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Point and Counterpoint |

Rebuttal From Prof Silverman and Dr HendrixRebuttal From Prof Silverman and Dr Hendrix FREE TO VIEW

Ross D. Silverman, JD, MPH; Kristin S. Hendrix, PhD
Author and Funding Information

From the Indiana University Fairbanks School of Public Health (Prof Silverman); the McKinney School of Law (Prof Silverman); Children’s Health Services Research (Dr Hendrix), Department of Pediatrics, Indiana University School of Medicine; Indiana University Center for Bioethics (Dr Hendrix); and The Regenstrief Institute, Inc (Dr Hendrix).

CORRESPONDENCE TO: Ross D. Silverman, JD, MPH, Indiana University Fairbanks School of Public Health, and McKinney School of Law, 714 N Senate Ave, EF250, Indianapolis, IN 46202; e-mail: rdsilver@iu.edu


FUNDING/SUPPORT: Dr Hendrix is supported by the National Institutes of Health [Grant K01AI110525].

CONFLICT OF INTEREST: R. D. S. has, in the past 3 years, received funding for his work as a mentor in a Robert Wood Johnson Foundation/Georgia State University program on public health law education and has spoken publicly on the issue of vaccine law, policy, and ethics. K. S. H. has received grant funding from the National Institutes of Health and The Indiana University Clinical and Translational Sciences Institute Pediatric Project Development Team to study vaccine attitudes and decision-making. She has also been quoted by various public news and media outlets on the topic of childhood immunization and parental attitudes.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2015;148(4):856-857. doi:10.1378/chest.15-1164
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We agree with much of what Drs Schröder-Bäck and Martakis1 argue in their counterpoint editorial. The benefits of vaccination outweigh any individual and societal risks accrued by remaining unvaccinated. Ethical arguments in favor of mandating measles vaccination may outweigh appeals to liberty or individual or parental autonomy. Furthermore, mandates would minimize free-riding and maximize public fairness by appropriately imposing shared burdens across society. Where we largely diverge is how we would balance societal burdens when implementing policy to achieve such goals.

Implicit in their argument is an assumption that innovative implementation of incentives, societal “nudges,” or both could lead to successful attainment and maintenance of vaccination levels high enough to protect against outbreaks (herd immunity) if not ultimately eradicate measles. They state, “Our societies can afford incentives.” We have several concerns about using such an approach for measles control.

It is unclear how nudge-based policies differ from the array of public health measures2 already undertaken to encourage measles vaccine uptake3 or whether such interventions are effective absent already existing public policies encouraging the healthy behavior (as with smoking bans).4 The direct5 and indirect costs society would bear while aspiring to achieve nudge-induced herd immunity are high. Public health initiatives are undertaken in systems with rationed, sometimes austere, resources. Increasing funding for resource-intensive public health campaigns, aiming to nudge the population to increase its acceptance of a vaccine long demonstrated to be highly safe and effective, demands that funding be further diverted away from other core public health and government functions, including costs associated with responding to outbreaks that would surely continue during the interim until such innovative interventions might take hold. Furthermore, absent a mandate, vaccination levels are more likely to be at risk for a precipitous drop should public confidence in measles vaccination6 again waver.

Our colleagues also argue their approach avoids an ethical tradeoff between education and health. We disagree, as the burden of making such tradeoffs would be shifted to those least capable of self-protection. Children living in a high exemption cluster who are unable to be vaccinated against measles would be forced to make such choices, as their public school classroom would subject them to a potentially deadly, ongoing risk. Their approach preferences the right of otherwise able families to forgo parental and societal duties and opt out of vaccination over the needs of more vulnerable populations who cannot opt in and must rely upon the rest of the community for protection.

The weight and the strength of moral, scientific, legal, and economic evidence strongly supports measles vaccine uptake. Although we support pursuing innovative approaches to foster widespread measles vaccine acceptance, as well as narrowly crafted exemption policies as an effort to balance public health and public trust, a default of an evidence-based measles vaccine mandate for children best protects public health and prioritizes the needs of the vulnerable.

Acknowledgments

Role of sponsors: The sponsor had no role in the design of the study, the collection and analysis of the data, or the preparation of the manuscript.

Schröder-Bäck P, Martakis K. Counterpoint: should childhood vaccination against measles be a mandatory requirement for attending school? No. Chest. 2015;148(4):854-856.
 
Bonell C, McKee M, Fletcher A, Wilkinson P, Haines A. One nudge forward, two steps back. BMJ. 2011;342:d401. [CrossRef] [PubMed]
 
Jarrett C, Wilson R, O’Leary M, Eckersberger E, Larson HJ; SAGE Working Group on Vaccine Hesitancy. Strategies for addressing vaccine hesitancy: a systematic review [published online ahead of print April 17, 2015]. Vaccine. doi:10.1016/j.vaccine.2015.04.040.
 
House of Lords, Science and Technology Select Committee. 2nd report of session 2010-12: Behaviour change. UK Parliament website. http://www.publications.parliament.uk/pa/ld201012/ldselect/ldsctech/179/179.pdf. Published 2011. Accessed May 4, 2015.
 
Ortega-Sanchez IR, Vijayaraghavan M, Barskey AE, Wallace GS. The economic burden of sixteen measles outbreaks on United States public health departments in 2011. Vaccine. 2014;32(11):1311-1317. [CrossRef] [PubMed]
 
Larson HJ, Cooper LZ, Eskola J, Katz SL, Ratzan S. Addressing the vaccine confidence gap. Lancet. 2011;378(9790):526-535. [CrossRef] [PubMed]
 

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Tables

References

Schröder-Bäck P, Martakis K. Counterpoint: should childhood vaccination against measles be a mandatory requirement for attending school? No. Chest. 2015;148(4):854-856.
 
Bonell C, McKee M, Fletcher A, Wilkinson P, Haines A. One nudge forward, two steps back. BMJ. 2011;342:d401. [CrossRef] [PubMed]
 
Jarrett C, Wilson R, O’Leary M, Eckersberger E, Larson HJ; SAGE Working Group on Vaccine Hesitancy. Strategies for addressing vaccine hesitancy: a systematic review [published online ahead of print April 17, 2015]. Vaccine. doi:10.1016/j.vaccine.2015.04.040.
 
House of Lords, Science and Technology Select Committee. 2nd report of session 2010-12: Behaviour change. UK Parliament website. http://www.publications.parliament.uk/pa/ld201012/ldselect/ldsctech/179/179.pdf. Published 2011. Accessed May 4, 2015.
 
Ortega-Sanchez IR, Vijayaraghavan M, Barskey AE, Wallace GS. The economic burden of sixteen measles outbreaks on United States public health departments in 2011. Vaccine. 2014;32(11):1311-1317. [CrossRef] [PubMed]
 
Larson HJ, Cooper LZ, Eskola J, Katz SL, Ratzan S. Addressing the vaccine confidence gap. Lancet. 2011;378(9790):526-535. [CrossRef] [PubMed]
 
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