Anti-vaxxers aren’t the main problem

DESPITE THE BELIEF that low vaccination rates are due to anti-vaxxers – those opposed in principle to vaccination — the majority of people who have not vaccinated their children in Massachusetts are not anti-vaccine. Most unvaccinated children are in that gap because of issues of access or other logistical reasons.

Legislation proposed on Beacon Hill would eliminate all non-medical exemptions to vaccination, but a smarter approach would be to tackle the larger, if more prosaic, issue of vaccination access and enforcement of current laws. More importantly, inappropriately singling out anti-vaccination adherents as the only cause of low vaccination rates distracts from less controversial factors that contribute to vaccine-preventable disease nationwide.

According to self-reported data collected by the Massachusetts Department of Public Health, religious exemptions to vaccination in 2018-2019 accounted for 1.1 percent of children in kindergarten and 0.9 percent of seventh-graders. In contrast, 3.1 percent of Massachusetts children in kindergarten and 6.9 percent of those in grade 7 are in “the gap” – unvaccinated but not because of a non-medical exemption. Thus, the gap for kindergarten and seventh grade students is about 3 and 7 times greater than the rate of religious exemptions statewide.

Research suggests those seeking “religious exemptions” are a mix of people drawn by religious beliefs and those holding anti-vaccine cultural beliefs, including a distrust of vaccine safety. The gap, meanwhile, is caused primarily by the inability of parents to get their kids to the doctor or to transfer paperwork documenting vaccination amid life’s other complications.

In other words, there are many more people who simply have difficulty getting vaccines on schedule than there are people who truly don’t want their children to receive them. In many ways, this is welcome news.

According to the World Health Organization, the recommended goal to prevent outbreaks by maintaining “herd immunity” for childhood vaccinations is 95 percent. According to the National Center for Health Statistics, Massachusetts ranked No. 1 in 2016 for fully vaccinated children aged 19-35 months. Unfortunately, people who exempt from vaccines tend to cluster in small geographic areas. This means that despite a 97 percent statewide average in kindergarten for the measles, mumps, and rubella vaccine, or MMR, some regions are below the recommended 95 percent threshold.

By improving accessibility and crafting smart legislation, rates can be raised above the 95 percent mark without inflaming the vaccine debate. One such intervention would be to designate schools as sites for vaccinations clinics. This type of system is used in numerous countries, and it would streamline reporting and record-keeping as school nurses are already responsible for maintaining vaccinations records for students. When a nurse finds a student behind schedule, clinicians could offer the vaccine at school, instead of instructing parents to bring their child to the doctor, a step that contributes to the vaccination gap.

Another effective policy option is to make the religious exemption more difficult to get, instead of removing it altogether. This approach could minimize the backlash from vaccine opponents but also decrease exemption rates. For example, requiring parents seeking a religious exemption to visit a doctor annually to discuss vaccinations would be a reasonable action. As exemptions are currently easier to receive than vaccines, the path of least resistance is to avoid vaccination. One reason we don’t always enforce vaccination law (i.e., remove a non-compliant student from school) is because if a school nurse told a parent that they had to come home from work to take care of their child, parents might just sign an exemption to take the pressure off. Making the exemption harder to get than the necessary vaccines would shift the path of least resistance towards the positive choice.

These systematic changes are relatively easy to implement when compared to the implications of how we understand anti-vaccination as a culture. The Centers for Disease Control and Prevention estimate that the flu killed 79,400 people last year; measles hasn’t killed anyone since 2015. Skipping a flu shot doesn’t make anyone label you as anti-vax, but skipping a measles shot defines you in this way. This is dangerous because it allows us to view a small group of people as the problem when there are larger systemic issues represented in the data.

In Massachusetts, only 58 percent of residents get the flu shot, compared with 97 percent of kindergarten students who get the measles vaccine. Vaccine-resistant parents are part of the problem but by looking again at the data we can see many people who are pro-vaccination aren’t getting recommended shots. This is especially true of non-mandatory vaccines like the flu shot, and HPV and shingles vaccines.

The consequence of understanding low vaccination rates solely as an anti-vaccine problem is that we make anti-vaccination sentiment more visible and direct too much of our effort in less fruitful directions. The underlying cultural determinants of anti-vaccination are well known to include distrust of government, distrust of the medical system, fear of side effects, and consumption of misinformation. When legislating, we must consider how to set public policy to avoid inflaming the underlying causes, which can lead to the further spread of anti-vaccine beliefs.

The cautionary tale of the Lyme disease vaccine illustrates what we risk by provoking even small groups of anti-vaxxers. Unknown to many, there was an effective vaccine to prevent Lyme disease; as of 2002, it was no longer available.

Having had Lyme disease, both of us agree we would fight to be first in line to get the vaccine today. Unfortunately, unsubstantiated claims coalesced anti-vax advocates into a group to fight the vaccine. A class action suit against the manufacturer, coupled with declining vaccination rates, convinced the drug maker to discontinue the vaccine. Although the nullification of the Lyme disease vaccine was not due to removing exemptions, it does demonstrate the power of small groups of people to spread their view if given a platform to do so.

By fighting anti-vaxxers instead of providing solutions for unvaccinated people, we may once again give the people with whom we disagree a platform to spread their views. Alternately, if we provide structural support to those who want to be vaccinated, the Commonwealth will more effectively reach the goal to increase the vaccination rate with less controversy.

Nathaniel Fuchs is a Fulbright Scholar currently in a master of public health program at Brown University. Lawrence S. DiCara is a former president of the Boston City Council, author, and attorney.