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A number of vaccines are mandatory for children before they are allowed to go to school in the US (with personal belief exemptions allowed in some states), for diseases such as measles, tetanus, and polio.

A recent measles outbreak in the US has brought a lot of media attention to vaccinations and whether personal belief exemptions should be allowed at all.

As we debate this topic, let’s consider:

 Flu deaths are always  difficult to track exactly , so consider this estimate
Flu deaths are always difficult to track exactly , so consider this estimate “loose” but in the right order of magnitude.

(Measles source; flu source)

Seeing this, how do you feel knowing that 42% of Americans get the flu vaccine each year? Do you see it as a major health problem in the US, or not? 

Do you think US policy should be the same regarding measles and flu vaccines? If different, how? Let us know what you think in comments below!

46 Comments

  • Benjamin Long, March 2, 2015 @ 10:03 pm Reply

    An interesting related question: should those who go vaccinated and end up spreading the disease face any legal liability for damages? Does this behavior rise to reckless conduct?

    • Benjamin Long, March 3, 2015 @ 6:04 pm Reply

      To expound on my question here from my own personal perspective:

      As a moral issue, battery doesn’t become ok just because enough people say you have to, therefore I fairly strongly oppose mandatory vaccination. I have less issue with it being used as a precondition to other services. Want your kid to go to public school? That free education can come with vaccination as a precondition, and I’m pretty much fine with that. There are available alternatives. Likewise I’m probably on the side of ‘if you’re unvaccinated and infectious and you infect other people, you probably fall somewhere between negligent and reckless on the mens rea scale (a pretty solid summary for those not familiar: http://lawcomic.net/guide/?p=173). What we do with it from there is a far more involved question.

      • Daniel Kane, March 4, 2015 @ 3:12 am Reply

        You say that you potentially support vaccination as a required preconditioner for use of public services. Let us take this to the extreme then. Would you support mandatory vaccination as a precondition for using public roads and sidewalks? Is there a fundamental difference between that and school other than as a difference in magnitude?

        • nathan lachenmyer, March 5, 2015 @ 3:57 pm Reply

          One could probably argue that the risk of disease transmission is much higher at a school (where 20-40 people share an entire room, desk, chairs, etc. with each other for 6-8 hours a day) than a road or sidewalk, which has much more transient interactions.

          I don’t think Benjamin’s idea is a bad one — but I think that it should be made mandatory only where there is an appropriate amount of demonstrated risk (ugh, now that is some vague criteria).

          If you could demonstrate to me that there’s as much risk having an unvaccinated child using the sidewalk as being in a classroom, I’ll think about it some more.

          • Daniel Kane, March 5, 2015 @ 4:27 pm

            Firstly, "leads to ask much risk of infection as being in a classroom" is a really weird risk threshold to have.
            Secondly, my main point is really that once you start making it mandatory that you vaccinate in order to use public services which might lead you to infecting other people, you open the door to making them effectively mandatory.

            On another note, could an employer mandate vaccinations in order to work there? I’ve never heard of it being the case, but it seems like a reasonable thing to do.

          • Erik Fogg, March 5, 2015 @ 4:31 pm

            I really like Dan’s point: it sounds like "as much risk as infection in a classroom" is a benchmark based in accepting what’s already there. That is, "this is how we do it now, it must be good," or something.

            I have no idea how to create a rigorous/just/consistent definition for where you draw the line at someone’s duty to protect others from disease. I was about to despair about this, and then remembered that "oh wait that’s why I wrote this post!"

          • Daniel Kane, March 5, 2015 @ 6:08 pm

            Well ideally, you measure your duty to protect others by comparing the expected cost to others (in terms of discomfort and lost work and health) coming from not vaccinating and compare that to the cost to yourself of vaccinating (in terms of time and money). If the former exceeds the latter, you should see yourself as having a duty to vaccinate.

          • Benjamin Long, March 5, 2015 @ 5:33 pm

            Regarding roads: That’s just bad policy, the risk being managed is in no way related to the service being provided. It logically follows that a school is concerned about the risk of communicable disease, and therefore it follows logically that there may be a mandate placed there. I should have logic’d it out more and been more clear before, thanks for running that down a bit.

            As far as employers go, I have no problem with employers mandating vaccination, to do otherwise would go against free association – people should be free to choose how and with whom they interact. I also would be surprised if hospitals didn’t have such mandates in place.

          • Christopher Grouard, March 5, 2015 @ 6:07 pm

            I think one of the reasons we like to talk about schools is that it involves children. One of the things I keep hearing in this vaccination discussion is about how the children suffer needless for the beliefs of their parents. So in that way at least I think the argument is fundamental different for say the streets. It’s targeted at those who have much less ability to speak for themselves. My only concern about using the schools. Is that it might lead more crazy parents to home schooled by their poor kids. Which feels like a positive feedback loop of crazy just waiting to happen.

            I know there’s always going to be some give, and take with these kinds of discussions. Still the fact that we have to have a debate about something this obviously good for you blows my mind. Which I think is one of the reasons I feel more comfortable saying we should just make it mandatory. Full stop period. Of course at that point yes it’s also a personal liberty thing, and it becomes a more complicated issue. sigh

          • nathan lachenmyer, March 5, 2015 @ 6:27 pm

            Daniel: I agree that it’s an arbitrary threshold, but I thought you were comparing the two situations — you were arguing if $x, then why not $y?

            Perhaps I shouldn’t be asking for you to provide evidence to show that the risk of $y is equal to the risk of $x — but unless there is evidence that they’re in at least the same category, I think the point still holds.

  • Tom Hendrix, March 2, 2015 @ 11:12 pm Reply

    Measels Vaccine is different – it is long lasting and definitely works. That is, it doesn’t depend on our annual cycle of "guess the dominant strain" like the flu vaccine does. The flu numbers seem small in compaison to bigger health problems, but a shot is a simple and quick way to maybe save lives and expense. Still, I would sooner go after reducing other reckless behaviors (like over eating or smoking) with moves like increased deductibles and premium scaling for healthcare coverage.

    • Erik Fogg, March 4, 2015 @ 1:54 am Reply

      Totally agreed and maybe there’s a "responsibility to others" question that pops up with vaccines in a way that doesn’t with smoking/overeating, which is why we feel differently about it?

      Though as the amount of money spent by the taxpayer on healthcare increases, we get an interesting dilemma of whether we regulate people’s unhealthy behavior due to the economic externalities involved. Now there’s something to consider (soon to be a blog post!)

  • Telmo Correa, March 3, 2015 @ 12:41 am Reply

    I’ll bite.

    Disclaimer: I’m not an epidemiologist. Or a biologist. This is just my understanding of the related issues.

    I don’t think that comparing the number of cases and deaths is sufficient information for discussing epidemics and vaccination. A main characteristic of both measles and influenza is that they are infectious — people become infected due to other people already infected.

    One of the simplest compartimental models in epidemiology is the SIR model. An homogeneous population has Susceptible individuals, Infected individuals, and Resistant individuals. Each infected individual exposes infection to the whole population; exposed susceptible individuals become infected, and infected individuals decay into resistant individuals as the disease takes its course.

    One of the parameters of this model is the basic reproduction number, $R_0$. It represents how many individuals an infected individual will expose during the course of the disease. On a population without resistance, if that value is greater than 1, the disease will spread throughout the population; if it is less than 1, the disease will die out eventually.

    This is a simple model, assuming that the population is homogeneous / has homogeneous contact / the infectivity rate is constant, but it is good enough to reason about vaccination and immunity.

    The basic reproduction number for influenza epidemics is estimated to be 2 – 3, and for measles, 12 – 18. Measles is incredibly infectious / spreads considerably easier than the flu on a susceptible population.

    Vaccines introduce immunity on a population; if a vaccine causes someone to become immune, they acquire immunity, and move from the S to the R group. This reduces the effective reproduction number.

    A related and important concept is herd immunity: once a given number of the population becomes immune, the reproduction number becomes 1 or smaller, and the disease becomes self-limiting. The herd immunity threshold is computed as $1 – 1/R_0$; for measles, it is 83 – 94%. If the estimated influenza number holds, its immunity threshold is 50% – 67%. If a vaccine were 100% effective in providing immunity, then having 67% of the population vaccinated would cause (the current strain of) influenza to be self-limiting.

    Unfortunately, vaccines are not 100% effective, and/or may not cover all of the current strains of a disease. Unfortunately, for the dominant H3N2 strain in 2015, vaccine effectiveness seems to be estimated at only 18% (http://abcnews.go.com/Health/flu-vaccine-effective-expected-cdc/story?id=29293197). This means that even with 100% vaccination, herd immunity would not be achieved. Some immunity is still better than none — immune people won’t die from it while immune.

    Herd immunity is also important because not all people are vaccinable. Costs and opportunity may prevent people from receiving vaccines, or allergies to egg proteins used on the fabrication of the vaccines, or a weaker immune system that will not receive full immunity from a vaccine. If someone opts to not be vaccinated, they are not only putting themselves at risk — they are failing to decrease the reproduction number, and making it more likely that other people who could not be vaccinated get sick.

    Finally — it isn’t obvious to me that mandatory vaccinations are the adequate policy, or only policy; I don’t have a formed opinion. I would be interested in the effectiveness of such a law, compared to providing incentives / public safety information incentivizing people to get vaccinated / cover their mouth / wash their hands.

    • Benjamin Long, March 3, 2015 @ 5:50 pm Reply

      Nice bit of info there Telmo. Is there anywhere convenient to compare infectivity numbers?

    • Erik Fogg, March 4, 2015 @ 1:52 am Reply

      This is amazing.

      I have a question: is herd immunity a binary thing? That is, would more people getting the vaccine protect a significant (though not complete) portion of the population? Or are there just too many vectors and having 18% of the population being immunized has only a very marginal effect? I am trying (and failing) to do the math on paper here but figured you might know.

      • Telmo Correa, March 4, 2015 @ 4:57 am Reply

        More vaccinations provide more herd immunity — susceptible people are less likely to become infected. The population threshold is the point at which a disease will be eradicated — when it can’t, on average, infect at least a new person for each infected person, and so it would die off when reintroduced on a large population before infecting all. Herd immunity to measles means that a traveler who introduce measles into a population won’t start a epidemic.

        18% is a very bad efficacy for the flu vaccine this year — the one from 2010 – 2012 seems to have been 74% effective (http://www.cdc.gov/flu/about/qa/vaccineeffect.htm). It isn’t always this bad, but it is for this flu season. And the flu viruses mutate enough that new vaccines need to keep being developed.

        Having 18% of the population immunized means those 18% will not be infected by this strain, and that strain will cause no deaths on those 18%. (The 18% represents average immunity, not a split of the population — a specific person might end up 30% immune, rather than fully immune or not immune.) It also means that rather than infecting R new people, each infectious person will infect only 0.82R people, the disease will be slower to spread.

        So: vaccinations can eradicate measles from a population, but not necessarily the flu. The flu mutates fast enough that vaccines have to be redeveloped each year. Being vaccinated against the flu still prevents deaths on immunized people, and it reduces the number of cases among non-immunized people. Actually working out the impact on the number of cases from number of vaccinations means solving a few differential equations, but we can use computers for that.

        Paper on herd immunity: http://cid.oxfordjournals.org/content/52/7/911.full

        Applet showing the dynamics for an SEIR model (E means exposed, i.e. infected but not yet contagious): http://demonstrations.wolfram.com/ReedFrostSEIRModel/

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