Supreme Court Justice Oliver Wendell Holmes probably wasn't thinking about child vaccines or parental rights when he said "the right to swing my fist ends where the other man's nose begins."
But the intersection of private rights and the public good addressed by Holmes is a subject much on the minds of parents, doctors, and public health experts these days, as a vocal and apparently growing minority of parents and alternative health care practitioners question the need for, or safety of, childhood immunizations.
"We are seeing in some states an increasing proportion of families who are choosing to delay or not immunize their children, and unfortunately, when this happens, we do see sporadic outbreaks of diseases like measles," says Neal Halsey, MD, a director of the Institute for Vaccine Safety at the Johns Hopkins Bloomberg School of Public Health in Baltimore.
In February, 12 San Diego area children came down with measles. Eight of the children were eligible to be vaccinated against measles but hadn't been, and three were infants too young to be immunized.
In Indiana in 2005, a measles outbreak infected 34 people ranging from 9 months to 49 years of age. Three of the 34 needed to be hospitalized, including one 34-year-old adult who had to be put on a ventilator for six days, and a 6-year-old child and 45-year-old adult who suffered from severe dehydration. Only two of the 34 were known to have been vaccinated against measles: one with one dose, which affords about 95% protection, and the other with the two recommended doses.
The Indiana outbreak was eventually traced to a 17-year-old girl who had not been vaccinated against measles, and had recently returned from volunteer work at an orphanage and hospital in Bucharest, Romania, where a wide-scale measles outbreak was later reported. She had apparently transmitted the infection to a 6-year-old girl while both were attending a church function in northwestern Indiana. The six-year-old was later hospitalized after she became ill while visiting relatives in Cincinnati, according to the CDC.Â
Measles Is Not Child's Play
But according to the CDC:
- Up to 1 in 20 children with measles will get pneumonia
- About 1 in 1,000 children with measles will get encephalitis -- an acute inflammation of the brain that can cause permanent nerve and/or brain damage
- 1 or 2 in 1,000 children who get measles will die from the disease.
"While measles is almost gone from the United States, it still kills about half a million people a year around the world," a CDC fact sheet for parents points out. "Measles can also make a pregnant woman have a miscarriage or give birth prematurely."
Before measles vaccines were developed, most children contracted the disease by the time they were 15, the CDC notes, resulting in:
Yet some parents who object to childhood immunizations will host or bring their children to so-called "measles parties," where the kids can get exposed to an infected child, get the disease, and develop immunity naturally. One such mother told the New York Times "I refuse to sacrifice my children for the greater good."
"It would be a terrible mistake for a parent to deliberately expose their child to measles, or chickenpox, for that matter," Halsey tells WebMD. "To deliberately give a child measles in this day and age is not only inappropriate, but it actually might be considered to be criminal, because it's preventable."
But that mother is no different from any other parent who wants what she thinks is best for her children, says Barbara Loe Fisher, president of the National Vaccine Information Center, a consumer-oriented vaccine safety watchdog group she co-founded. Fisher and NVIC co-founder Kathi William blame serious reactions to the diphtheria, pertussis, and tetanus (DPT) vaccination for their children's learning disabilities and attention deficit disorder.
"I disagree that individual health and public health are two different things," Fisher says in an interview with WebMD. "Individuals make up the community, and if you have a number of individuals who are suffering adverse effects to a medical intervention, a public health intervention, by extension that eventually becomes a matter of public health."
Penelope H. Denehy, MD, professor of pediatrics at the Warren Alpert Medical School of Brown University in Providence, R.I., notes that in addition to protecting individual children against infectious diseases, universal vaccinations cover those children who for medical reasons cannot be vaccinated, a concept known as "herd immunity."
"One of the things we know quite clearly is that if there are enough parents in an area who [refuse to vaccinate], there actually then becomes a large-enough group of non-immune kids to actually sustain outbreaks," she tells WebMD. "There's an area in Colorado where the rates of pertussis [whooping cough] were quite high because there was enough of a population who were not immunized to sustain the passage of pertussis around the community."
In addition, even if an unvaccinated child is protected by herd immunity at home, if that child travels with her family, she runs a high risk of infection from a person from a part of the world with low vaccination rates, as happened in the case of the Indiana measles outbreak.
Vaccination for children entering school is mandatory in all 50 states, but all states allow exemptions for medical reasons.
"Even in a well-vaccinated population, there are going to be some children who can't be vaccinated, either because they're too young -- for measles less than 12 months of age -- or they may have cancer chemotherapy or some other compromising medical condition that makes it not possible to vaccinate them," says Lance Rodewald, MD, director of the immunization services division at the CDC's National Center for Immunization and Respiratory Diseases.
Rodewald notes that there is also a low but still significant failure rate for some vaccinations: "For example, with one dose of measles vaccine there's a 4% to 5% failure rate, and with two doses of course it's much smaller, but still there will be some susceptibles in the population," he tells WebMD.
In addition to allowing medical exemptions for immunization, all states except Mississippi and West Virginia also allow exemptions from immunizations for deeply held religious beliefs, and 18 allow exemptions for "philosophical" objections, according to the NVIC.
In states where this is allowed, 2.54% of parents declined vaccines, according to a Johns Hopkins researcher.
One of the reasons for the rise in the number of parents requesting philosophical or religious exemptions from vaccination is that the standards for medical exemptions are so rigorous and that the exemption-granting authorities make it hard to claim them, Fisher says.
"It's extremely difficult to get a medical exemption -- it's given out in all 50 states, but it is given out extremely rarely," she says. "So what does a parent do in this country when they believe they have a child that has either been harmed or children who they believe are genetically risk? The only two exemptions they have are the religious or conscientious belief or philosophical belief exemptions."
In a 2005 survey of vaccine-refusing parents published in the journal Archives of Pediatrics & Adolescent Medicine, more than two-thirds of respondents said their chief reason for rejecting vaccines was concern that they might be harmful, and nearly half said that vaccines "might overload the immune system." The vaccine most often refused was against chickenpox (varicella), which was refused by slightly more than half of all vaccine objectors.
Some vaccine objectors say that they're protecting their children from neurologic damage and that mainstream media are in cahoots with the medical establishment to downplay evidence linking vaccines and autism.
The Hannah Poling Case
Those who are convinced that there is a vaccine-autism connection point to the recently publicized case of Hannah Poling, who developed autism-like symptoms after receiving childhood vaccinations. The federal government recently agreed to award the Poling family compensation from a vaccine injury fund established to encourage vaccine research and development and protecting vaccine manufacturers from liability by offering an alternative to lawsuits.
But lost or buried in many of the news stories about the case was the fact that Hannah Poling also suffers from a mitochondrial dysfunction disorder, an extremely rare defect in the mitochondria or "power supplies" found in the nuclei of human cells. The disorder puts her at increased risk for side effects not just from immunization, but also from common infectious diseases, says Halsey of Johns Hopkins.
"That's not a case of overwhelming the immune system, it's oxidative stress associated with many infections, and children with these disorders can just get a mild cold at a certain time in their lives, and they will develop this neurologic deterioration, so just any stress will cause it in these children," Halsey explains.
Denehy, who practices pediatrics at Hasbro Children's Hospital in Providence, tells parents who worry about immune overload from vaccines that the simple bacterium that causes strep throat has hundreds of immune-system provoking antigens on its surface, whereas even when children receive multiple vaccinations, they receive only about 20 antibody-stimulating antigens.
"You're immune system is going to be taxed much harder from things you're being exposed to in the community than by vaccines, and your immune system has the potential to deal with many, many more challenges than any vaccination schedule presents to it," she says.
The practice of inoculation -- the attempt to induce natural immunity by exposing healthy people to small samples of a disease -- goes back centuries. But it was Edward Jenner, a country doctor in rural England, who developed the first modern vaccination in 1796, after observing that dairy farmers who were exposed to the relatively mild disease cowpox never seemed to contract smallpox, a related but far more deadly disease. The word "vaccination" is derived from vaccinia, the Latin name for the cowpox virus.
Today, smallpox, once one of mankind's most devastating diseases, has been wiped from the face of the earth and is known to exist only for investigational purposes in small quantities in tightly guarded laboratories.
Even the staunchest opponents of mandatory immunization acknowledge that the smallpox vaccination, and select others, such as the polio vaccine, have had incalculable benefits for mankind and that the theoretical risk of vaccinations against theses diseases are outweighed by the benefits.
But the NVIC and other groups question whether children get too many vaccines in too short a time and challenge the rationale for mandatory immunizations against less serious conditions such as chickenpox.
"Chickenpox is not smallpox, and hepatitis B is not polio," the NVIC's Fisher said in a November 2007 interview on CNN.
Fisher and like-minded parents, as well as some health care professionals trained in both conventional Western medicine and alternative therapies, feel that the potential risks of vaccines and the incidence of vaccine-related adverse events have been underreported, and that children are subjected to too many vaccines with too little proof of their and safety and effectiveness.
"We have been asking for almost three decades now for the basic science research to be done to identify those children who are biologically and genetically at higher risk than others for suffering vaccine injury and death," she tells WebMD. "Those studies have not been done; the authorities refuse to do them."
But to those parents who wish to "cherry pick" vaccinations for their children in the belief some vaccines are unnecessary, Denehy offers this cautionary advice:
"After you've been in practice for a while, you see children who are perfectly normal who are affected by these diseases, and 100 perfectly normal, healthy children a year died from chickenpox/varicella before we had the vaccine," she says. "We had a child who died here in Rhode Island, whose mother didn't believe in vaccines and took her to a chickenpox party -- a perfectly normal 4-month-old who died.
"You can't always assume that nothing bad is going to happen to your child."