Barriers and Outbreaks: States Begin to Address U.S. Vaccination Trends

By Andria Caruthers, Smith/Patterson Fellow

For most people, they get the recommended shots, go about life, and rarely, if ever, think about it again. And that ladies and gentlemen, is public health at work; not overt, not in your face, just…doing its job in secret–kind of like ninjas. This is all dependent, of course, on the public being vaccinated against threatening diseases. But most likely, you and your family have not gotten sick with polio, so it’s all-good, case closed, right?

Not exactly.

Currently, there are two issues we’re facing in Missouri, and across the country, that make this whole vaccination issue murkier. One issue we’re facing is the financial burden of vaccinations on low-income families and the underinsured.

There are three ways adults can finance vaccines for themselves and their children: private insurance, public safety net programs (like Vaccines for Children program), and paying out-of-pocket (National Academies of Science, 2003). However, a study reported in the July 15 Morbidity and Mortality Weekly Report found that vaccine uptake is greatly influenced by the source of financing (2015). To no surprise, individuals with higher incomes or insurance coverage are three times more likely to get the recommended vaccinations than those with lower incomes or no insurance.

Lynelle Phillips, an instructor at the Sinclair School of Nursing, agrees.

“We have a fragmented health care system. In Missouri, we have the Vaccines for Children program (VFC) and then we have people with insurance, so between those two things, kids should be able to get vaccinated,” said Phillips, MPH, RN, who also coordinates programs at the University of Missouri School of Health Professions. “But then you have people who are underinsured and have big deductibles.”

However, there is some encouraging news. Under the Affordable Care Act (ACA), new private health plans, and many Medicaid and Medicare plans, come with no copays or deductibles for preventive services like vaccinations. This means more families would be able to afford these vaccinations through low- or no-cost options.

Exemptions, state laws and the impact on vaccination rates

A separate challenge happens when parents seek vaccination exemptions. Exemptions are release forms that waive a child from a vaccination. For some parents, it may be easier to submit a form, exempting their child from receiving a vaccine, than it is to find money to pay for it (, 2014). This may solve a financial problem, but it creates a health one. These exempted children are 22 times more likely to contract measles than their vaccinated peers (Journal of American Medical Association, 2000).

With statistics like that, it is easy to see how exemptions like these could lead to serious public health consequences down the road. Parents can have their kids exempted from vaccinations for medical, religious, and philosophical reasons, depending on where they live. All states must offer a medical exemption, but religious and philosophical exemptions vary state to state. In states with a philosophical exemption, data show lower rates of vaccinations.

Map of school vaccine exemptions by state. Credit: Vox magazine

School vaccine exemptions by state Image credit: Vox

Source: Vox Magazine

“In states with philosophical exemptions, we’re seeing higher exemption rates and it’s starting to impinge on herd immunity,” continued Philips. “While a state as a whole might have a decent rate, you have pockets of well-to-do communities that have 15, up to 20 percent exemption rate. That’s definitely compromising herd immunity for that community and setting you up for outbreaks.”

Timely examples are found in some elite neighborhoods of Los Angeles, where low vaccination rates rival that of Sudan’s (The Atlantic, 2014).

With the resulting whooping cough outbreaks in these neighborhoods, and a measles outbreak at Disneyland over the winter holiday, states are starting to take action. California recently banned all exemptions (except medical), and Missouri’s proposed House Bill No. 976, while not banning philosophical exemptions, would require daycares to inform parents/guardians if a fellow attendee was not vaccinated.

Many states, like California, now realize the impact exemptions can have not only on vaccination rates, but also on communities’ health. While there is no call for widespread alarm, states need to consider how their laws and policies on exemptions can impact vaccination rates and ultimately their state’s health.

A closer look at vaccination rates

Vaccination rates by state

Vaccination rates by state. Image credit: Mother Jones

Source: Mother Jones

According to data from the Centers for Disease Control (CDC), in 2014, 70 percent of U.S. children (19-35 months) received the recommended combined vaccine series (diphtheria, tetanus, polio). But for children who live below the poverty line, their rates of vaccination against these diseases is even less: 64 percent across the U.S. Missouri’s vaccine rates for the combined series were 67.9 percent (Morbidity and Mortality Weekly Report, 2014). For communicable diseases like measles and pertussis (whooping cough), the rates of vaccination drop even further. And guess which diseases are on the uptick?

The resurgence of these diseases should not cause widespread alarm yet, but we need to address the root of the problem now. According to Phillips, “The concern is the isolated pockets of high exemption. Imagine being in a school where 20 percent of the kids aren’t vaccinated.” It’s a real-life scenario states need to think about deeply.

Balancing health promotion and individuals’ rights

This is where public health becomes a balancing act. “It’s a question of greater goods or individual rights. [Infectious diseases] are not visible anymore so you are taking a shot for greater good. Most people feel good about it, and then others worry for their children’s safety. So when you have a disease that becomes less and less visible and almost non-existent, and you have a vaccine that has some rare but real, adverse events, that becomes more visible than the disease and then that throws off people’s decision making,” said Phillips.

And that becomes the challenge. Many of today’s parents were not even born when diseases like polio and measles claimed thousands of lives. Because of that unlived history, it’s easy to think of these diseases as single epidemics in our country’s history, and not as the sleeping threats that they are.

This is why public health promotion of the science is so important. Health advocates like Philips are quick to remind us that diseases don’t just disappear. We just don’t see them because past vaccination programs were so successful.

If you are interested in learning more on what vaccinations are recommended or where you can find low-cost vaccinations, check out the Vaccines for Children program.


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