Volume 36 • Number 5

May 2015
www.aapnews.org

ID Snapshot
Why is herd immunity so important?
by H. Cody Meissner, M.D., FAAP

Herd immunity, also called community immunity, occurs

when a sufficient portion of a population is immune to a
specific disease, thereby protecting individuals who have not
developed immunity. The greater the proportion of a popula-
tion that is immune or less susceptible to a disease, the lower
the probability that a susceptible person will come in contact
with an infectious person. If a sufficient number of people
(herd) are immune, the infection will no longer circulate.
The benefits of herd immunity apply to various segments
of our society: to children too young to be vaccinated, to
immunosuppressed patients who cannot be vaccinated, to
elderly people who cannot mount an optimal immune re-
sponse to a vaccine, to people in whom vaccine-induced
immunity has waned, to people who have inadequate access
to immunizations and to people who remain unvaccinated
by choice.
The principle of herd immunity or indirect protection is clustered in subgroups by socioeconomic or cultural factors. If a
shown in the figure above. The susceptible person (C) is indirectly pathogen is introduced into this subgroup, an outbreak may occur.
protected from infection because person B is immunized. The basic reproduction number R0 (r naught) is a theoretical
Which of the following statements about herd immunity is not average number of secondary infectious cases that are produced by
correct? a single index case in a completely susceptible population. R0 is a
a. Vaccines reduce disease by directly protecting the vaccinee and measure of the potential a disease has for spread in a population.
by indirectly protecting non-immune people. When R0 is less than 1, the infection will not persist because the
b. The herd immunity threshold is the number of immune indi- infection is not transmitted to at least one person. If R0 is greater
viduals above which a disease may no longer circulate. than 1, the infection may spread. The larger the value of R0, the
c. The herd immunity threshold is the same for all infectious more difficult to control an outbreak. Conversely, the lower R0, the
diseases. more easily a spreading infection can be brought under control.
d. Only a small fraction of the population can be left unvacci- In practice, R0 is a function of the duration of infectivity asso-
nated for herd immunity to be effective. ciated with the illness, the infectiousness of the organism and the
Answer: c is not correct.
number of susceptible people in the population who are in contact
with the index case. Early in an outbreak, an infected individual
The herd immunity threshold differs among infectious diseases may be more likely to spread disease than late in the outbreak
because not all diseases present the same risk of transmission. (fewer susceptibles remain).
In theory, herd immunity means not everyone in a community The degree of herd immunity necessary to prevent or to stop
needs to be immune to prevent spread of disease. If a high enough an outbreak varies by disease. Measles (R0 12 to 18) and pertussis
proportion of individuals in a population are immune, the majority (R0 12 to 17) have the highest R0 among the common infectious
will protect the few susceptible people because the pathogen is less diseases. Ebola, which is spread by contact with body fluids, has
likely to find a susceptible person. But herd immunity has not an R0 1.5 to 2.5.
prevented outbreaks of measles or rubella in communities with im- Measles is one of the most transmissible infectious diseases;
munization levels as high as 85% to 90%. Oftentimes, in a highly therefore, a high herd immunity threshold of approximately 95%
immunized population, a small number of susceptible persons are

Copyright © 2015 AAP News

is necessary. In the United States, the efficacy of one dose of
measles vaccine is about 95%, but coverage never reaches 100%.
Thus, a second dose of measles vaccine is necessary at 4 to 6 years
of age to induce immunity in children who failed to respond to
the first dose (primary vaccine failure). This results in more than
98% protection.
The following example from the Centers for Disease Control and
Prevention presents a simple analogy regarding herd immunity.
Question: If all my child’s friends are vaccinated, won’t he be
protected by herd immunity? Why should I put my child at risk
for vaccine reactions if all the other children around him are al-
ready immune?
Answer: This is like riding in a carpool where everyone contrib-
utes each month to pay for gas, repairs and parking. One morning,
a new neighbor shows up and says, “I think I’ll ride along with you.
But I’m not going to pay, since you’re going downtown anyway and
you have an empty seat.” If enough people choose to take a free ride
on other children’s immunity, herd immunity will soon disappear.
Dr. Meissner is professor of pediatrics at Floating Hos-
pital for Children, Tufts Medical Center. He also is an
ex officio member of the AAP Committee on Infectious
Diseases and associate editor of the AAP Visual Red
Book.