pediatria polska 87 (2012) 381–385

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Review/Praca pogla˛dowa Anti-Vaccination Movement and Parental Refusals of Immunization of Children in USA Ruchy antyszczepionkowe i brak zgody rodzico´w na szczepienie dzieci w USA

Marian Ołpin´ ski *

Advocate Lutheran General Children's Hospital, Park Ridge, IL, USA Alexian Brothers Medical Center, Elk Grove Village, IL, USA article info abstract

Article history: Despite an enormous success of the vaccination programs in the USA and an all time low Received: 01.04.2012 incidence rate of vaccine preventable diseases (VPDs) pediatricians and family doctors are Accepted: 08.05.2012 seeing increasing numbers of parents who refuse to vaccinate their children. Vaccine Published on line: 09.06.2012 coverage decreases causing outbreaks of VPDs in the USA. Fear of potentially deadly diseases has been replaced by the fear of real and, more often, imaginary side effects of Keyword: vaccination. This fear fuels an anti-vaccination movement with the help of media (espe-  anti-vaccination movement cially Internet), celebrities, and politicians. Parents are being misled and are not trusting  mandatory immunization their doctors. After all attempts to persuade parents to vaccinate their children have failed,  immunization program some doctors are refusing to see those patients. There is no easy solution to the problem,  vaccine refusal however, most important is to continue public education and persuasion and addressing  vaccine preventable disease vaccine refusal by respectfully listening to parental concerns and discussing the risks of nonvaccination. © 2012 Polish Pediatric Society. Published by Elsevier Urban & Partner Sp. z o.o. Słowa kluczowe: All rights reserved.  ruchy antyszczepionkowe  szczepienia obowia˛zkowe  szczepienia ochronne  odmowa szczepienia dzieci  zapobieganie chorobom zakaz´nym

Despite the undoubted success, the nearly forgotten VPDs Introduction in the U.S. are back. From 2001 – 2008, a median of 56 (range: 37–140) measles cases were reported to the CDC annually. Vaccines are among the greatest and most effective public During the first 19 weeks of 2011, 118 cases of measles were health interventions in preventing morbidity, mortality and reported, the highest number reported for this period since public health costs caused by infectious diseases [1]. Today, 1996. Of the cases, 105 (89%) were imported from other incidence rates of vaccine preventable disease (VPDs) in the countries and unvaccinated persons accounted for 105 (89%) U.S. have declined to an all time low [2]. [3]. There were outbreaks of mumps [4], an invasive HiB

* 1775 Dempster Street, Park Ridge, IL 60068, USA. Tel.: +1 847 723-2210. E-mail address: [email protected] 0031-3939/$ – see front matter © 2012 Polish Pediatric Society. Published by Elsevier Urban & Partner Sp. z o.o. All rights reserved. 10.1016/j.pepo.2012.05.003 382 pediatria polska 87 (2012) 381–385

disease [5]. The CDC reports on its website that in 2010, In the third period, the fear of a vaccine increases. It is 9 143 cases of pertussis were reported in California, the most fueled by: anti-vaccination movements, lack of trust in the cases reported since 63 years. Among them were 10 infants government and national and global public health institu- who died from the disease. There were outbreaks in Michigan, tions (CDC, WHO), media (especially Internet [9],conspiracy Ohio and other states [6]. The USA is on the verge of becoming theories [10] (government, Big Pharma and doctors making a victim of this success, because increasing numbers of money and controlling people using vaccines) and the lack parents, who apparently love their children, refuse to of scientific explanation of the etiology of many diseases. vaccinate them. Why does it happen? All this causes continuing decrease in vaccination coverage, finally leading to an increasing morbidity and mortality from VPD. Natural history of an immunization program In the fourth period, the morbidity and mortality caused by the return of the VPD increases to the level causing the fear of The answer to this question is not easy and straightforward. the disease to come back. People start vaccinating their Robert Chen tried to answer this question showing the graph children and themselves again. Finally, in the last fifth period, dubbed – ‘‘Natural history of an immunization program’’ the disease may be eradicated and vaccination can be stopped (Fig. 1) [7]. (i.e.: smallpox). In the first, pre-vaccine period, people feel threatened The fear of vaccines appeared with the first developed by the disease, especially if the disease is communicable and vaccine, the Jenner’s vaccine against smallpox. This fear and hard to treat. They often know victims of the disease, who the belief that vaccines themselves may cause those diseases either died or suffered from the complications. When against which they are made or at least cause serious a vaccine becomes available, people widely and enthusias- complications, has been and still is a breeding ground for tically accept it, even despite side effects the vaccine can the development and duration of anti-vaccination move- cause. The best example of this is a national enthusiasm in the ments. USA after developing the polio vaccine in the 1950s. In the second period, when a vaccine causes a massive decrease in VPD cases and deaths, people start to forget the Modern history of anti-vaccination movement in threat, a memory of the victims and social disruptions of the USA the disease fades. With the increased use of a vaccine, the focus is on real and imaginary side effects of vaccination. As April 19th, 1982 is considered the beginning of the modern vaccination becomes more common, events that occur around history of the U.S. anti-vaccination movement. On that date, the time of administration of a vaccine (in the first 12 months WRC-TV in Washington, D.C., aired a program entitled DPT: of life an infant receives vaccines every 2 months on average) Vaccine Roulette, singling out the DTP vaccine, particularly may seem to be a cause-and-effect relationship. This causes it’s pertussis component, of causing severe brain damage, a vaccine to be accused of causing seizures, diabetes mellitus, seizures and delayed mental and motor development. In SIDS, mental retardation, ADHD, autism, MS and many other response to this program, many parents refused to vaccinate diseases [8]. People start feeling threatened by the vaccine. their children, not only in the U.S. but around the world. The Instead of knowing people suffering or dying from the disease largest decrease in vaccination coverage was in Great Britain, many parents now know somebody who was ‘‘hurt by where it caused an epidemic of pertussis and the deaths of a vaccine’’. This is the time when a vaccine becomes many children. Parents who thought their children were a victim of its own success and the vaccination coverage harmed by the vaccine directed class action law suits in the reaches a plateau. civil courts for huge damages. Numbers of lawsuits against [(Fig._1)TD$IG] vaccine manufacturers and the amount of compensation paid by them have increased to such an extent that in 1986 one of the last two vaccine manufacturers in the United States withdrew from production. This caused a real threat to public health in the United States and pushed the U.S. Congress to act. On October 18th, 1986 The United States Congress passed a bill that protected vaccine manufacturers. The act was called the National Childhood Vaccine Injury Act and was signed by President Ronald Reagan two months later. The purpose of the Act was to allow children to be compensated for vaccine damages without suing in state courts; to protect pharmaceutical companies from litigation; and to encourage vaccine makers to produce new vaccines. The institution established to oversee these cases was the National Vaccine Injury Compensation Program (NVICP), better known as Vaccine Court. Another important institu- tion established by the Act was the Fig. 1 – Natural History of an Immunization Program [7] Report System (VAERS) – a mechanism to inform parents pediatria polska 87 (2012) 381–385 383

about vaccine safety and the means to report suspected side , adding that petitioners had ‘‘fallen far effects [11]. short’’ of establishing such a link [11]. In 1998, another, and perhaps the most influential Finally, in January 2010, the British General Council issued milestone in the development of the anti-vaccination move- the results of its years-long inquiry into Andrew Wakefield’s ment and the most damaging for public health was an article research. The 143 page report concluded that Wakefield acted by Dr. A. Wakefield, published in ‘‘Lancet’’ which suggested unethically and with ‘‘callous disregard’’ for his patients [17]. a link between the MMR vaccine and autism [12]. In February 2010, The Lancet formally retracted the Andrew In 1999, uncertainty about the possible harmful effects of Wakefield study asserting a link between the MMR vaccine and thimerosal, the preservative compound used in vaccines for autism [18]. decades, prompted the decision to remove it from vaccines even though there was no evidence that it caused any harm. This decision and a vaguely worded statement by the U.S. Immunization Requirements and Exemptions American Academy of Pediatrics (AAP) and Public Health Services that, ‘‘the current levels of thimerosal in vaccines will Immunizations were introduced in the USA in 1809 in not hurt children, but reducing those levels will make safe Massachusetts, to prevent and control smallpox outbreaks. vaccines even safer’’, only strengthened the opponents of In 1905, in the case of Jacobson v. Massachusetts, the U.S. vaccination that something was up. After all, if thimerosal was Supreme Court endorsed the rights of states to pass and safe it would not need to be removed. The belief that the MMR enforce compulsory vaccination laws. In 1922, the Supreme vaccine or thimerosal (since 2001 only present in a vaccine Court found the school immunization requirement to be against influenza), or both factors together causing autism is constitutional. The modern era of immunization laws in the consistently one of the most important reasons for refusing USA began in 1960’s and 1970’s and was associated with vaccination. This is despite the fact that in 2004 a panel at the difficulties to control measles outbreaks. In 1969, a total of 17 Institute of Medicine, the US leading independent advisor on states had laws that required children to be vaccinated against science and health policy, unanimously determined that measles before entering school and 12 states required a review of more than 200 epidemiological and biological vaccination against all six diseases for which routine studies had revealed no evidence of a causal relationship immunizations were carried out at the time. By the beginning between either thimerosal or MMR vaccine and autism [13]. of the 1980’s, all 50 states had school immunization This statement did not change the views of those who claimed requirements [19]. There are differences between states that vaccines cause autism. Their views were confirmed again because the requirements are state-based. All states permit by statements made by many politicians from all sides of the certain exemptions. As of August 2011, all states permitted political scene. medical exemptions from school immunization require- In June 2005, ‘‘Rolling Stone Magazine’’ published a piece by ments, 48 states allowed religious exemptions, and 20 states congressman Robert F. Kennedy, Jr. called ‘‘Deadly Immunity’’, allowed exemptions based on philosophical or personal accusing the government of protecting drug companies from beliefs [20]. With the increasing activity of the anti-vaccination litigation by concealing evidence that mercury in vaccines may movement, especially active in the media, particularly in the have caused autism in thousands of children. The article was Internet, the number of vaccine exemptions is rising. Between then discredited, corrected many times and finally retracted by 1991 and 2004, the mean state-level rate of nonmedical the magazine [10]. Other politicians like U.S. Senators John exemptions increased from 0.98 to 1.48%. For states that Kerry, Chris Dodd and Joseph Lieberman also stated publicly allowed only religious exemptions, the rate remained at that they believe vaccines cause autism. The fear about approximately the same level of 1% but in states with vaccines was also fueled by many celebrities, among them exemptions for philosophical or personal beliefs, the mean former Playmate Jenny McCarthy, her then husband, actor Jim exemption rate increased from 0.99 to 2.54% [21]. Carrey. They reached a huge audience being hosted by Oprah Winfrey and Larry King on their very popular TV shows [11, 14]. In 2007, Dr. Robert Sears, the popular pediatrician known as Parents’ beliefs about vaccines ‘‘Dr Bob’’ published a book – The Vaccine Book: Making the Right Decision for Your Child – where he offered ‘‘Dr Bob’s Alternative Smith PJ et al. [22] evaluated the association between parents’ Vaccine Schedule’’, a formula by which parents can delay, beliefs and vaccines, their decision to delay or refuse vaccines withhold, separate, or space out vaccines. The proposed new for their children, and vaccination coverage of children at aged schedule was based on no scientific data [15]. Regarding parents 24 months, using data from 11,206 parents of children aged who are afraid of the MMR vaccine, he writes: ‘‘I also warn them 24–36 months at the time of the 2009 National Immunization not to share their fears with neighbors, because if too many Survey. They found that in 2009, approximately 60.2% of people avoid the MMR, we’ll likely see the diseases increase parents neither refused or delayed vaccines, 25.8% only significantly’’ [16]. He was simply asking those parents to delay delayed, 8.2% only refused, and 5.8% both delayed and refused vaccination or skip them while hiding in the highly vaccinated vaccines. Parents who delayed or refused vaccine were more population. likely to have vaccine safety concerns and perceived fewer In 2009, the Vaccine Court denied the claims of more than benefits associated with vaccines. Patient’s beliefs about 4000 parents of children with autism who claimed their vaccines were studied over the last years. In a study published children were harmed by vaccines. The court found in favor of in Pediatrics in 2000, 14% of responders stated that parents the science that demonstrates no causal relationship between should have the right to send unvaccinated children to school 384 pediatria polska 87 (2012) 381–385

[23]. A new study, published in 2010 showed that now the Suburban physicians caring for wealthier, better educated percentage of parents sharing that belief rose to 31%. The families experience more vaccine concerns and/or refusals same study found that 25% of parents believe that vaccines and are more likely to dismiss families for vaccine refusal [27]. can cause autism and more than 50% of the respondents The doctors and other health providers remain the most expressed concerns regarding serious adverse effects. important source of reliable information about vaccines. This Parents especially seem to question the safety of newer is why communication with concerned parents to deliver the vaccines [24]. information is so important [30]. Poland and Jacobson [31] believe that vaccine proponents must (1) continue to fund and publish high-quality studies to investigate concerns Anti-vaccination movement in the Internet about vaccine safety, (2) maintain, if not improve, monitoring programs, such as VAERS, making compensation available The most influential medium for parents beliefs about to anyone, who is legitimately injured by a vaccine, immunizations seems to be Internet. Approximately 74% of (3) teach health care professionals, parents and patients Americans have Internet access. In 2006, 16% of users how to counter antivaccinationists’ false and injurious searched online for information on immunizations or vacci- claims, (4) enhance public education and public persuasion. nations. Over half (52%) of users believe ‘‘almost all’’ or ‘‘most’’ It has to be emphasized, however, that due to lack of trust information on health sites are credible, yet the availability of among many ‘‘hard-core anti-vaccination activists’’ provi- inaccurate and deceptive information online has labeled the ding more ‘‘education’’ will not be effective. They are simply Internet a ‘‘modern Pandora’s box’’ [25]. Kata A. [9] analyzed not persuadable. Postmodern society questions the legiti- the arguments proffered on anti-vaccination websites to macy of science and authority so the vaccine controversy is determine the extent of misinformation present, and to unlikely to be solved in the near future. examine discourses used to support vaccination objections. Most common arguments were focused on: (1) safety and effectiveness – vaccines: contain poisons, cause diseases of Summary unknown origin, erode immunity; (2) – promotion of treatments superior to vaccination (e.g. homeo- Vaccinations are one of the most important successes in pathy) and ‘‘natural’’ approaches (chickenpox party); (3) civil public health in the USA in the twentieth century. Vaccination liberties; (4) conspiracy theories; (5) morality and religion – coverage is high and the incidence rates of vaccine preven- vaccination is against God’s will. Misinformation and false- table disease (VPDs) in the U.S. have declined to an all time hoods on those websites were also prevalent. There were low. Despite that, VPD are back in the USA and children are outdates sources, misinterpretations, self-referencing, unsup- dying from them. Vaccines have become a victim of their own ported statements noted. success. The fear about vaccines fueled by an anti-vaccination movement, using Internet and other media, causes more and more parents to refuse to immunize their children. Between Pediatricians’ response to parental refusal to 30–40% of pediatricians and family physicians are now vaccinate discharging patients whose parents don’t want to vaccinate them. Despite that, the American Academy of Pediatrics Pediatricians and family doctors are seeing increasing advices against this and recommends that physicians respond numbers of parents who question the safety of vaccines or to vaccine refusal by respectfully listening to parents concerns refuse to vaccinate their children [22, 26, 27]. There is and discussing the risks of nonvaccination. a discussion in medical literature about how to respond to parents refusing vaccinations for their children. The American ł Academy of Pediatrics in a statement ‘‘Responding to Parental Authors’ contributions/Wk ad autoro´ w Refusals of Immunization in Children’’ published in 2005, recommends that pediatricians should: (1) listen carefully and According to order. respectfully to the parent’s concerns, (2) share honestly what is and is not known about the risks and benefits of the vaccine in question, (3) attempt to correct any misperceptions and Conflict of interest/Konflikt interesu misinterpretations, (4) assist parents in understanding that the risks of any vaccine should not be considered in isolation None declared. but in comparison to the risks of remaining unimmunized, (5) discuss concerns about each vaccine separately, (6) explore the possibility that cost is a reason for refusing, (7) respect references/pis´ miennictwo and document every refusal. The AAP recommends that pediatricians in general should avoid discharging patients [1] Ten Great Public Health Achievements, United States 1900- from their practices solely because parents refuse to vaccinate 1999. MMWR Morb Mortal Wkly Rep. 1999;48:241-243. [28]. Despite that, more and more pediatricians decide to [2] Roush SW, Murphy TV, Vaccine-Preventable Disease Table discharge such patients [29]. A study from Connecticut shows Working Group. Historical Comparisons of mortality and that more than 30% of pediatricians responding to a survey morbidity for vaccine-preventable diseases in the United have dismissed families because of their refusal to immunize. States. JAMA 2007;298:2155–2163. pediatria polska 87 (2012) 381–385 385

[3] Measles – United States, January-May 20, 2011 MMWR Morb [20] Vaccine Exemptions. John Hopkins Bloomberg School of Mortal Wkly Rep. 2011;60:666-668. Public Health – Institute for Vaccine Safety, 2008. - accessed [4] Update: Mumps Outbreak – New York and New Jersey, June on March 27, 2012, at http://www.vaccinesafety.edu/ 2009 – January 2010. MMWR Morb Mortal Wkly Rep. ccexem.htm. 2010;59:125-128. [21] Omer SB, Pan WK, Halsey NA, Stokley S, Moulton LH, Navar [5] Invasive Haemophilus Type B Disease in Five Young AM, et al. Nonmedical exemptions to school immunization Children – Minnesota, 2008. MMWR Morb Mortal Wkly Rep. requirements; secular trends and association of state 2009;58:58-59. policies with pertussis incidence. JAMA 2006;296:1757–1763. [6] http://www.cdc.gov/pertussis/outbreaks.html - accessed [22] Smith PJ, Humiston SG, Marcuse EK, Zhao Z, Dorell CG, on March 25th, 2012. Howes C, et al. Parental Delay or Refusal of Vaccine Doses, [7] Chen RT, Hibbs B. Vaccine safety: Current and future Childhood Vaccination Coverage at 24 Months of Age, and challenges. Pediatric Annals 1998;27:445–455. the Health Belief Model. Public Health Reports [8] Campion EW. Suspicions about the safety of vaccines. 2011;126:135–146. N Eng J Med 2002;347:1474–1475. [23] Gellin BG, Maibach EW, Marcuse EK. Do parents understand [9] Kata A. A postmodern Pandora’s box: Anti-vaccination immunizations?. A national telephone survey. Pediatrics misinformation on the Internet. Vaccine 2010;28:1709–1716. 2000;106:1097–1102. [10] Kennedy RF. Deadly Immunity. Rolling Stone Magazine [24] Freed GL, Clark SJ, Butchart AT, Singer DC, Davis MM. 2005 June 30-Jul 14. Parental Vaccine Safety Concerns in 2009. Pediatrics [11] Wallace A. A Short History of Vaccine Panic. Wired 2010;125:654–659. Magazine. October 23, 2009 -accessed on March 31, 2012, at [25] Mayer M, Till J. The Internet: a modern Pandora’s box? http://www.wired.com/magazine/2009/10/a-short-history- Qual Lif Res 1996;5:568–571. of-vaccine-panic/. [26] American Academy of Pediatrics, Division of Health Policy [12] Wakefield AJ, Murch SH, Anthony A, Linnell J, Casson DM, Research. Periodic Survey of Fellows No. 48; Immunization Malik M, et al. Ileal-lymphoid-nodular hyperplasia, non- Administration Practices. Elk Grove Village, IL: AAP 2001. specific colitis, and pervasive developmental disorder in [27] Leib S, Liberatos P, Edwards K. Pediatricians’ Experience children. Lancet 1998;351:637–641. with and Response to Parental Vaccine Safety Concerns [13] Institute of Medicine. Immunization Safety Review: and Vaccine Refusals: A Survey of Connecticut Vaccines and Autism. Washington, DC: National Pediatricians. Public Health Reports 2011;126:13–23. Academies Press; 2004. [28] Diekma DS. AAP Clinical Report: Responding to Parental [14] Offit PA. Deadly Choices. How the Anti-Vaccine Movement Refusals of Immunization of Children. Pediatrics Threatents Us All. New York, NY: Basic Books; 2011. 2005;105:1428–1431. [15] Offit PA, Moser CA. The Problem With Dr Bob’s Alternative [29] More Doctors ‘Fire’ Vaccine Refusers. The Wall Street Vaccine Schedule. Pediatrics 2009;123:164–169. Journal Online - accessed on March 29, 2012 at http:// [16] Sears RW. The Vaccine Book: Making the Right Decision for online.wsj.com/article/ Your Chid. New York, NY: Little, Brown; 2007. SB10001424052970203315804577209230884246636.html. [17] http://briandeer.com/solved/gmc-charge-sheet.pdf - [30] Taylor JA, Darden PM, Slora E, Hasemeier CM, Asmussen L, accessed on March 28, 2012. Wasserman R, et al. The influence of provider behavior, [18] http://briandeer.com/solved/lancet-retraction-2010.pdf - parental characteristics and public policy initiative on the accessed on March 29, 2012. immunization status followed by private pediatricians; a [19] Omer SB, Salmon DA, Orenstein AW, deHart P, Halsey N. study from Pediatric Research in Office Settings. Pediatrics Vaccine Refusal, Mandatory Immunization, and the 1997;99:209–215. Risk of Vaccine Preventable Disease. N Engl J Med [31] Poland GA, Jacobson RM. The Age-Old Struggle against the 2009;360:1981–1988. Antivaccionists. N Engl J Med 2011;364:97–99.