national



Center for Disease Control and

Prevention (CDC) typically uses
community immunity as its



principle asserts that once a






immunized, the majority of the

population obtains immunity to
that disease due to a decreased

Source: Community Immunity, 2012

risk of outbreak (Community

Immunity, 2012). Reaching the community immunity benchmark significantly reduces
chronic transmission rates of vaccine-preventable diseases, and has been a major contributor
to low incidence of disease outbreak (Omer, 2009). Vaccine-exemption policy varies from
state to state, but virtually every state excluding West Virginia and Mississippi offer
exemptions for non-medical reasons. Initially, these exemptions were thought to be

insignificant because community immunity could still be attained. Recent evidence suggests
that this may no longer be the case. Increasing incidence of vaccine refusal is putting larger
groups of individuals at risk and is simultaneously creating localized disease hotspots (Ciolli,

(Source: State Vaccine Requirements, National Vaccine Information Center)



Defining the Issue

Significant portions of the US population remain susceptible to vaccine-preventable
disease outbreak due to nonmedical vaccine exemptions. Although national vaccination rates in
the USA have reached record highs, they fail illustrate the distribution of immunity across
regions and demographics (CDC, 2011). Granting vaccine exemptions for non-medical reasons

has created regions of concentrated risk populations which have been responsible for disease
outbreaks in the past (Ciolli, 2008). Furthermore, the perception that vaccination is unnecessary
or risky has gained ground in the public eye, and has spread to diseases to which the statemandate does not apply, such as influenza (National Committee for Quality Assurance, 2011).
The CDCs National Immunization survey found that approximately 40 percent of parents delay
or refuse at least one recommended immunization for their children each year (National
Committee for Quality Assurance, 2011). Even momentary declines in immunization rates may
pose significant risks to communities because they are usually accompanied by corresponding
increases in infection rates (Nixon, 2010).

The US government has empirically regarded larger scale political entities like states and
countries as communities. However, new findings report that initial ideas regarding community
size may have been misguided. For herd immunity purposes, communities are much smaller than
initially thought, which explains the resurgence of diseases once thought eradicated (Ciolli,
2008). The epidemiological impact of smaller communities may have once been limited by high
immunization rates present in surrounding communities, but as more people avoid vaccinating
their children, this may no longer be the case. Larger populations are becoming increasingly
vulnerable. Younger children are especially susceptible to infection due to their relatively
underdeveloped immune systems and their inability to obtain vaccines due to age limitations.
Subsequently, they rely on the people that surround them to confer immunity (Omer, 2009). The
spread of preventable disease places financial strain on healthcare, decreases worker
productivity, and increases mortality (Calandrillo, 2005).

Table 1: National percent of children 19-35 months old receiving vaccinations as of 2009
(National Center for Health Statistics, 2011)

Percent of children 19-35 months old

receiving vaccinations

Diphtheria, Tetanus, Pertussis (4+ doses

DTP, DT, or DTaP)


Polio (3+ doses)


Measles (MMR) (1+ doses)


Haemophilus influenzae type b (Hib)

(primary series +booster dose)


Hepatitis B (Hep B) (3+ doses)


Chickenpox (1+ Varicella doses)





Secular and Geographic Trends

The number of nonmedical exemptions to vaccinations has been on the rise for several
years, but has not varied uniformly (Omer, 2009). Overall, nonmedical exemption rates increased
from 0.98 to 1.48% between 1991 and 2004. However, in states that only allowed religious
exemptions, rates remained steady at approximately 1% during the same time period. States that
permitted philosophical exemptions saw increases from 0.99 to 2.54% (Omer, 2009). Within
states, even greater variation was present, especially in areas where exemptors clustered
geographically. This trend was especially evident in Washington, where the statewide exemption
rate was 6% while the countywide exemption rate ranged from 1.2 to 26.9% (Omer, 2009).
Incidences of disease outbreak have also been known to occur in areas where large numbers of
exemptors reside. In 2010, over 6,000 Californians were infected with pertussis, or whooping

cough, leading to the death of ten babies, nine of which were too young to have been vaccinated,
further reinforcing the reliance of young children on their communities for immunity. The area
that was primarily affected was known to possess a larger population of vaccine exemptors
(Nixon, 2007). Throughout the course of the last decade, the personal belief exemption rate for
children in kindergarten has tripled, rising from 0.77% in 2000 to 2.33% in 2010 some schools
reported personal belief exemption rates as high as 84% in 2010 (Cherry and Harriman,
2012). Empirically, schools possessing even the lowest of exemption rates (between 2 and 4%)

are at a greater risk for infectious disease outbreaks (Colgrove, 2006). California has already
experienced outbreaks in the past, most notably the 1989 Los Angeles measles epidemic which
occurred due to disproportionately low vaccination rates among blacks and Hispanics, despite
the national rate appearing high enough to achieve community immunity (Ciolli, 2008).


Children with nonmedical exemptions possess a greater risk for acquiring and
transmitting vaccine preventable diseases (Omer, 2009). A retrospective study examining previous
measles outbreaks and demographic data found that throughout 1985 and 1992, children with
exemptions were 35 times more likely to contract measles as nonexempt children at the national
level (Salmon, 1999). Another retrospective study analyzed data taken at the state level in
Colorado from 1987 to 1998, and found that children with exemptions were 22 times as likely to
have had measles and six times as likely to have had pertussis relative to unvaccinated children
(Feikin, 2000).
Susceptibility to infection seems to be highest among the very young children and adult
age groups. Novel vaccine schedules may have potentially increased this demographics
vulnerability to infectious disease because parents choose to follow the recommendations of

individual physicians rather than obtaining immunizations for their children as prescribed by the
Advisory Committee on Immunization Practices (Omer, 2009). The majority of these new
schedules rely on administering vaccines over longer periods of time, which may leave young
children vulnerable at early ages.
The measles eradication has been highly successful in reducing mortality among children,
but pockets of vulnerability still remain within the US. The number of measles cases dropped
from 500,000 before state-mandated measles vaccination to 62 after state-mandated measles
vaccination annually (Omer, 2009). Between January 1, 2008 and April 25, 2008, five measles
outbreaks occurred and 64 cases were reported, though 63 of those cases involved unvaccinated
individuals. 13 of these cases occurred in children too young to be vaccinated (Omer, 2009).
Adults are also highly predisposed to infection. Annually, vaccine-preventable diseases
contribute to the deaths of 30,000 American adults (above the age of 18) (Calandrillo, 2005).

Religion, Ethnicity and Economic Status

Infectious diseases have taken root with specific religious groups, such as Christian
Scientist, Amish, and Mennonite communities, because these populations are more likely to file
for vaccine exemptions (Ciolli, 2008). Consequently, the US has seen a localized resurgence of
polio, measles, and rubella because community immunity has been compromised within these
areas. Areas that possess larger populations with religious objections to vaccinations are more
likely to serve as reservoirs for infectious diseases (Ciolli, 2008).

Significant differences in vaccination rates by ethnicity were not observable on the

national scale (National Center for Health Statistics, 2011). By 2009, vaccination rates for the

Hepatitis B, varicella, and PCV vaccines was approximately equal for children 19-35 months of
age across ethnicities (National Center for Health Statistics, 2011). Differences were observable
across socioeconomic boundaries, with individuals at lower income brackets possessing lower
vaccination rates than their more affluent counterparts. However, when comparing unvaccinated
children to undervaccinated children, unvaccinated children were more likely to be male, to be
white, [and] to belong to households with higher income (Omer, 2009). This may demonstrate
that more affluent individuals are more inclined towards refusing vaccines due to safety concerns
or due to matters of convenience (Omer, 2009).

Scale and Intensity

The majority of exemption-related disease outbreaks are localized issues that have large
economic impacts because the regional medical infrastructure is not entirely prepared to treat
unexpected diseases (Omer, 2009). However, due to increasing momentum in the antivaccination movement, community immunity for larger populations may be compromised in the
future, which could pose a significant threat to the general health of the US. Empirically, diseases
such as smallpox have resurfaced when vaccination efforts became more lax. While smallpox
infection rates declined between 1802 and 1840, several physicians and advocates of
unorthodox medical theories opposed vaccination efforts. The resultant decline in
immunizations led to a resurgence of smallpox in the 1870s (Omer, 2009). Maintaining herd
immunity requires routine and successive vaccination campaigns of each generation; failing to
do so may lead to a return of previously eradicated diseases.
There have been numerous incidences of disease outbreaks in recent years that should
call this issue to government attention. In 2005, a measles outbreak in Indiana caused by the

importation of measles created the potential for a much larger outbreak. Most infected
individuals were young and active, thereby putting hundreds at risk for exposure in the two
weeks before the Indiana State Department of Health was notified and efforts to contain the virus
began (Parker, 2006). The disease did not spread extensively because the majority of the
populace in the surrounding communities had been vaccinated (Parker, 2006). Regardless,
approximately $167,000 had to be apportioned for containing a disease that had spread to no
more than 34 people (Parker, 2006). Furthermore, it was found that the cause of the outbreak was
the spread of an imported strain of measles into a group of children who had not received the
measles vaccine due to parental objections regarding vaccine safety (Parker, 2006). This event
also demonstrates the virulence of vaccine-preventable diseases in unvaccinated populations, as
it was caused by a single incubating host who spread it to others, 94% of whom were
unvaccinated (Parker, 2006).
The CDC conducted an extensive cost-benefit analysis regarding the long-term economic
viability of vaccines and found that direct medical savings amounted to $6.30 per vaccine with
an aggregate value of $10.5 billion. Indirect savings amounted to $18.40 per vaccine and an
aggregate of $42 billion after accounting for losses due to missed work, death, and disability
(Ross, 2003). Further studies conducted by the National Committee on Quality Assurance, a
healthcare watchdog group, expanded on these values, finding that current vaccination schedules
prevented approximately 42,000 deaths and 20 million cases of disease while saving $14 billion
in direct costs and $69 billion in societal costs per year (National Committee for Quality
Assurance, 2011). Currently, the primary victims of the anti-vaccination mentality are adults,
who are already predisposed to infection due to the lack of a vaccine state mandate during their
childhoods. American adults continue to contract vaccine-preventable diseases, leading to 30,000

unnecessary deaths and $10 billion worth in easily circumventable healthcare costs each year
(Calandrillo, 2005).


Public Agency
Center for Disease
Control and
Prevention (CDC)




Primary goal:
Preserve national
health integrity,
promote healthy

Administration for
Children and Families

Primary goal:
protect the health
of all Americans,
provide public
medical services

research and
analysis of
trends, provides
information and
for statewide and
national policy
Provides medical
services through
public hospitals,

Agency for Health

Care Research and
Quality (AHRQ)

Primary goal:
Improve the
quality, safety,
efficiency, and
effectiveness of
health care for all

The CDC is tasked

with gathering
regarding highrisk demographics
and providing
in the case of an
The ACF seeks to
promote early
vaccination in
especially those
aged 19-35
months. Early
reduces the
vulnerability of
youth to vaccinepreventable illness
researches vaccine
safety and tries to
develop new
vaccines to
cultural objections.
In addition, it
reviews prescribed

evaluates current
health policy and
for change

vaccine schedules
and makes

Committee for
Quality Assurance



Primary Goal: Improve

health care quality

medical policy,
resources into
benefits of

National Vaccine
Information Center

Primary Goal:
Expanding exemption
options, exploring
vaccines for safety,
encouraging political

American Academy
of Pediatrics (AAP)

Primary Goal: Attain

optimal physical,
mental, and social
health and well-being
for all infants,
children, adolescents,

Policy Subsystem

The NCQA is a
watchdog group
that works closely
with the CDC in
information. It
seeks to educate
parents and
children regarding
the benefits of
Assists those
The NVIC serves
who have
as an interest
suffered vaccine group that tries to
reactions, funds expand exemption
research to
options in states
that possess
vaccine safety
limited exemption
avenues. This
group possesses a
distrust of
vaccines and has
furthered the antivaccine
The AAP works
youth to provide
communityhealthcare services
based health
such as

and young adults



immunizations to
those who cannot
afford it.


This issue warrants government attention because the federal government is the only
institution with sufficient resources to lead a nationwide vaccination and education campaign.
Decreasing the incidence of infectious diseases within localized areas requires a region-specific,
targeted approach, and the federal government already possesses the research and administration
infrastructure to quickly and efficiently administer vaccines and educational resources. One
approach that is being considered to combat exemptions is using tort law reform to allow for
class action lawsuits against groups of individuals that refuse to receive vaccines on non-medical
grounds (Ciolli, 2008). This approach would allow communities to sue individuals or groups of
people for refusing to get vaccinated because doing so poses a threat to the wellbeing of the
community as a whole (Ciolli, 2008). Other options include making it more difficult to obtain
exemptions for nonmedical reasons, because many parents opt not to obtain vaccinations for
their children due to matters of convenience (Ciolli, 2008). A prospective avenue to accomplish
this would be to create state panels that review applications for nonmedical exemptions on
philosophical bases, because the current process involves little more than marking a check in a
box (Ciolli, 2008). A third option would be to eliminate the nonmedical exemption option at the
national level, though the cultural inclinations of the United States render this option unrealistic
(Anderson, 2011, p. 37).



Rising vaccine exemption rates have historically created localized threats to public health,
and have had significant economic and mortality impacts. Ethnic vaccination gaps have largely
closed, though immunization disparities still exist along the lines of religion, social status, and
age. Accounting for these disparities may save thousands of lives and may reduce costs imposed
on state healthcare infrastructure. The anti-vaccine movement is gaining momentum, which may
pose a long-term threat to maintaining herd immunity. Empirically, similar situations have led to
the resurgence of virulent illnesses such as smallpox. Public agencies such as the CDC have
worked with non-governmental organizations like the NCQA to disseminate information
regarding vaccine safety and improve immunization rates among susceptible demographics.
Other organizations like the NIVC have sought to expand exemptions due to distrust of vaccine
safety. This issue warrants greater attention due to its severity, and may be addressed through tort
law, state exemption availability, and national exemption policy reforms.

Works Cited
"AAP Facts." American Academy of Pediatrics. AAP, n.d. Web. 27 Apr. 2013.
Agency for Healthcare Research and Quality. N.p., n.d. Web. 27 Apr. 2013.
Anderson, James E. Public Policymaking: An Introduction. Boston, MA: Cengage, 2011. Print.
Baden, Lindsey R., et al. "Human papillomavirus vaccineopportunity and challenge." New
England Journal of Medicine 356.19 (2007): 1990-1991.
Calandrillo, Steve P. "Vanishing vaccinations: why are so many Americans opting out of
vaccinating their children?." American Law & Economics Association Annual Meetings.
bepress, 2005.
C. D. C. "National, State, and Local Area Vaccination Coverage Among Children Aged 1935
MonthsUnited States, 2011."
"CDC Works for You 24/7." Centers for Disease Control and Prevention. CDC, 26 Aug. 2011.
Web. 27 Apr. 2013.
Cherry, James D., and Kathleen H. Harriman. "Why Do Vaccine-Preventable Disease Outbreaks
Occur in the United States?." (2012).
Ciolli, Anthony. "An Overview of Mandatory School Vaccinations." National Center for
Biotechnology Information. U.S. National Library of Medicine, Sept. 2008. Web. 27 Apr.
Colgrove, James. "The ethics and politics of compulsory HPV vaccination." New England
Journal of Medicine 355.23 (2006): 2389-2391.

Community Immunity ("Herd Immunity")." Vaccines. U.S. Department of Health and Human
Services, 20 Nov. 2012. Web. 27 Apr. 2013.
Feikin, Daniel R., et al. "Individual and community risks of measles and pertussis associated
with personal exemptions to immunization." JAMA: the journal of the American Medical
Association 284.24 (2000): 3145-3150.
National Center for Health Statistics. Health, United States, 2011: With Special Feature on
Socioeconomic Status and Health. Hyattsville, MD. 2012.
National Committee for Quality Assurance. Rep. National Committee for Quality Assurance,
2011. Web. 27 Apr. 2013.
Nixon, Robin. "Vaccination Rates Drop, Putting More Kids at Risk." National Broadcasting
Corporation. NBC, 21 Nov. 2010. Web. 27 Apr. 2013.
Omer, Saad B., et al. "Vaccine refusal, mandatory immunization, and the risks of vaccinepreventable diseases." New England Journal of Medicine 360.19 (2009): 1981-1988.
Parker, Amy A., et al. "Implications of a 2005 measles outbreak in Indiana for sustained
elimination of measles in the United States." New England Journal of Medicine 355.5
(2006): 447-455.
Ross Rapoport, CDC: Immunizations High But Shot In Arm Still Needed, Cox News Service.1
August 2003
Salmon, Daniel A., et al. "Health consequences of religious and philosophical exemptions from
immunization laws." JAMA: the journal of the American Medical Association 282.1
(1999): 47-53.

"State Vaccine Requirements National Vaccine Information Center." National Vaccine

Information Center. NVIC, n.d. Web. 27 Apr. 2013.

"What We Do." Administration for Children and Families. ACF, n.d. Web. 27 Apr. 2013.