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VACCINATION ALL CHILDREN ACT
Vaccination All Children Act
2019 Adriana Weaver
Liberty University
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VACCINATION ALL CHILDREN ACT
ABSTRACT
Childhood vaccination provides protection against specific diseases while reducing the
number of communicable diseases amongst the population. The rise of under vaccinated children
is a growing a concern not only in the United States, but across the world, due to the increased
occurrence of vaccine preventable diseases in children. US HB2527 Vaccinate All Children Act
of 2019 is a Partisan Bill introduced into the House by Rep. Frederica Wilson [D-FL] which has
since been referred to the Subcommittee on Health. The bill states that mandatory vaccination be
a federal-enforced bill that will show no preference for childhood vaccination except to those
who are declared medically unable to comply, thereby restricting the grounds available to refuse,
and using enforcement measures for nonparticipation.
Many groups advocate for vaccination; however, there is a growing number of parents
and social groups that are against mandatory vaccination for school children. Social media is
being used to convey disinformation and dispel the beliefs that vaccinations are in the best
interest of children. In addition to many forums on social media, celebrities have taken to voice
their opinion on mandatory vaccination which has led to a higher incidence of non-vaccination
children across the U.S. In order to decrease the number on non-vaccinated children, healthcare
professionals must effectively communicate information pertaining to vaccinations by
developing trust, education, and debunking common myths that are associated with routine
vaccines.
Keywords: Mandatory Vaccination, Communicable Diseases, Vaccines, Social Media, United
States House of Representatives, Anti-Vaccination
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VACCINATION ALL CHILDREN ACT
Vaccination All Children Act
2019 Problem/Issue and Related
Bill
Childhood vaccination provides protection against specific diseases while reducing the
number of communicable diseases amongst the population. Most parents will choose to
vaccinate their children according to their pediatrician and recommended vaccination schedule;
however, in today’s society some parents are choosing not to vaccinate due to religious reasons,
personal beliefs or philosophical reasons, safety concerns, or may have many questions about
vaccines, and getting answers they can trust may be hard (Mckee & Bohannon, 2016).
For some, research pertaining to vaccination is done online and by use of social media.
Social media is being used to convey disinformation and dispel the beliefs that vaccinations are
in the best interest of children. In addition to many forums on social media, celebrities have
taken to voice their opinion on mandatory vaccination which has led to a higher incidence of
non-vaccination children across the U.S., as well as many other countries.
The decision not to vaccinate children is a growing a concern not only in the United
States, but across the world, due to the increased occurrence of vaccine preventable diseases in
children. Studies have shown that in the past 20 years, rates of children who are not vaccinated
have steadily increased (Phadke et al., 2016). These preventable illnesses are causing children to
miss numerous days in school which results in a lack of education, and government funding
(Phadke et al., 2016). In an attempt to alleviate the lost school days and funding from
absenteeism among school children, a bill has been introduced into Congress to help alleviate
this problem.
US HB2527 Vaccinate All Children Act of 2019 is a Partisan Bill introduced to the House
on May 3, 2019 by Rep. Frederica Wilson [D-FL]. Rep. Wilson [D-FL] quickly gained many
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followers amongst her peers and gained 17 cosigners to the bill. Rep. Alma Adams [D-NC],
Rep. Steve Cohen [D-TN], Rep. Karen Bass [D-CA], Rep. G. Butterfield [D-NC], Rep. James
Clyburn [D-SC], Rep. Marcia Fudge [D-OH], Rep. Alcee Hastings [D-FL], Rep. Eddie
Johnson [D-TX], Rep. Robin Kelly [D-IL], Rep. Al Lawson [D-FL], Rep. John Lewis [D-GA],
Rep. Gregory Meeks [D-NY], Rep. Gwen Moore [D-WI], Rep. Donald Payne [D-NJ], Rep.
Terri Sewell [D-AL], Rep. Stacey Plaskett [D-VI], Rep. Ayanna Pressley [D-MA], and Rep.
Joseph Morelle [D-NY] (US Congress, 2019) all signed the bill on the day of introduction. The
bill was then referred to the House Committee on Energy and Commerce on the same day of
introduction (US Congress, 2019). As of May 6, 2019 US HB2527 Vaccinate All Children Act
of 2019 has been referred to the Subcommittee on Health where it has been in legislation (US
Congress, 2019). To date, US HB2527 Vaccinate All Children Act of 2019 is still listed as
introduced; however, no roll call or votes have taken place since being sent to the Subcommittee
on Health (US Congress, 2019).
Background/Significance and Scope of the Problem
Vaccines are one of the greatest success stories in public health with success attributed to
negligible rates of adverse complications (Giubilini, et al., 2019). The side-effects of vaccines
tend to be mild rather than serious with the most common reaction happens at the injection site
(Giubilini, et al., 2019). More serious side effects are uncommon or rare, and the most severe are
so infrequent that they are difficult to assess statistically (Giubilini, et al., 2019). Vaccine
coverage was generally lower for most recommended vaccines among children who are
uninsured or insured by Medicaid when compared with children with private health insurance
(Zimlich, 2019). Specifically, 17.2% of unvaccinated children were uninsured compared with
2.8% of all children (Zimlich, 2019). Vaccination rates also were lower in rural areas to which
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researchers also discovered disparities for vaccines that required a booster dose in the second
year of life, including diphtheria/tetanus/acellular pertussis (DTaP), Haemophilus influenzae
type b (Hib), and pneumococcal conjugate vaccine (PCV) (Zimlich, 2019).
Studies have shown that there have always been parents who have refused to vaccinate
their child due to a religious or philosophical belief; however, the World Health Organization
named hesitancy to vaccinate as one the ten gravest threats to global health (Drew, 2019). As a
result, governments around the world are considering policies that would make vaccinations
mandatory (Drew, 2019). Over the past 5 years, legislators in Australia, France and Italy have
restricted school access for children who haven’t received the country’s recommended panel of
vaccinations, including MMR (Drew, 2019). To date, only five US States (California, New
York, West Virginia, Mississippi, and Maine) have existing State Bills that remove the ability
for parents to legally refuse vaccines for non-medical reasons. These Bills, particularly
California SB 277, were enacted after a 2014 outbreak of measles.
In 2014 at the Disneyland Park in Anaheim, California a customer entered the park and
brought with her an unlikely guest: measles (Lobo, 2016). By early 2015, this extremely
contagious and vaccine-preventable disease ("VPD") had spread to a reported 100 confirmed
cases across California ,Colorado, Utah, Oregon, Washington, Nebraska, Arizona, Mexico, and
Canada (Lobo, 2016). In response, health officials in Orange County, California-a region with
high rates of parents who opt out of vaccinating their children-ordered about two dozen high
school students without proof of immunization to stay home after learning that an infected
student had come to school following the school's winter break (Lobo, 2016). Approximately
half the cases were among unvaccinated persons, most of whom were eligible for vaccination yet
intentionally remained unvaccinated (Phadke et al., 2016). By the end of 2015, 188 confirmed
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cases were reported to the CDC only to have the numbers continue to rise each year (CDC,
2020). At the of end 2019, an all-time high of over 1,100 confirmed cases of measles have been
reported, and so far according to the CDC, 5 cases have been reported since January 1, 2020
(Measles and mumps, 2019; CDC, 2020).
While measles has had an increase over the years in school aged children, it is not the
only disease that is on the rise. Haemophilus influenzae type b disease, varicella, pneumococcal
disease, and pertussis have all seen an increase with the “anti-vax” movement (Phadke et al.,
2016). Due to recent outbreaks, many policymakers' have increased commitment to securing
community immunity through a combination of coercion and persuasion (Silverman & Wiley,
2017). This had lead Lawmakers in several states to tighten the requirements for non-medical
exemptions from vaccination requirements tied to both public and private school attendance
which also includes public ran daycares (Silverman & Wiley, 2017). By tightening restrictions
and regulations, lawmakers’ such as Rep. Frederica Wilson (D-FL) have created US HB2527:
Vaccinate All Children Act of 2019.
US HB2527 Vaccinate All Children Act of 2019 is not the first bill of its kind. In 1855,
Massachusetts became the first state to mandate that all children be inoculated against a
communicable disease (smallpox) as a condition for entering public school (Weithorn & Reiss,
2018). Since then, states have proceeded slowly in adopting similar policies, with most
expansion occurring in the second half of 20th century (Weithorn & Reiss, 2018). By 1963,
twenty states conditioned entry to public school on evidence that children had been immunized
against specific diseases (Weithorn & Reiss, 2018). By 1980, all fifty states and the District of
Columbia adopted school vaccination policies, as scientific developments which has led to safer
and more effective vaccines for an increasing number of diseases (Weithorn & Reiss, 2018).
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US HB2527 Vaccinate All Children Act of 2019 was reintroduced by Rep. Frederica
Wilson (D-FL). This bill was initially introduced during the 114th Congress but was stricken
before it could even be voted on. In her letter to her Congressional colleagues, Rep. Frederica
Wilson (D-FL) stated that “The health and safety of children must be our top priority. Vaccines
play an important role in keeping all children safe, especially those with compromised immune
systems who rely on herd immunity to safeguard against potentially deadly viruses, and that a
high immunization rate helps protect those who cannot safely be vaccinated, either because they
are too young or have a medical condition such as a weakened immune system. The Measles
virus is so contagious that one carrier can infect up to 90 percent of the unvaccinated people in
their vicinity. Therefore, vulnerable populations rely on a high vaccination rate. The Centers for
Disease Control and Prevention estimates that vaccinations will prevent more than 21 million
hospitalizations and 732,000 deaths in the United States among children born in the last 20
years” (Where do you stand?, 2020). Rep. Wilson further states that, “The ongoing measles
outbreak, which has spread to 23 states, is a national health crisis that requires a national
solution. We must allow science and fact-based research to guide us in making the right
decision for our communities and our children” (Where do you stand?, 2020). Since her
reintroduction of the US HB2527 Rep. Wilson has gained 17 cosponsors for this bill. Currently,
all 50 states require specific vaccinations for school aged children; however, they also all grant
exemptions for children who can’t be vaccinated for medical reasons. According to National
Conference of State Legislatures (2020), there are 45 states and Washington D.C. that grant
religious exemptions for people who have religious objections to immunizations, and 15 states
that allow philosophical exemptions for those who object to immunizations because of personal,
moral or other beliefs.
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US HB2527 Vaccinate All Children Act of 2019 is a bill that will prevent states from
offering non-medical exemptions for meeting school vaccine requirements, thereby requiring
children for whom immunization is safe to be vaccinated in accordance with the
recommendations of the Advisory Committee on Immunization Practices (Where do you stand?,
2020; US Congress, 2019). US HB2527 will also prohibit the Department of Health and Human
Services from awarding grants to public entities of a state for preventive health service programs
unless the state institutes certain vaccination requirements for its public schools (US Congress,
2019). Specifically, a state must require each student in public elementary or secondary school
to be vaccinated in accordance with the recommendations of the Advisory Committee on
Immunization Practices (US Congress, 2019). The bill provides an exception for students whose
health would be endangered by vaccination in the opinion of a physician conforming to the
accepted standard of medical care (US Congress, 2019).
Proponent and Opponent Arguments
Proponent
Vaccination protects the individual, and the state may have a paternalistic interest in
protecting children over their parents' objection, but vaccination of the individual also benefits
others (Silverman & Wiley, 2017). Studies have shown that if enough of the population is
vaccinated, the resulting community immunity protects everyone by reducing transmission from
person to person, making it easier to contain an outbreak (Silverman & Wiley, 2017).
Community immunity protects those who are vaccinated but not immune (because the vaccine is
ineffective in a small percentage of cases); those who cannot be vaccinated safely because they
are too young, are allergic to vaccine components (e.g., eggs), or have immune systems
compromised by illness (e.g., leukemia) or medical treatments (e.g., chemotherapy); those who
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lack access to vaccination for financial or other reasons; and those whose parents have refused
vaccination (Silverman & Wiley, 2017). However, if the proportion of a community that is
unvaccinated rises above a specific threshold (determined by the transmissibility of the pathogen,
the effectiveness of the vaccine, and social characteristics of the community), all who lack
individual immunity are at risk and an outbreak will ensue (Silverman & Wiley, 2017).
Mandate is defined as the strongly preferred, legally enforced option of the government
to require the recommended series of vaccinations be completed by every child as a condition of
entry into larger social settings, such as regulated daycares and schools (Silverman & Hendrix,
2015). Vaccination mandates facilitated the realization of critical public health goals coupled
with education and outreach to vulnerable and remote populations which led to the elimination of
endemic measles in 2000 (Silverman & Hendrix, 2015). Safety has been repeatedly
demonstrated, and while side effects are rare, they are minimalized by mandating a vaccination
policy (Silverman & Hendrix, 2015). Those unable to participate because of illness could be
accommodated through well-structured medical exemption protocols (Silverman & Hendrix,
2015). However, infectious diseases coupled with the heterogeneous and mobile nature of some
populations, means that population-level protection can only be obtained through high
vaccination rates (Silverman & Hendrix, 2015). Compared with programs centered on education,
accessibility, and incentives, a mandate offers a stronger defense against declining vaccination
rates (Silverman & Hendrix, 2015). Focusing the mandate on children who are most likely to be
exposed to and adversely affected by infectious diseases and who would be offered lifelong
protection against these diseases through vaccinations, offering medical exemptions for those
unable to be vaccinated (and, at most, a narrow nonmedical exemption for those with
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philosophical objections), and asking that those able to be vaccinated do so ensures a policy with
maximal fairness/justice across the population (Silverman & Hendrix, 2015).
Rep. Frederica Wilson (D-FL) as well as the 17 cosponsors of US HB2527 recommends
that mandatory vaccination be a federal-enforced bill that will show no preference for childhood
vaccination except those who are declared medically unable to comply, thereby restricting the
grounds available to refuse, and using enforcement measures for nonparticipation, such as
exclusion from certain services (e.g., school) or imposing fiscal penalties (e.g., denial or
reduction of a child care tax exemption) (Silverman & Hendrix, 2015).
To further the widespread vaccination among school children an Immunization Action
Coalition has been formed. The Immunization Action Coalition has 64 partners who believe that
vaccine requirements are necessary for public safety. The Centers for Disease Control and
Prevention (CDC), American Academy of Family Physicians (AAFP), American Academy of
Pediatrics (AAP), American College of Physicians (ACP), American Nurses Association (ANA),
American College of Obstetricians and Gynecologists (ACOG), and Association for
Professionals in Infection Control and Epidemiology (APIC) are part of this coalition (IAC
Immunization Partners, 2019).
Due to the increasing number of incidences of VPD’s, other countries across the world
that has begun requiring mandatory vaccinations for school children. Thirty one countries were
analyzed with one hundred percent of its citizens that was in favor with mandatory vaccinations
during childhood (Bozzola et al., 2018). Eleven countries have already introduced mandatory
vaccination (35.4%) and the other twenty countries have a recommended vaccination schedule
(Bozzola et al., 2018).
Opponent
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Many people believe that initiating a mandatory vaccination schedule for children is in
the best interest for the population; however, in todays’ society, social media has created a forum
where parents can congregate with like-minded others to convey their concerns and rights
against vaccinating their children. Social media such as Facebook and YouTube, as well as
celebrities, has become the voice for groups such a Vaccine Choice and the Green Rainbow
Party who use this outlet to oppose mandatory vaccination.
It is their belief that mandatory vaccination impinges upon individual autonomy, privacy,
and liberty rights and challenges parental rights, and secondary burdens of such a mandate
include consequences imposed for nonparticipation, such as school or daycare exclusion
(Silverman & Hendrix, 2015). Other beliefs among these groups include: vaccines that can
produce serious negative health effects and disabilities, they can cause the disease they are
supposed to prevent, most are tainted or contaminated with toxic or carcinogenic substances,
most if not all are not tested for safety with double blind studies or held to rigorous standards that
are required for testing other pharmaceuticals, the risk of injury from some vaccines is greater
than the risk of contracting and being injured by the disease that the vaccine was created to
prevent, flu vaccines are sometimes ineffective for the current endemic strain, yet still can cause
negative health effects, the MMR vaccine is not available as three separate vaccines that would
lesson risk of injury if injected separately, executives from big pharma mega-corporations such
as Merck which produce vaccines have "revolving door" careers as government officials in
regulatory agencies such as the Center for Disease control, the U.S. federal law grants legal
immunity to vaccine makers (pharmaceutical companies), and vaccine makers cannot be held
legally or financially liable for injuries caused by administering the vaccines they produce
(Rolde, 2020). Many believe that supporting Bills such as California SB277 and US HB2527 the
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limitations to just public and private schools, as well as public daycare, could spiral into public
venues as well. Due to these beliefs and state mandates, many parents have opted out of sending
their children to public school, and have instead began to homeschool.
Nursing’s OR Human Services Perspective
Childhood immunization programs that are aimed at achieving or maintaining herd
immunity are justified from both a public health and an ethical perspective. The consensus
among most people are that routine vaccinations are safe for children and that initiating herd
immunity is in the best interest for those children who are unable to receive vaccines. Since the
outbreak of measles in 2014 at the Disneyland amusement park, more states have created laws
that require mandatory immunizations for public schools, as well as public daycare centers and
private schools. According to the CDC (2016) even though all states are now requiring
vaccinations, each state has provided medical exemptions, and some state laws also offer
exemptions for religious and/or philosophical reasons.
However, by protecting individuals from infectious disease, reducing morbidity and
mortality, conferring protection for those of poor health and/or immunocompromised status, and
facilitating herd immunity, the vaccination process is both medical intervention and public health
measure, an individual and a societal good (Silverman & Hendrix, 2015). Therefore, the
germane ethical considerations cannot be limited to those impacting individuals; it is necessary
to consider the policy in a public health ethics context (Silverman & Hendrix, 2015).
Studies and surveys have consistently shown that the key persons for vaccine uptake,
transmission of information and clarifications are physicians and health care workers, who act as
trusted role models whose advice is followed by parents/guardians and patients (Holzmann &
Wiedermann, 2019). Therefore, profound education of medical students in vaccinology and
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further training of physicians of all disciplines—as well as of other health care workers—is a
high priority to improve their knowledge and strengthen their own positive attitudes towards
vaccines (Holzmann & Wiedermann, 2019).
Policy/Bill Recommendations
Vaccines are one of the most important measures of preventative medicine in order to
protect the population from disease and infections. Studies have shown that vaccines have
contributed to the decreasing rates of common childhood diseases and, in some cases, have even
eradicated diseases that were common in past years (Hussain et al., 2018). Beginning vaccination
during early childhood provides protection against specific diseases while reducing the number
of communicable diseases amongst the population (Hussain et al., 2018). Fear of vaccines and
myths against them are not a new phenomenon; however, most parents will choose to vaccinate
their children according to their pediatrician and recommended vaccination schedule. While
exercising autonomy and refusing vaccination is valid for sensitive personal issues, it will cause
more harm than good if a certain percentage of the population does not get vaccines causing the
immunization rate to fall below the herd immunity threshold (Hussain et al., 2018).
The anti-vaccination movement was most strongly rejuvenated in recent years by the
publication of a paper in The Lancet by a former British doctor and researcher, Andrew
Wakefield (Hussain et al., 2018). His research suggested a connection between the measles,
mumps, and rubella (MMR) vaccine and development of autism in young children (Hussain et
al., 2018). Although several studies published later disproved a causal association between the
MMR vaccine and autism, the damage was already done and the myth was spread to many
different parts of the world, especially Western Europe and North America (Hussain et al.,
2018). Wakefield drew severe criticism for his flawed and unethical research methods, which he
used to
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draw his data and conclusions (Hussain et al., 2018). A journalistic investigation also revealed
that there was a conflict of interest with regard to Wakefield’s publication because he had
received funding from litigants against vaccine manufacturers, which he obviously did not
disclose to either his co-workers nor medical authorities (Hussain et al., 2018). For all of the
aforementioned reasons, The Lancet retracted the study, and its editor declared it “utterly false.”
As a result, three months later, he was also struck off the UK Medical Registry, barring him
from practicing medicine in the UK (Hussain et al., 2018). The verdict declared that he had
"abused his position of trust" and "brought the medical profession into disrepute" in the studies
he carried out (Hussain et al., 2018).
Recommendations
Research has shown that many parents lack the basic knowledge of how vaccines work,
as well as access to accurate information explaining the importance of the process. The rise of
anti-vaccination movements across the world confirms these studies which has now posed a dire
threat to people’s health and the collective herd immunity. In recent years, people of all ages
have fallen victim to recent outbreaks of diseases that once was thought of as eradicated
including measles and pertussis. These are some of the most notable “eliminated” diseases that
has made a comeback as a direct consequence of not reaching the immunization threshold
through vaccination. These outbreaks not only put a strain on national healthcare systems but
also cause fatal casualties. Therefore, it is of the utmost importance that all healthcare workers
including but not limited to physicians, nurses, researchers, educators, and governments unite to
curb the influence of the anti-vaccination movement.
Respect for individual autonomy in health care decision making and parental discretion in
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childrearing are core values within our society, and it is important to incorporate any legal
framework principles around these values. I agree that parents have the right to be informed and
decide on vaccinations for their child, and we as healthcare professionals must effectively
combat the inaccurate information pertaining to vaccinations that is spread through social media
and news media platforms. In order to combat the anti-vaccination movement, there must be a
strong emphasis on helping parents develop trust in health professionals, educating them on the
facts and figures, debunking the myths that are spread by the anti-vaccination movements, and
even introducing legislation that promotes vaccination rather than coerces vaccination. For those
that still refuse to vaccinate regardless of recommendation, I believe that they must bear the
financial costs associated with any harm ultimately caused by that conduct.
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