Should vaccines be compulsory?

As long as there have been vaccinations, there has been an antivaccine movement, and as long as there has been an antivaccine movement, there have been parents who refuse to vaccinate. In a past that encompasses the childhood of my parents, polio was paralyzing and killing children in large numbers in yearly epidemics, the fear of which led to the closure of public pools every summer. In such an environment, the new polio vaccine introduced by Jonas Salk in the mid-1950s wasn’t a hard sell. In fact, satisfying the initial demand for it was the problem, not parents refusing to vaccinate their children. Since then, more and more vaccines have been developed to protect more and more children from more and more diseases, to the point where the incidences of most vaccine-preventable diseases is so low that, unlike 60 years ago, most parents today have never seen a case or even known other parents whose child suffered from a case. Even as recently as the 1980s, Haemophilus influenza type B was a dread disease that could cause meningitis, pneumonia, sepsis, and death. Since the introduction of the the Hib vaccine a mere quarter century ago, Hib has been virtually eliminated. Most pediatricians in residency now have never seen a case.

As much of a cliche as it is to say so, unfortunately vaccination has been a victim of its own success, at least in developed countries. Parents no longer fear the diseases childhood vaccines protect against, which makes it easy for antivaccine activists to provide what I like to call “misinformed consent,” by spreading misinformation that vastly exaggerates the risk of vaccines compared to the benefit of vaccinating. Basically, parents who believe the misinformation conclude, based on a warped view of the risk-benefit ratio of vaccines, that not vaccinating is safer. Add to the mix fear mongering against the MMR based on Andrew Wakefield and his dubious 1998 case series that popularized the then-recent idea that vaccines cause autism, and it’s no wonder that parents decide that not vaccinating is safer than vaccinating. If you believe the misinformation, it’s not an entirely unreasonable conclusion. Then add to that the easy availability of “personal belief exemptions” to school vaccine mandates in many states, which include anything from religious exemptions to parents just signing a form that says they are “personally opposed” to vaccination, and it isn’t a huge surprise that vaccine uptake has fallen in some areas to the point where outbreaks can occur. It was happening in California and my own state of Michigan.

The question then becomes: What to do about it? This question always brings up hard questions about how far the state should go to encourage vaccination, and that’s what this post is about, prodded by a recent article on advocating mandatory vaccination for all children written by two pediatrics residents, Dr. Phoebe Danziger and Dr. Rebekah Diamond. This lead me to ask the question: Should vaccines be mandatory? Basically, mandatory vaccination of the sort described by Danziger and Diamond would represent a major change in policy. In the US, the general strategy to encourage adherence to the CDC-recommended vaccination schedule does not rely on making vaccines mandatory for all children, but rather requiring certain vaccines as a precondition for enrollment in day care centers and public schools. Basically, the idea is that parents don’t have to vaccinate, but if they choose not to there will be consequences and measures taken to lessen the risk of outbreaks due to their refusal to vaccinate. You might think this is a distinction without a difference in that most children go to public schools, but in reality it is a clever compromise between individual liberty and responsibility to one’s community. Included in this compromise are nonmedical exemptions, specifically religious exemptions and so-called “personal belief exemptions,” which basically boil down to parents saying that vaccinating their children conflicts with a “strongly held personal belief.” As long as nonmedical exemptions were uncommon and the number of unvaccinated children small, there wasn’t a major problem. However, over the last couple of decades, the number of unvaccinated children has increased, and those children’s parents tend to cluster, facilitating outbreaks of vaccine-preventable diseases, particular the highly contagious ones like measles and whooping cough.

One strategy to counter this tendency, initially tried, for example, in California and Michigan , has involved keeping nonmedical personal belief exemptions but making them more difficult to obtain. In California, a law (AB 2109) was passed that required parents seeking personal belief exemptions to have a physician sign the exemption certifying that he had counseled the parents on the benefits and risks of vaccines and the dangers of not vaccinating. In Michigan, parents were required to go to a local health department office to sign their waver, which would not be permitted until they had undergone a brief state-mandated education session with a local health official educating them on, yes, the benefits and risks of vaccines and the dangers of not vaccinating. At this point, there were only two states that didn’t allow nonmedical exemptions, West Virginia and Mississippi.

Then came the Disneyland Measles outbreak a year and a half ago. In response, California passed SB 277, a law that, as of July 1, 2016, eliminated all nonmedical exemptions. The battle over SB 277 has been vociferous and reignited the argument of how far the state should go to ensure the vaccination of children. Not surprisingly, antivaccine activists painted SB 277 as incipient fascism, a horrific violation of parental rights, and “forced vaccination.” Also not suprisingly, a cottage industry of quacks and antivaccine-sympathetic physicians like Dr. Bob Sears, has sprung up to generate cookie-cutter medical exemptions not based in legitimate science. (More on that later this week.) Still, the basic compact remains in place, even in California: Parents can’t be forced to vaccinate, but if they refuse their children can’t access public schools and certain services, like day care. It’s just that exemptions to that social compact are now much harder to come by in California. Whether other states will follow California’s lead seems doubtful right now; so the current status quo appears likely to remain for the foreseeable future.

Enter Drs. Danziger and Diamond and their article The Vaccination Double Standard, which is subtitled: “Despite years of research, there’s no good way to convince anti-vaxxers of the truth. It’s time to make vaccination mandatory for all kids.” It’s a viewpoint to which I’m sympathetic but in the end just can’t bring myself to sign on for. I’ll explain why momentarily, but first there is much in the article that does hit the proverbial nail on the head. For example, Danziger and Diamond start out with the story of a 28 week preemie who was doing well in the NICU with a caring, appropriate, but disadvantaged mother. They describe how “when we were able to reach his mother by telephone in between her work shifts, she was always loving, caring, appropriate, and eager for the day when her son, a perfect illustration of how modern medicine can impact even the tiniest baby’s chance for a long and healthy life, would be ready to come home.” Then, after they rotated off of the NICU, they later heard from their successors as NICU residents that there was a Child Protective Services (CPS) investigation underway because “CPS and the medical team were concerned his mother—young, single, and working two full-time jobs in a town hours away from the hospital while supporting two other toddlers at home—simply could not pull together the resources to be present enough at the hospital to demonstrate her competence and commitment to caring for her baby.” Danziger and Diamond compare this mother as “another example of poor, disadvantaged parents being held to impossible standards” standing in stark contrast to what they view as a case of more serious parental neglect, refusing vaccines.

They note:

We see the mother, who works double shifts at minimum wage to avoid eviction, traumatized by a CPS investigation instigated because she cannot possibly be present at a hospital bedside. We see the family whose incompletely immunized child is refused entry to a school, not because they oppose vaccines but because they lack reliable transportation and predictable time off to receive all the shots.

And then we watch parents who willingly expose their children, and society at large, to the real and specific risk of deadly diseases that should have been eradicated long ago—and we kowtow to them. These parents almost always come from privilege, and they are almost never punished for their actions. It seems to us that this reaction is at least partially—and perhaps subconsciously—informed by the fact that they are by and large white, educated, and affluent.

This is, of course, nothing that I haven’t been saying for a long time now. Parents who refuse vaccines are largely privileged, affluent, and white, although, I noted, despicable antivaccine activists like Del Bigtree, Polly Tommey, and Andrew Wakefield sure are trying to persuade disadvantaged African-Americans not to vaccinate too, apparently not caring that not vaccinating will likely impact minorities people much more seriously than their privileged white followers.

Be that as it may, our good pediatrics residents do couch their arguments in a lot of social justice, and, to a large extent, they make good points. Right now, the bulk of the most vocal antivaccine activists are in general white, educated, and affluent. Because they’re educated they’re very good at motivated reasoning, and because they’re affluent they have the resources to cluster in expensive neighborhoods and pay cash-only, antivaccine-sympathetic pediatricians like Dr. Bob Sears.

Drs Danziger and Diamond also correctly note that science is unlikely to persuade antivaccinationists that vaccines are safe, but there’s a problem. Their statements lack nuance and appear (to me at least) to incorrectly lump all antivaccinationists into one group, with all of them being equally unpersuadable. I’ve said it many times before: My message is not aimed at die hard antivaccine parents. Those are the parents Danzinger and Diamond no doubt mean when the write about science not persuading them, but there are, as I like to put it, shades of antivax. They range from the hard-core leaders of the antivaccine movement and Andrew Wakefield’s admirers to parents who are concerned because so many needles are being stuck into the most precious thing in the world to them and they saw some stuff about vaccines on the Internet—and everywhere in between. The former are, with rare exceptions, not persuadable. The latter are very much potentially persuadable.

I also agree that there is a double standard with respect to vaccines:

...we have also decided there is a limit to what parents can choose. Parents must use correct car seats and seat belts for their children; they must care for them in safe homes and provide sufficient food; they must also follow basic medical standards for their children’s health. Thus, there is ample precedent for removing the decision-making capacity from parents who are determined not to act in their child’s best interest. Take, for instance, the 2009 case of this child with leukemia who was successfully treated with chemotherapy on court order against her parents’ wishes, because they believed in “natural” treatment for cancer.

And yet, unlike any other aspect of pediatric medicine and child safety, if a parent explains that they have a personal objection to vaccination, they are allowed to deny their children proper care. It is true that some promising laws have been passed, such as California’s SB 277, which eliminates personal belief exemptions. But even these lauded policies have significant loopholes and pitfalls.

As Drs. Danziger and Diamond note with frustration:

We have spent hours explaining to CPS case-workers that it is impossible for the homeless parents of a critically ill infant to simultaneously attend medical rounds, to participate in medical decision-making for their child, and apply for public housing and employment. Then we turn around and treat a purposefully un-immunized child for a serious brain infection caused by vaccine-preventable bacterium—requiring weeks of hospitalization with intravenous antibiotics—and watch his mother continue to refuse vaccines for him or his siblings, and we can’t do anything about it.

I can see the appeal of this argument. I really can. I can see how such an argument could lead to this conclusion:

There is simply no reason vaccinations should be treated differently than any other form of medical care, and they must be protected within the same framework that has been created for child protection and against medical neglect. There are many ethically gray areas of medicine, but this is not one. Our laws must unambiguously and without loopholes reflect this, and there cannot be conflicting standards of child protection based on race, wealth, and education. By continuing to allow exceptions, we are fueling the misconception that vaccinations are an option, a choice, a subjective topic about which people can have different opinions that ought to be respected, when in fact all of the data proves they are not. Enacting a policy that is consistent with the science would provide clarity for the parents—the majority of whom are loving caretakers trying to do the right thing. We are failing our society by creating unequal standards of parenting, and worse, we are failing our children by not protecting their right to be vaccinated against deadly, preventable diseases. Competent parenting must include fully immunizing all children according to the medical standard of care.

While I sympathize with this point of view, I also have a hard time adopting this sort of a plan for the simple reason that I don’t think that Dr. Diamond and Dr. Danziger have thought their position through to its conclusion or clearly thought about what it could lead to. Let’s assume, as appears reasonable based on what they have argued, that what they mean by “make vaccines mandator” is that vaccines administered according to the recommended CDC schedule should be mandatory, barring any medical contraindication of course. If someone made them emperor of the US, have Drs. Danziger and Diamond thought about how they would go about enforcing this policy? It’s easy enough to say that “vaccines should be mandatory” and to castigate antivaccine parents for being privileged, selfish, entitled white people, but laws and policies have to be clearly written, and there has to be an enforcement mechanism, complete with some form of punishment for non-compliance.

The big question is: How far are Drs. Danziger and Diamond willing to go to enforce the “mandatory vaccination” that they liken to medical neglect? Don’t get me wrong, regular readers know that I am as pro-vaccine as anyone; I’ve spent a dozen years combatting antivaccine misinformation I’ve suffered online attacks and attempts to get me fired from my job for my trouble. So I won’t let anyone claim that I’m not sufficiently pro-vaccine. Let’s say, as would arguably be reasonable in a policy of mandatory vaccination, that parents who refuse to comply face an escalating series of consequences or punishments the longer they remain out of compliance. One could imagine, for instance, a series of escalating fines or even potentially jail time. Now, let’s imagine parents who still absolutely refuse to vaccinate. Again, how far are Drs. Danziger and Diamond willing to go? Have they really thought about this?

Again, I don’t think they have, and to illustrate that point I’ll just ask a couple of questions about what they would do in the case of parents who, despite escalating fines and the threat of jail time, still refuse to vaccinate their child. This is not such a far out scenario, either. Just look at all the parents in California talking about moving out of state, home schooling, and in general resisting SB 277. Are Drs. Danziger and Diamond, for instance, willing to allow courts to order forced vaccination and have the police enforce this order? I can’t help but note that in such a case, a lot of physicians would have ethical qualms about being the ones to oversee the administration of vaccines. Or, more relevant to their analogy, are they willing to give CPS the power to remove children from their homes solely because their parents won’t vaccinate them? This is something CPS is exceedingly reluctant to do even in the case of families refusing to treat their cancer-stricken child with standard-of-care chemotherapy and radiation, and in this case the children are perfectly happy. I won’t make the question easy for them, either. Imagine that this is the only problem that CPS finds and that otherwise CPS finds that the parents are loving, supportive, provide all other medical care, do not abuse their children, and are well off? Would they remove a child from a home like that to place him in foster care and be vaccinated? I assume they know just how overburdened the foster care system is and how hard it is to find good placements. Would it really be better to have the child in a the crappy foster care systems in some parts of this country and vaccinated rather than unvaccinated and with their family?

Perhaps Dr. Danziger and Diamond will think I exaggerate, but make no mistake. When they equate failure to vaccinate to medical neglect on par with or even worse than failing to let a child with cancer be treated with chemotherapy, almost any measure is justifiable. I would also remind them that whenever parents refuse to treat their children with cancer with chemotherapy, they make martyrs. Popular opinion rarely favors CPS. I’ve documented this time and time and time again. Consider the case of Sarah Hershberger and Cassandra Callender. Consider Makayla Sault. Consider Abraham Cherrix, whose battle to refuse chemotherapy led the Virginia State legislature to pass “Abraham’s Law,” basically permission for teens over a certain age to refuse medical treatment in favor of quackery.

Now imagine the public reaction if CPS tries to take what appear to be perfectly healthy children away from their parents because their parents don’t vaccinate. While it is true that most people support mandatory vaccination in the abstract, for a significant minority “parental rights” and “health freedom” arguments resonate among the electorate to the point that Republican politicians were pandering to them last year during the primaries, and my home state of Michigan considered a bill to re-loosen nonmedical exemption requirements. How well do you think that would go over? I think you know the answer.

No, Drs. Danziger and Diamond, for all their justified righteous anger, have not thought this through. In fact, taken from a point of view of social justice, whom do you think would be most affected by such a policy of compulsory vaccination? Hint: It won't be the affluent white antivaxers whom they rail against. They have the resources, the social media, and the ability to project a sympathetic picture of themselves that could easily turn them into "health freedom martyrs." We see it every time parents refuse to treat their child with cancer in favor of choosing "natural therapies." Although much less numerous, there are vaccine-hesitant minorities. The African-American community, in particular, has reason to be suspicious of modern medicine. I rather suspect that, as is the case for most issues, enforcement of a compulsory vaccination law would fall disproportionately on minorities and the poor, who are not as able to afford fines and legal representation.

There’s a reason why we don’t have compulsory vaccination in the US. The CDC vaccine schedule is not mandatory. However, we do have school vaccine mandates, which require that children be up-to-date on the their vaccinations before they can attend school or be placed in day care, and all but three states allow nonmedical exemptions, either religious, personal belief exemptions, o The current system of requiring vaccination before children can attend school and day care is actually a reasonable compromise between social responsibility and individual liberty, as long as nonmedical exemptions are not too freely available. In an ideal world, there would be no nonmedical exemptions, and all states would have a law like SB 277—or at least policies like Michigan that make it more difficult to obtain a nonmedical exemption and require parental education. The system we have now, for all its flaws, actually works well, producing high overall vaccination rates, even if there are pockets of vaccine uptake sufficiently low to abrogate herd immunity. Of course, could be improved if additional states would either eliminate nonmedical exemptions or make them harder to obtain. In any case, making vaccination compulsory is a bad idea if it is enforced to its logical conclusion in cases of parents who will not budge and an even worse idea if it isn’t enforced.

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At its base, I agree with you that direct compulsion is impractical and will have undesirable consequences. It's happened before.

But I think it's worth discussing and considering other measures beyond school immunization requirements, and by laying out the problem so starkly the authors help that discussion.

By Dorit Reiss (not verified) on 25 Jul 2016 #permalink

At its base, I agree with you that direct compulsion is impractical....

That I would generously describe as an understatement, and raise you an "undesirable."

Over here, certain vaccines are in theory compulsory (and available free of charge). And parents face fines if they fail to vaccinate their children. I've written "in theory", because our authorities do not enforce these fines very strongly - and affluent parents can afford them easily anyway.

Where do you live Alia?

By PuppyBoners (not verified) on 25 Jul 2016 #permalink

I absolutely agree. You cannot put a price on health and wellbeing. I agree wholeheartedly. I think vaccination should be just part of every day life.

By Elisa Kits (not verified) on 25 Jul 2016 #permalink

The same debate happened in Scotland, where there was a proposal to put fluoride in the drinking water. The idea being to benefit kids who otherwise might not be too assiduous about cleaning their teeth. It was opposed most strongly by a certain woman, whom the media noted had no teeth left in her head. But in the end, the proposal was abandoned, because (rightly in my opinion) the state should not have the power to medicate people without their express consent.

By Les Neilson (not verified) on 26 Jul 2016 #permalink

It is not surprising that the opinions of two pediatrics residents lacks nuance. It is the voice of inexperience. I am not faulting them. They are entitled to their opinions, but I suspect they will have rethought things in 20 years or so.

It is worth having a discussion about how the irrational behavior of a few are threatening the rest of us, and how we, as a society, needs to respond to protect ourselves.

By Michael Finfer, MD (not verified) on 26 Jul 2016 #permalink

Instead of making the results of the parents negligence a simple inability to attend schools and such, make it a real financial burden. If you don't vaccinate your child, you are responsible for obtaining insurance policies that cover the care and damage caused to anyone else that your child infects. If your child dies due to your negligence, that's on you. If someone else who cannot be vaccinated becomes ill or dies due to being in contact with your unvaccinated child, then you are on the hook to pay their medical bills/funeral costs/lost income.
As you point out, the other options are morally and ethically suspect. However, it is still a public health concern, and is part of living in a society. Much like taxes, and limiting your personal freedoms for the greater good are necessary to a functional society. If they are really that opposed to vaccination, there are other nations out there that would probably have no issues with their immigrating.

By Anonymous Pseudonym (not verified) on 26 Jul 2016 #permalink

On a side note, aren't school nurses qualified to administer vaccinations? If getting kids to a doctor is such a burden, set a-side a day a year for all the students to get their jab or provide proof of vaccination / proof of medical exemption. Attendance can be easily monitored and those that don't attend / cannot prove their vaccinated state get to bring home the above mentioned insurance policy application that needs to be active before the child can return to school. My guess would be that they would quickly get their children vaccinated against the very real high costs.

By Anonymous Pseudonym (not verified) on 26 Jul 2016 #permalink

Other than the elimination of non-medical exemptions to school vaccination requirements, it might be more effective to make getting vaccinated easier. Make it free for everyone. Make it easily accessible so that those who are less well-off are able to get their kids vaccinated in a timely manner. It should not be a hardship to take your child to get immunized.

@Todd W.: I think that's at least in part an argument for school-based vaccine clinics, which are a very effective way to help children get vaccinated.

Of course, then the anti-vaccine people claim it's a conspiracy to get children vaccinated against the parents' will.

By Dorit Reiss (not verified) on 26 Jul 2016 #permalink

In reply to by Todd W. (not verified)

The authors refer to people of privilege as they make their case for compulsory vaccination. Well, anti-vaccine physicians are people of unusually high privilege, and until state medical boards and groups like the AAP, AMA and AAFP root out and censor anti-vaccine physicians, with the medical boards stripping anti-vaccine physicians of their license to practice (you all know the ones like Bob Sears, Jay Gordon, Sherri Tenpenny, Suzanne Humphries, Jack Wolfson, Eric Mercola, etc) to show the public that doctors are serious about vaccines, I do not favor making vaccine rates increase with laws like (or even stronger than ) SB277. As Brian Deer mentioned in a a comment on the Slate board yesterday, vaccine rates in the UK were brought back up (after Wakefield's fraudulent 1998 Lancet paper without passing of vaccine laws (though there were also huge oubreaks to remind people in the UK of what happens when vaccine rates fall). I still believe some of the vaccination rate recovery in the UK stems from the exposing and discipline of Wakefield. Here in the US, I cannot come up with one single anti-vaccine physician who has been disciplined in the slightest for their actions, which is shameful. How can we expect the 95-99% of parents we need vaccinating their children to decide on vaccination when there are so many anti-vaccine doctors proudly and publicly willing to tell you otherwise and who all remain in good standing as physicians due to the unwillingness of medical groups to give them the professional thrashing they so richly deserve?

By Chris Hickie (not verified) on 26 Jul 2016 #permalink

I think SB277 has it exactly right: children must be vaccinated (or have documented medical contraindications) in order to enroll in day care or school. Parents who do not wish to comply can home school their children (there seems to be a substantial overlap anyway between anti-vax parents and home schoolers). Going further than that is likely to be counterproductive, given the prevalence of politicians who espouse libertarian philosophy (whether or not they actually practice what they preach).

By Eric Lund (not verified) on 26 Jul 2016 #permalink

@ Eric Lund #15--my issue is, had groups like the CA-AAP spent as much time going after anti-vaccine groups and physicians as they did lobbying for SB-277, maybe SB-277 wouldn't have been necessary. And Bob Sears has been reported to the California Medical Board, but nothing has ever happened. Now we have SB-277 following a horrendous measles outbreaks (along with 2 awful pertussis outbreaks in California in 2010 and 2014 that killed 14 infants).

On a brighter note, it appears an anti-vaccine family physician in Tennessee who caught a sh*tstorm when he went publicly anti-vaccine a few months ago is now resorting to gofundme to help pay for his defense before the state medical board (…). Here's to hoping Dr. Kalb loses his license.

By Chris Hickie (not verified) on 26 Jul 2016 #permalink

I wonder how many anti-vaxxers there are within the native populations of the Third World that still suffer wide-spread ravages of the diseases the vaccines prevent.

I wanna say anything between negative 3% to 0%.

Excellent article. I totally support mandatory vaccination for children attending public school/daycare, but I think the harms would outweigh the benefits if we were to hunt down all of the parents who believe it wrong to vaccinate their kids, and this post summarizes the problems nicely.

By Heidi_storage (not verified) on 26 Jul 2016 #permalink

Mandated vaccination might be a step to far: but I think it's good people are calling for it. That expands the 'overton window'. In other words: mandated vaccination for school/daycare children would become a compromise, middle of the road sollution.


Oh, there are anti-vaccine folks everywhere, including developing nations. What tends to happen there, however, is a more conspiratorial angle, along the lines of "It's a plot by the West to sterilize you". I'd venture to guess that they are still somewhat of a minority, but arguably they do exist.

I'm all for eliminating non-medical exemptions, stripping licenses from anti-vaccine, etc. But I've heard in other discussions people saying medical exemptions should be limited to the CDC list of contraindications for vaccines, which worries me. I recently found out my nephew, who is developmentally disabled and diabetic, no longer gets vaccines. His parents found that if he had a reaction to the vaccine, such as fever, his diabetes, already difficult to control, becomes more complicated. He is non-verbal and unable to participate in his own care. his parents uderstand the risk, especially with anti-vaccine nuts out there, but in his case, the risk-benfit analysis tips on the side of managing his blodd sugar.

There are kids who can't be vaccinated, e.g. autoimmune diseases, being treated for cancer, or, simply, who were vaccinated and the vaccine did not elicited a sufficient immunological response. These kids go shopping with their mothers, go to playgrounds, travel by air, go to birthday parties, etc. I don't know the answer; but how do we protect them? Home-schooled kids who are not vaccinated won't infect others at school; but they also go shopping with their mothers, go to playgrounds, travel on airplanes, go to birthday parties, etc. Since several diseases are contagious prior to being symptomatic, what should we do? Living in complex societies, we have rights and we have responsibilities. Unfortunately, many Americans seem to "know" their rights; but feel nothing for their responsibilities. I don't know the answer; but whatever it is, it should weigh in on protecting those children who, for whatever reason, either couldn't be vaccinated or the vaccine didn't take, it should weigh in on the side of responsibilities in a community.

By Joel A. Harris… (not verified) on 26 Jul 2016 #permalink

Chris@16: Most health and safety regulations, at least in the US, are enacted because people died without the regulation. This phenomenon is hardly limited to vaccines--reinforced and locked cockpit doors, which would have prevented 9/11 had they been in use at the time and had been recommended several years earlier, are one of the most common examples. Most people tend not to deal with problems until they are forced to do so--this is the tendency spoofed by the SEP (Somebody Else's Problem) field in the works of Douglas Adams.

Todd@20: In the case of Pakistan, the conspiracy theorists actually have a justification. The CIA project to locate Osama bin Laden used a polio vaccination program as cover. Pakistan happens to be among the handful of countries where polio is still endemic.

By Eric Lund (not verified) on 26 Jul 2016 #permalink

Oh, there are anti-vaccine folks everywhere, including developing nations. What tends to happen there, however, is a more conspiratorial angle, along the lines of “It’s a plot by the West to sterilize you”. I’d venture to guess that they are still somewhat of a minority, but arguably they do exist.

Certainly they exist. Most recently, I wrote about them in Kenya:………

Why jump to a more extreme method when data from California, Mississippi, and West Virginia demonstrate simply removing non-medical exemptions to be effective? This is by all appearances a solved problem; what we lack implementation. Drs. Danzig and Diamond's proposal actually has much higher implementation barriers.

By capnkrunch (not verified) on 26 Jul 2016 #permalink

Why jump to a more extreme method when data from California, Mississippi, and West Virginia demonstrate simply removing non-medical exemptions to be effective? This is by all appearances a solved problem; what we lack implementation.

I'd go even further and say that a less radical solution than even SB 277 can be effective as well, depending on the state, namely an AB 2109- or Michigan-like solution of requiring parents who want personal belief exemptions to undergo counseling and education before they can have it. It won't stop the die-hards, but they're only around 3% or so of the population anyway.

Slightly OT, I recently had a case with the 48 YOM having low back pain. He came to the ED repeatedly, and discharged with an anti-inflammatory. When I got him, I noticed his ecg had several spams ticks as if in a-tach or some aberrant pacemaker site/AVNRT. Upon physical exam, his radial pulse was normal mid-80 and was uncontrollably shivering. No fever, no seizure, and no neuro deficits, but slight muscle weakness in legs. His past lab values all normals. We started a workup for sepsis anyway (he passed both SIRS and qSOFA criteria, slight tachypnea, but it was transient) -- we were working on gestalt or gut feeling. His CBC/CMP values again, normals. Vitals/temp also stayed normals. But, we felt he was sick and decided to admit based on slightly elevated procalcitonin. We ran an MRI on the lower back looking for osteomyelitis, no joy, but possible it's hiding in his pelvis.

Turns out he was HIV pos. He was at the point couldn't mount an effective defense, so his lab values could not get elevated. Blood cultures grew out....Hib. Obviously, a serious and life-threatening infection, bacteremia being the dx. We think we got ahead of the curve by using empirics and fluid resuscitation (even though he passed SIRS and qSOFA). He's still an admit, but on the mend.

As far as vaccines being compulsory, no. Access to vaccines being yes, of course. Surprisingly, I've worked on two patients with significant brain injury from vaccine (seeing one occurrence is about one in a million, correct?). There's enough flexibility in the timeline to maintain the evidence-based schedule, and that the benefits of vaccination greatly outweigh the risks to the individual and community health.

I could even go with allowing more exemptions if in addition to some education it came with additional financial burden. Akin to having smokers pay more for insurance have a rider that if you don't vaccinate you pay extra to cover the costs of both your potential risk for illness and your risk to spreading it to others. Even have it earmarked so the money can only be used for either vaccine preventable disease care or programs to increase vaccination among the disadvantaged like bringing back vaccination clinics in school (we had a few of those as vaccines came out so I know we know how to do those).

Fine, you can go to public schools, but have to pay extra tax into a fund that pays for remote learning systems for those days your kid will be home quarantined if there is an outbreak and would also help fund the technology for those kids who may not be able to be protected because of a medical problem when they are either too ill to go to school as even a cold would be really bad for them or also must stay away because of an outbreak.

Part of my thought is the more they work hard to increase their numbers the more money that is earmarked to cover the costs. Now it may need to be sliding scale so the more money you make the more you pay after all we can't convert the poor and disadvantaged to the cause if they can't pay for it, so yep, make it progressive and clearly transparent that each rich person pays for a poor person and if they keep up trying to spread their -ism to the poor, then they'll be paying for 2 poor people each.

FWIW, I suspect most won't mind paying more to have their special snowflake in the special programs that must be better because they cost more, but if they are subsidizing others that can't be so special and shouldn't have the same privilege...that may get them to decide the social contract the rest of us agree to isn't so bad after all.

Compulsory no, required for public school, public daycare, certain jobs (in contact with other people) etc.; yes.

If want to see a documentary that cause tears; see Gleason. It opens Friday, unfortunately the closest showing to me is 200 miles away.

I do not think vaccinations should be compulsory outside of an imminent threat, such as for instance a biowarfare attack with weaponized smallpox or something terrifying like that. Lacking such an imminent threat, we can't force it.

Yes, vaccines are for a child's good. But I don't think we can compare it to withholding food or cancer treatment. Vaccinations do not treat disease (generally speaking). They are preventative only, and the child isn't directly harmed by not getting them. We don't mandate that children eat their vegetables; we don't need to mandate that they get vaccinated. We are doing well merely encouraging it.

I am also leery of financial penalties for non-vaccination. In our system, the most obvious way of implementing them would be an increase in medical premiums. This would be unfair to people who have a medical reason not to get vaccinated, and would perpetuate the problem where those who most need insurance are least able to afford it -- because premiums are based on how likely you are to get sick. I would prefer to see single-payer health care, completely removing the financial component from the minds of caregivers. And although I know this cheeses off the antivaxxers, I'd like to see more combo vaccines. The vast majority of parents skip vaccines not because they're against them but because they forget to get it done, and because it's unpleasant for the kid. If more vaccines can be grouped into a single appointment, I believe coverage will improve. The antivaxxers will find a way to be upset no matter what, so frankly I don't see much point factoring their concerns into the decision.

By Calli Arcale (not verified) on 26 Jul 2016 #permalink

Since the commentariat is multi-national, I want to ask about the case of Henri Joyeux, in France.

In France, only the vaccines against diphtheria, tetanus and polio are compulsory. According to WHO, there is NOT an infant vaccine (<12 months) for just those 3 diseases.

In the European Italy has a monovalent infant diphtheria vaccine; a monovalent infant tetanus vaccine; and a stand-alone inactivated polio vaccine (various European other countries have one or more of the monovalent vaccines as well.)

Joyeux's action is to demand (I think) that the French government make available either the monovalent vaccines, or a DT-Polio vaccines without aluminum, which he claims is a neurotoxin.

So according to French sources, Joyeux's (Google translate follows)

anti-vaccine positions have riled up the Ministry of Health in June 2015. The surgeon and oncologist appears this Friday, May 27 before the Disciplinary Division of the Council of the Order of Languedoc-Roussillon doctors in Montpellier for "discredited the profession", holding" alarmist "and based on" non-established scientific evidence. "

In June, Joyeux (who retired in 2014) was struck off the medical register.

What I want to know is, how much influence does he actually have in France?…

Link to Joyeux's petition, which has over a million signatures.

The website for the not-a-documentary "Man-Made Epidemic" is talking up Joyeux's case. About the film:

interviews with leading doctors, scientists and families to find out the truth about the autism epidemic and whether or not vaccines have a role to play.

The film explores the common misconception that autism is solely genetic and looks into scientists concerns over recent years about environmental factors such as medication and pesticides which continue to leave our children with physical and neurological damage.

The film does not seem to have gotten much attention...

Lacking such an imminent threat, we can’t force it.

Many countries (I don't happen to know if the US is among them) have vaccination requirements for foreign travelers; the only exceptions are for documented medical contraindications, with the document translated into the local language as appropriate. The most common requirement is for a yellow fever vaccination to have been given in the last ten years, e.g., Brazil, which I visited in 2005 (so I would need a booster to go back there). There is no reason why a national government could not impose vaccination requirements if it doesn't have them already--it could be a condition for issuing a visa, for instance.

It wouldn't be a perfect solution, because not all countries have such a requirement, and unvaccinated kids (or adults) could pick up something while traveling abroad and bring it back. But it might cut down a bit on the spread of vaccine-preventable diseases.

By Eric Lund (not verified) on 26 Jul 2016 #permalink

Like many others, social strictures is my preferred methodology. I remember the days when getting on a bus (in the UK) meant you would stink of smoke all day long. Then smoking was confined to the upper deck (or rear of a single decker). Eventually all smoking on buses banned. Followed several years later with no smoking in public areas.
Vaccinations is harder to monitor, but increase social pressure to keep unvaxxed (but which vaxs to be affected is a far harder question) out of public areas (med exempt excepted).
Imagine going down the pub with a smoker. In the past the group was under pressure to cave to the requirements of the sole smoker. Not nowadays.
Dorect monitoring and implementation would be hard. Indirect methods can also be used. If someone catches a VPD and it can be shown that 'you' are the source, sue for the costs. Make them a social pariah the same way smokers are in public. Only those who are more hardcore will continue to be unvaxxed.

Danziger and Diamond aren't taking the public health case, so uptake rates don't really address their argument. It's a social justice argument, about the poor having an increased exposure to disease, or maybe just having to pay too much for what ought to be a societal burden, as community immunity serves the common good, not just the individual. I think what the authors are doing is trying to leverage the anti-antivax thing to backdoor what Todd suggests: free immunizations for low income families, in their schools and communities etc. If these were 'compulsory', the next logical step would be: 'these people are poor and can't get to Drs. easily, so we have to make it free and take it to them.'

Orac doesn't say if the authors address penalties at all (and I have no time to go to the source essay). But Prof. Reiss is suggesting this needn't be a binary between mandate/no-mandate, or 'punishment'/nothing.

Especially if the idea isn't to shove shots at the kids of the commited AVs, but to help the poor and perhaps clueless, nothing like jail or protective services need be involved, as we could let them have easy loopholes, since they're 'not the point'. The authors make a car-seat analogy, and I don't think CPS gets a call if parents forego that now and then (not that I know, being childless...).

Note that what they really seem to be after here is the rhetorical force of a mandate, not the material consequences.

By continuing to allow exceptions, we are fueling the misconception that vaccinations are an option, about which people can have different opinions that ought to be respected. Enacting a policy would provide clarity for the parents...

Seems to me we have a number of laws like this – that don't have much teeth, but help establish norms, just, as the authors say, clarifying 'this is wrong, don't do that'. And it seems to me these rules-without-dire-consequences-for-violation still get followed pretty well. E.g. I don't know what penalties, if any CA can impose on individuals who don't adhere to the drought-response water-use restrictions due to washing their car too often, but the cops aren't out in cruiser looking for scoflaws. But the watering restrictions definitely help...

I am very pro-vaccine. My daughters (3 and 7) are up to date with the CDC recommended vaccines. we have even enrolled our children in multiple vaccine studies with Johns Hopkins researchers developing a new vaccine for RSV.

However, I am adamantly opposed to mandatory vaccination. Government injecting vaccines at the point of a gun into kids will likely do more to lower the real vaccination rate than anything else as there will be a large backlash.

every time some says "There ought to be a law" remember that every law is enforced at the point of gun as no law is followed all of the time.


"Seems to me we have a number of laws like this – that don’t have much teeth, but help establish norms, just, as the authors say, clarifying ‘this is wrong, don’t do that’."

Do you want "crime" Eric Gardner was committing before he was killed in police custody? Selling black market cigarettes. Only minimal fines. so even laws with minimal penalties do get enforced physically and with deadly consequences to people.

Mike: Reductio ad absurdam. If laws with minimal penalties get enforced with deadly consequences, that's policing insanity, not a problem with the legislation. I'm sure there are cops who'd shoot African-Americans motorists after stopping them for littering. I don't think the answer would be removing all fines for chucking a bag of Burger King wrappers out the car window.

It is not Reductio ad absurdam when it is an established fact in our reality that it happens.

Now, you may want to reject reality and pretend that it does not happen, but then that is not very science based.

Would love to see your examples, Mike.

@ LIz Ditz Joyeux's action is to demand (I think) that the French government make available either the monovalent vaccines, or a DT-Polio vaccines without aluminum, which he claims is a neurotoxin.

Aluminum is a neurotoxin. This is not just some wacky idea.

By PuppyBoners (not verified) on 26 Jul 2016 #permalink

"Aluminum is a neurotoxin. This is not just some wacky idea."

The wacky idea is that Aluminum could be a neurotoxin in the dosages you get from vaccines...

By Vincent Iannelli, MD (not verified) on 26 Jul 2016 #permalink

The ever-interesting Prof. Steve Dutch has this on one of his pages: "Prince George’s County, Maryland decided to crack down on parents who failed to get their children vaccinated. This shocking example of nanny-state bullying has been duly hyped on various libertarian and anti-vaccination sites.
So, I can expose myself and my kids to the (minuscule) risks of vaccination, then we create a disease free society and you and your kids enjoy the benefits without that nasty needle. Or, horror of horrors, having somebody tell you what to do.
There are all sorts of dark corners of the world we could send these people where they will never, ever have to face a needle. The not having somebody tell you what to do part, not so much. I'm sure the folks we bring here to replace them would eagerly line up at dawn to get their kids immunized."
This essay is here:

By Old Rockin' Dave (not verified) on 26 Jul 2016 #permalink

The wacky idea is that Aluminum could be a neurotoxin in the dosages you get from vaccines…

Is it really the concentration that matters here or are some (just not so many) neurons always sacrificed for the shot??

Especially if the idea isn’t to shove shots at the kids of the commited AVs, but to help the poor and perhaps clueless, nothing like jail or protective services need be involved, as we could let them have easy loopholes, since they’re ‘not the point’. The authors make a car-seat analogy, and I don’t think CPS gets a call if parents forego that now and then (not that I know, being childless…).

Here's the problem. Danziger and Diamond make a social justice argument, starting out contrasting the poor woman whose struggle to put food on the table for her other kids and pay the rent made it difficult for her to learn how to care for her preemie ready for discharge from the NICU to privileged antivaccine parents who choose not to protect their children from disease, with the poor mother being reported to CPS and the antivaxers facing no government action. They are, of course, understandably outraged at this disconnect. The problem is that later they make an explicit analogy between parents who refuse to vaccinate and parents who withhold chemotherapy and other effective life-saving treatment from their children with cancer, referring to them both as medical neglect. OK, you might say, but not all medical neglect is the same; so the punishments don't have to be the same. Sounds reasonable, right? For instance, withholding chemotherapy from a child with a treatable cancer almost certainly will result in the very unpleasant death of that child. That's very bad, and CPS will often ultimately intervene to take the child away, even though it will always try its best not to. Parents will be dragged before a judge and sometimes even jailed. So, you might say, failure to vaccinate is not as serious; odds are that the child will not die or even get sick unless there is an outbreak, and even then the odds are probably in a healthy child's favor, at least compared to the analogy of withholding chemotherapy from a child with cancer. So the punishment doesn't have to be the same. The problem is that, in terms of severity of medical neglect, Danziger and Diamond don't seem to make that distinction, stating:

Instead of spinning our wheels producing ineffectual research, the time has come to call vaccine refusal by another name that more accurately sums it up: medical neglect. We can continue our scholarly inquiry to find more effective ways for convincing parents that vaccines are worthwhile, but it is time to declare, unequivocally, that vaccination is a human right no child should be denied.

If this is your position, that vaccines are a human right that no child should be denied, then a "slap on the wrist" penalties and a lot of easy loopholes will not suffice. This is a declaration that the law needs to be willing to do whatever it takes, even if it means forcibly vaccinating against the parents' will, fining or throwing the parents in jail, and/or taking the children away, temporarily or permanently as the situation requires.

Here in Italy some child vaccinations are compulsory, other ones only "recommended". However, even if theoretically a child could not be enrolled in public schools unless vaccinated, in practice there is no penalty for skipping vaccinations, as it would be deemed contrary to the right to instruction, which is compulsory, too.
Now a proposal is emerging in some parts of the country to bypass this conundrum: children with no record of vaccination may not be admitted to nursery schools. These schools are not compulsory, so no risk of a conflict between health or instruction.

By perodatrent (not verified) on 26 Jul 2016 #permalink

If there aluminum in a vaccine were dangerous, then we'd all be dead now from all the aluminum naturally in the environment. It's not exactly a rare element.

By Gray Falcon (not verified) on 26 Jul 2016 #permalink

The wacky idea is that Aluminum could be a neurotoxin in the dosages you get from vaccines…

Why is that a wacky idea?

How much intramuscular Aluminum [μg/Kg] would you say is neurotoxic?

I have not been able to find an answer to this, and I have looked.

By PuppyBoners (not verified) on 26 Jul 2016 #permalink

@ GrayFalcon If there aluminum in a vaccine were dangerous, then we’d all be dead now from all the aluminum naturally in the environment. It’s not exactly a rare element.

Studies have shown that we only absorb between .01-.05% of ingested aluminum.

The people that primarily get alumunum induced neuropathy are people on heomodialysis, welders, and vaccine recipients.

By PuppyBoners (not verified) on 26 Jul 2016 #permalink

Eric Lund @34: Except that in a lot of places where immunization records are required to travel between countries, it is just as easy to get a fake record as a real vaccination. I have friends who did that because they did not trust (or see the need for) a yellow fever vaccination in two countries that don't have yellow fever.

So that's not a perfect solution either.

By JustaTech (not verified) on 26 Jul 2016 #permalink

@#52: A study by Christopher Shaw? Bwahahahaha! He's basically perfected the dark art of doing injecting vaccines or vaccine ingredients into mice and then using dubious, unblinded behavioral tests to "prove" how evil the vaccine ingredient is.

Thanks for the chuckle!

The Shaw studies are the only ones that have been published.

ORAC. I hope you buy an Aluminum saucepan and make marinara sauce in it twice a week.

And bake some French-style bread with double acting baking powder while you are at it.

By PuppyBoners (not verified) on 26 Jul 2016 #permalink

How about a very simple carrot and stick: Parents who vaccinate get it on their records, and consequently, in every non-emergency, the whole family gets priority service in medical, dental and eye-care, plus discounts. Parents who do not vaccinate, get lower standards of service and longer wait times.
In some communities, like say, Orange County, have a two tiered service for vaccines: regular folks get the discount, wealthy suburbanites get 'the premium vaccines' (really, just regular vaccines at a new price. Worked for bottled water.) One of the quickest ways to make something valuable is to announce a scarcity; if vaccines are suddenly hard to find in anti-vax communities, they will become more valuable.

By Politicalguineapig (not verified) on 26 Jul 2016 #permalink

PB just loves him some anti-vax talking points....

If there aluminum in a vaccine were dangerous, then we’d all be dead now from all the aluminum naturally in the environment.

Plants sure have a problem with it, Gray Falcon #48:

Aluminum (Al) toxicity is a major constraint for crop production in acidic soil worldwide...

To develop high tolerance against Al stress is the major goal of plant sciences. This review examines our current understanding of the Al signaling with the physiological, genetic and molecular approaches to improve the crop performance under the Al toxicity.

But we're not potted plants like Ollie North's lawer or anything.

"I hope you buy an Aluminum saucepan and make marinara sauce in it twice a week"

We have some aluminum cookware. Apparently it causes limericks.

Here is study without Shaw:!divAb…

They basically gave rats alzheimers by ingecting them with Al₂O₃.

Here are the micrographs of the brain slices, with Al elucidated with the Morin Stain:…

Basically Aluminum accumulates in the brain and makes people dumb and forgetful. Aluminum should be avoided.

By PuppyBoners (not verified) on 26 Jul 2016 #permalink

Oh, no! It is the Aluminati coming to spread fear and loathing about the most abundant metal element on this planet's crust!

PB: "How much intramuscular Aluminum [μg/Kg] would you say is neurotoxic?"

So you never fell and scraped your knee in dirt, which is composed of minerals containing aluminum. Lots and lots of nanoscale alumina in that dirt... and not in mice, but any kid who was allowed to play outside.

I would place a bet that the tetanus spores in the soil are more dangerous than the aluminum.

I hope you buy an Aluminum saucepan and make marinara sauce in it twice a week.

And bake some French-style bread with double acting baking powder while you are at it.

Yes, I use aluminum pans. I inherited them from my mother. Also, a wonderful aluminum citrus press for making fresh orange juice.

But, no, I don't use baking powder of any kind when making French bread. I use yeast as the recipes call for. I use my double acting backing power in cakes and biscuits. I make very good biscuits.

Darn. Block quote fail.

@Meg I use my double acting backing power in cakes and biscuits.

I am sure that your Aluminized "autism biscuits" are wonderful Meg.

By PuppyBoners (not verified) on 26 Jul 2016 #permalink


I've been known to be dumb and forgetful sometimes. You don't think... it wasn't my childhood vaccination series, was it??? I SHOULD SUE.

I'd love it if we could get an SB277-style law passed on a federal level. While I'm wishing, I'd also like Wakefield to shut his cavernous maw permanently, David Wolfe to take up a life of ascetic monasticism on a mountaintop somewhere, and Crystal Pepsi to come back...

@PuppyBoners I'm from Poland.
As for other proposals put here, we had immunisations at school. There would be a day when the whole class would go to the nurse's room, there was the school nurse and some doctor invited for the event, and we would get our vaccines (I remember oral polio vaccine in primary school very well and then rubella). And then in high school we had Mantoux skin tests - TB was still a problem here at that time.
Nowadays it's probably different. Don't know about primary schools but in high schools there are certainly no vaccines given - the school nurse only checks such things as blood pressure, weight, does basic eyesight tests, etc.

Studies have shown that we only absorb between .01-.05% of ingested aluminum.

Speaking for myself, I eat everyday. OTOH, even as a toddler, I received, at the worst, one vaccine every other week, if not every other year.
(exception: special mention for my military period, 3 multishots in one day; if it was to brainwash us and make us compliant, it didn't work well, especially compared to our drill sergeants)

The people that primarily get alumunum induced neuropathy are people on heomodialysis, welders, and vaccine recipients.

Again, I have this feeling that people on heomodialysis or welders get enough weekly exposure to aluminium that they don't have to worry about the one coming with the occasional vaccine.

tl;dr: alu toxicity may well be an issue, but I suspect that vaccines are not the main source. Especially for adults.

By Helianthus (not verified) on 26 Jul 2016 #permalink

@69 I have failing kidneys. I can't even use my favorite antacid because it's made from aluminum. I understand that my kidneys no longer eliminate the metals they should. However, you can be sure if there was a vaccine I needed, that would protect me from a potentially dangerous VPD, and it had some aluminum in it, I wouldn't hesitate for a moment (with professional advice, of course).

Here in Oz there's a financial incentive. There is a tax refund given to parents depending on the age of your kids (and there's an income component but it's complicated) and there's reimbursement for childcare. If your kids aren't up to date on their vaccines and you don't have a good medical excuse, you get nothing.

So the only people who can afford not to vaccinate are the pampered stay at home mums.

I'd like to see a system where every family who slips behind gets a phone call from the mother and child health nurse to schedule a checkup. If the appointment was for either vaccination or a counseling session to explain exactly why it's recommended, at least there wouldn't be parents forgetting about it or letting it slip.

A nurse visit for a vaccine is free so there's no access issue. They have centrally located mass-vaccine days or you can schedule an appointment with your own clinic or the mother and baby clinic.

We also still have school vaccine day for kids at certain grade levels. They get sent home with a consent card and information including the website for a documentary explaining why it's done.

We used to have the dentist van come around every 2 years for a checkup too. If anyone needed any work done they would generally send home a note explaining and schedule a follow-up appointment. I think it's still happening in the country. Kids' dental is free so it's a great opportunity.

But with all the awesome stuff we get, there are still so many people insisting on private schools, private healthcare, private decision-making. There's this sense of not wanting to do what the hoi polloi are expected to do, of assuming that the baseline isn't really good enough, even though it's proven to be awesome. The theosophist schools are the usual disease vectors in Australia.

By Mama-Don't-Sleep (not verified) on 27 Jul 2016 #permalink

Medscape has an article about vaccine acceptance.

Medscape Vaccine Acceptance Report 2016

Susan B. Yox, RN, EdD; Laura A. Stokowski, RN, MS | July 27, 2016

Does the Democrat Party Platform include anything on making vaccines compulsory?
Will Hillary be addressing this in her speech this week?

If not, why not?

By See Noevo (not verified) on 27 Jul 2016 #permalink

I’d love it if we could get an SB277-style law passed on a federal level.

I know it's only a wish, but it will never happen. Vaccine policy is set at the state level. What I wish is that every single state have a medical-exemptions only policy, with maybe a personal exemption that requires taking and passing a comprehensive course on the immune system, the burdens of the diseases we vaccinate against, and vaccine manufacture.

Liz - that's a great idea.

And yes, getting anything done on the Federal Level (outside of the military) would be legally impossible, based on all of the various case law which has been built up over the last two hundred years.

It is very much a state-level affair (and even NYC was slapped down by a judge when they tried to do something on their own with a Flu vaccine mandate at the local level).

The issue with having school nurses give vaccines is that not all schools have nurses anymore. It's a budget thing, although it's not just a poor-community thing. In Seattle a child was not allowed to go to school because his school did not have a nurse and none of the teachers were willing to administer his EpiPen if he needed it. The only way he could go to school was if one of his parents was there. All day.

So until there actually are nurses in schools again, we can't use that as a way to make it easy to get vaccinated (which is too bad).

By JustaTech (not verified) on 27 Jul 2016 #permalink

Just wondering if anyone knows what penalties parents face for not using seat belts and car seats for their children? If the penalty for non-vaccination was of the same order of magnitude, then you might get compliance from on-the-fence parents.

By Broken Link (not verified) on 27 Jul 2016 #permalink

Broken Link @77: It depends on the state, but generally it's a ticket, just like for adults not wearing seatbelts or talking on phones. I think it depends on the state if it is a primary violation (something you can get pulled over for) or a secondary violation (they can't pull you over for that, but if they pull you over for speeding they can get you on seatbelts/carseast/etc).

By JustaTech (not verified) on 27 Jul 2016 #permalink

SN @73

Does the Democrat Party Platform include anything on making vaccines compulsory?

I fail to see what the relevance of the platform of a fringe political party dedicated to horse draw conveyances is to the topic at hand.

By Militant Agnostic (not verified) on 27 Jul 2016 #permalink

FYI, it appears that and some of its clones have lapsed on their domain renewal. It would be interesting if the site fell into the right hands...

By Infernal Wedgie (not verified) on 28 Jul 2016 #permalink

The problem with "you either get yourself/your children vaccinated or you have to buy this insurance" is that either it's another penalty that is a lot more onerous for poor parents than rich ones (both because something like $500/year is anything from impossible to trivial depending on your income, and because of the increasing tendency to throw people in jail if they can't pay fines); it's unenforceable, because what do you do if someone refuses to buy the insurance?; or it's mandatory vaccination for the poor, and optional for people who can afford the insurance.

Politicalguineapig: I am dubious of any policy that requires people to show their medical records, both for reasons of privacy and because paperwork gets lost, and it's not always the fault of the person whose paperwork it is. There are chunks of my medical history that I remember parts of, and my mother may remember other parts, but the doctors retired without us getting the records. (One of those was a doctor I had seen relatively recently; I found out she had retired because a friend called her to make an appointment and was told something like "Dr. Villanueva is retiring soon and isn't making any more appointments.") And then there's the eye doctor who somehow lost several years of my records when he moved from one practice to another....

"I’d love it if we could get an SB277-style law passed on a federal level. ..."

And I'd love it if they would roll back the decision to disallow lawsuits against vaccine manufacturers because of severe, permanent damage or deaths as a result of their obscene chemical injection mandate.

And I’d love it if they would roll back the decision to disallow lawsuits against vaccine manufacturers because of severe, permanent damage or deaths as a result of their obscene chemical injection mandate.

So do I, in my less charitable moments. Could you lay out your specific arguments in favor of a lottery system with extremely high priced tickets in this realm?

@ Narad #83

Lol fierce logic combined with a florid writing style. Makes me rather relieved that you are in the states and not against me in a pub argument :)

Orac and all those that support the violation of fundamental human rights should be in fucking jail.

You don't have a fundamental human right to refuse to protect your child from disease. A child is a human being and deserves the protection.

I would also recommend reading the article before commenting.

By Dorit Reiss (not verified) on 31 Jul 2016 #permalink

In reply to by jason (not verified)

Yeah, I have to wonder if someone posted this to an antivax list.

It is rather obvious, though, that those who protest the loudest about "natural rights" and claim that it is the parents' "absolute right" to determine what goes into their child's body don't give a damn about the child and his rights as an autonomous being. It's all about the parent, pure narcissism.

Apparently "jay" wants to cast Orac in his new pornographic film.

By Mephistopheles… (not verified) on 31 Jul 2016 #permalink

I live in a country where vaccines are mandatory, bar medical exemptions. Technically, if someone would refuse vaccines, it could end up by a court order enforced by police but the system is that if parents refuse, they're send to a district Public Health Office which has a designated person to explain vaccination to refuseniks of all colours. I hear that at the end, most of the parents are persuaded, one way or another, to vaccinate and if they persist, the child's paediatrician is informed to keep an eye on the child. I am not aware of any court ordered vaccination, I guess I would notice the kerfuffle because I vaguely follow the local loony scene but I might have missed it entirely.
And, well, it sorta works.

By kultakutri (not verified) on 31 Jul 2016 #permalink

My apologies to Jay - I meant jason.

By Mephistopheles… (not verified) on 31 Jul 2016 #permalink

@ Orac #46

I take the point that Danziger and Diamond's argument could be extended into justification for harsh penalties including incarceration and stewardship. But, back to the car-seat analogy, that too is a form of neglect, but draconian punishments don't follow. In fact, any number of existing laws that could be used to toss parents in stir or take their kids away are only rarely enforced, usually only in extreme cases.

I could argue that D&D are engaging in polemic – employing some harsh rhetoric in an attempt to stir the pot and establish a hard-line position as an opening gambit in an inevitable bargaining exchange that could only result in a moderated much weaker policy, but one they'd be content with. I think your point would be that this is bad strategy: not that the harsh penalties would ever be instituted, but that the fear they could be implemented is so easily activated that the counter-pressure would likely scuttle any effort at policy reform at all. That's a fair concern.

I hadn't read the full text on Slate before, and in total it comes off as more hard-core than the quotes you pulled. By the time they get to the conclusion that seems to emphasize the rhetorical force of mandates over material enforcement, they've made enough statements about the failure of persuasion, and enough references to actual severe policing that the distinction might not even register, much less carry any weight. On the whole it's a pretty confused piece that could have used a good editor. But just because D&D may be off-the-rails doesn't mean we need to abandon the discussion of vaccination mandates. We can look at the issue, and see if we can come up with a more specific policy proposal that addresses the concerns you've raised in #46.

Why go beyond SB277? Buried in D&Ds essay is an issue with SB277 that only Vicki seems to have really picked up on;

We see the family whose incompletely immunized child is refused entry to a school, not because they oppose vaccines but because they lack reliable transportation and predictable time off to receive all the shots.

The LAST people we ought to be keeping out of school are the children of poor parents who may delay vaccination for economic reasons, and/or may be vax-hesitant by virtue of being poorly informed. They can't buy PMEs from Dr. Bob; can't home school, can't buy more insurance, etc. etc. That's the 'social justice' argument for mandates: in practice 'your kids must be immunized, or else they can't go to school' discriminates against the already educationally-disadvantaged poor, and a mandate would likely have be accomanied by free immunizations administered in schools to pass muster under the Equal Protection Clause. True, a mandate might not be the only means of achieving this end, but it's worth discussing on that point among other possible merits.

I looked at Prof. Reiss's 'continuum of options to handle non-vaccination' and it's strikes me that what's missing is a continuum of enforcement methods and steps to go with "criminal sanctions for non-vaccination". Back to the car-seat analogy, and JustaTech noting first violations just yield a ticket, not a report to CPS. But unlike carrying a kid w/o a car seat, non-vaccination is not a criminal act, but a condition demanding action-to-remedy. When citizens are in non-compliance with a law, the penalties they face are based on how long they remain so after receiving notification.

Drive with a broken tail-light in CA, you get a fix-it ticket with a conditional fine revoked if you take the car to the Police Station and show an officer the repair within X-number of days. After that, you're levied the rather nasty fine, and after a while, if you don't comply, they suspend your DL, and so on*. With some creative thinking, we could propose specific enforcement measures for a vaccine mandate that would be eminently fair, reasonable, non-draconian, and stop well short of either incarceration or loss of custody, except perhaps for only the most ridiculously egregious instances... (and maybe not even that).
* So I was driving back from an errand, just a few block from home, and unbeknownst to me my tail-light fuse had blown somehow during the day. It was just getting dark, and sure enough, just as I turned on my lights, I passed a police cruiser, got pulled over for no tail-lights, and was issued a fix-it ticket. I replaced the fuse as soon as I pulled into my driveway, checked that everything worked... and then forgot about it and didn't get to the PD on time. Then once I got the clearance note from the city police, I forgot to mail it to the County Court on time. Then I sent in the late payment fee and the copy of the ticket slipped out of the envelope somewhere along the way, so they sent it back. By the time I got that notice, my license had been suspended. I had an acquaintance drive me down the 30+ miles to the traffic court to try to straighten things out in person, but the line was so long I didn't get to the front before the window closed. Then I couldn't get another ride, and then... and THEN.... I finally got it straightened out before my license got permanently revoked, but it wasn't cheap. Anyway, I did learn something about mandates enforced with less than a slap-on-the-wrist at first, but that can lead to digging yourself steadily into a deeper and deeper hole via non-compliance.

The day that I am compelled to take a thimerosal shot for the flu is the day that I start flogging health officials.

I'll take vaccines for the scary diseases only. I don't need a vaccine for archaic wimpy diseases like: influenza, mumps, measles, ect...

By Annabel Lee (not verified) on 01 Aug 2016 #permalink

Annabel Lee: "I don’t need a vaccine for archaic wimpy diseases like: influenza, mumps, measles, ect…"

So influenza is wimpy because it "only" kills an average of a hundred American kids per year? Is measles "wimpy" because it puts "only" one out of ten cases in the hospital and "only" kills about one out of a thousand cases?

Or is the is the only thing that is "wimpy" is your grasp of reality?

Not as wimpy as you Chris.

By Annabel Lee (not verified) on 01 Aug 2016 #permalink

And here I thought "whimpy" was spelt with an "h".

Sorry, up way past my bedtime.

By Science Mom (not verified) on 01 Aug 2016 #permalink

My impression of Chris:

"I need a measles vaccine to keep the measles away because I am so wimpy. My immune system is like Freddy Mercury with AIDS."

By Annabel Lee (not verified) on 01 Aug 2016 #permalink

Annabel Lee is using a P.R.A.T.T. I haven't written down on my list.

I’ll take vaccines for the scary diseases only. I don’t need a vaccine for archaic wimpy diseases like: influenza, mumps, measles

All the disease we vaccinate against can kill, and have negative sequelae far more severe and far more likely to occur than vaccine adverse reactions.

By Julian Frost (not verified) on 01 Aug 2016 #permalink

Whatever. I would take influenza, mumps, and measles over autism, guilaine-barré, and POTS!

By Annabel Lee (not verified) on 01 Aug 2016 #permalink

Two P.R.A.T.T.s in one. Miscalculating the risks of vaccines comparative to the diseases and blaming vaccines for things they don't cause.
Vaccines do not cause autism. A meta-analysis comprising over 14.5 million subjects looked at the question. No link.
Guillaine-Barre was 17 times more common in people who got the flu than people who were vaccinated.
What is your evidence that POTS is caused by vaccination?

By Julian Frost (not verified) on 01 Aug 2016 #permalink

Published in "Clinical Rheumatology".
Title: Hypothesis: Human papillomavirus vaccination syndrome--small fiber neuropathy and dysautonomia could be its underlying pathogenesis.
The very first word is Hypothesis. That's not evidence.
Below the abstract is the Comment in section. And one of the articles mentioned under this subheading is:
Proposed HPV vaccination syndrome is unsubstantiated.
Extremely weak tea, and nowhere near proof.

By Julian Frost (not verified) on 01 Aug 2016 #permalink

They have even come up with the phrase: Human papillomaaluminovirus vaccination syndrome


Orthostatic intolerance and postural tachycardia syndrome as suspected adverse effects of vaccination against human papilloma virus

SUSPECTED Adverse Event, not proven adverse event.

35 women aged 23.3 ± 7.1 years participated.

A sample size of 35 is not nearly large enough.
Again, this is a case of "might be", not "is", with strong emphasis on "might".

By Julian Frost (not verified) on 01 Aug 2016 #permalink

One has to wonder why the HPV vaccine is so very different from others that there are such weird side effects postulated (with no logical mechanism to be found).


That's enough for me! (and apparently for our latest sock puppet/troll as well).

By Dangerous Bacon (not verified) on 02 Aug 2016 #permalink

Only anti-vaxers (and nuts) could lose their minds over something that prevents cancer.....

Annabel: Vaccines work through the immune system. If we didn't believe in our immune systems, we wouldn't vaccinate. I highly recommend getting the basic facts right before commenting on a subject.

By Gray Falcon (not verified) on 02 Aug 2016 #permalink

@Gray Fuckon

Yes, I know how they work. They do, like all drugs, carry toxicological risks. Scientists have been hunting for the "autism factor" for years now.

@Julian Frost

OK, there may not be sufficient proof that Gardasil causes POTS, but can you prove that HPV can cause cancer?

By Annabel Lee (not verified) on 02 Aug 2016 #permalink

Yes, I can.

My mother has HPV-derived Cervical Cancer.



By Annabel Lee (not verified) on 02 Aug 2016 #permalink

Scientists have been hunting for the “autism factor” for years now.

With a singular lack of success.

Vaccines are not associated with autism: An evidence-based meta-analysis of case-control and cohort studies
Vaccine, Volume 32, Issue 29, Pages 3623-3629
Luke E. Taylor, Amy L. Swerdfeger, Guy D. Eslick

Whatever. I would take influenza, mumps, and measles over autism, guilaine-barré, and POTS!

Pretty stupid trade-off considering none of those vaccines cause Autism and POTS [sic] and influenza vaccines raise the risk of GSB only slightly.

By Science Mom (not verified) on 02 Aug 2016 #permalink

There is no lack of successful associations:

Now I'm going to take a wild guess that Annabel doesn't know how to parse studies else she never would have invoked the Geiers.

By Science Mom (not verified) on 02 Aug 2016 #permalink

If she's quoting the Geiers - well, that explains a lot.

Better than quoting Swerdfeger and Eslick!

As was done on post #112

Swerdfeger likes to feg swerds, that is where her name came from.

And Eslick likes to lick esses.

By Annabel Lee (not verified) on 02 Aug 2016 #permalink

Annabel Lee is a pretty poor excuse for a troll. She's probably been relegated to a culvert.

And Lee is infested with fleas.

Do you see the immaturity you display with your childish insults and vacuous references? At least try to demonstrate that you're a competent and intelligent adult.

else she never would have invoked the Geiers.

Our nym-shifting aluminium-Concerned visitor (Phoebe C. / James Castle / PuppyBoners et al) knows perfectly well the opprobrium and contempt associated with the Geiers, from previous visits. I imagine that he or she is linking to their career of grifting mainly as a wink to the audience.

By herr doktor bimler (not verified) on 02 Aug 2016 #permalink

"Oh Mr Dork Terrible" is an anagram for "Herr Doktor Bimler"

By Annabel Lee (not verified) on 02 Aug 2016 #permalink

None of the anagrams for "anagram" are particularly satisfying.

By herr doktor bimler (not verified) on 02 Aug 2016 #permalink

Who let the preschoolers out to play in the comments?

I got my MMR today. Outside of a bit of soreness, no side effects.

Less than three weeks after my one year old got his, he started walking.

He's been trying to get into places and things that can hurt him since. Well, before too, but since then he's better at it.

By Dorit Reiss (not verified) on 02 Aug 2016 #permalink

In reply to by MI Dawn (not verified)

Herr Docktor: there was a Doctor Who novel called "Managra". They were playing around with the tendency of many Dr Who villains to have anagrammatic names. ;-)

By Calli Arcale (not verified) on 02 Aug 2016 #permalink

@MI Dawn I got my MMR today

Well, enjoy your last week of almost normal intelligence before plummeting into the 5th quintile.

By Annabel Lee (not verified) on 02 Aug 2016 #permalink

It seems Annabel Lee is three years old. One who actually thinks the MMR contains thimerosal. What kind of bargain basement troll was sent here. Let's send it back,


I never said that the "MMR contains thimerosal".

The MMR is autismogenic in manners that have yet to be elucidated.


By Annabel Lee (not verified) on 02 Aug 2016 #permalink

The MMR is autismogenic in manners that have yet to be elucidated.

Cart before horse? Please do elaborate.

By Science Mom (not verified) on 02 Aug 2016 #permalink

@ rs

I'm afraid the opposite demonstration has already been done.

Successfully garnering attention under its initial 'nym, and then scuttling its reputation by going into an hurricane of sockpupetting.... I'm left to wonder if our troll is really that stupid or in need of psychiatric help.

@ Science Mom

Please do elaborate.

Let's not. 'Tis a silly place anyway.

By Helianthus (not verified) on 02 Aug 2016 #permalink

The MMR is autismogenic in manners that have yet to be elucidated.

Leaving aside the strange Emily Post reference, "autismogenic" may well be the most comically abysmal attempt a coining a neologism that I've ever seen. It's Greek! It's English! Let's make Greconglish!

Oh, and presuming this was from "Annabel Lee," it's killfiled, so don't bother.

^ "at coining"

Successfully garnering attention under its initial ‘nym

Fendlesworth has been reduced to necromancing in a further bid for attention at AoA, by the way.

The MMR is autismogenic in manners that have yet to be elucidated.

I mentioned a meta-analysis comprising over 14.5 million subjects that looked at the question and found no link. If MMR was autismogenic even in some way that has yet to be discovered, that study would have found it.
MMR is not autismogenic.

By Julian Frost (not verified) on 02 Aug 2016 #permalink

I got my MMR today. Outside of a bit of soreness, no side effects.

Now here is a thought that has been plaguing my mind. If MMR is so autismogenic, then there must loads of cases of MMR causing immediate onset of severe Autism, in adults!?!

I mean there's an epidemic out there!!! There must be loads of cases!!!!!



This is not my neologism. This is from Dr. Lyons-Weiler:…

It’s Greek! It’s English! Let’s make Greconglish!
If Autism had a Greek name then I'd use that. But obviously, the Greeks didn't have vaccines so the didn't have a word for Autism.

Have you ever heard of a Hybrid Word Narad? There are dozens that come from two different languages:

Such a douchebag Narad.

By Annabel Lee (not verified) on 03 Aug 2016 #permalink

Such a douchebag Narad.

"Douche" is a French / Italian root, "bag" is Old Norse, HOW CAN YOU COMBINE THEM!?

By herr doktor bimler (not verified) on 03 Aug 2016 #permalink


Just wait Jay.

MI Dawn will stop making eye-contact any day now. It takes a while for the Autism to manifest itself after an MMR.

I has to cause a gut-pathology first, as first described by Dr. Wakefield.

By Annabel Lee (not verified) on 03 Aug 2016 #permalink

If Autism had a Greek name then I’d use that. But obviously, the Greeks didn’t have vaccines so the didn’t don't* have a word for Autism.

* fixed that for you.

Approximately 13 million speakers of Greek are about to prove you wrong...


@Annabel Lee: does pointing at you and laughing hysterically count as stopping eye contact?

At my age, and after the number of MMRs I've had in my life (along with mumps and measles - you know, those "minor" diseases that are supposed to give you life-long immunity), I'm not too worried about a vaccine.

And, it's a good thing you a)aren't my child and b)within arms' reach. You'd have been punished for your nasty remarks about those with autism or mental disabilities. What a little nasty critter you are. And a lousy troll.

(and, by the way...I hope you are a relative to Edgar Allen with that 'nym.)

No Annabel, as people are starting to get to grips with the idea that Autism starts in the womb, way before MMR, the idea that MMR could cause formation of disorganization in the neocortex after birth, just looks ridiculous.

Mr. (not a Doctor) Wakefield:
1) Failed to declare that he had been hired to find evidence that MMR caused autism;
2) Withheld the fact that the 12 children he saw were referred to him by the solicitors looking to build a case that vaccines cause autism, they didn't come in off the street;
3) Never disclosed that he was working on a single measles vaccine;
4) Tried to set up a company to sell "test kits" for "MMR induced autism";
5) Committed multiple ethical violations, and;
6) When the data he gained from testing those autistic children failed to support his hypothesis, lied, distorted and misrepresented it.
If you are relying on the "case report" of not a Doctor Wakefield, you have nothing.

By Julian Frost (not verified) on 03 Aug 2016 #permalink

@ Annabel Lee #109

Yes, I know how they work. They do, like all drugs, carry toxicological risks. Scientists have been hunting for the “autism factor” for years now.

Hum, yes, and since they didn't find a convincing association, they decided to look elsewhere. I keep tracks of autism research for my job ; there are a lot of hypothesis more convincing than vaccines nowadays.
For example, age / weight of the parents, antidepressants / paracetamol / sodium valproate taken in utero, exposure in utero to flu / pesticides (although not specifically glysophate and in much more nuanced terms than Seneff and Lyons-Weiler)...

Notice the absence of MI Dawn only one day after the MMR?

Someone should call for help.

By Annabel Lee (not verified) on 03 Aug 2016 #permalink

“Douche” is a French / Italian root, “bag” is Old Norse, HOW CAN YOU COMBINE THEM!?

No. "Autismogenic" is incompetent from any angle. The attempted interfix 'o' merely creates a new morpheme with an extra syllable, "autismo." Simple euphony should be enough to tell one that something has gone horribly wrong with their coinage.

"Austistogenic" avoids that problem, but it's still abysmally stupid.

Wonky wording aside., I would still like Annabel to clarify this:

The MMR is autismogenic in manners that have yet to be elucidated.

Maybe she should call for help.

By Science Mom (not verified) on 03 Aug 2016 #permalink

"She"? <Janis>C'mon man, get it together.</Janis>.

Is there an antidote for the MMR?

By Annabel Lee (not verified) on 03 Aug 2016 #permalink

“She”? C’mon man, get it together..

All right all right, just going along with his chosen 'nym.

By Science Mom (not verified) on 03 Aug 2016 #permalink

Oh, Annabel, it's so sweet you're worried about me. However, it's just that my off-line life has been quite busy so I haven't been on line as much as my norm. I'm feeling quite well. My only issues at the moment have to do with construction, not health.

@Annabel Lee

I has to cause a gut-pathology first, as first described by Dr. Wakefield.

Actually, Dr. Wakefield failed to find any connection between MMR and his alleged gut pathology. To quote from his 1998 (retracted) study:

We did not prove an association between measles, mumps, and rubella vaccine and the syndrome described.

He did not even prove an association, let alone any kind of causal connection.

Newest sock puppet: "Is there an antidote for the MMR?"

For what effects? Provide the PubMed citation, obviously nothing by Wakefield because he did not really find anything.

"Is there an antidote for the MMR?" Well, if you have your bone marrow obliterated then that generally removes your immunological memory, including to vaccines like MMR, so I guess sort of?

By JustaTech (not verified) on 04 Aug 2016 #permalink


I suppose a sufficiently high dose of measles virus itself could counteract the MMR, if there were enough virions to evade the immune response long enough to set up shop and wipe out the immune memory. But then, if you were bombarded with that much measles virus, you'd have much greater things to worry about than whether the MMR causes some delusional illness.



Pharmaceutical Prescription Opioid overdose deaths
are now the leading cause of accidental death in the US, with 18,893 overdoses in 2014.

How can we call the skeptics of Big Pharm "quacks"? The very industry we seek to advocate is directly responsible for the greatest drug epidemic in United States history.

By William Godfrey (not verified) on 23 Sep 2016 #permalink

@William Godfrey:

Pharmaceutical Prescription Opioid overdose deaths
are now the leading cause of accidental death in the US, with 18,893 overdoses in 2014.

Citation Needed.

By Julian Frost (not verified) on 23 Sep 2016 #permalink

How can we call the skeptics of Big Pharm “quacks”? The very industry we seek to advocate is directly responsible for the greatest drug epidemic in United States history.

Leaving aside the incorrect wording of your sentence, it is physicians responsible for Rx opioid use. While pharma does engage in dodgy practices, what exactly is your complaint re: vaccines?

By Science Mom (not verified) on 23 Sep 2016 #permalink

William Godfrey seems to have forgotten about deaths in car crashes. Or are those not accidents?