Following the recent measles outbreaks, legislative efforts seeking to tighten or remove nonmedical exemptions to vaccination have been proposed in multiple states.1 In part, these concerns were fueled by how quickly measles spread across the country. And, while in most parts of the country, vaccine exemption rates are low, previous studies have shown that geographic pockets of higher exemption rates are worrisome.2,3
When surveyed, parents indicate a variety of reasons for delaying or refusing vaccines for their children. Many of these reasons center on concerns about vaccine safety and a reported lack of belief in the need for vaccination.4-7 In addition, those who argue against vaccination mandates often cite feelings of being forced to vaccinate or not having the ability to choose what is best for them and their families.8,9 To this end, we wanted to explore some of the emotions associated with philosophical and personal belief exemptions a bit more closely.
At their heart, philosophical and personal belief exemptions to vaccination rest on two emotional pillars — fear and control. Indeed, human nature is to fear things we do not know and to control as much as we can. So when parents are confronted with giving their babies vaccines, both of these emotions tend to work against making the safest decisions. However, we would argue that vaccines, when understood, should expunge fear and augment control.
Vaccines suffer an irony. On one hand, they are among the best-studied products we put into our bodies. Before a vaccine can be given to anyone, it must undergo years of testing in thousands of people to show that it works and is safe.10 Indeed, the paperwork submitted to the FDA for one of the two rotavirus vaccines on the market (RotaTeq®) would, if stacked, stand as tall as the Sears Tower.11
Yet, for most of the population what is in that vial and how it works to protect from disease is not well understood. And, when something is not well understood, it becomes difficult to consider it without concern. A recent small study, while a bit off-topic, is instructive as it suggested that future biology teachers reported a lack of “the necessary knowledge, conviction and role models to teach evolution properly.”12 Indeed, one respondent was quoted, “I’m, you know, pretty ignorant on this topic...is there enough of scientific evidence to say for sure?”12 Whether about the science of vaccines or evolution, uncertainty leads to fear of the unknown.
Compounding the uncertainties related to what is in the vaccine vial is the fact that for most young parents, vaccine-preventable diseases are themselves unknown. Indeed, historically, fear was directed at these diseases, and unfortunately, those most passionate about preventing these diseases today, are often, themselves, victims of vaccine-preventable diseases. Parent groups composed of families profoundly affected by these diseases and doctors who have watched children succumb to them are among the most passionate — because for them the real threat (as distinct from ill-founded fear) has been realized firsthand.
Vaccine-preventable diseases are not all equal in their capacity to maim or kill, but watching someone die from any one of them is a stark reminder of the importance of prevention. The viruses and bacteria that cause these diseases are the appropriate target of these fears. Indeed, even today in parts of Africa, some families do not name their babies until the fear of losing them to measles has passed.13 In the United States, parents benefit from living without constant fear of these diseases thanks to vaccines. Unfortunately, vaccines do not benefit because parents no longer think they are necessary.
In this time characterized by helicopter parenting and natural foods, the value placed on control is obvious. Parents control their children’s play experiences by scheduling playdates and keeping children busy with organized activities. They control what goes into their children’s bodies by buying organic foods and making baby food at home. So, it is only natural that they would want to control what goes into their children’s bodies when they visit the doctor. And, the thought that someone is telling them they need to give their children vaccines appears to run counter to an all-natural environment. But, vaccines actually afford a control that no other medical intervention allows. Parents who vaccinate know exactly the date their children were exposed to measles, mumps, rubella, chickenpox, and so on. Not only do they know the exact date, but they also know the children were exposed to a quantity that was “just right” — not too much (to make them sick) and not too little (to keep them susceptible).14
Of course, the conversation always returns to the notion of being forced to give children vaccines, which feels like it is out of one’s control. It also moves the discussion into a political-legal arena. In an article by Jeffrey Mervis15 about a recent issue of The ANNALS of the American Academy of Political and Social Science devoted to the politics of science,16 co-editor Elizabeth Suhay, was quoted, “Political values are unavoidably wrapped up with scientific research, because science tells us what’s possible.” She continues, “Science is inherently controversial because nobody wants to hear that their options are limited.”
Editor’s note: A recent article by Dorit Rubenstein Reiss, UC Hastings Professor of Law, in the Wake Forest Law Review, discusses the recent measles outbreak and pending state law changes.
While the national conversation is about whether nonmedical exemptions should exist at the state level, and they may or may not succeed in states around the country, remember that these choices are often based on misplaced fears and misconstrued control. Regardless of the outcomes of this legislation, you can work with your patient families to refocus their fears and reframe the control because the price of the choice to not vaccinate by parents may be too high for some of their children to pay.
- Canon G. Is your state trying to outlaw vaccine exemptions? Published 3/2/15. Accessed 3/19/15 at http://www.motherjones.com/politics/2015/02/vaccine-map-exemption-bills.
- Vaccination coverage among children in kindergarten – United States, 2013-14 school year. MMWR. 2014; 63(41): 913-20.
- Omer SB, Enger KS, Moulton LH, et. al. Geographic clustering of nonmedical exemptions to school immunization requirements and associations with geographic clustering of pertussis. Am J Epidemiol. 2008; 168(12): 1389-96.
- Dempsey AF, Schaffer S, Singer D, et. al. Alternative vaccination schedule preferences among parents of young children. Pediatrics. 2011;128(5):1-9.
- Smith PJ, Humiston SG, Marcuse EK, et. al. Parental delay or refusal of vaccines doses, childhood vaccination coverage at 24 months of age, and the health belief model. Public Health Rep. 2011; 126(Suppl 2); 135-46.
- Wang E, Clymer J, Davis-Hayes C, and Buttenheim A. Nonmedical exemptions from school immunization requirements: A systematic review. Am J Pub Health. 2014; 104(11):e62-84.
- Luthy KE, Beckstrand RL, Callister LC, and Cahoon S. Reasons parents exempt children from receiving immunizations. J School Nursing. 2012;28(2): 153-60.
- Loe Fisher B. Vaccination: Defending your right to know and freedom to choose. Published 11/13/14. Accessed 3/19/15 at http://articles.mercola.com/sites/articles/archive/2014/11/13/vaccination-health-freedom.aspx.
- Margulis J. Parents deserve to have a choice about vaccination. Published 3/23/14. Accessed 3/19/15 at http://www.nytimes.com/roomfordebate/2014/03/23/making-vaccination-mandatory-for-all-children/parents-deserve-to-have-a-choice-about-vaccination.
- Vaccine Education Center at The Children's Hospital of Philadelphia. Vaccine science: How are vaccine made? Accessed 3/19/15 at http://www.chop.edu/centers-programs/vaccine-education-center/making-vaccines/how-are-vaccines-made.
- Offit PA and Moser CA. Vaccines and Your Child: Separating Fact from Fiction. Columbia University Press, 2011, p.15.
- Mervis J. Why many U.S. biology teachers are ‘wishy-washy’: Future science teachers lack knowledge and role models. Science. 2015;347(6226):1054.
- Measles and Rubella Initiative. Accessed 3/19/15 at http://www.measlesrubellainitiative.org/sophie-blackall/.
- Vaccine Education Center at The Children's Hospital of Philadelphia. Recommended Immunization Schedule: What You Should Know. Accessed 3/19/15 at http://media.chop.edu/data/files/pdfs/vaccine-education-center-recomm-immuniz-sched-eng.pdf [PDF, 338KB].
- Mervis J. Politics, science and public attitudes: What we’re learning, and why it matters. Science. Accessed 3/19/15 at http://news.sciencemag.org/social-sciences/2015/02/politics-science-and-public-attitudes-what-we-re-learning-and-why-it-matters.
- Suhay E and Druckman JN. The politics of science: Political values and the production, communication and reception of scientific knowledge. Annals of the Am Academ of Pol and Soc Science. 2015; 658(1).