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Point and Counterpoint |

Rebuttal From Drs Schröder-Bäck and MartakisRebuttal From Drs Schröder-Bäck and Martakis FREE TO VIEW

Peter Schröder-Bäck, PhD; Kyriakos Martakis, MD
Author and Funding Information

From the Department of International Health (Drs Schröder-Bäck and Martakis), CAPHRI—School of Public Health and Primary Care, Faculty of Health, Medicine, and Life Sciences, Maastricht University; the Faculty for Human and Health Sciences (Dr Schröder-Bäck), University of Bremen, Bremen, Germany; and the Children’s and Adolescents’ Hospital, University Hospital of Cologne (Dr Martakis), Cologne, Germany.

CORRESPONDENCE TO: Peter Schröder-Bäck, PhD, Maastricht University, Faculty of Health, Medicine and Life Sciences, School for Public Health and Primary Care (CAPHRI), Department of International Health, Postbox 616, 6200 MD Maastricht, The Netherlands; e-mail: Peter.Schroder@maastrichtuniversity.nl


CONFLICT OF INTEREST: None declared.

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):857-858. doi:10.1378/chest.15-1161
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We agree with Prof Silverman and Dr Hendrix1 that the risks of measles outbreaks are to be taken very seriously and call for action to raise the immunization rate. We disagree, however, about how to approach this challenge. The question is if measles vaccination should be a mandatory and rigorously enforced requirement for attending school.

Prof Silverman and Dr Hendrix1 rightly point out that current methods of communication to raise the rates of measles immunization are not sufficient. Yet, this does not necessarily lead to their assumption that “mandates are necessary.” To conclude this is a fallacy, given there are further alternative interventions possible. In fact, a measles vaccination requirement for attending school has been proven to be neither the only nor the most effective intervention for herd immunity.2,3 In practice, this intervention is undermined by high rates of exemptions for philosophical reasons2,4 and also can be evaded through home schooling, a trend gaining in popularity in the United States.5,6 Furthermore, countries without any form of mandatory vaccination still reach high immunization rates.3,7

If achieving herd immunity is the ultimate aim, it is important to remember that adults lack immunization as much as children. Adults, however, remain unreached by the intervention we discuss here. Hence, this form of mandate would not serve a fast closure of the immunization gap (if at all), but at best “over time,” as Prof Silverman and Dr Hendrix1 also recognize. Thus, immunization mandates are not the golden bullet for reaching herd immunity. They seem neither necessary nor sufficient for closing the vaccination gap, and in addition to ethical reservations against this measure, these mandates should not be the focus of immunization program reforms.2

In fact, Prof Silverman and Dr Hendrix1 also mention a promising alternative: incentives for being immunized. Incentives—but also nudges—that are less threatening to individual autonomy than the intervention of interest are prima facie ethically preferable as long as one has reason to assume that the immunization status can also be significantly raised by implementing them.2,4 Unless there is evidence contrary to claim that these approaches would be less effective than the mandates we discuss here, it is not convincing to presuppose, as Silverman and Hendrix do, that these mandates are a “stronger bulwark against declining vaccination rates.”1

In short, arguing for measles vaccination being a mandatory requirement for attending school has a strong burden of proof that this measure is significantly more effective, more efficient, and faster than any less compulsory (set of) intervention(s), including, for example, strengthened efforts in communication and public education in combination with using incentives and nudges. According to the current state of available evidence, we consider it ethically necessary, proportionate, and, from a population health point of view, preferable to explore such alternatives first before enforcing these mandates rigorously. In either case, (more rigorously enforced) mandates are not the only alternative to significantly raise immunization rates.

References

Silverman RD, Hendrix KS. Point: should childhood vaccination against measles be a mandatory requirement for attending school? Yes. Chest. 2015;148(4):852-854.
 
Constable C, Blank NR, Caplan AL. Rising rates of vaccine exemptions: problems with current policy and more promising remedies. Vaccine. 2014;32(16):1793-1797. [CrossRef] [PubMed]
 
Elliman D, Bedford H. Should the UK introduce compulsory vaccination? Lancet. 2013;381(9876):1434-1436. [CrossRef] [PubMed]
 
Gostin LO. Law, ethics, and public health in the vaccination debates: politics of the measles outbreak. JAMA. 2015;313(11):1099-1100. [CrossRef] [PubMed]
 
Salisbury DM. Should childhood vaccination be mandatory? No. BMJ. 2012;344:e2435. [CrossRef] [PubMed]
 
Noel A, Stark P, Redford J. Parent and Family Involvement in Education, From the National Household Education Surveys Program of 2012 (NCES 2013-028). Washington, DC: National Center for Education Statistics, Institute of Education Sciences, US Department of Education; 2013.
 
Haverkate M, D’Ancona F, Giambi C, et al; VENICE project gatekeepers and contact points. Mandatory and recommended vaccination in the EU, Iceland and Norway: results of the VENICE 2010 survey on the ways of implementing national vaccination programmes. Euro Surveill. 2012;17(22):20183. [PubMed]
 

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References

Silverman RD, Hendrix KS. Point: should childhood vaccination against measles be a mandatory requirement for attending school? Yes. Chest. 2015;148(4):852-854.
 
Constable C, Blank NR, Caplan AL. Rising rates of vaccine exemptions: problems with current policy and more promising remedies. Vaccine. 2014;32(16):1793-1797. [CrossRef] [PubMed]
 
Elliman D, Bedford H. Should the UK introduce compulsory vaccination? Lancet. 2013;381(9876):1434-1436. [CrossRef] [PubMed]
 
Gostin LO. Law, ethics, and public health in the vaccination debates: politics of the measles outbreak. JAMA. 2015;313(11):1099-1100. [CrossRef] [PubMed]
 
Salisbury DM. Should childhood vaccination be mandatory? No. BMJ. 2012;344:e2435. [CrossRef] [PubMed]
 
Noel A, Stark P, Redford J. Parent and Family Involvement in Education, From the National Household Education Surveys Program of 2012 (NCES 2013-028). Washington, DC: National Center for Education Statistics, Institute of Education Sciences, US Department of Education; 2013.
 
Haverkate M, D’Ancona F, Giambi C, et al; VENICE project gatekeepers and contact points. Mandatory and recommended vaccination in the EU, Iceland and Norway: results of the VENICE 2010 survey on the ways of implementing national vaccination programmes. Euro Surveill. 2012;17(22):20183. [PubMed]
 
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