Vaccines Mandates Work, But They’re Messy Business

In the fall of 2019, before anyone had ever heard of COVID-19, California lawmakers attempted to pass a law to increase vaccination rates in children. Five years ago, someone in Disneyland had triggered a measles outbreak in which more than 100 people, mostly unvaccinated, were infected in the state – as well as in six other states, Canada and Mexico. The incident shocked lawmakers and resulted in a number of laws The aim was to limit the religious and philosophical exemptions that would allow parents not to have their children vaccinated before sending them to school. Take away the exceptions, it was thought, and vaccination rates would go up. But the level of vitriol entering politics when trying to prescribe vaccines can be … intense.

“The California Senate had to be evacuated because someone took away – and these are more details than you want – a cup full of menstrual blood and tossed it in the Senate, ”Alison Buttenheim, professor of nursing and health policy at the University of Pennsylvania told me.

Today it is similarly tense. COVID-19 Compulsory vaccination come into force nationwide. Universities are require students to get vaccinated. Companies are Prescribe vaccines for employees and customers. conditions, Cities and the US military have made the COVID-19 vaccination a must for public employees. But like in California, the pushback was fierce, with Protests, forged vaccination cards and complete bans on mandates in some states.

It is not enough to simply pass a law or regulation that makes vaccines mandatory. California eventually spent years removing loopholes parents used when vaccinating their children. The fact that California lawmakers were still tinkering with the state’s vaccination laws in 2019 says a lot. The state medical association is still today Dealing with doctors who were ready to write Thousands of fake medical exemptions.

Mandates work. When the laws changed Vaccination rates among California kindergarten children have increased. But ideological values, deeply personal fears and (increasingly) political polarization mean that a vaccine mandate is not just a switch to be thrown and left. Instead, a mandate is a delicate machine that needs to be serviced so it doesn’t fall apart.

School entry regulations are probably the most effective thing we’ve done to get high vaccination rates in the United States, said James Colgrove, Professor of Social Medicine at Columbia University. “Can you do this on a voluntary basis? No. Not really, ”he told me.

The mandates have focused on children both because they are particularly at risk of developing serious illnesses and because schools are a perfect incubator for transmission. Put a bunch of people with no naturally acquired immunity in one building five days a week, add in the utter limitlessness of a child, and you have disease soup.

But the country has long waxed and waned over whether to vaccinate children. School vaccine requirements has been with us for a long time – almost as long as the public school itself. The smallpox vaccination – the only vaccine that existed at the dawn of public education – was required for entry into public schools in Boston in 1827. But for much of American history, the rules have been applied inconsistently across geography and have tended to come and go over time. For example, Washington and Wisconsin ended school vaccination in 1919 and 1920, respectively, and in the 1920s the Utah and North Dakota legislatures passed laws banning mandatory vaccination.

But mandates became more of a mainstay in the late 20th century when a series of school measles outbreaks flooded the nation in the 1970s – and it quickly became clear that vaccines could help. In Texarkana, a city divided by the Texas-Arkansas border, the Arkansas side had a vaccination mandate and fared far better than the Texas sidethat had no mandate. In 1980, every state had some form of compulsory vaccination for school-age children. Annual measles cases fell from tens of thousands in the 1970s to fewer than 2,000 by 1983. In the 20th century, measles infected an average of more than 500,000 Americans each year. In 2005, after decades of school vaccination regulations and vaccination rates of over 90 percent, she infected 66 people. Vaccines reduced the spread of disease and made vaccines mandatory so they were almost completely eradicated.

It is Evidence like this This gives public health experts good reason to believe that the need for a COVID-19 vaccine – be it at work, to go to school, or to go to restaurants – would increase vaccination rates and reduce disease in ways that are purely voluntary Vaccination campaigns just can’t.

But it’s not that easy to snap your fingers and let everything work out. To get them right, vaccine mandates require compromise, tinkering, and lots of legal and political follow-up. COVID-19 mandates will almost certainly ask for the same.

Hanging above all is the tradeoff between vaccinating more people and excluding those who are not. Douglas Diekema, director of education at the Treuman Katz Center for Pediatric Bioethics at Seattle Children’s Hospital, noted that every time a government introduces a school mandate, it balances two public goods: disease prevention and children’s education. “I think you need a good reason … to take advantage of people who don’t get vaccinated,” he said.

The COVID-19 vaccination requirements will inevitably face similar priority battles. As a society, we want more people to be vaccinated – we also want people to be employed and to go to college. And unlike the diseases that have been severely curbed by vaccinations in children, COVID-19 is an active pandemic. The choice is not just about “prevention” or “access to social services”. You also need to consider other people’s health and life.

Not everyone will make the same decisions about balancing access and security. States have significantly different requirements about how many vaccinations it takes to go to school and if they are Yes, really necessary. Some vaccines are required for school entry in every state – measles, polio, diphtheria – because they have extremely high rates of effectiveness and are related to diseases that spread through normal daily contact with other children in school. But only six states – plus New York City – need flu vaccines that are less effective. Only three states require vaccination against human papillomavirus – a disease spread through sexual contact and which has been heavily politicized by groups who portray it as allowing adolescents and teenagers to have sex.

It’s likely that the requirements for COVID-19 vaccines will also remain a patchwork quilt, said several experts I spoke to. Politicization and groundbreaking cases will likely mean the COVID-19 vaccine has more in common with those against HPV and flu than with those against measles.

Even once you’ve decided on rules, you need to decide how consistently you will enforce them. In schools, all states allow medical exemptions because some children have immune disorders or specific allergies to vaccine ingredients. Forty-four states allow parents to exclude their children from vaccinations based on religious beliefs. a product of vigorous lobbying Efforts by Christian Scientists in the 1970’s. Other exceptions to vague “philosophical beliefs” – now offered by 18 states – developed over time in response to legal concerns about states’ religious preference. Colgrove called all of these exceptions a “safety valve” – ​​a way to accommodate the very small percentage of people who will never accept a vaccination without creating political confrontations or forcing children out of school.

The challenge for COVID-19 vaccines, like vaccines for children, is to offer exceptions without making exceptions too easy. Several of the five researchers I spoke to told me that over the past decade, several states have addressed the issue of vaccination in children by tightening restrictions and providing better access to vaccines – which makes it logistically makes getting vaccinated easier than leaving it.

Still, the question arises as to what to do if some disobey the rules. “Nobody enjoys pushing this through,” said Buttenheim. “In California, at least with public schools, schools have a major stumbling block on excluding children because they are not paid. So if you exclude a child from vaccination, you lose money as a school. ”Across the country, it is not uncommon for schools to give parents time to find out about mandatory vaccines without kicking children out – and sometimes as soon as the parents have extra time Schools do not have the human resources to track it, said Peter Hotez, professor of Pediatrics and Molecular Virology at Baylor College of Medicine.

Establishing a vaccine mandate – and enforcing it – will almost certainly require governments and institutions to find ways to deal with loopholes and fraud. After the Disneyland outbreak in California, the state eliminated all non-medical exemptions and became one of a total of six states. But the change didn’t mean a direct line to higher vaccination rates.

“Suddenly there were a lot more medical exceptions,” Buttenheim tells me. Medical exceptions increased by 250 percent in the next two years – with many of the exemptions signed by a handful of doctors. Between 2016 and 2018, the number of unvaccinated kindergarten children who are homeschooled has quadrupled. That the mandate actually works has turned out to be a game of where lawmakers enact laws specifying which medical issues are considered exemptions from vaccines and putting in place a surveillance system that approves exemptions and displays doctors for examination when they are passed give out many cards to pass out of the vaccine. Although Buttenheim’s research suggests that this has, and will continue to reduce, the overall proportion of unvaccinated children in California, it requires a great deal of work and resources to Increase vaccination rates by 1 percent or even less.

Pushing for COVID-19 mandates could also impact other childhood vaccinations. Tennessee lawmakers have already responded to the COVID-19 vaccination by pressuring the state Department of Health to stop promoting any vaccination For minors – including school vaccine clinics, something research has shown is critical to getting vaccines for children whose parents might be familiar with vaccines but have budgets and work hours, or a lack of medical access to vaccinate moves down the family’s priority list. . That is on top of the social disruption due to the pandemic itself, which has already occurred reduced national vaccination intake among children.

The bottom line, according to the researchers I spoke to, is that vaccination regulations are a really powerful public health tool. They are effective, child vaccination regulations have received widespread support, and they have been consistently upheld by the Supreme Court. But that doesn’t mean they’re easy to implement. Buttenheim put it this way: “It’s a chaotic business.”

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