To the Editor: Omer et al. (May 7 issue)1 skirt the crucialquestion: Does a developed, educated democracy such as thatin the United States still need compulsory vaccination lawsto achieve target compliance rates of 90 to 95%? It was thelegislation for compulsory smallpox vaccination that led tothe conscientious objector laws in the United States and theUnited Kingdom. Jacobson may have lost the 1905 Supreme Courtcase2 against the Commonwealth of Massachusetts, but the courtconcluded that the state government could not pass laws in orderto protect an individual person but could do so to protect thepublic. The U.K. compulsory smallpox vaccination laws of 18533led to riots, demonstrations, the circulation of tracts, andvaccine refusal, leading the Royal Commission to amend the lawswith a conscientious objector clause in 1898 and culminatingin the end of compulsory vaccination in 1946. Most member statesof the European Union, especially the Scandinavian countries,achieve high levels of compliance with the use of information,education, persuasion, and subtle coercion — but not compulsion.The European Academy of Paediatrics is campaigning to make accessto immunization a stated right of children. Surely compulsoryimmunization is anticonstitutional with respect to parentalautonomy?
Denis G. Gill, M.B. Royal College of Surgeons in Ireland Dublin, Ireland gilldenis{at}gmail.com
References
Omer SB, Salmon DA, Orenstein WA, deHart MP, Halsey N. Vaccine refusal, mandatory immunization, and the risks of vaccine-preventable diseases. N Engl J Med 2009;360:1981-1988. [Free Full Text]
Jacobson v. Massachusetts, 1 97 U.S. 11 (1905).
Wolfe RM, Sharp LK. Anti-vaccinationists past and present. BMJ 2002;325:430-432. [Free Full Text]
To the Editor: Omer et al. review vaccine refusal, vaccine mandates,and disease clustering, but only in the context of the UnitedStates. In Australia, low levels of vaccine coverage (53% completeat 2 years of age in 1995) led to a national plan that instituteddelivery of all recommended vaccines free of charge and financialincentives for parents whose children were fully immunized by2 years of age. Parents who did not want their children to bevaccinated were also eligible for the payment (approximately200 Australian dollars, or about 156 U.S. dollars) if they submitteda signed conscientious objection form that documented discussionwith an immunization provider.1
In 2009, coverage by 2 years of age is stable at approximately94%, but for vaccines due at 4 years of age it falls to 88%.In contrast, in the United States, immunization coverage atschool entry is approximately 95%, but among preschoolers itis about 86%.
Julie Leask, Ph.D., M.P.H. Peter B. McIntyre, M.B., Ph.D. National Centre for Immunisation Research and Surveillance Sydney, NSW, Australia peterm{at}chw.edu.au
References
Lawrence GL, MacIntyre CR, Hull BP, McIntyre PB. Effectiveness of the linkage of childcare and maternity payments to childhood immunisation. Vaccine 2004;22:2345-2350. [CrossRef][Web of Science][Medline]
The authors reply: In the United States, the constitutionalityof immunization requirements is well established. The perceptionarticulated by Gill that U.S. immunization laws are "anticonstitutional"perhaps results from a misreading of the current laws. The lawsare less draconian than might be perceived, as states allowexemptions to the requirements (all states allow medical exemptionsand 48 have nonmedical exemptions). In our report, we are notadvocating elimination of exemptions. As indicated in the U.S.data we described, many of the exemptions are exemptions ofconvenience, and more stringent procedures are associated withlower rates of exemption.1 The laws play a role in tilting thebalance of convenience in favor of vaccination while providingavenues for opting out. Given the availability of exemptions,forced vaccination is unlikely.1,2 But we do believe that theprocedures called for in seeking exemptions should not be anyless rigorous than those involved in obtaining vaccination.
There are no data to support the notion that U.S. immunizationlaws delay vaccination. In fact, states that were early implementersof school laws for varicella vaccine had higher rates of coveragefor preschool children than states without varicella requirements.Moreover, vaccine coverage for preschool children is generally90% or higher.
Although not labeled "mandatory immunization," approaches toensure immunization coverage in Australia share some similaritieswith their U.S. counterparts. For example, in a majority ofAustralian states and territories, legislation requires provider-authenticateddocumentation of immunization before school entry.3,4 Childrenwith incomplete immunization records are allowed to enroll butmay not be allowed to attend school during an outbreak.4 Moreover,in Australia, the Family Assistance Act provides a means-testedmaternity allowance and universal child-care benefits, contingenton proof of vaccination (while permitting conscientious exemptions).3
Mandatory immunization is not the only tool available to immunizationprograms, and it may not be appropriate for all countries. Itmay be that school entry requirements are most useful in countries,such as the United States, that have fragmented health caresystems. When health care is delivered and controlled by multipleentities, school entry provides a uniform time point relevantto almost all children. In other situations, such as in theUnited Kingdom and Australia, where health care delivery ismore centralized, other approaches to maintain high coverage,such as physician incentives, may be more appropriate.
Saad B. Omer, M.B., B.S., Ph.D. Emory University Atlanta, GA somer{at}emory.edu
Daniel A. Sanders, Ph.D., M.P.H. U.S. Department of Healthand Human Services Washington, DC
for the Reducing Vaccine Hesitancy Team
The views expressed in this letter are those of the authorsand do not necessarily represent the positions of the Departmentof Health and Human Services.
Since publication of the article, Dr. Omer reports receivingthe Early-Stage Career Investigator Award from the NationalFoundation for Infectious Diseases, which is funded throughan unrestricted educational grant from Merck. No further potentialconflict of interest relevant to this letter was reported.
References
Omer SB, Pan WK, Halsey NA, et al. Nonmedical exemptions to school immunization requirements: secular trends and association of state policies with pertussis incidence. JAMA 2006;296:1757-1763. [Free Full Text]
Orenstein WA. The role of measles elimination in development of a national immunization program. Pediatr Infect Dis J 2006;25:1093-1101. [CrossRef][Web of Science][Medline]
Salmon DA, Teret SP, MacIntyre CR, Salisbury D, Burgess MA, Halsey NA. Compulsory vaccination and conscientious or philosophical exemptions: past, present, and future. Lancet 2006;367:436-442. [CrossRef][Web of Science][Medline]
Previous
