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\par }{\b\scaps\insrsid10906221 Mandatory Vaccination: Why We }{\b\i\scaps\insrsid10906221 Still}{\b\scaps\insrsid10906221  Got to Get Folks to Take Their Shots
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\par Ben Balding
\par Class of 2006
\par April 27, 2006
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\par This paper is submitted in satisfaction of the Food and Drug Law course paper and the Harvard Law School 3L Written Work Requirement
\par 
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{\*\bkmkstart _Toc133934382}ABSTRACT}{\insrsid10906221 {\*\bkmkend _Toc133928167}{\*\bkmkend _Toc133934382}
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\par }{\insrsid13645297 Vaccination is widely considered one of the greatest medical achievements of modern civilization.  Childhood diseases that were commonplace less than a generation ago are now increasingly rare because of vaccines.}{\insrsid10906221   
In order to be effective at }{\insrsid13645297 eliminating}{\insrsid10906221 
 communicable diseases, vaccines must be administered to sufficient levels of persons in the community.  Because of this, public health officials have mandated vaccination for certain diseases as a condition to school
 attendance.  The overwhelming effectiveness of vaccination programs may lead }{\insrsid13645297 individuals}{\insrsid10906221  to ignore the benefits of vaccination and focus more on the risk of side effects.  Moreover, some }{\insrsid13645297 have}{
\insrsid10906221  criticize}{\insrsid13645297 d}{\insrsid10906221  the coercive nature of these programs.  These objections may lead to an unacceptably high number of exemptions, which can compromise vaccination program}{\insrsid13645297 s}{
\insrsid10906221  and leave the }{\insrsid13645297 population}{\insrsid10906221  susceptible to outbreaks.
\par 
\par This paper explores vaccination programs with an eye toward greater public safety without ignoring the
 reality of a small but committed group of vaccine critics.  The paper begins with a discussion of the historical development of mandatory vaccination policies and the issues posed by exemptions.  It then addresses some of these issues in the context of v
a
ccine safety.  It also seeks solution by framing the discussion in economic terms.  It concludes by recommending stricter enforcement of mandatory requirements for most vaccines and greater dissemination of information on the continued importance of vacci
nation.
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\par }{\lang1024\langfe1024\noproof\insrsid470107 Dangers of Widespread Exemptions\tab }{\field{\*\fldinst {\lang1024\langfe1024\noproof\insrsid470107  PAGEREF _Toc133934398 \\h }{\lang1024\langfe1024\noproof\insrsid470107 {\*\datafield 
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\par }{\lang1024\langfe1024\noproof\insrsid470107 Partial Exemptors \endash  A Modern Phenomenon\tab }{\field{\*\fldinst {\lang1024\langfe1024\noproof\insrsid470107  PAGEREF _Toc133934399 \\h }{\lang1024\langfe1024\noproof\insrsid470107 {\*\datafield 
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\b0\caps0\fs24\lang1024\langfe1024\noproof\insrsid470107 \tab }{\lang1024\langfe1024\noproof\insrsid470107 THE ROLE OF THE FEDERAL GOVERNMENT\tab }{\field{\*\fldinst {\lang1024\langfe1024\noproof\insrsid470107  PAGEREF _Toc133934400 \\h }{
\lang1024\langfe1024\noproof\insrsid470107 {\*\datafield 08d0c9ea79f9bace118c8200aa004ba90b02000000080000000e0000005f0054006f0063003100330033003900330034003400300030000000}}}{\fldrslt {\lang1024\langfe1024\noproof\insrsid470107 30}}}{
\b0\caps0\fs24\lang1024\langfe1024\noproof\insrsid470107 
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{\field{\*\fldinst {\lang1024\langfe1024\noproof\insrsid470107  PAGEREF _Toc133934401 \\h }{\lang1024\langfe1024\noproof\insrsid470107 {\*\datafield 
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\par }{\lang1024\langfe1024\noproof\insrsid470107 Thimerosal\tab }{\field{\*\fldinst {\lang1024\langfe1024\noproof\insrsid470107  PAGEREF _Toc133934402 \\h }{\lang1024\langfe1024\noproof\insrsid470107 {\*\datafield 
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\par }{\lang1024\langfe1024\noproof\insrsid470107 Vaccine Injury Compensation Program\tab }{\field{\*\fldinst {\lang1024\langfe1024\noproof\insrsid470107  PAGEREF _Toc133934403 \\h }{\lang1024\langfe1024\noproof\insrsid470107 {\*\datafield 
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\b0\caps0\fs24\lang1024\langfe1024\noproof\insrsid470107 \tab }{\lang1024\langfe1024\noproof\insrsid470107 ANALYTICAL MEANS OF ADDRESSING THE ISSUE\tab }{\field{\*\fldinst {\lang1024\langfe1024\noproof\insrsid470107  PAGEREF _Toc133934404 \\h }{
\lang1024\langfe1024\noproof\insrsid470107 {\*\datafield 08d0c9ea79f9bace118c8200aa004ba90b02000000080000000e0000005f0054006f0063003100330033003900330034003400300034000000}}}{\fldrslt {\lang1024\langfe1024\noproof\insrsid470107 41}}}{
\b0\caps0\fs24\lang1024\langfe1024\noproof\insrsid470107 
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We got to get folks to take their shots\'94 \endash  Sheriff Andy Taylor\tab }{\field{\*\fldinst {\lang1024\langfe1024\noproof\insrsid470107  PAGEREF _Toc133934405 \\h }{\lang1024\langfe1024\noproof\insrsid470107 {\*\datafield 
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\par }{\lang1024\langfe1024\noproof\insrsid470107 Economic Analysis\tab }{\field{\*\fldinst {\lang1024\langfe1024\noproof\insrsid470107  PAGEREF _Toc133934406 \\h }{\lang1024\langfe1024\noproof\insrsid470107 {\*\datafield 
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\par }{\lang1024\langfe1024\noproof\insrsid470107 Altruism and Free Riding\tab }{\field{\*\fldinst {\lang1024\langfe1024\noproof\insrsid470107  PAGEREF _Toc133934408 \\h }{\lang1024\langfe1024\noproof\insrsid470107 {\*\datafield 
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\par }{\lang1024\langfe1024\noproof\insrsid470107 Ex Ante Versus Ex Post\tab }{\field{\*\fldinst {\lang1024\langfe1024\noproof\insrsid470107  PAGEREF _Toc133934409 \\h }{\lang1024\langfe1024\noproof\insrsid470107 {\*\datafield 
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\par }{\lang1024\langfe1024\noproof\insrsid470107 Other Issues\tab }{\field{\*\fldinst {\lang1024\langfe1024\noproof\insrsid470107  PAGEREF _Toc133934410 \\h }{\lang1024\langfe1024\noproof\insrsid470107 {\*\datafield 
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\b0\caps0\fs24\lang1024\langfe1024\noproof\insrsid470107 \tab }{\lang1024\langfe1024\noproof\insrsid470107 CONCLUSION\tab }{\field{\*\fldinst {\lang1024\langfe1024\noproof\insrsid470107  PAGEREF _Toc133934411 \\h }{
\lang1024\langfe1024\noproof\insrsid470107 {\*\datafield 08d0c9ea79f9bace118c8200aa004ba90b02000000080000000e0000005f0054006f0063003100330033003900330034003400310031000000}}}{\fldrslt {\lang1024\langfe1024\noproof\insrsid470107 56}}}{
\b0\caps0\fs24\lang1024\langfe1024\noproof\insrsid470107 
\par }\pard\plain \s1\ql \li0\ri0\sl480\slmult1\keepn\widctlpar\aspalpha\aspnum\faauto\outlinelevel0\adjustright\rin0\lin0\itap0\pararsid1129838 \b\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 }}\pard\plain \s1\ql \li0\ri0\sl480\slmult1
\keepn\widctlpar\aspalpha\aspnum\faauto\outlinelevel0\adjustright\rin0\lin0\itap0\pararsid1129838 \b\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid470107 \page }{\insrsid10906221 {\*\bkmkstart _Toc133934384}INTRODUCTION
{\*\bkmkend _Toc133928168}{\*\bkmkend _Toc133934384}
\par }\pard\plain \ql \li0\ri0\sl480\slmult1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid10906221 
\par }\pard \ql \fi720\li0\ri0\sl480\slmult1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\insrsid10906221 Vaccination is widely consid
ered one of the greatest medical achievements of modern civilization.  Childhood diseases that were commonplace less than a generation ago are now increasingly rare because of vaccines.  The smallpox vaccine has eradicated a disease that was responsible f
or centuries of outbreaks and had a 30% fatality rate.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {
\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  Center for Disease Control, \'93Smallpox Disease Overview,\'94 }{\i\insrsid16601275 at}{\insrsid16601275  }{\insrsid16601275\charrsid14434892 http://www.bt.cdc.gov/agen
t/smallpox/overview/disease-facts.asp}{\insrsid16601275  (last visited April 27, 2006).}}}{\insrsid10906221 
  Physical handicaps resulting from polio can still be observed on some of those who were children before Jonas Salk developed a vaccine in 1955.  Formerly common childhood diseases are now rarely obser
ved.  Even ear infections may soon be prevented by vaccination.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 
\fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  GlaxoSmithKline is currently developing an ear infection vaccine and plans to seek regulatory approval shortly.  Jessica Said, \'93
Vaccine Could End Children\rquote s Ear Infections,\'94 CNN online article, March 3, 2006 (on file with author). }}}{\insrsid10906221   The widespread success of vaccinations has led one medical report to comment that \'93
[n]ext to clean water, no single intervention has had so profound an effect on reducing mortality from childhood diseases as has the widespread introduction of vaccines.\'94}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275 
 Institute of Medicine.  CP Howson, et al. eds. Adverse Effects of Pertussis and Rubella Vaccines.  Washington, DC: National Academy Press; 1991, at 1.}}}{\insrsid10906221 
\par }\pard \ql \li0\ri0\sl480\slmult1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\insrsid10906221 \tab The story of modern vaccination begins with Edward Jenner\rquote 
s development of the vaccine for smallpox, one of the most feared diseases in recent history.  At first, vaccination was optional and not everyone chose to vaccinate.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  James G. Hodge, Jr. and Lawrence O. Gostin, }{\i\insrsid16601275 
School Vaccination Requirements: Historical, Social, and Legal Perspectives}{\insrsid16601275 , 90 Ky. L. J. 831, 867 (2001).}}}{\insrsid10906221 
  In time, states would allow municipalities to mandate vaccination in time of outbreak in order to protect the public from epidemics.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  See, e.g., }{\i\insrsid16601275 Jacobson v. Massachusetts}{
\insrsid16601275 , 197 U.S. 11 (1905).  }}}{\insrsid10906221   A further step }{\insrsid2390683 was taken}{\insrsid10906221  when states imposed smallpox vaccination as a prerequisite for attending public schools.}{\cs17\super\insrsid10906221 \chftn 
{\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  Hodge and Gostin, }{\i\insrsid16601275 
supra}{\insrsid16601275  note 4, at 867.  }}}{\insrsid10906221   These requirements were amended in time as new vaccines were developed.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 Id. }{\insrsid16601275 at 868.}}}{
\insrsid10906221   At some point actual outbreaks and epidemics ceased to be the trigger for mandatory vaccination, and prevention became the overriding justification.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  \'93Rather than having health department
s require immunization in emergency conditions, legislatures acted to prevent disease by mandatory immunization as a condition of enrollment or attendance in schools or licensed day care facilities.\'94  }{\i\insrsid16601275 Id.}}}{\insrsid10906221  
 Most states today require vaccination for a multitude of childhood diseases, including measles, diphtheria, pertussis, polio, and now even chickenpox.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 See id.}{\insrsid16601275 ; }{
\i\insrsid16601275 see also infra}{\insrsid16601275  Part I (chart describing the current recommended vaccination schedule).}}}{\insrsid10906221   
\par }\pard \ql \fi720\li0\ri0\sl480\slmult1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\insrsid10906221 Because of the success and the mandatory nature of vaccination, most people would probably not consid
er vaccination an optional method of medical treatment.  For most parents, the \'93decision\'94 to vaccinate is equivalent to the \'93decision\'94 to feed one\rquote s child.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275 
 The Center for Disease Control has gone so far as to suggest that \'93to have a medical intervention as effective as vaccination in preventing disease not use it would be unconscionable.\'94  Center for Disease Co
ntrol, National Immunization Program publication, \'93Six Common Misconceptions About Vaccination and How to Respond to Them,\'94 }{\i\insrsid16601275 at}{\insrsid16601275  }{\insrsid16601275\charrsid16612792 
http://www.cdc.gov/nip/publications/6mishome.htm}{\insrsid16601275  (last visited April 27, 2006) (hereinafter \'93Six Common Misconceptions\'94).}}}{\insrsid10906221 
  Typically, a doctor informs parents of the school vaccination schedule and the parents consent to 
having their child vaccinated.  Since the vaccination schedule usually corresponds to the scheduled doctor visits for infants, full compliance with mandatory vaccination schedules is typically not a problem and can usually be}{\insrsid6235647 
 substantially}{\insrsid10906221  accomplished by age two.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {
\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  Center for Disease Control, National Immunization Program publication, \'93Ten Things You Need to Know about Immunizations,\'94 }{\i\insrsid16601275 at}{\insrsid16601275  }{
\insrsid16601275\charrsid14434892 http://www.cdc.gov/nip/publications/fs/gen/shouldknow.htm}{\insrsid16601275  (last visited April 27, 2006). }}}{\insrsid10906221   
\par For some parents, however, vaccination is no routine matter.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {
\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  This is not to imply that parents who vaccin
ate without carefully considering the pros and cons of vaccination are in the wrong.  The health and safety of a child is of paramount importance to most parents, and every parent must make decisions that affect the welfare of the child.  Most parents app
roach such decisions with a sincere desire to promote the child\rquote s best interests, and this desire is no different in the context of vaccination.}}}{\insrsid10906221   From the time of Jenner\rquote 
s smallpox vaccine, vaccination has had its critics.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {
\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  \'93Despite its utility, vaccination has provoked popular resistance from the beginning.\'94  Hodge and Gostin, }{\i\insrsid16601275 supra}{\insrsid16601275  note 4, at 834.  }}}{\insrsid10906221 
  In the two centuries since that time, many different types of objections have been raised.  Some have questioned the scientific qualifications of mass immunization.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  \'93
Some opponents express valid scientific objections about effectiveness or need for mass vaccinations; some fear harmful effects arising from the introduction of foreign particles into the human body; and others worry that vaccination
 actually transmits, rather than prevents, disease, or weakens the immune system.\'94  }{\i\insrsid16601275 Id.}}}{\insrsid10906221 
  Others have focused on the personal liberty interests at stake and have objected to the paternalistic nature of government imposition of what is viewed as a personal medical choice.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 See, e.g.}{\insrsid16601275 , }{
\i\insrsid16601275 Jacobson v. Massachusetts}{\insrsid16601275 , 197 U.S. 11 (1905) (constitutional challenge to government mandated smallpox vaccination); \'93Six Common Misconceptions,\'94 }{\i\insrsid16601275 supra}{\insrsid16601275  note 10 (\'93
[s]ome see mandatory vaccination as interference by the government into what they believe should be a personal choice\'94). }}}{\insrsid10906221   Still others have opposed vaccination for personal or religious reasons.}{\cs17\super\insrsid10906221 
\chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  \'93Six Common Misconceptions,\'94 
}{\i\insrsid16601275 supra}{\insrsid16601275  note 10. }}}{\insrsid10906221   
\par Today, some parents raise similar objections.  The idea that a potentially harmful substance is being placed directly into the bloodstream raises a red flag for some.  Additionally, the d
ecline of many diseases for which vaccination is still mandated may make some parents skeptical of the continued wisdom of subjecting a child to a vaccine}{\insrsid6235647 , even if the vaccine is considered extremely safe.  This}{\insrsid10906221 
 skepticism grows when some point to the corr
elation between vaccinations and conditions such as SIDS and autism.  Whether or not such a correlation is scientifically significant, many parents simply wonder if it is wise to vaccinate against a disease unlikely to afflict their child if any chance ex
ists that the vaccine will cause autism, SIDS, or any other side effect.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 
\fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  A more detailed explanation of this subject appears in Part I of this paper.}}}{\insrsid10906221   
\par Since the efficacy of a particular vaccine corresponds directly with the percentage of a given population that has been vaccinated, proponents of mandatory vaccination have sought t
o convince those with reservations about vaccines that vaccination is the right choice.  The Center for Disease Control has attempted to allay possible reservations parents may have with vaccinations by rebutting some of the commonly held fears about vacc
ines.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  
}{\i\insrsid16601275 Id.}}}{\insrsid10906221   The CDC has pointed out, for example, that most adverse effects from vaccines are \'93minor and temporary, such as a sore arm or mild fever.\'94}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 Id.}}}{\insrsid10906221 
  Because vaccination often involves the introduction of a harmful live (although seriously weakened) organism
 into the patient, vaccination can never be 100% safe.  Serious side effects usually occur only between one per thousands to one per millions of doses, while some serious reactions and death occur so rarely that accurate risk assessment is difficult.}{
\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{
\i\insrsid16601275 Id.}}}{\insrsid10906221   The
 CDC has also responded to many of the other concerns raised about the need for vaccination, and the FDA continually works to ensure vaccine safety and efficacy, but many still harbor reservations toward vaccination.  
\par This paper will endeavor to discuss s
ome of the most common objections to vaccination programs in general while trying to shed light on the veracity and tenability of these objections.  Part I will discuss the nature of mandatory vaccination programs in this country; both scientific and hist
o
rical issues will play a key part in this discussion.  Part II will describe the role of the FDA and other governmental bodies in the overall vaccination picture.  Part III will attempt to utilize multiple analytical tools in search of possible solutions 
to the dangers posed by those who may attempt to opt out of vaccination programs.  It will first examine vaccination through the lens of }{\insrsid2522388 an old television show episode}{\insrsid10906221 
.  It will then adopt an economic analytical framework to discuss the balance between indi
vidual and general welfare in the context of vaccination.  Part IV will conclude with some observations on how the goal of greater public health might be achieved without completely neglecting the concerns of many in the community regarding the prudence o
f using a medical technique that by definition relies on a degree of coercion.
\par 
\par }\pard\plain \s1\ql \li0\ri0\sl480\slmult1\keepn\widctlpar\aspalpha\aspnum\faauto\outlinelevel0\adjustright\rin0\lin0\itap0\pararsid10056933 \b\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid10906221\charrsid10056933 
{\*\bkmkstart _Toc133928169}{\*\bkmkstart _Toc133934385}I.\tab MANDATORY VACCINATION{\*\bkmkend _Toc133928169}{\*\bkmkend _Toc133934385}
\par }\pard\plain \ql \li0\ri0\sl480\slmult1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\b\insrsid10906221 
\par }\pard\plain \s2\ql \li0\ri0\sb240\sa60\keepn\widctlpar\aspalpha\aspnum\faauto\outlinelevel1\adjustright\rin0\lin0\itap0\pararsid10056933 \fs24\ul\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid10906221 {\*\bkmkstart _Toc133928170}
{\*\bkmkstart _Toc133934386}Historical Background{\*\bkmkend _Toc133928170}{\*\bkmkend _Toc133934386}
\par }\pard\plain \ql \fi720\li0\ri0\sl480\slmult1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid10906221 Jenner\rquote 
s smallpox vaccine led to the research and development of vaccines for other widespread and epidemic diseases.  The twentieth century saw the development of vaccines for such diseases as polio, diphtheria, tetanus, pertussis, measles, and others.}{
\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{
\i\insrsid16601275 See, e.g.}{\insrsid16601275 , \'93Ten Things You Need to Know about Immunizations,\'94 }{\i\insrsid16601275 supra}{\insrsid16601275  note 11. }}}{\insrsid10906221   }{\insrsid1510493 As with}{\insrsid10906221 
 the smallpox vaccine, many of these vaccines soon found their way into vaccination programs mandated by the government, albeit through a somewhat different pathway.  
\par Mandatory smallpox vaccination programs typically arose through state police power legislation authorizing municipalities to deal with outbreaks.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  Angie A. Welborn, \'93
Mandatory Vaccinations: Precedent and Current Laws,\'94 CRS Report for Congress, }{\i\insrsid16601275 at}{\insrsid16601275  http://www.fas.org/sgp/crs/RS21414.pdf (last updated Jan. 18, 2005). }}}{\insrsid10906221 
  Typically, when a local municipality decided that the threat of outbreak was sufficient to exercise this authority it would require vaccination of everyone in the community}{\insrsid1510493  (with a possible exception for}{\insrsid10906221  individual}{
\insrsid1510493 s}{\insrsid10906221  who could demonstrate uncommonly high health risk}{\insrsid1510493 s}{\insrsid10906221  from receiving the vaccine, although this exception
 sometimes applied only to children) and fine and/or quarantine those who refused to be vaccinated.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 
\fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  For a typical scenario of public health response to outbreak, see the facts of }{\i\insrsid16601275 Jacobson v. Massachusetts}{
\insrsid16601275 , 197 U.S. 11 (1905).}}}{\insrsid10906221   When other diseases became preventable by vaccination, outbreak ceased to be the trigger for mandatory vaccination.  Rather, because of their cost-efficie
ncy and their ability to reduce and ultimately eliminate disease, vaccination programs became an important part of general public health policy.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  Hodge and Gostin, }{\i\insrsid16601275 supra}{\insrsid16601275 
 note 4, at 833-34.   }}}{\insrsid10906221   
\par Most of the time, vaccination programs are accomplished through the dual efforts of national entities (which
 tend to develop and recommend vaccines) and state legislatures and local boards of health (which usually implement these recommended vaccines through vaccination programs).}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 Id.}{\insrsid16601275  at 867-68.  }}}{
\insrsid10906221   It is not entirely accurate to refer to this as \'93mandatory vaccination,\'94 as typically individual states will not criminally punish parents for not vaccinating their children or forcefully subject individuals to vaccination.}{
\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{
\i\insrsid16601275 Id. }{\insrsid16601275 at 833.}}}{\insrsid10906221   Instead, states typically condition school enrollment on proof of vaccination.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 Id.}}}{\insrsid10906221 
  Though it may be a high price
 to pay, home schooling is usually an available means parents have if they wish to bypass these vaccination requirements.  Moreover, most states grant exemptions to vaccination requirements for religious reasons and some even grant exemptions for philosop
hical reasons (in addition, every state exempts from school vaccination requirements individuals who cannot be vaccinated for medical reasons).}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 Id.}}}{\insrsid10906221   
\par The connection between school enrollment and vaccination programs may now seem obvious.  Public health officia
ls, faced with a means of protecting the general population from the harmful disease smallpox, realized that mass vaccination could lead to a sufficient level of immunity to eliminate the risk of outbreak, even for those in the community unable to vaccina
te (because of medical reasons, for instance).}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {
\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  This level of immunity is often referred to as \'93herd immunity,\'94 the concept that not everyone in a population must be vaccinated in order for the entire population to be protected.  Abi Berger, 
\'93How Does Herd Immunity Work?\'94 319 BMJ 1466 (1999).  \'93As long as a sufficient number of children are immunised}{\super\insrsid16601275  }{\insrsid16601275 against each disease for which there is a vaccine, protection}{\super\insrsid16601275  }{
\insrsid16601275 against that disease will be conferred on everybody.\'94  }{\i\insrsid16601275 Id.}{\insrsid16601275   Also, the level of vaccination necessary to attain herd immunity increases as the infectivity of the disease increases.  }{
\i\insrsid16601275 Id.}{\insrsid16601275   Highly infectious diseases, therefore, require higher levels of immunity for herd immunity to occur.  }{\i\insrsid16601275 Id.  }{\insrsid16601275 
The concept of herd immunity will arise throughout this paper, with particular emphasis in Part III.}}}{\insrsid10906221 
  Because of the concept of herd immunity, public health officials considering the proper utilization of vaccines were dealing with a medical procedure quite out of the ordinary.  Since vaccination itself does 
not typically provide 100% immunity to a disease, vaccinated individuals can still contract the disease.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 
\fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  This is evidenced by the
 fact that in time of outbreak, the vaccinated population can still be susceptible to the disease, although usually the vaccinated population is far less susceptible to the disease than the unvaccinated population.  Vaccines typically produce the desired 
antibody in an individual around 90% of the time, with actual percentages varying from vaccine to vaccine.  Some vaccines, moreover, lose their efficacy and require boosters.  These concepts will be further developed throughout this paper.  }}}{
\insrsid10906221   Yet because of herd immunity, if a sufficient level of vaccination within a population is attained, the entire population will no longer be susceptib
le to the disease.  In this way, vaccination came to be viewed not only as a personal medical choice but also as a step taken to improve the overall health of the population.
\par With the rise of public schooling in the mid- to late-nineteenth century, cities decided to condition public school attendance on smallpox vaccination.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  Hodge and Gostin, }{\i\insrsid16601275 supra}{\insrsid16601275 
 note 4, at 850-51.}}}{\insrsid10906221   By the latter part of the century, many states had adopted this practice.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 
\fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 Id. }{\insrsid16601275 at 851.}}}{\insrsid10906221 
  Such a policy makes sense when one considers the increased risk of infectious disease in public areas like 
cities in general and schools in particular.  By mandating vaccination for school attendance, of course, the state would eventually have ensured the vaccination of the entire population by the time the initially vaccinated generation became the oldest liv
ing one.
\par These vaccination schemes have faced challenges, both legal and social, throughout their existence.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 
\fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 Id.}{\insrsid16601275  at 834.}}}{\insrsid10906221 
  The reasons for such challenges have ranged from personal liberty interests to doubts about the efficacy of vaccines.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 Id.}{\insrsid16601275  at 834-35.}}}{
\insrsid10906221   State courts in the nineteenth century typically upheld both the enactment of mandatory vaccination programs and the delegation of power to local authorities.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 See, e.g.}{\insrsid16601275 , }{
\i\insrsid16601275 Duffield v. Sch. Dist.}{\insrsid16601275 , 29 A. 742 (Penn. 1894).}}}{\insrsid10906221   More importantly for the future of mandatory vaccination policy, two important Supreme Court decisions in the early part 
of the twentieth century affirmed the power of state governments both to mandate vaccination and to delegate a broad degree of authority to local municipalities and health boards to carry out particular vaccination programs.  
\par }\pard\plain \s2\ql \li0\ri0\sb240\sa60\keepn\widctlpar\aspalpha\aspnum\faauto\outlinelevel1\adjustright\rin0\lin0\itap0\pararsid10056933 \fs24\ul\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid10906221 {\*\bkmkstart _Toc133928171}
{\*\bkmkstart _Toc133934387}Judicial Approval{\*\bkmkend _Toc133928171}{\*\bkmkend _Toc133934387}
\par }\pard\plain \ql \fi720\li0\ri0\sl480\slmult1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid10906221 In 1905 the Court held in }{\i\insrsid10906221 Jacobson v. Massachusetts}{
\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275 
 197 U.S. 11 (1905).}}}{\insrsid10906221  that the }{\insrsid1510493 general police power}{\insrsid10906221  }{\insrsid1510493 of states is}{\insrsid10906221 
 broad enough to overcome a Due Process claim brought by an individual who claimed his personal liberty interests were unconstitutionally invaded by the mandatory smallpox vaccination program in question.}{\cs17\super\insrsid10906221 \chftn {\footnote 
\pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\i\insrsid16601275  Id.}{\insrsid16601275   }}}{\insrsid10906221 
  In an opinion by Justice Harlan, the Court ruled that the constitutional guarantee of liberty \'93does not import an absolute right in each person, to be, at all times and in all circumstances wholly free from restraint.\'94}{
\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{
\i\insrsid16601275 Id. }{\insrsid16601275 at 26.}}}{\insrsid10906221   
\par This case still represents the initial constitutional basis of most mandatory vaccination legislation.  Many states still provide for the governor or a public health official to mandate vaccination for all in the event of an outbreak.}{
\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275 
 Welborn, }{\i\insrsid16601275 supra}{\insrsid16601275  note 22.}}}{\insrsid10906221   Individuals who cannot vaccinate for health reasons or who refuse to vaccinate may be quarantined in order to protect the population in some states.}{
\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{
\i\insrsid16601275 Id.}}}{\insrsid10906221   These laws gained greater relevance following the terrorist attacks of 9/11 and the increased public concerns regarding bio
terrorism.  For the most part, however, mandatory vaccination laws in the name of outbreak control have given way to vaccination requirements as a prerequisite for school attendance.
\par The issue of school vaccination came before the Court nearly two decades after }{\i\insrsid10906221 Jacobson}{\insrsid10906221 .  In }{\i\insrsid10906221 Zucht v. King}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  260 U.S. 174 (1922). }}}{\insrsid10906221 
, the plaintiff challenged a general grant of authority from Texas to local boards of health to condition }{\insrsid1510493 school entry}{\insrsid10906221  on proof of vaccination.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 Id. }{\insrsid16601275 at 175. }}}{
\insrsid10906221   To differentiate the case from }{\i\insrsid10906221 Jacobson}{\insrsid10906221 , the plaintiff noted that the San Antonio ordinances mandated vaccination even in the absence of evidence of outbreak.}{\cs17\super\insrsid10906221 \chftn 
{\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 Id. }{
\insrsid16601275 (\'93[t]he bill charges that there was then no occasion for requiring vaccination\'94 and that the ordinances \'93in effect, mak[e] vaccination compulsory\'94).  }}}{\insrsid10906221 
  The Court, speaking this time through Justice Brandeis, upheld the validity of the ordinances as well as the broad grant of authority to local health boards.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 Id.}}}{\insrsid10906221   On the issu
e of the state\rquote s power to mandate vaccination, he merely cited }{\i\insrsid10906221 Jacobson}{\insrsid10906221 : \'93[l]ong before this suit was instituted, Jacobson v. Massachusetts\'85
had settled that it is within the police power of a state to provide for compulsory vaccination.\'94}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 
\fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 Id.}{\insrsid16601275  at 176.  }}}{\insrsid10906221   As for entrustin
g a broad degree of authority on local health officials, he noted that }{\i\insrsid10906221 Jacobson}{\insrsid10906221  and other cases had affirmed that a state may \'93
delegate to a municipality authority to determine under what conditions health regulations shall become operative.\'94}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 Id.}}}{\insrsid10906221   This delega
tion includes the permission to vest municipal officials with \'93broad discretion in matters affecting the application and enforcement of a health law.\'94}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 Id.}}}{\insrsid10906221 
  In summary, the Court found that these ordinances were valid assignments of \'93that broad discretion required for the protection of the public health.\'94}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 Id. }{\insrsid16601275 at 177.}}}{
\insrsid10906221   The language of the opinion emphasizes the importance of the public health as the key justification for mandatory vaccination.  
\par }{\i\insrsid10906221 Zucht}{\insrsid10906221 , along with }{\i\insrsid10906221 Jacobson}{\insrsid10906221 , thus became the legal foundation for the mandatory
 vaccination laws of the twentieth century.  Modern school vaccination laws and policies have grown from early mandatory smallpox vaccination laws:
\par }\pard \ql \li1440\ri1440\widctlpar\aspalpha\aspnum\faauto\adjustright\rin1440\lin1440\itap0 {\insrsid10906221 The early successes of school vaccination laws against most political, legal, and social challenges helped l
ay the foundation for modern immunization statutes.  Since the introduction of smallpox vaccination policies in the mid-to-late 1800s, states have amended them to include additional diseases as new vaccines become available.}{\cs17\super\insrsid10906221 
\chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  Hodge and Gostin, }{
\i\insrsid16601275\charrsid15102175 supra}{\insrsid16601275  note 4, at 867-68.}}}{\insrsid10906221   
\par }\pard \ql \li0\ri0\sl480\slmult1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\insrsid10906221 
\par \tab Though various amendments 
and additions have been made to mandatory vaccination laws throughout their history, the past half century has experienced the true culmination of mandatory vaccination policy.  Public health officials have been able to institute a scheme for near-univers
al vaccination:
\par }\pard \ql \li1440\ri1440\widctlpar\aspalpha\aspnum\faauto\adjustright\rin1440\lin1440\itap0 {\insrsid10906221 
Many existing school vaccination laws were enacted in response to the transmission of measles in schools in the 1960s and 1970s.  State legislatures at that time were influenced by the significantly lower incidence rates of measles among sch
ool children in states that strictly enforced vaccination requirements and school exclusions in outbreak situations without significant community opposition.  Rather than having health departments require immunization in emergency conditions, legislatures
 acted to prevent disease by mandatory immunization as a condition of enrollment or attendance in schools or licensed day care facilities.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 Id.}{\insrsid16601275  at 868.}}}{
\insrsid10906221 
\par }\pard \ql \li0\ri0\sl480\slmult1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\insrsid10906221 
\par }\pard \ql \fi720\li0\ri0\sl480\slmult1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\insrsid10906221 Moreover, states have not been completely left to implement the recommended immunization schedule.}{\cs17\super\insrsid10906221 \chftn 
{\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275 
 The schedule of immunizations is published by the Center for Disease Control, and follows the recommendations of the Advisory Committee on Immunizations Practices, the American Academy of Pediatrics\rquote 
 Committee on Infectious Diseases, and the American Academy of Family Physicians. }{\i\insrsid16601275 Id.}}}{\insrsid10906221   Though school r
equirements are still a state matter, national public health officials are typically able to enact their recommendations through federally funded immunization plans.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 Id. }{\insrsid16601275 at 869.}}}{
\insrsid10906221   These plans require states to implement and enforce federally recommended immunization requirements before the states can receive federal funds.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 Id.}}}{\insrsid10906221 
  The current recommended vaccination schedule appears below.
\par }\pard\plain \s2\ql \li0\ri0\sb240\sa60\keepn\widctlpar\aspalpha\aspnum\faauto\outlinelevel1\adjustright\rin0\lin0\itap0\pararsid10056933 \fs24\ul\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid10906221 \page {\*\bkmkstart _Toc133928172}
{\*\bkmkstart _Toc133934388}Recommended Childhood and Adolescent Immunization Schedule}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 
\fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275 
 Based on chart publicized by Center for Disease Control, approved by Advisory Committee on Immunization Practices, American Academy of Pediatrics, American Academy of Family Physicians, }{\i\insrsid16601275 available at }{
\insrsid16601275\charrsid14434892 http://www.cispimmunize.org/IZSchedule_2006.pdf}{\insrsid16601275  (last visited April 27, 2006).}}}{\insrsid10906221 {\*\bkmkend _Toc133928172}{\*\bkmkend _Toc133934388}
\par }\pard\plain \qc \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\b\insrsid10906221 
\par }\trowd \irow0\irowband0\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 
\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 
\cltxlrtb\clftsWidth3\clwWidth2214\clshdrawnil \cellx2106\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2214\clshdrawnil \cellx4320\clvertalt\clbrdrt\brdrs\brdrw10 
\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2214\clshdrawnil \cellx6534\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 
\cltxlrtb\clftsWidth3\clwWidth2214\clshdrawnil \cellx8748\pard \qc \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\b\insrsid10906221 Vaccine\cell Common Name or Symbol\cell Number of Doses\cell Age(s)\cell }\pard 
\ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\b\insrsid10906221 \trowd \irow0\irowband0\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh
\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb
\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2214\clshdrawnil \cellx2106\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2214\clshdrawnil \cellx4320
\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2214\clshdrawnil \cellx6534\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr
\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2214\clshdrawnil \cellx8748\row }\pard \qc \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\insrsid10906221 Hepatitis B \cell HepB\cell 3\cell Birth, 1-2 months, after 24 weeks\cell 
}\pard \ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\insrsid10906221 \trowd \irow1\irowband1\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh
\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb
\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2214\clshdrawnil \cellx2106\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2214\clshdrawnil \cellx4320
\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2214\clshdrawnil \cellx6534\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr
\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2214\clshdrawnil \cellx8748\row }\pard \qc \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\insrsid10906221 Diphtheria and tetanus toxoids and acellular pertussis\cell DTaP\cell 5+\cell 
2 months, 4 months, 6 months, 15-18 months, 4-6 years, Td booster at age 12 and every 10 years thereafter\cell }\pard \ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\insrsid10906221 \trowd \irow2\irowband2
\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 
\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 
\cltxlrtb\clftsWidth3\clwWidth2214\clshdrawnil \cellx2106\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2214\clshdrawnil \cellx4320\clvertalt\clbrdrt\brdrs\brdrw10 
\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2214\clshdrawnil \cellx6534\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 
\cltxlrtb\clftsWidth3\clwWidth2214\clshdrawnil \cellx8748\row }\pard \qc \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\i\insrsid10906221 Haemophilus influenzae}{\insrsid10906221  type b conjugate \cell Hib\cell 3\cell 2 mon
ths, 4 months, 12-15 months\cell }\pard \ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\insrsid10906221 \trowd \irow3\irowband3\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 
\trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol \clvertalt\clbrdrt\brdrs\brdrw10 
\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2214\clshdrawnil \cellx2106\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 
\cltxlrtb\clftsWidth3\clwWidth2214\clshdrawnil \cellx4320\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2214\clshdrawnil \cellx6534\clvertalt\clbrdrt\brdrs\brdrw10 
\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2214\clshdrawnil \cellx8748\row }\pard \qc \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\insrsid10906221 Inactivated Poliovirus 
\cell IPV\cell 4\cell 2 months, 4 months, 6-18 months, 4-6 years\cell }\pard \ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\insrsid10906221 \trowd \irow4\irowband4\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl
\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 
\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 
\cltxlrtb\clftsWidth3\clwWidth2214\clshdrawnil \cellx2106\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2214\clshdrawnil \cellx4320\clvertalt\clbrdrt\brdrs\brdrw10 
\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2214\clshdrawnil \cellx6534\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 
\cltxlrtb\clftsWidth3\clwWidth2214\clshdrawnil \cellx8748\row }\pard \qc \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\insrsid10906221 Measles, mumps, and rubella\cell MMR\cell 2\cell 
Two shots at least four weeks apart beginning at age 12 months\cell }\pard \ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\insrsid10906221 \trowd \irow5\irowband5\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl
\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 
\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 
\cltxlrtb\clftsWidth3\clwWidth2214\clshdrawnil \cellx2106\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2214\clshdrawnil \cellx4320\clvertalt\clbrdrt\brdrs\brdrw10 
\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2214\clshdrawnil \cellx6534\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 
\cltxlrtb\clftsWidth3\clwWidth2214\clshdrawnil \cellx8748\row }\pard \qc \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\insrsid10906221 Varicella\cell Chickenpox\cell 1\cell Any time after age 12 months if 
the child has not had chickenpox\cell }\pard \ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\insrsid10906221 \trowd \irow6\irowband6\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 
\trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol \clvertalt\clbrdrt\brdrs\brdrw10 
\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2214\clshdrawnil \cellx2106\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 
\cltxlrtb\clftsWidth3\clwWidth2214\clshdrawnil \cellx4320\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2214\clshdrawnil \cellx6534\clvertalt\clbrdrt\brdrs\brdrw10 
\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2214\clshdrawnil \cellx8748\row }\pard \qc \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\insrsid10906221 Meningococcal\cell MCV4
\cell 1\cell 11-12 years\cell }\pard \ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\insrsid10906221 \trowd \irow7\irowband7\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr
\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2214\clshdrawnil \cellx2106\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 
\cltxlrtb\clftsWidth3\clwWidth2214\clshdrawnil \cellx4320\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2214\clshdrawnil \cellx6534\clvertalt\clbrdrt\brdrs\brdrw10 
\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2214\clshdrawnil \cellx8748\row }\pard \qc \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\insrsid10906221 Pneumococcal\cell PCV
\cell 4\cell 2 months, 4 months, 6 months, 12 months\cell }\pard \ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\insrsid10906221 \trowd \irow8\irowband8\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 
\trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol \clvertalt
\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2214\clshdrawnil \cellx2106\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 
\cltxlrtb\clftsWidth3\clwWidth2214\clshdrawnil \cellx4320\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2214\clshdrawnil \cellx6534\clvertalt\clbrdrt\brdrs\brdrw10 
\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2214\clshdrawnil \cellx8748\row }\pard \qc \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\insrsid10906221 Influenza\cell Influenza
\cell Annual\cell 6 months and annually thereafter for children with certain risk factors\cell }\pard \ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\insrsid10906221 \trowd \irow9\irowband9\ts11\trgaph108\trleft-108\trbrdrt
\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 
\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 
\cltxlrtb\clftsWidth3\clwWidth2214\clshdrawnil \cellx2106\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2214\clshdrawnil \cellx4320\clvertalt\clbrdrt\brdrs\brdrw10 
\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2214\clshdrawnil \cellx6534\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 
\cltxlrtb\clftsWidth3\clwWidth2214\clshdrawnil \cellx8748\row }\pard \qc \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\insrsid10906221 Hepatitis A\cell HepA\cell 2\cell First dos
e at 12 months, second dose at least 6 months thereafter\cell }\pard \ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\insrsid10906221 \trowd \irow10\irowband10\lastrow \ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl
\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 
\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 
\cltxlrtb\clftsWidth3\clwWidth2214\clshdrawnil \cellx2106\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2214\clshdrawnil \cellx4320\clvertalt\clbrdrt\brdrs\brdrw10 
\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2214\clshdrawnil \cellx6534\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 
\cltxlrtb\clftsWidth3\clwWidth2214\clshdrawnil \cellx8748\row }\pard \ql \fi720\li0\ri0\sl480\slmult1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\insrsid10906221 
\par \page 
\par }\pard\plain \s2\ql \li0\ri0\sb240\sa60\keepn\widctlpar\aspalpha\aspnum\faauto\outlinelevel1\adjustright\rin0\lin0\itap0\pararsid10056933 \fs24\ul\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid10906221 {\*\bkmkstart _Toc133928173}
{\*\bkmkstart _Toc133934389}Challenges and Concessions{\*\bkmkend _Toc133928173}{\*\bkmkend _Toc133934389}
\par }\pard\plain \ql \li0\ri0\sl480\slmult1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid10906221 \tab 
While school vaccination requirements have been credited with bringing about the control and elimination of many devastating childhood diseases, critics have continued
 to voice concerns and raise legal and political challenges to the entire process of mandatory vaccination.  
\par }\pard\plain \s3\ql \li0\ri0\sb240\sa60\keepn\widctlpar\aspalpha\aspnum\faauto\outlinelevel2\adjustright\rin0\lin0\itap0\pararsid10056933 \i\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid10906221 {\*\bkmkstart _Toc133928174}
{\*\bkmkstart _Toc133934390}Personal Liberty Concerns{\*\bkmkend _Toc133928174}{\*\bkmkend _Toc133934390}
\par }\pard\plain \ql \fi720\li0\ri0\sl480\slmult1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid10906221 
One key argument against mandatory school vaccination has always focused on government intrusion into what is considered a personal medical choice.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  Indeed, the law in }{\i\insrsid16601275 Jacobson}{
\insrsid16601275  was challenged for this reason.}}}{\insrsid10906221 
  Just as the government cannot force a person to have surgery to repair a torn ligament, for example, the government should not be able to force parents to vaccinate their children if the parents believe that vaccination is not
 the best medical decision.  One prominent critic of mandatory vaccination has stated her organization\rquote s goal as simply providing parents with choices: \'93
[w]e believe that health care consumers should have the right to choose the type of preventive he}{\insrsid1510493 alth care that they want to use \endash  }{\insrsid10906221 including choosing whether to use one, ten, or no vaccines.\'94}{
\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275 
 Statement of Barbara Fisher, founder of National Vaccine Information Center, }{\i\insrsid16601275 quoted in}{\insrsid16601275  Neenyah Ostrom, \'93First Do No Harm,\'94 }{\i\insrsid16601275 at}{\insrsid16601275 
 http://www.chronicillnet.org/online/Fisher.html (last visited April 27, 2006). }}}{\insrsid10906221   Other objections }{\insrsid1510493 along}{\insrsid10906221 
 similar bases argue that mandatory vaccination violates the medical ethic of informed consent or even that school district control over mandatory vaccination policies amounts to the unlawful practice of medicine without a license.}{
\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275 
 K.N.O.W. Vaccines, Vaccine Awareness of Florida fact sheet, }{\i\insrsid16601275 at}{\insrsid16601275  }{\insrsid16601275\charrsid14434892 http://www.know-vaccines.org/vaccine_fact.html}{\insrsid16601275  (last visited April 27, 2006).}}}{
\insrsid10906221 
\par }\pard \ql \fi720\li0\ri0\sl480\slmult1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\insrsid10906221 The typical counterargument given by the public health officials is to point out that one\rquote s decision to vaccinate, unlike one
\rquote s decision whether to undergo surgery, affects the health of others in the community.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 
\fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  The most direct way 
in which this occurs surrounds the concept of herd immunity, as discussed elsewhere throughout this paper.  If a sufficient number of persons in the community does not vaccinate, herd immunity may be unattainable and others may be put at risk.}}}{
\insrsid10906221   To allow parents the right to choose not to vaccinate is to infringe on the ability of other parents to raise their children in a society free of certain deadly diseases.  From a legal standpoint, }{\i\insrsid10906221 Jacobson}{
\insrsid10906221  still seems to have settled the issue that at least under some circumstances, the government may force an individual to receive a vaccination.  
\par }\pard \ql \fi720\li0\ri0\sl480\slmult1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\insrsid10906221 Although public health officials have the legal authority to mandate vaccination for the public health under Jaco
bson, they should be very mindful of the personal liberty concerns just stated.  Those with such views often cling to them vigorously.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 See, e.g.}{\insrsid16601275 ,
 the discussion in Part III involving The Andy Griffith Show.}}}{\insrsid10906221   As certain vaccine-preventable diseases decline, such concerns become even stronger.  For this reason, it is important 
for public health officials to support their mandatory vaccination programs with justifiable arguments rather than simply citing }{\insrsid9786353 legal}{\insrsid10906221  precedent }{\insrsid9786353 or historical tradition in support of}{
\insrsid10906221  their exercise of power.}{\insrsid9786353   Fortunately for public health officials, the benefits provided by vaccination programs can be utilized to justify the existence of such programs. }{\insrsid10906221 
\par }\pard\plain \s3\ql \li0\ri0\sb240\sa60\keepn\widctlpar\aspalpha\aspnum\faauto\outlinelevel2\adjustright\rin0\lin0\itap0\pararsid10056933 \i\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid10906221 {\*\bkmkstart _Toc133928175}
{\*\bkmkstart _Toc133934391}Safety Accountability Concerns{\*\bkmkend _Toc133928175}{\*\bkmkend _Toc133934391}
\par }\pard\plain \ql \fi720\li0\ri0\sl480\slmult1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid10906221 
A variation on the consumer choice challenge to mandatory school vaccination requirements tends to accuse the public health community of conspiring with or at least willfully acquiescing to powerful vaccine manufacturers at the expense of citizens.}{
\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{
\i\insrsid16601275 See}{\insrsid16601275  Statement of Barbara Fisher, }{\i\insrsid16601275 quoted in}{\insrsid16601275  Ostrom, }{\i\insrsid16601275 supra}{\insrsid16601275  note \-\-56.  }{\i\insrsid16601275 See also }{\insrsid16601275 \'93
Autism and Vaccines: Activists Wage a Nasty Campaign to Silence Scientists,\'94 Wall Street Journal, February 16, 2004, }{\i\insrsid16601275 at}{\insrsid16601275 
 http://www.opinionjournal.com/forms/printThis.html?id=110004700 (last visited April 27, 2006) (citing vaccination critics who had accused the vaccination-defending writers of \'93having an \lquote industry profit promoting agenda\rquote \'94).}}}{
\insrsid10906221   Mandatory programs, the argument goes, eliminate any accountability from vaccine manufacturers that the free market might otherwise provide.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 See}{\insrsid16601275  Statement of Barbar
a Fisher, }{\i\insrsid16601275 quoted in}{\insrsid16601275  Ostrom, }{\i\insrsid16601275 supra}{\insrsid16601275  note \-\-56.}}}{\insrsid10906221 
  Both the safety and efficacy of vaccines fail to improve because manufacturers do not have to respond to consumer concerns.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 Id.}}}{\insrsid10906221 
  Mandatory programs thus prevent better vaccines.  A prominent critic of these programs has stated that if mandatory vaccination programs are ended, \'93
we will have the ability to put economic pressure on the drug companies and on the health agencies to do a better job with vaccine safety and efficacy.\'94}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 Id.}{\insrsid16601275  }}}{\insrsid10906221 
  
\par The strength of this argument lies in its apparent lack of hostility
 toward vaccines per se.  Given the historical success of vaccination in eradicating smallpox and in reducing or eliminating the risk of other childhood diseases, any critique of mandatory vaccination programs that focuses on the use of vaccines generally
 
is likely to be dismissed by those in the field of public health.  By focusing on the economic drawbacks inherent in a mandatory vaccination program and how those drawbacks can negatively affect the quality of vaccines, this argument may gain more tractio
n.  Indeed, all sides of this debate claim to desire both safer and more effective vaccines.
\par The response to this argument, I would imagine, would be to emphasize the drawbacks of opening up the \'93market\'94 in this case.  Because vaccination programs depend on
 a sufficient percentage of the community being vaccinated, complete consumer choice carries with it problems that might be absent in a standard market.  As for vaccine quality, FDA regulation is in place to ensure a sufficient level of safety and efficac
y to accomplish the goals of vaccination.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {
\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  See the discussion in Part II regarding vaccine safety.}}}{\insrsid10906221 
  The pressure faced by vaccine manufacturers to obtain and maintain FDA approval should provide a check sufficient to guarantee proper vaccine quality.  If not, the answer should be to raise FDA standards, rather t
han to jettison the entire mandatory vaccination process and with it the likelihood of maintaining a sufficient level of immunity among the population.
\par This response might be unacceptable to those concerned.  If the connection between public health officia
ls entrusted with implementing the mandatory vaccination schedule and FDA regulators entrusted with ensuring the safety and efficacy of vaccines is seen as too close, proposing higher FDA standards as a solution may not allay concerns.  The independence a
nd integrity of FDA is therefore critical in this arena, just as it is in other areas of public health. 
\par }\pard\plain \s3\ql \li0\ri0\sb240\sa60\keepn\widctlpar\aspalpha\aspnum\faauto\outlinelevel2\adjustright\rin0\lin0\itap0\pararsid10056933 \i\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid10906221 {\*\bkmkstart _Toc133928176}
{\*\bkmkstart _Toc133934392}Concern of Unknown Risks{\*\bkmkend _Toc133928176}{\*\bkmkend _Toc133934392}
\par }\pard\plain \ql \li0\ri0\sl480\slmult1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid10906221 \tab 
In what may be a combination of the two challenges previously discussed, many individuals challenge vaccine programs because of a lack of information about vaccines.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 See, e.g.}{\insrsid16601275 , \'93
Six Common Misconceptions,\'94 }{\i\insrsid16601275 supra}{\insrsid16601275  note 10.}}}{\insrsid10906221 
  Many people, for example, legitimately question the wisdom of forced vaccination before long-term effects of a vaccine are studied.  One website that purports \'93to provide a wide range of news and views on vaccination and vaccination policy\'94
 has summarized this challenge to vaccines simply as opposing the idea of \'93a parent, any parent, being forced to do something that has even a remote chance of harming their child.\'94}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  Mission Statement of Vaccination News website, }{
\i\insrsid16601275 at}{\insrsid16601275  }{\insrsid16601275\charrsid14434892 http://www.vaccinationnews.com}{\insrsid16601275  (last visited April 27, 2006).}}}{\insrsid10906221   Since long-term (ten or more years down the roa
d) and low-risk (on the order of one-per-million or less, for example) side effects may truly be unknown, this concern does present a challenge for public health officials.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275 
 As the discussion in Part II on vaccine safety demonstrates, pre-licensing testing for very rare adverse effects cannot take place if vaccines are ever to reach the market.  Phase 4 post-licensing testing does exist, but ma
y take years to discover extremely rare adverse effects.}}}{\insrsid10906221   
\par }\pard \ql \fi720\li0\ri0\sl480\slmult1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\insrsid10906221 Unfortunately, even the best studies are unable to fully determine all long-term consequences of vaccination.  In addition, \'93}{
\cf1\insrsid10906221 [t]here is no such thing as a \lquote perfect\rquote  vaccine which protects everyone who receives it AND is entirely safe for everyone.\'94}{\cs17\cf1\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  World Health Organization Immunization Safety page, \'93
Adverse Events Following Immunization,\'94 }{\i\insrsid16601275 at}{\insrsid16601275  }{\insrsid16601275\charrsid14434892 http://www.who.int/immunization_safety/aefi/en/}{\insrsid16601275  (last visited April 27, 2006). }}}{\cf1\insrsid10906221   }{
\insrsid10906221 Therefore, it is true that mandatory vaccination probably forces }{\ul\insrsid10906221 some}{\insrsid10906221  parents to inject their children with a substance that will cause }{\ul\insrsid10906221 some}{\insrsid10906221  unknown harm.  

\par As with the other objections to mandatory vaccination, however, this objection suffers from a critical flaw.  Mandatory school vaccination requirements are not justified solely on the 
benefit they provide to the recipient.  Instead, it is the benefit they provide to the community as a whole by ensuring a sufficient level of vaccination to prevent outbreak that justifies their intrusive nature on individual medical decision-making.}{
\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275 
 As the recent mumps
 outbreak in Iowa demonstrates, not everyone who receives a vaccine develops immunity to the disease.  For this reason, the success of vaccination depends on a sufficient level of vaccination in the community.  When a significant percentage of the populat
ion has not received the vaccine, an outbreak can occur and even threaten some of those who have been vaccinated.   }{\i\insrsid16601275 See}{\insrsid16601275  David Pitt, \'93Iowa Mumps Epidemic Continues to Broaden,\'94
 Associated Press, April 13, 2006, }{\i\insrsid16601275 at}{\insrsid16601275  }{\insrsid16601275\charrsid14434892 http://www.breitbart.com/news/2006/04/13/D8GVGL600.html}{\insrsid16601275 
 (last visited April 27, 2006).  See also the above discussion of the history of vaccination.}}}{\insrsid10906221   For this reason, if public health officials did not enact the mandatory vaccination program, they }{\ul\insrsid10906221 would}{
\insrsid10906221  be forcing on parents a system that had at least a \'93remote chance of harming their child.\'94}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 
\fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  Mission Statement of Vaccination News website, }{\i\insrsid16601275 supra }{\insrsid16601275 note 66.}}}{\insrsid10906221 
  Because the decision to enact a community-wide vaccination pro
gram must be made at the general level if it is to be made at all, and because some children will undoubtedly suffer some health consequences regardless of which policy is chosen, individuals will always be able to raise this argument against mandatory va
ccination programs.  
\par A better critique of these programs would focus on whether mandatory vaccination causes more }{\ul\insrsid10906221 overall}{\insrsid10906221 
 harm than a voluntary system; that is, is it better when viewed at the general, rather than the individual, level?  Ironically, the ve
ry success of vaccination programs in reducing the incidence of once-prominent diseases has led some to ignore the overall and continuing benefit of community vaccination (herd immunity).}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 See, e.g.}{\insrsid16601275 
, Ross D. Silverman, \'93No More Kidding Around: Restructuring Non-Medical Childhood Immunization Exemptions to Ensure Public Health Protection,\'94 12 Annals Health L. 277, 278-79 (2003). 
\par }\pard \s16\ql \li720\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin720\itap0 {\insrsid16601275 [A]s risks of contracting many deadly and crippling diseases continue to decline to near negligible levels, and rates of childhood immunization cont
inue to reach record levels, the public today places greater attention on the relative weaknesses and dangers of immunizations, and the systems through which they are administered.
\par }\pard \s16\ql \li720\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin720\itap0 {\i\insrsid16601275 Id.}}}{\insrsid10906221   But for parents to decry the \'93remote chance\'94 of harm from vaccinat
ion while ignoring the very real chance of outbreak in an under-vaccinated population is to reframe the issue entirely.  
\par }\pard\plain \s3\ql \li0\ri0\sb240\sa60\keepn\widctlpar\aspalpha\aspnum\faauto\outlinelevel2\adjustright\rin0\lin0\itap0\pararsid10056933 \i\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid10906221 {\*\bkmkstart _Toc133928177}
{\*\bkmkstart _Toc133934393}Other Concerns{\*\bkmkend _Toc133928177}{\*\bkmkend _Toc133934393}
\par }\pard\plain \ql \fi720\li0\ri0\sl480\slmult1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid10906221 
Other challenges to vaccination laws have cited strongly held religious or philosophical positions against vaccination 
in general.  Such challenges require a different type of response from public health officials; often the options are limited to overriding such objections and excluding children of parents adhering to such positions from public schools (which is constitu
tionally permissible under }{\i\insrsid10906221 Jacobson}{\insrsid10906221  and its progeny) or creating exemptions to vaccination requirements (which is detrimental to the overall goals of mandatory vaccination if a sufficient number of }{
\insrsid9786353 exemptors}{\insrsid10906221  exist).  Reactions to such religious and philosophical concerns vary from state to state, with a general trend toward greater accommodation of objectors.
\par }\pard\plain \s2\ql \li0\ri0\sb240\sa60\keepn\widctlpar\aspalpha\aspnum\faauto\outlinelevel1\adjustright\rin0\lin0\itap0\pararsid10056933 \fs24\ul\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid10906221 {\*\bkmkstart _Toc133928178}
{\*\bkmkstart _Toc133934394}Exemptions{\*\bkmkend _Toc133928178}{\*\bkmkend _Toc133934394}
\par }\pard\plain \ql \fi720\li0\ri0\sl480\slmult1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid10906221 
In response to these and other challenges to mandatory vaccination laws, states have enacted various exemptions to vaccination requirements for school entry.  Actual enforcement varies by state.}{\i\insrsid10906221 
\par }\pard\plain \s3\ql \li0\ri0\sb240\sa60\keepn\widctlpar\aspalpha\aspnum\faauto\outlinelevel2\adjustright\rin0\lin0\itap0\pararsid10056933 \i\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid10906221 {\*\bkmkstart _Toc133928179}
{\*\bkmkstart _Toc133934395}Medical{\*\bkmkend _Toc133928179}{\*\bkmkend _Toc133934395}
\par }\pard\plain \ql \fi720\li0\ri0\sl480\slmult1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid10906221 
All states provide exemptions for those with medical risks associated with vaccines.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 
\fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  Hodge and Gostin, }{\i\insrsid16601275 supra}{\insrsid16601275  note 4, at 874.}}}{\insrsid10906221 
  If certain contraindications indicate a likelihood of harm from a particular vaccine, the exemption will be allowed.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  Usually this requires physician certification.  }{
\i\insrsid16601275 Id.}}}{\insrsid10906221   Because such cases are rare and exemptions relatively easy to enforce, there usually is very little risk of compromising the efficacy of the overall vaccination program by granting these exemptions.}{
\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275 
 Indeed, the CDC itself presupposes the existence of medical exemptors in any broad mandatory vaccination program.  }{\i\insrsid16601275 See }{\insrsid16601275 \'93Six Common Misconceptions,\'94 }{\i\insrsid16601275 supra}{\insrsid16601275 
 note 10 (noting that the mandatory vaccination program can work to protect even those few who cannot vaccinate because of the possibility of adverse medical reactions). }}}{\insrsid10906221   The ability to grant medical exemptions wh
ile still maintaining sufficient levels of vaccination to provide community-wide immunity is one of the great accomplishments of the vaccination system.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 Id.}}}{\insrsid10906221 
\par }\pard\plain \s3\ql \li0\ri0\sb240\sa60\keepn\widctlpar\aspalpha\aspnum\faauto\outlinelevel2\adjustright\rin0\lin0\itap0\pararsid10056933 \i\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid10906221 {\*\bkmkstart _Toc133928180}
{\*\bkmkstart _Toc133934396}Religious{\*\bkmkend _Toc133928180}{\*\bkmkend _Toc133934396} 
\par }\pard\plain \ql \fi720\li0\ri0\sl480\slmult1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid10906221 
In addition to medical exemptions, almost every state grants religious exemptions for those with sincere religious beliefs }{\insrsid9130705 opposing}{\insrsid10906221  vaccination.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  Hodge and Gostin, }{\i\insrsid16601275 supra}{\insrsid16601275 
 note 4, at 874.}}}{\insrsid10906221   Individual states tend to vary with regard to the level of religious conviction necessary to obtain a religious exemption.  Such exemptions reflect the sometimes uneasy balance between mandatory vacci
nation programs and First Amendment Free Exercise rights, even though the Supreme Court has validated the right of states to mandate vaccination without providing for such exemptions.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 Jacobson v. Massachusetts}{\insrsid16601275 
, 197 U.S. 11 (1905).  }{\i\insrsid16601275 See also}{\insrsid16601275  }{\i\insrsid16601275 Employment Division v. Smith}{\insrsid16601275 , 494 U.S. 872 (1990) (permitting neutral laws of general applicability that incidentally affect religion); }{
\i\insrsid16601275 Boone v. Boozman}{\insrsid16601275 , 217 F.Supp.2d 938 (E.D. Ark. 2002) (\'93constitutionally-protected free exercise of religion does not excuse an individual from compulsory immunization\'85the rig
ht to free exercise of religion and parental rights are subordinated to society\rquote s interest in protecting against the spread of disease\'94).  }}}{\insrsid10906221   West Virginia, for example, does not provide religious exemptions.}{
\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275 
 W. Va. Code Sec. 16-3-4 (2004).}}}{\insrsid10906221   
\par Some religious exemption statutes have spurred challenges on Establishment Clause grounds by those who claim they favor organized or recognized religions over the sincerely held religious views of others.}{\cs17\super\insrsid10906221 \chftn {\footnote 
\pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 See, e.g.}{\insrsid16601275 , }{
\i\insrsid16601275 Boone v. Boozman}{\insrsid16601275 , 217 F.Supp.2d 938 (E.D. Ark. 2002).  The challenged Arkansas immunization statute exempted \'93individuals for whom \lquote 
immunization conflicts with the religious tenets and practices of a recognized church or religious denomination of which [they are] an adherent or member.\rquote \'94  The statute was struck down under the Establishment Clause using the test laid out in }
{\i\insrsid16601275 Lemon v. Kurtzman}{\insrsid16601275 , 403 U.S. 602 (1971).  217 F.Supp.2d at 950.  The Arkansas legislature subsequently amended the exemption generally to allow for religious or philosophical objections without regard to re
cognized churches.  Ark. Code Sec. 6-18-702(d).    }}}{\insrsid10906221   These challenges, if successful, would lead to the invalidation of many religious exemption statutes.  Rather than decrease the number of religious exemptors, however, this may }{
\insrsid9130705 actually lead to more religious}{\insrsid10906221  exemptors.  The political climate of our day, along with the experience of a few states already 
(such as Arkansas), suggests that legislatures may respond to invalidation of religious exemption statutes that require adherence to an organized religion by drafting more general and expansive religious exemption statutes.}{\cs17\super\insrsid10906221 
\chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 See}{
\insrsid16601275  Silverman, }{\i\insrsid16601275 supra}{\insrsid16601275  note 71, at 290-93.}}}{\insrsid10906221   By subjugating religion to com
pulsory vaccination, courts may actually be helping to bring about a system with even more religious exemptors, thereby harming the very vaccination programs to which religious objections had been subordinated.}{\cs17\super\insrsid10906221 \chftn 
{\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 See id.}}}{
\insrsid10906221   
\par }\pard\plain \s3\ql \li0\ri0\sb240\sa60\keepn\widctlpar\aspalpha\aspnum\faauto\outlinelevel2\adjustright\rin0\lin0\itap0\pararsid10056933 \i\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid10906221 {\*\bkmkstart _Toc133928181}
{\*\bkmkstart _Toc133934397}Philosophical{\*\bkmkend _Toc133928181}{\*\bkmkend _Toc133934397}\tab 
\par }\pard\plain \ql \fi720\li0\ri0\sl480\slmult1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid10906221 The possibility that some p
arents who strongly oppose vaccination for other than religious reasons has led to other means of exempting from mandatory vaccination programs.  In some states, people may avoid vaccination requirements by way of philosophical exemptions.}{
\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275 
 Hodge and Gostin, }{\i\insrsid16601275 supra}{\insrsid16601275  note 4, at 874.}}}{\insrsid10906221   In California, for example, a parent need only \'93submit a letter or affidavit stating that the immunization is contrary to his or her beliefs\'94
 to exempt their child from vaccination requirements.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {
\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  Cal. Health and Safety Code Sec. 120365 (2003).}}}{\insrsid10906221   \'93Where available, parents are taking advantage of such exemptions with gr
owing regularity; and in states offering both exemptions, the number of philosophical exemptions far exceeds the number of religious and medical exemptions.\'94}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  Silverman, }{\i\insrsid16601275 supra}{\insrsid16601275 
 note 71, at 284.  }}}{\insrsid10906221   
\par States without philosophical exemptions, moreover, are often lax with their enforcement of religious exemptions.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 
\fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 Id. }{\insrsid16601275 at 285.}}}{\insrsid10906221 
  Because of this, parents in these states can usually submit insincere affidavits purporting to object to vaccination for religious reasons and local health officials, unconcerned with delving into the sincerity of such affidavits, will 
widely grant exemptions.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }
{\insrsid16601275  }{\i\insrsid16601275 Id.}}}{\insrsid10906221 
  In most states, therefore, persistent parents can usually find some way to exempt their children from vaccination requirements.  If all else fails and vaccination is still regarded as unacceptable to the parent, the option of hom
e schooling may provide a final avenue }{\insrsid9130705 of evading these }{\insrsid10906221 school vaccination requirements.
\par }\pard\plain \s3\ql \li0\ri0\sb240\sa60\keepn\widctlpar\aspalpha\aspnum\faauto\outlinelevel2\adjustright\rin0\lin0\itap0\pararsid10056933 \i\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid10906221 {\*\bkmkstart _Toc133928182}
{\*\bkmkstart _Toc133934398}Dangers of Widespread Exemptions{\*\bkmkend _Toc133928182}{\*\bkmkend _Toc133934398}
\par }\pard\plain \ql \fi720\li0\ri0\sl480\slmult1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid10906221 
The ease with which non-medical exemptions can typically be obtained has raised concerns among many that the benefits of widespread immunization are being compromised.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 See id.}}}{\insrsid10906221 
  Because of the nature of medical exemptions, unvaccinated persons in a community with only medical exemptions would be expected to be few and dispersed.   Herd immunity can be attained, and protection is ensured for both
 the vaccinated majority and the unvaccinated few.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {
\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  Recall that for those unable to vaccinate for medical reasons, herd immunity provides the only protection from the disease.  }{\i\insrsid16601275 See}{\insrsid16601275  \'93Six Common Misconceptions,
\'94 }{\i\insrsid16601275 supra}{\insrsid16601275  note \-\-10.}}}{\insrsid10906221 
  Broadly granted philosophical and religious exemptions make herd immunity more difficult to attain and increase the risk to the community.  This risk is exacerbated by the fact that many of those who apply for such exemptions \'93
will cluster together in one geographic area.\'94}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {
\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  Silverman, }{\i\insrsid16601275 supra}{\insrsid16601275  note \-\-71, at 285. }}}{\insrsid10906221   This cluster effect tends to increase the likelihood of serious outbreaks:
\par }\pard \ql \li1440\ri1440\widctlpar\aspalpha\aspnum\faauto\adjustright\rin1440\lin1440\itap0 {\insrsid10906221 Recent studies have shown that clusters of exemptors, who are significantly more susceptible to contracting 
vaccine preventable illnesses, pose an increased risk of spread of diseases not only to their unimmunized peers, but also to the surrounding, largely vaccinated population.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 Id.}{\insrsid16601275 
  The recent mumps outbreak may directly demonstrate this.  Officials have pointed out that vaccination only confers immunity on 95% of patients, and of those affected in the recent outbreak, 25% have been vaccinated.  }{\i\insrsid16601275 See}{
\insrsid16601275  Pitt, }{\i\insrsid16601275 supra}{\insrsid16601275  note 69.  The strong implication is that the 75% of those inflicted who were not vaccinated have put the entire community at risk.  }}}{\insrsid10906221  
\par }\pard \ql \fi720\li0\ri0\sl480\slmult1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\insrsid10906221 
\par Given that many childhood diseases seem to be in decline, exemptors may fail to 
realize the continued value of vaccination.  As the mumps outbreak in Iowa makes clear, however, vaccination programs take time and are at risk if vaccination rates fall.  Other diseases are still prevalent in other parts of the world, and outbreaks can s
till occur in this country due to the prevalence of international travel.  }{\insrsid9130705 Ever though measles is rarely observed in the US, for example, t}{\insrsid10906221 
he World Health Organization has reported that nearly 900,000 measles-related deaths occurred in developing countries in 1999.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275 
 Center for Disease Control, National Immunization Program publication, \'93What Would Happen If We Stopped Vaccinations?\'94 }{\i\insrsid16601275\charrsid16612792 at}{\insrsid16601275  }{\insrsid16601275\charrsid16612792 
http://www.cdc.gov/nip/publications/fs/gen/WhatIfStop.htm}{\insrsid16601275  (last visited April 27, 2006). }}}{\insrsid10906221   Until diseases are eradicated globally, it may be necessary to continue vaccination. 
\par Because many of the aforementioned risks are frequently underappreciated by those who seek exemptions, some have suggested a combination of stricter enforcemen
t of exemption requirements and increased public knowledge of the reasons underlying childhood vaccination requirements.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  Silverman, }{\i\insrsid16601275 supra}{\insrsid16601275  note 71,
}{\i\insrsid16601275  }{\insrsid16601275 at 293.}}}{\insrsid10906221   Knowledge is indeed essential to the resolution of this problem.  The easier it is to obtain an exemption, the less likely individual
s are to understand and appreciate the importance of widespread participation to the success of a vaccination program.  Greater public appreciation of the need for such participation (even for diseases that seem to be in retreat), along with greater infor
mation on the safety of vaccines can go a long way toward increasing public health in this area.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 
\fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  Silverman suggests that eliminating philosophical and religious exemptions would do more harm than good.  This approach, he believes, \'93
would exacerbate feelings of animosity and skepticism toward vaccination and the public health system in general.\'94  }{\i\insrsid16601275 Id.}{\insrsid16601275 
 at 293.  On this score he is probably correct, and I agree that wider knowledge, at the very least, is a better initial response to this problem.  }}}{\insrsid10906221 
\par }\pard\plain \s3\ql \li0\ri0\sb240\sa60\keepn\widctlpar\aspalpha\aspnum\faauto\outlinelevel2\adjustright\rin0\lin0\itap0\pararsid10056933 \i\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid10906221 {\*\bkmkstart _Toc133928183}
{\*\bkmkstart _Toc133934399}Partial Exemptors \endash  A Modern Phenomenon{\*\bkmkend _Toc133928183}{\*\bkmkend _Toc133934399}
\par }\pard\plain \ql \fi720\li0\ri0\sl480\slmult1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid10906221 
The availability of exemptions has led to other interesting developments in the vaccination debate.  Recently, for exam
ple, challenges have been raised against the need for mandatory chickenpox and hepatitis B vaccines.  Diseases such as these, which are either not greatly feared (chickenpox) or transmitted primarily through voluntar}{\insrsid3278621 
y rather than involuntary }{\insrsid10906221 contact (hepatitis B), do not fit neatly into the typical justification for mandatory vaccination.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  Incidentally, it is worth
 mentioning that of the more longstanding vaccines, the tetanus vaccine stands out as unique.  Tetanus is a very harmful disease with about a 20% fatality rate.  \'93What Would Happen If We Stopped Vaccinations?\'94 }{\i\insrsid16601275 supra}{
\insrsid16601275  note 91.  What makes it unique in the va
ccine schedule is that tetanus is not contagious.  That is, herd immunity is not attainable and cannot be used to justify mandatory tetanus vaccination.  The reason for the general acceptance of the tetanus vaccine seems to stem both from the high risk of
 
the disease and the fact that tetanus can only be prevented by immunization.  In addition, the tetanus vaccine for infants has been combined with the vaccines for diphtheria and pertussis.  On strictly public health grounds, however, the status of the tet
anus shot on the compulsory vaccination schedule comes closest to government fiat of individual health decisions.  }}}{\insrsid10906221 
  Nevertheless, public health officials have decided that recently-developed vaccines for these diseases should be placed on the recommended schedule.  This has given rise to a significant number of partial exemptors \endash 
 those who are not opposed to vaccination requirements per se, but who oppose particular vaccines on the schedule.  Such a position may not have been comprehended by those who drafted the religious and philoso
phical exemptions, which seem to assume that a parent\rquote s opposition is to vaccination generally, rather than to a specific vaccine.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275 
 Because medical risks may vary from vaccine to vaccine, and thus the justification for such exemptions remains even if the risk is to some but not all vaccines, medical exemptions are somewhat outside the scope of this discussion.}}}{\insrsid10906221   

\par }\pard \ql \li0\ri0\sl480\slmult1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\insrsid10906221 \tab Because the religious exemption is usually constructed to apply to those who oppose vaccination generally because of sinc
ere religious beliefs, would-be partial exemptors have difficulty fulfilling their optimal desires.  In states without a philosophical objection, parents must choose }{\insrsid3278621 either to accept}{\insrsid10906221 
 the entirety of the recommended schedule of vaccines }{\insrsid3278621 or to obtain}{\insrsid10906221  a religious exemption for all vaccinations.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  Sean Coletti, }{\i\insrsid16601275 
Taking Account of Partial Exemptors in Vaccination Law, Policy, and Practice}{\insrsid16601275 , 36 Conn. L. Rev. 1341, 1344 (2004).}}}{\insrsid10906221 
  Parents who live in states with a philosophical exemption are much more able to tailor their objection to those vaccines with which they disagree.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 Id.}}}{\insrsid10906221   
\par }\pard \ql \fi720\li0\ri0\sl480\slmult1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\insrsid10906221 From the standpoint of a public health official, this presents two 
possible worlds.  In the world with traditional religious exemptors but no philosophical exemptors, overall percentages of vaccinations would be relatively equal from vaccine to vaccine, and higher vaccination rates would be obtained for diseases associat
ed with more objectionable vaccines at the expense of lower vaccination rates for diseases associated with less objectionable vaccines.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  This follows directly from
 the all-or-nothing nature of the vaccination decision in this world.}}}{\insrsid10906221   By contrast, in the world with philosophical exemptors, the public health official would observe higher vaccination rat
es for the less objectionable vaccines and lower vaccination rates for the more objectionable vaccines.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 
\fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  Again, this follows directly from the nature of the decision.  }}}{\insrsid10906221   
\par The difference between these two worlds can have far-reaching implications.  If parents are forced to make the all-or-nothing choice, a significant e
nough number could choose to forego vaccines (including some which they would otherwise accept) that herd immunity is lost, even for less objectionable vaccinations.  On the other hand, a significant enough number could accept the more objectionable vacci
n
ations to bring about herd immunity for those diseases.  Though the public health official might prefer a world in which neither religious nor philosophical exemptions exist, such a world may not be possible.  Therefore, the official should determine whic
h
 of the two possible worlds provides a greater overall level of safety for the society.  In addition, potential public reaction to a vaccine should cause the public health official to consider the ramifications the addition of a vaccine to the schedule wi
ll have on those vaccines already on the schedule.  
\par Because partial exemptors have the potential to sway the balance between herd immunity and vulnerability, public health officials must take account of their concerns.  Unlike in years past, today the deve
lopment of a new vaccine presents public health officials with a choice that can affect other vaccines on the recommended schedule.  Though the possibility for a chickenpox- and Hepatitis-B-free nation may seem tempting, officials should now consider the 
possible consequences of mandating such \'93borderline\'94
 vaccines.  Parents who might otherwise vaccinate according to the old schedule might have second thoughts about the new vaccines on the schedule and seek means of avoiding the new requirements.  If no mea
ns exist for avoiding the new vaccines other than complete exemption on religious grounds, parents who would subsequently pursue such exemptions would bring about a lower level of immunization for older diseases.  
\par Studies may be necessary in the above sit
uation to determine whether herd immunity status could be in jeopardy for those diseases for which vaccines are already on the schedule.  While one solution might be to provide parents with greater ability to tailor their individual vaccination desires, s
u
ch a solution would undermine the efficacy of newly scheduled vaccines.  In addition, greater levels of flexibility in vaccination choice would undermine public understanding of the community-based nature of vaccination.  I think it might be worth sacrifi
c
ing the efficacy of the newer vaccines in order to maintain that of the more established ones.  The public might be willing to suffer the possibility of chickenpox outbreaks, for example, in order to prevent an even minor epidemic of diphtheria or the mea
sles.   
\par Again, information should play a key role in the resolution of this issue.  Many of the websites urging parents to carefully consider the vaccination decision do not inform parents that their decision to vaccinate may affect the overall health of t
he community.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{
\insrsid16601275  }{\i\insrsid16601275 See, e.g.}{\insrsid16601275 , National Vaccine Information Center, }{\i\insrsid16601275 at}{\insrsid16601275  }{\insrsid16601275\charrsid8661995 http://www.nvic.org}{\insrsid16601275 
 (last visited April 27, 2006) (urging parents to consider eight questions before vaccinating, none of which inform parents of the effect their decision may have on others).  }}}{\insrsid10906221 
  The CDC, for its part, does urge parents to take note of this concern.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 
\fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  See \'93Six Common Misconceptions,\'94 }{\i\insrsid16601275 supra}{\insrsid16601275  note 10.}}}{\insrsid10906221 
  The very persons who most need to know of this concern (those seeking exemptions), however, are often those most likely to distrust CDC publications.  For supposed cit
izen-oriented websites to urge individuals to make vaccination choices without considering how such decisions affect the community is irresponsible, especially given the scientific stability of the concept of herd immunity.
\par 
\par }\pard\plain \s1\ql \li0\ri0\sl480\slmult1\keepn\widctlpar\aspalpha\aspnum\faauto\outlinelevel0\adjustright\rin0\lin0\itap0\pararsid10056933 \b\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid10906221 {\*\bkmkstart _Toc133928184}
{\*\bkmkstart _Toc133934400}II.\tab THE ROLE OF THE FEDERAL GOVERNMENT{\*\bkmkend _Toc133928184}{\*\bkmkend _Toc133934400}
\par }\pard\plain \ql \fi720\li0\ri0\sl480\slmult1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid10906221 
\par Some of the problems posed to vaccination programs by exemptors and others could be partially solved through greater public awareness of the stringent safety and efficacy testing done on vaccines before they may enter the market.  This section sum
marizes the role of FDA in the context of vaccination programs.  In addition, this section will discuss other ways in which the federal government gets involved in the vaccination issue, concluding with a brief synopsis of the no-fault compensation scheme
 enacted pursuant to the National Childhood Vaccine Injury Act of 1986.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 
\fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  42 U.S.C. \'a7\'a7 300aa-1 to 300aa-34.}}}{\insrsid10906221 
\par }\pard\plain \s2\ql \li0\ri0\sb240\sa60\keepn\widctlpar\aspalpha\aspnum\faauto\outlinelevel1\adjustright\rin0\lin0\itap0\pararsid10056933 \fs24\ul\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid10906221 {\*\bkmkstart _Toc133928185}
{\*\bkmkstart _Toc133934401}FDA Regulation{\*\bkmkend _Toc133928185}{\*\bkmkend _Toc133934401}
\par }\pard\plain \ql \fi720\li0\ri0\sl480\slmult1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid10906221 
Though state governments determine which vaccinations are mandatory for school attendance, the federal government plays a key role in vaccination.  Perhaps most importan
tly, the federal government regulates the safety and effectiveness of all vaccines.  The FDA\rquote s Center for Biologics Evaluation and Research (CBER) is charged with this critical task.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  U.S. Food and Drug Administration, Cente
r for Biologics Evaluation and Research, \'93Vaccine Product Approval Process,\'94 updated July 27, 2002, }{\i\insrsid16601275 at}{\insrsid16601275  http://www.fda.gov/cber/vaccine/vacappr.htm (last visited April 27, 2006) (hereinafter \'93
Vaccine Product Approval Process\'94).}}}{\insrsid10906221   The role of CBER ranges from pre-approval testing of potential vaccines to facility inspection to continued oversight and sampling after approval.}{\cs17\super\insrsid10906221 \chftn {\footnote 
\pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 See id.}}}{\insrsid10906221 
  Regulation of vaccines can be more stringent than for other biologics or drugs.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 
\fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 See, e.g.}{\insrsid16601275 , Isadora Stehlin, \'93How FDA Works to Ensure Vaccine Safety,\'94
 FDA Consumer magazine (December 1995), }{\i\insrsid16601275\charrsid16612792 at}{\insrsid16601275  http://www.fda.gov/fdac/features/095_vacc.html (last visited April 27, 2006). }}}{\insrsid10906221 
  Even after a vaccine is licensed, for example, FDA oversight is prevalent.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 
\fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  \'93Licensing of a vaccine is only the beginning of FDA\rquote s oversight.\'94 }{\i\insrsid16601275 Id.}}}{\insrsid10906221 
  Since vaccines are derived from living organisms and are particularly susceptible to contamination and other environmental factors, manufacturers usually must submit samples of each vaccine lot for testing before release.}{\cs17\super\insrsid10906221 
\chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 Id.}}}{
\insrsid10906221   
\par Before a vaccine can even be licensed for distribution and use, it must go through an extensive testing process relatively similar to that of drugs and other biologics.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 Id.}}}{\insrsid10906221 
  First, a new vaccine must be tested for safety on animals.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {
\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  \'93Vaccine Product Approval Process,\'94 }{\i\insrsid16601275 supra}{\insrsid16601275  note 103.}}}{\insrsid10906221   The vaccine manufacturer next must file an Investigational New Drug applic
ation (IND) with the FDA.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn 
}{\insrsid16601275  }{\i\insrsid16601275 Id.}}}{\insrsid10906221   Studies are then undertaken to ensure safety before any human testing takes place.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 Id.}}}{\insrsid10906221 
  In addition, the IND must describe the studies intended for humans.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 
\fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  Stehlin, }{\i\insrsid16601275 supra}{\insrsid16601275  note 105.}}}{\insrsid10906221 
\par Once these initial steps are completed, proposed vaccines must undergo three phases of clinical trials, in which the vaccine is tested on humans.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 Id.}}}{\insrsid10906221 
  Phase 1 testing looks only for very serious or very common problems.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 
\fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 Id.}}}{\insrsid10906221 
  A small number of subjects (usually less than 100) are closely monitored, usually for only a few months.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 
\fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 Id.}{\insrsid16601275 ; \'93Vaccine Product Approval Process,\'94 }{\i\insrsid16601275 supra }{\insrsid16601275 note 103.}
}}{\insrsid10906221   Testing expands in Phase 2 to begin evaluating efficacy, as well as to further test safety.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 
\fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  Stehlin, }{\i\insrsid16601275 supra}{\insrsid16601275  note 105.}}}{\insrsid10906221 
  Phase 2 trials can last up to two years and typically include hundreds of subjects.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 
\fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 Id.}}}{\insrsid10906221   The final stage of testing, Phase 3, further studies safety and effectiveness.}{
\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  \'93
Vaccine Product Approval Process,\'94 }{\i\insrsid16601275 supra}{\insrsid16601275  note 103.}}}{\insrsid10906221   Thousands of people may be involved in this stage of testing, and if successful it can lead to application for FDA licensing.}{
\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{
\i\insrsid16601275 Id.}}}{\insrsid10906221   
\par Once the clinical trials are completed, the FDA can examine the results of the tests to determine whether the vaccine is safe and effective enough to be placed on the market.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 Id.}}}{\insrsid10906221 
  At any point in the process, the FDA may halt ongoing studies if safety concerns require such action.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 
\fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 Id.}{\insrsid16601275 ; Stehlin, }{\i\insrsid16601275 supra}{\insrsid16601275  note 105.}}}{\insrsid10906221 
  The FDA also reviews the data from the studies and inspects the manufacturing facility.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 
\fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 Id.}}}{\insrsid10906221   At this point the vaccine may be licensed.  
\par As stated above, the FDA\rquote s role in protecting the safety and effectiveness of vaccines does not end at the licensing stage.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275 
 Indeed, the National Immunization Program has confidently pointed to the FDA\rquote s role in continued oversight of vaccines:
\par }\pard \s16\ql \li720\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin720\itap0 {\insrsid16601275 FDA would recall a lot of vaccine at the first sign of problems.  There is no benefit 
to either the FDA or the manufacturer in allowing unsafe vaccine to remain on the market.  The American public would not tolerate vaccines if they did not have to conform to the most rigorous safety standards.  The mere fact that a vaccine lot [is] still 
in distribution says that the FDA considers it safe.
\par }\pard \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\insrsid16601275 \'93Six Common Misconceptions,\'94 }{\i\insrsid16601275 supra}{\insrsid16601275  note 10.}}}{\insrsid10906221 
  Before any vaccines from a particular lot can be released, the manufacturer must typically submit samples for potency, safety, and purity testing.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  \'93Vaccine Product Approval Process,\'94 }{\i\insrsid16601275 
supra}{\insrsid16601275  note 103.}}}{\insrsid10906221   Periodic facility inspections also continue for the duration of the license.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 Id.}}}{\insrsid10906221 
  Furthermore, formal post-market studies may be conducted in order to identify problems that would not show up in pre-market clinical testing.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 Id.}}}{\insrsid10906221 
  These tests are referred to as Phase 4 tests and are not mandatory, but can help identify problems that may only occur very infrequently.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  Stehlin, }{\i\insrsid16601275 supra}{\insrsid16601275  note 105.}
}}{\insrsid10906221   Post-marketing surveillance programs are important because manufacturers are \'93never going to be able to do studies big enough to detect risks that might happen at a level of one in 100,000 or one in 1 million.\'94}{
\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275 
 So states Susan Ellenberg, Ph.D., director of CBER\rquote s division of biostatistics and epidemiology.  }{\i\insrsid16601275 Id.}}}{\insrsid10906221   
\par The Vaccine Adverse Event Reporting System (VAERS) is another valuable tool in identifying problems with a vaccine once it has been approved for the market.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  \'93Vaccine Product Approval Process,\'94 }{\i\insrsid16601275 
supra}{\insrsid16601275  note 103.}}}{\insrsid10906221   VAERS was developed following Congress\rquote 
s enactment of the National Childhood Vaccine Injury Act of 1986 and has become a very useful tool for identifying possible adverse effects that would otherwise escape detection.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  Stehlin, }{\i\insrsid16601275 supra}{\insrsid16601275  note 105.}
}}{\insrsid10906221   VAERS allows anyone to report a problem that may be associated with any vaccine.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 
\fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 Id.}}}{\insrsid10906221   
\par It is important to keep in mind that VAERS is simply a reporting system.  Experts and others use the data in VAERS to attempt to determine whether a vaccine actually causes a particular a
dverse effect, but the events that VAERS documents are not all caused by vaccines.  It is therefore easy to understand why VAERS encourages doctors and others to report any adverse event that may be related to a vaccine.  \'93
VAERS is designed to detect signals or warnings that there might be a problem rather than to answer questions about what caused the adverse event.\'94}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 Id.}}}{\insrsid10906221 
  It is important to keep these facts in mind when looking at VAERS data, as many of the adverse effects may be completely unrelated to the v
accine in question.  Often the effects are correlated with, but unrelated to, vaccination simply because many of the problems reported are those usually associated with events happening during the vaccination period (the first few years of life).}{
\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{
\i\insrsid16601275 Id.}}}{\insrsid10906221   
\par Used correctly, VAERS can lead to useful studies and the discovery of potentially rare adverse effects.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 
\fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 Id.}}}{\insrsid10906221   VAERS can also be used to monitor individual lots of a vaccine.}{\cs17\super\insrsid10906221 
\chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 Id.}}}{
\insrsid10906221   Unfortunately, by encouraging individuals to report any adverse effect that may possibly h
ave been caused by a vaccine, VAERS can provide ammunition for those claiming a definite link between a vaccine and a particular adverse effect, even if the data is silent on whether such a link exists.}{\cs17\super\insrsid10906221 \chftn {\footnote 
\pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 See, e.g.}{\insrsid16601275 , 
\'93Six Common Misconceptions,\'94 }{\i\insrsid16601275 supra}{\insrsid16601275  note 10 (\'93[o]nly some of the reported health conditions are 
side effects related to vaccines.  A certain number of VAERS reports of serious illnesses or death do occur by chance alone among persons who have been recently vaccinated\'94). }}}{\insrsid10906221   While VAERS is in place to help identify actual ris
ks associated with vaccines, these risks cannot be accurately assessed solely on the basis of reported incidents of adverse effects.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  \'93
VAERS reports have many limitations since they often lack important information, such as laboratory results, used to establish a true association with the vaccine.\'94  }{\i\insrsid16601275 Id.}}}{\insrsid10906221   
\par }\pard \ql \fi720\li0\ri0\sl480\slmult1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\insrsid10906221 The real value of VAERS lies in the testing and hypotheses that are developed in response to the data that has been repo
rted.  Because of the serious adverse effects already occurring during the typical vaccination period, it will often be easy and convenient to point to the correlation between vaccines and reported adverse events.  Lost in the picture is the foundational 
proposition that VAERS is, at its core, a data collection system.  To forego scientific inquiry and point instead to simple correlation may be convenient, but it is unwise.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  \'93In summary, scientists are not able to identify a problem\'85
based on VAERS reports alone without scientific analysis of other factors and data.\'94  }{\i\insrsid16601275 Id.}}}{\insrsid10906221   
\par }\pard\plain \s2\ql \li0\ri0\sb240\sa60\keepn\widctlpar\aspalpha\aspnum\faauto\outlinelevel1\adjustright\rin0\lin0\itap0\pararsid10056933 \fs24\ul\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid10906221 {\*\bkmkstart _Toc133928186}
{\*\bkmkstart _Toc133934402}Thimerosal{\*\bkmkend _Toc133928186}{\*\bkmkend _Toc133934402}
\par }\pard\plain \ql \li0\ri0\sl480\slmult1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid10906221 \tab The recent public discussion surrounding the use of thimerosal as a p
reservative in vaccines helps to illustrate the importance of the FDA and other factors in furthering the goals of vaccine safety and public confidence in the entire safety regulatory process.  Thimerosal is a mercury-containing organic compound that for 
many years has been used as a preservative in vaccines to help prevent contamination with microbes that could potentially be fatal.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  U.S. Food 
and Drug Administration, Center for Biologics Evaluation and Research, \'93Thimerosal in Vaccines,\'94 }{\i\insrsid16601275 at}{\insrsid16601275  http://www.fda.gov/Cber/vaccine/thimerosal.htm (last updated Sept. 6, 2005).}}}{\insrsid10906221 
  Recently, fears that mercury at very low levels may be toxic to the brain have raised concern among many in the public about allowing the use of thimerosal in vaccines.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 Id.}}}{\insrsid10906221 
  Many began to fear a connection between thimerosal and autism.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 
\fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 See, e.g.}{\insrsid16601275 , Gardiner Harris and Anahad O\rquote Connor, \'93On Autism\rquote s Cause, It\rquote 
s Parents vs. Research,\'94 New York Times, June 25, 2005, }{\i\insrsid16601275\charrsid4006766 at}{\insrsid16601275 
 http://www.nytimes.com/2005/06/25/science/25autism.html (last visited April 27, 2006) (reporting the ongoing tension between parents of autistic children and the medical community over the use of thimerosal in vaccines). }}}{\insrsid10906221 
  Standard FDA testing of lots, as well as studies measuring the amount of mercury contained in the standard immunization schedule versus accepted safe amounts, did not lead to safety concerns sufficient to pull thimerosal from the market.}{
\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{
\i\insrsid16601275 See, e.g.}{\insrsid16601275 , Center for Disease Control, National Immunization Program publication, \'93Mercury and Vaccines (Thimerosal),\'94 }{\i\insrsid16601275 at}{\insrsid16601275 
 http://www.cdc.gov/nip/vacsafe/concerns/thimerosal/default.htm (last visited April 27, 2006) (studies have failed to find any association between exposure to thimerosal in vaccines and autism); \'93On Autism\rquote s Cause, It\rquote 
s Parents vs. Research,\'94 }{\i\insrsid16601275 supra}{\insrsid16601275  (noting that the amount of ethyl mercury in each childhood vaccine was once about the same as the amount of methyl 
mercury, a more toxic compound, found in an average tuna sandwich). }}}{\insrsid10906221   Though one committee (the Immunization Safety Review Committee, commissioned by the Institute of Medicine) concluded that a theoretical link between thimerosal
 and autism was biologically plausible, most health experts continue to assert that there simply is no scientific evidence of a link between the two.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  \'93Thimerosal in Vaccines,\'94 }{\i\insrsid16601275 supra}{
\insrsid16601275  note 139.}}}{\insrsid10906221   
\par }\pard \ql \fi720\li0\ri0\sl480\slmult1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\insrsid10906221 During this time period FDA performed additional tests to verify or refute the supposed link between thimerosal and autism.}{
\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{
\i\insrsid16601275 Id.}}}{\insrsid10906221   In 1999, FDA performed a comprehensive study and review of thimerosal use in vaccines for children.  This review revealed no risk from thimerosal use, other than \'93local hypersensitivity reactions.\'94}{
\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{
\i\insrsid16601275 Id.}}}{\insrsid10906221   Indeed, none of the standard safe
ty protocols in place suggested or required that FDA pull thimerosal from the market.  This is not to say, however, that no risk existed.  As is clear from the foregoing summary of FDA vaccine approval, not all adverse effects will be known from clinical 
trials.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{
\insrsid16601275  Stehlin, }{\i\insrsid16601275 supra }{\insrsid16601275 note 105.}}}{\insrsid10906221   It may take years or longer to assess some of the risks of vaccines, including the risk of thimerosal as a preservative.}{\cs17\super\insrsid10906221 
\chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 Id.}}}{
\insrsid10906221   
\par Continued public concern over the safety of thimerosal caused FDA to begin to work with vaccine manufacturers in order to reduce or eliminate thimerosal from vaccines as a precautionary measure.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 Id.}}}{\insrsid10906221 
  About this time, the American Academy of Pediatrics and the Public Health Service urged the removal of thimerosal from vaccines.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  \'93On Autism\rquote s Cause, It\rquote s Parents vs. Research,
\'94 }{\i\insrsid16601275 supra}{\insrsid16601275  note 141.}}}{\insrsid10906221   Today, with the exception of the inactivated influenza vaccine, all recommended childhood vaccines are either thimerosal free or contain only trace amounts of the compound.
}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  \'93
Thimerosal in Vaccines,\'94 }{\i\insrsid16601275 supra}{\insrsid16601275  note 139; }{\i\insrsid16601275 see also}{\insrsid16601275  \'93On Autism\rquote s Cause, It\rquote s Parents vs. Research,\'94}{\i\insrsid16601275  supra}{\insrsid16601275 
 note 141 (\'93[b]y 2001, no vaccine routinely administered to children in the United States had more than half a microgram of mercury \endash  about what is found in an infant\rquote s daily supply of breast milk\'94). }}}{\insrsid10906221 
  Even though the risk may not have been as great as feared by the public or even existent at all, if the new vaccines are equally eff
ective, the elimination of thimerosal from vaccines can probably be seen as a safety improvement, albeit at the expense of the added research and development needed to create the new thimerosal-free vaccines.  
\par Rather than quell the existing safety concerns, this action led many of those who had decried the use of thimerosal to accuse FDA of participating in a cover-up to protect vaccine manufacturers.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  \'93
Autism and Vaccines: Activists Wage a Nasty Campaign to Silence Scientists,\'94 Wall Street Journal editorial, February 16, 2004, }{\i\insrsid16601275\charrsid4006766 at}{\insrsid16601275  }{\insrsid16601275\charrsid4006766 
http://www.opinionjournal.com/forms/printThis.html?id=110004700}{\insrsid16601275  (last visited April 27, 2006).}}}{\insrsid10906221   Government agencies, for their part, continue to claim that vaccines with thimerosal are as safe as thim
erosal-free vaccines, suggesting that the added development may have been superfluous.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 
\fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  \'93On Autism\rquote s Cause, It\rquote s Parents vs. Research,\'94 }{\i\insrsid16601275 supra }{\insrsid16601275 note 141.}}}{
\insrsid10906221   While this may be so, the availability and now prevalence of thimerosal-free vaccines does provide the scientific and medical community with a new means of assessing t
he possible autism-causing effects of thimerosal.  Namely, since thimerosal is suspected to cause autism within the first few years of life (the routine vaccination calendar), those who were vaccinated in the years since thimerosal-free vaccines have comp
rised the overwhelming majority of vaccines (that is, those born after 2001) would be expected to experience lower incidences of autism than the groups vaccinated with thimerosal-containing vaccines.}{\cs17\super\insrsid10906221 \chftn {\footnote 
\pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275 
 Indeed, one recent study has suggested that neurological disorders have decreased with the removal of thimerosal from most vaccines.  See David A. Geier and Mark R. Geier, \'93Early Downward Tre
nds in Neurodevelopmental Disorders Following Removal of Thimerosal-Containing Vaccines,\'94
 11 J. Am. Physicians and Surgeons 8 (2006).  This study should be taken with a grain of salt, however, as the Geiers are widely known thimerosal critics.  Years before this study, Dr. Mark Geier called thimerosal use in vaccines the world\rquote s \'93
greatest catastrophe that\rquote s ever happened, regardless of cause.\'94  \'93On Autism\rquote s Cause, It\rquote s Parents vs. Research,\'94 }{\i\insrsid16601275 supra}{\insrsid16601275  note 141.  A witness in many vaccine cases, a judge once rul
ed that he was \'93a professional witness in areas for which he has no training, expertise and experience.\'94  }{\i\insrsid16601275 Id.}{\insrsid16601275   Scientists have criticized his prior studies and even called his methods \'93voodoo science.\'94  
}{\i\insrsid16601275 Id.}{\insrsid16601275   }}}{\insrsid10906221 
\par   In spite of the potentially costly decision to encoura
ge the development of thimerosal-free vaccines when there is no sufficient safety concern to pull thimerosal from the market, FDA and other government officials have had little success in assuaging the fears and concerns of thimerosal critics.}{
\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{
\i\insrsid16601275 Id.}}}{\insrsid10906221   Scientific arguments often fail to persuade, either because they are inconclusive or because of a perceived bias favoring vaccine manufacturers.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 See id.}}}{\insrsid10906221 
  To back up their own arguments, thimerosal critics rarely point to scientific studies.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 
\fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 See }{\insrsid16601275 \'93The Politics of Autism: Lawsuits and Emotion vs. Science and Childhood Vaccines,\'94
 Wall Street Journal editorial, Dec. 29, 2003, }{\i\insrsid16601275 at}{\insrsid16601275  }{\insrsid16601275\charrsid8661995 http://www.opinionjournal.com/forms/printThis.html?id=110004487}{\insrsid16601275 
 (last visited April 27, 2006) (characterizing the position of thimerosal critics as \'93scientifically untenable\'94).  }}}{\insrsid10906221   Instead, their reasoning seems
 to stem more from anecdotal evidence and comparison of thimerosal (which contains ethyl-mercury) to methyl-mercury-containing fish.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 See generally}{\insrsid16601275  \'93
On Autism\rquote s Cause, It\rquote s Parents vs. Research,\'94 }{\i\insrsid16601275 supra}{\insrsid16601275  note 141.}}}{\insrsid10906221 
  Representative Dan Burton (R-Indiana), a key supporter of the fight against thimerosal, explained that his belief in the toxicity of thimerosal stemmed from a personal episode: \'93
[m]y grandson received nine shots in one day, seven of which contained thimerosal, which is 50 percent mercury as you know, and he became autistic a short time later.\'94}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 Id.}}}{\insrsid10906221 
  Others point to the rise in autism rates in the past twenty years and put the onus on the medical community to prove that this rise is not due to thimerosal.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 Id.}}}{\insrsid10906221  
\par The response of health officials has been to ask why }{\insrsid7021084 the burden}{\insrsid10906221  should be placed on them to disprove a link between thimerosal and autism; cell phones, ultrasound, or diet soda could just as easily be the culprit.}{
\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{
\i\insrsid16601275 Id.}}}{\insrsid10906221   Indeed, the typical response to those charging vaccination with causing many of the adverse effects occurring in life\rquote s first few years is to point out that usually 
such accusations are based on nothing more than the temporal proximity of the vaccine and the illness.  Some have suggested that the rates of autism may be on the rise not because of thimerosal, but because of generally more accurate diagnosis of the affl
iction.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{
\insrsid16601275  \'93The Politics of Autism,\'94 }{\i\insrsid16601275 supra}{\insrsid16601275  note 156.}}}{\insrsid10906221   In the past, an autistic child may have been wrongfully diagnosed }{\insrsid8339799 with }{\insrsid7021084 other}{
\insrsid8339799  mental disorder}{\insrsid7021084 s}{\insrsid10906221 .}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 
\fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 Id.}{\insrsid16601275 ; \'93Study: Autism Rise from Labeling, Not Epidemic,\'94 April 3, 2006, }{
\i\insrsid16601275\charrsid8339799 at}{\insrsid16601275  }{\insrsid16601275\charrsid8339799 http://www.cnn.com/2006/EDUCATION/04/03/health.autism.reut/index.html}{\insrsid16601275 
 (last visited April 27, 2006) (noting rise in diagnosed cases of autism since 1994 is correlated with fall in diagnosed cases of mental retardation and learning disabilities). }}}{\insrsid10906221   Figures showing}{\insrsid8339799  a correlation between
}{\insrsid10906221  the rise in autism }{\insrsid7681749 and the drop in other diagnosed mental disorders}{\insrsid10906221  bolster such assertions, and suggest that vaccination may simply be a convenient scapegoat.}{\cs17\super\insrsid10906221 \chftn 
{\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  The Politics of Autism,\'94 }{
\i\insrsid16601275 supra}{\insrsid16601275  note 156.}}}{\insrsid10906221 
\par As the thimerosal issue makes clear, vaccines often provoke strong feelings amongst various segments of the population.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 See, e.g.}{\insrsid16601275 , \'93
Six Common Misconceptions,\'94 }{\i\insrsid16601275 supra}{\insrsid16601275 
 note 10 (noting that many anti-vaccine publications claim vaccines are unsafe on the basis of sheer numbers of reports to VAERS without noting that many of them may not represent actual vaccine side-effects).   }}}{\insrsid10906221 
  Proper consideration of public reaction to its actions is a delicate aspect of FDA re
gulation of vaccine safety.  To complicate matters further, one can easily imagine an equally vehement response and similar claims of conspiracy had the FDA not worked to reduce thimerosal from vaccines as a precautionary measure.  Indeed, public confiden
c
e in the safety of vaccines is often influenced by factors outside the typical FDA calculus.  Though FDA must act in the interests of the general safety regardless of public opinion, it may sometimes be necessary for FDA to consider public opinion, at lea
s
t when exercising discretionary oversight.  After all, the entire VAERS system is to a large extent dependant on public cooperation.  Nevertheless, when the choice is between FDA popularity and doing what is right for the safety of Americans, the FDA shou
ld not allow itself to be swayed by a misinformed public.
\par }\pard\plain \s2\ql \li0\ri0\sb240\sa60\keepn\widctlpar\aspalpha\aspnum\faauto\outlinelevel1\adjustright\rin0\lin0\itap0\pararsid10056933 \fs24\ul\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid10906221 {\*\bkmkstart _Toc133928187}
{\*\bkmkstart _Toc133934403}Vaccine Injury Compensation Program{\*\bkmkend _Toc133928187}{\*\bkmkend _Toc133934403}
\par }\pard\plain \ql \fi720\li0\ri0\sl480\slmult1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid10906221 
Congressional reaction to safety concerns goes beyond the adverse reporting system VAERS.  The National Childhood Vaccine Injury Act of 1986, which created VAERS, 
also created a no-fault compensation scheme for people injured or killed by vaccines as an alternative to the traditional tort system.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  National Vaccine Information Center, \'93
The Vaccine Injury Compensation Program,\'94 }{\i\insrsid16601275 at}{\insrsid16601275  }{\insrsid16601275\charrsid8661995 http://www.909shot.com/Issues/Comp_Summary.htm}{\insrsid16601275  (last visited April 27, 2006).}}}{\insrsid10906221 
  This system was intended to efficiently and rapidly compensate those who are actually injured by vaccines while maintai
ning an environment in which further vaccine research and safety improvement could exist.  The situation giving rise to this compensation program sounds remarkably similar to the more recent concerns surrounding thimerosal:
\par }\pard \ql \li1440\ri1440\widctlpar\aspalpha\aspnum\faauto\adjustright\rin1440\lin1440\itap0 {\insrsid10906221 In the early 1980's, reports of 
harmful side effects following the DTP (diphtheria, tetanus, pertussis) vaccine posed major liability concerns for vaccine companies and health care providers, and caused many to question the safety of the DTP vaccine. Parents began filing many more lawsu
i
ts against vaccine companies and health care providers. Vaccination rates among children began to fall and many companies that develop and produce vaccines decided to leave the marketplace, creating significant vaccine shortages and a real threat to the N
ation\rquote s health.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{
\insrsid16601275  Center for Disease Control, National Vaccine Program Office, Vaccine Fact Sheets, \'93National Vaccine Injury Compensation Program,\'94 }{\i\insrsid16601275 at}{\insrsid16601275  }{\insrsid16601275\charrsid8661995 
http://www.hhs.gov/nvpo/factsheets/fs_tableIV_doc1.htm}{\insrsid16601275  (last visited April 27, 2006). }}}{\insrsid10906221 
\par }\pard \ql \fi720\li0\ri0\sl480\slmult1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\insrsid10906221 
\par Funding for the no-fault compensation scheme initially came from Congressional grants of federal tax dollars totaling $110 million per year.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 See}{\insrsid16601275 
 National Vaccine Injury Compensation Program, }{\i\insrsid16601275 at}{\insrsid16601275  }{\insrsid16601275\charrsid8661995 http://www.hrsa.gov/vaccinecompensation/}{\insrsid16601275  (last visited April 27, 2006). }}}{\insrsid10906221 
  Since October 1, 1988, funding has proceeded from the Vaccine Injury Compensation Trust Fund, which is funded by a $0.75 excise tax on all doses of vaccines covered under the program.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 Id.}}}{\insrsid10906221 
\par One may wonder what makes vaccines worthy of an alternative dispute resolution system.  Perhaps it is the result of the power of the vaccine manufacturing lobby or simply an attempt by Congress to pass some legislation in the face of}{\insrsid7021084 
 strong public sentiment.  A}{\insrsid10906221 lthough these reasons may appear plausible, it seems more likely to me that the Act created this no-fault compensation scheme because of the mandatory nature of v
accination.  For those injured by other medical devices or drugs, the traditional tort system or medical insurance seem the proper means of addressing the issue.  When people are told to undertake a medical procedure they may not agree with because it hel
p
s further a public goal, however, it may make sense to have a system in place whereby they can obtain relief quickly if harmed by the procedure.  Moreover, because certain vaccines may be closely associated with particular adverse effects, the efficiency 
of a no-fault scheme may trump the standard fact-finding processes of the legal system.  The government has chosen to enact such a no-fault scheme, and err on the side of compensation.
\par 
\par }\pard\plain \s1\ql \li0\ri0\sl480\slmult1\keepn\widctlpar\aspalpha\aspnum\faauto\outlinelevel0\adjustright\rin0\lin0\itap0\pararsid10056933 \b\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid10906221 {\*\bkmkstart _Toc133928188}
{\*\bkmkstart _Toc133934404}III.\tab ANALYTICAL MEANS OF ADDRESSING THE ISSUE{\*\bkmkend _Toc133928188}{\*\bkmkend _Toc133934404}
\par }\pard\plain \ql \li0\ri0\sl480\slmult1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid10906221 
\par \tab The concerns and proble
ms raised in the context of mandatory vaccination programs do not readily suggest a simple answer.  In examining the issue, I came across two particularly useful tools for analyzing the problem.  The first comes from an old episode of The Andy Griffith Sh
ow}{\insrsid7021084  in which a local farmer refused}{\insrsid10906221 
 to accept a vaccination from the local nurse.  In addition to providing substantial entertainment to the viewer, the characters can be viewed metaphorically to represent the various parties in the mandatory vaccination debate.  The episode\rquote 
s solution, in turn, sheds some light on the current debate.
\par \tab This section will also utilize the analytical framework of economic analysis.  Though not as enjoyable a topic as The Andy Griffith Show, economic theory helps to reshape the v
accination discussion and greatly facilitates the process of assessing the various positions.  
\par }\pard\plain \s2\ql \li0\ri0\sb240\sa60\keepn\widctlpar\aspalpha\aspnum\faauto\outlinelevel1\adjustright\rin0\lin0\itap0\pararsid10056933 \fs24\ul\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid10906221 {\*\bkmkstart _Toc133928189}
{\*\bkmkstart _Toc133934405}\'93We got to get folks to take their shots\'94 \endash  Sheriff Andy Taylor}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 
\fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 The Andy Griffith Show: The County Nurse}{\insrsid16601275  (CBS television broadcast, March 19, 1962).}}}{
\insrsid10906221 {\*\bkmkend _Toc133928189}{\*\bkmkend _Toc133934405}
\par }\pard\plain \ql \fi720\li0\ri0\sl480\slmult1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid10906221 
The Andy Griffith Show addressed the concept of popular resistance to universal vaccination over forty years ago.  In \'93The County Nurse,\'94
 Sheriff Andy Taylor confronted a local nurse who was trying to bring everyone up to date on their tetanus shots.  Not surprisingly, at least to Andy, many of the mountain farmers had not been }{\insrsid13069312 inoculated}{\insrsid10906221 .  The na\'efv
e nurse would soon discover the }{\insrsid7021084 reason for the low vaccination rate}{\insrsid10906221 . 
\par Rafe Hollister, one of the leading farmers in Mayberry, had little use for modern medicine or doctors in general.  \'93We don\rquote t need any nurse, nobody gets sick up here.\'94}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 Id.}}}{\insrsid10906221   Thermometers?  
\'93I know when I got a fever, I\rquote m hot.\'94}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {
\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 Id.}}}{\insrsid10906221   Stethoscopes?  \'93I know my heart\rquote s beating, I\rquote m alive ain\rquote t I?\'94}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 Id.}}}{\insrsid10906221 
  But his strongest objection was saved for vaccinations: \'93I ain\rquote t never been jabbed and I ain\rquote t fixin\rquote  to be.\'94}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 Id.}}}{\insrsid10906221 
  Such were the views that the nurse was up against in her attempt to achieve 100% vaccination rates. 
\par 
\par 
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\par }\pard \ql \li0\ri0\sl480\slmult1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\b\insrsid10906221 Rafe Hollister
\par }\pard \ql \fi720\li0\ri0\sl480\slmult1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\insrsid10906221 
\par 
\par 
\par 
\par Rafe Hollister\rquote s reasons for opposing vaccination went beyond his desire to avoid getting \'93jabbed.\'94  He was a farmer who lived off the land, and when he got sick he let hi
s body fight the sickness naturally.  His daddy had lived to the age of hundred and he aimed to do the same.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 
\fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 Id.}}}{\insrsid10906221 
  The concept of a vaccination was certainly something foreign to him, as was the idea that a health official could force him to do anything.  Even in the wake of the nurse\rquote 
s impassioned plea to accept a shot that could someday save his life, he retorted simply, \'93I done alright before you come around and I\rquote m doing alright now.\'94}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 Id.}}}{\insrsid10906221 
\par }\pard \ql \fi720\li0\ri0\sl480\slmult1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\insrsid10906221 Although the county nurse was not acting pursuant to a mandatory vaccination program, under the circumstances her attempts to get Rafe }
{\insrsid13069312 inoculated}{\insrsid10906221  were pretty forceful.  The nurse was accompanied by the local sheriff to Rafe\rquote s farm to try to convince him to take the shot, and when he refused, the sheriff and nurse continued to 
attempt to make him acquiesce.  When Deputy Barney Fife heard of Rafe\rquote s stubbornness, he insisted the nurse return to Rafe\rquote s farm with him to force Rafe to take the shot.  After all, boasted the deputy, \'93Rafe Hollister\rquote 
s like a child and he\rquote s gotta be treated like one\'85I\rquote ll make him take his shot.\'94}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 
\fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 Id.}}}{\insrsid10906221   When the deputy arrived at Rafe\rquote 
s farm yelling that he was forcing Rafe to accept the vaccination, Rafe decided to fight the mandatory vaccination by drawing his rifle and forcing the deputy to leave the farm.  
\par In a classic manifestation of the early spirit of the television series, Sheriff Andy Taylor finally convinced Rafe to take the shot through a little reverse psychology.  Andy began by facetiously praising Rafe\rquote 
s refusal to take the shot as stemming from Rafe\rquote 
s desire for immortality.  Namely, by refusing to take the shot, Rafe was sure to become the impetus for all the other townspeople not to neglect to take their shots.  Unfortunately for Rafe, this heroic stature would only be achieved posthumously, as
 he will have succumbed to a violent and painful death from tetanus.  As Andy explained to Rafe, someday, after getting cut by a rusty saw or bitten by an animal, without the shot he\rquote ll \'93be a cinch to go.\'94}{\cs17\super\insrsid10906221 \chftn 
{\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 Id.  }{
\insrsid16601275  That is, there will be a high probability of death.}}}{\insrsid10906221  Eschewing the chance to be a dead hero, Rafe finally took the shot.  
\par 
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0202020202020202020202020202020202020202020202020202020202020202020202020202020202020202020202020202020202020202020202020000040000002701ffff030000000000}\par}}}{\insrsid10906221 
\par }\pard \ql \fi720\li0\ri0\sl480\slmult1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\insrsid10906221 
\par 
\par }{\b\insrsid10906221 Sheriff Andy Taylor}{\insrsid10906221 
\par 
\par 
\par 
\par 
\par 
\par Vaccination has changed the modern world.  Indeed, it has led to the elimination or significant decline of many diseases that once posed significant and potentially deadly health risks.  Public health offi
cials in the United States have managed to institute a program that, though subject to variations on a state by state basis, essentially mandates certain vaccinations as a requirement for school attendance.  While these vaccination programs are touted by 
most public health officials, a significant number of people oppose mandatory vaccination.  The County Nurse episode helps illuminate the perspectives of the various sides of the issue, as well as one possible solution.
\par The nurse herself represents the public health officials.  Though she is not implementing a mandatory vaccination program, her stated goal is to inoculate 100% of the population.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 Id.}}}{\insrsid10906221 
  As mentioned above, she has the assistance of local law enforcement and she is quite persistent.  Rafe Hollister
, the stubborn farmer, represents those within the community who oppose or resist mandatory vaccination programs.  His reasons initially rest on a general reluctance to stray from natural medicine.  In this way he represents the contingent of society that
 scientists and medical researchers will always find difficult to convince of any developments in the medical field.  In many ways, he is comparable to the plaintiff in }{\i\insrsid10906221 Jacobson}{\insrsid10906221 
.  Andy and Barney can be seen as the arms of the state that are entrusted with carrying out the general vaccination plan.  Their varying styles can be seen as varying state requirements and enforcement options for vaccination.  
\par }\pard \ql \fi720\li0\ri0\sl480\slmult1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\insrsid10906221 Though these comparisons may seem elementary and of little value, the character development that the chara
cters undertake during the episode greatly increases the episode\rquote 
s usefulness as a surrogate for real world concerns and issues.  Rafe resists the shot initially not only because he distrusts medicine in general, but also because he resents the idea that a
 county nurse can make him do anything.  Many who resist mandatory vaccination schemes do so because of personal liberty concerns; they do not want the government to tell them what to do, especially in the context of personal medical decisions.  Just as R
afe\rquote 
s stance becomes more vehement the harder the nurse attempts to convince him, many who oppose mandatory vaccination see the persistence of the medical community as evidence of blind adherence to a potentially dangerous system, or worse yet as an active 
promotion of the special interests of the vaccine manufacturers.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 
\fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 See}{\insrsid16601275  the discussion above in Part I of this paper.}}}{\insrsid10906221 
  The episode does not paint the nurse in this way at all, however.  Rather, after seeing how strongly Rafe opposes vaccination, the nurse passionately pleads with him to reconsider.  Her sta
nce truly seems to stem from a genuine concern that he not suffer the potentially terrible effects of the disease.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 
\fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275 
 For example, she begs Rafe to consider his family and what his decision could mean to them.  She literally appears to be on the verge of tears as he refuses. }}}{\insrsid10906221 
  As before, he refuses; this seems to illustrate that the stance of some may be so strong that they will never accept vaccination on the basis of arguments advanced by government officials.  
\par Barney Fife\rquote s insistence that Rafe accept the shot demonstrates the lack of understanding among many in the government and in the general population as to the vehemence with which those opposing mandatory
 vaccination hold to their views.  His paternalistic stand only serves to exacerbate the situation with Rafe.  Indeed, Barney Fife helps to illustrate that there cannot be a one-way solution to the issue of mandatory vaccination.  
\par Andy Taylor\rquote s method of 
convincing, which eventually carried the day, may not be very conducive to real-world implementation.  After all, it is unrealistic to think that reverse psychology will convince those currently opposed to vaccination programs to change their minds.  What
 
I think is important to notice, however, is the role information can play in this issue.  Andy finally convinces Rafe Hollister to take his shot after describing the horrible effects of the disease and how likely Rafe is to contract it.  Similarly, any so
l
ution to the issue of mandatory vaccination holdouts must rely on increased information dissemination.  That the information in the episode came from a trustworthy source may also have been crucial, which seems to imply that public health officials may ne
ed to work more closely with local personnel in order to obtain higher vaccination rates.  
\par Because this episode deals with the vaccine for tetanus, a non-communicable disease, the usual community-based arguments in favor of vaccination do not enter the equation.  Extra-personal consequences of Rafe\rquote 
s decision to vaccinate do exist, however.  Most importantly, as the unofficial leader of the farming community, his decision will be followed by the other farmers.  This is shown both in Andy\rquote s assurances to the
 nurse that Rafe is the most important of the farmers to convince on the issue and later, after Rafe has decided to get the shot, in his promise to the nurse that all she has to do is come with him and he\rquote 
ll get all the farmers to take their shots.  Perhaps those parents who support vaccination can help bring about higher vaccination rates by being more vocal and persistent with their neighbors who oppose vaccination programs.
\par }\pard\plain \s2\ql \li0\ri0\sb240\sa60\keepn\widctlpar\aspalpha\aspnum\faauto\outlinelevel1\adjustright\rin0\lin0\itap0\pararsid10056933 \fs24\ul\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid10906221 {\*\bkmkstart _Toc133928190}
{\*\bkmkstart _Toc133934406}Economic Analysis{\*\bkmkend _Toc133928190}{\*\bkmkend _Toc133934406}
\par }\pard\plain \ql \li0\ri0\sl480\slmult1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid10906221 \tab Economic analysis}{\cs17\super\insrsid10906221 \chftn {\footnote 
\pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275 
 In utilizing the theoretical framework of economic analysis, it is
 useful to keep in mind a few foundational concepts.  First, a policy or program (in this case mandatory vaccination) is desirable if the overall benefit to society as a whole outweighs the cost of the program, where benefits and costs include both moneta
r
y and non-monetary factors.  Second, individuals making rational choices regarding vaccination will vaccinate when the benefits of vaccination outweigh the risks or costs of non-vaccination to the individual.  This decision-making process can be skewed by
 externalities, such as an unforeseeable decrease in the effectiveness of a vaccine due to a reduction in vaccination by others unknown to the individual at the time of the decision. }}}{\insrsid10906221  provides a useful theoretical basis for eva
luating the }{\insrsid9510255 competing}{\insrsid10906221  }{\insrsid9510255 sides}{\insrsid10906221 
 of the vaccination debate.  Arguments regarding the wisdom of the current vaccination policy can often be recast as economic questions involving a cost-benefit analysis.  
\par }\pard \ql \fi720\li0\ri0\sl480\slmult1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\insrsid10906221 When an epidemic breaks out, for example, the benefits o
f vaccination (protection from the disease both for the individual and for society through herd immunity) seem more clearly to outweigh the costs (potential side effects of the vaccine, decreased ability of the immune system to defend the body from varian
t
 strands of the disease, or personal or religious objection).  Vaccination rates would, therefore, be expected to be highest during such epidemics.  Consequently, those few who continue to oppose vaccination during such epidemics would be expected to do s
o
 for only the strongest reasons.  This is due to the fact that in economic terms, the opponent of vaccination would have to believe that the benefits of vaccination still do not outweigh the costs, even during an epidemic.  This might stem from a relative
 
undervaluation of the benefits of vaccination (perhaps due to a belief that contracting the disease would not be so bad) or a relative overvaluation of the costs of vaccination (possibly due to the greater cost to the conscience of the personal or religio
u
s opponent of vaccination) or some combination of both.  Medical exemptions directly illustrate this cost-benefit analysis: for a person likely to suffer serious side effects from a vaccine, the cost of vaccination is much greater than the cost to the ave
rage individual.  }{\insrsid16601275 Even}{\insrsid10906221  in a time of epidemic,}{\insrsid16601275  therefore,}{\insrsid10906221  vaccination might not be rational for such an individual.
\par }\pard\plain \s3\ql \li0\ri0\sb240\sa60\keepn\widctlpar\aspalpha\aspnum\faauto\outlinelevel2\adjustright\rin0\lin0\itap0\pararsid10056933 \i\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid10906221 {\*\bkmkstart _Toc133928191}
{\*\bkmkstart _Toc133934407}Jacobson{\*\bkmkend _Toc133928191}{\*\bkmkend _Toc133934407}
\par }\pard\plain \ql \li0\ri0\sl480\slmult1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid10906221 \tab This economic analysis of vaccination is well illustrated by the facts of }
{\i\insrsid10906221 Jacobson v. Massachusetts}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {
\cs17\fs20\super\insrsid16601275 \chftn }{\fs20\insrsid16601275  197 U.S. 11 (1905). }}}{\insrsid10906221 , the first Supreme Court case a
ddressing the constitutionality of mandatory vaccination legislation.  The case involved a Massachusetts statute allowing local authorities to mandate vaccination for smallpox if necessary for the public health and safety.}{\cs17\super\insrsid10906221 
\chftn {\footnote \pard\plain \ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\fs20\super\insrsid16601275 \chftn }{\fs20\insrsid16601275  }{\i\fs20\insrsid16601275 Id.
}{\fs20\insrsid16601275  at 12.}}}{\insrsid10906221   Subsequently, and upon a determination that smallpox was \'93prevalent to some extent\'94 and \'93continues to increase,\'94 the city of Cambridge passed a mandatory vaccination ordinance.}{
\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\fs20\super\insrsid16601275 \chftn }{\fs20\insrsid16601275  }
{\i\fs20\insrsid16601275 Id.}}}{\insrsid10906221   This ordinance represented the economic determination that the benefit of mandatory vaccination outweighed t
he cost of supplying vaccines, finding and prosecuting holdouts (such as Jacobson), and the decreased liberty of individuals to be permitted to decide whether to vaccinate.  
\par }\pard \ql \fi720\li0\ri0\sl480\slmult1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\insrsid10906221 Jacobson subsequently challenged his prosecution under the ordinance by claiming 
it to be an unconstitutional denial of his liberty under the 14th Amendment (as well as in violation of the Preamble and the \'93spirit\'94 of the Constitution, arguments that were summarily dismissed).}{\cs17\super\insrsid10906221 \chftn {\footnote 
\pard\plain \ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\fs20\super\insrsid16601275 \chftn }{\fs20\insrsid16601275  }{\i\fs20\insrsid16601275 Id.}{
\fs20\insrsid16601275  at 13, 22.}}}{\insrsid10906221   In economic terms, this may simply indicate that he viewe
d the cost of accepting a forced vaccination (perhaps of any kind, in any circumstance) as greater than any possible benefit.  A closer look at his arguments, however, suggests that he may have performed a more detailed cost-benefit analysis.  One can eas
ily convert the various arguments he attempted to advance into economic costs.  Among these arguments were the likelihood of vaccination to bring about \'93serious and permanent injury\'94
 and occasional death, the inability of an individual to assess the risk of vaccination in a particular case, and the potential impurity of vaccines and inability to test such impurity, among others.}{\cs17\super\insrsid10906221 \chftn {\footnote 
\pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 Id.}{\insrsid16601275  at 36.  }
}}{\insrsid10906221   At the very least, it would appear that Jacobson attributed a greater than average cost to vaccination.  
\par The statute also provided that ordinances mandating vaccination provide an exception for \'93children who present a certificate, signed by a registered physician, that they are unfit subjects for vaccination.\'94}{\cs17\super\insrsid10906221 \chftn 
{\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 Id.}{
\insrsid16601275  at 12.}}}{\insrsid10906221   This reflects the state\rquote s determination that the cost of forcing vacci
nation upon those more likely to suffer adverse side effects outweighed the benefit of completely universal vaccination.  Given the determination that near-universal vaccination was required to provide the desired benefit, one would expect that the state 
expected to grant relatively few medical exemptions (or at least few enough not to seriously compromise the goal of providing protection against smallpox through vaccination).  
\par In rejecting Jacobson\rquote s liberty challenge to the ordinance, the Court endorsed the concept that the State\rquote s cost-benefit analysis can supersede that of the individual, at least in the area of public health.  The Court\rquote 
s decision, in fact, makes irrelevant any individual cost-benefit analysis in the face of a comprehensive mandatory vaccination program.  
\par Various vaccination-related developments in the century since }{\i\insrsid10906221 Jacobson}{\insrsid10906221 
 can also be cast in an economic analytical framework.  Certainly the benefit from vaccination disappears when a disease has been eradicated, which explains why the
 smallpox vaccine is no longer mandated.  Any cost greater than zero (the likely benefit of smallpox vaccination at this point, barring of course a reintroduction of the disease using laboratory samples) will suffice to outweigh this benefit.}{
\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275 
 As the CDC itself explains, \'93[e]ven one serious adverse effect in a million doses of vaccine cannot be justified if there is no benefit from the vaccination.\'94  \'93Six Common Misconceptions,\'94 }{\i\insrsid16601275 supra}{\insrsid16601275 
 note 10.}}}{\insrsid10906221   The success of vaccination policies, however, may lead to an undervaluation of the benefit of continuing to vaccinate due to the lack of visible instances of the disease.}{\cs17\super\insrsid10906221 \chftn {\footnote 
\pard\plain \ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\fs20\super\insrsid16601275 \chftn }{\fs20\insrsid16601275  In Japan in the 1970s, for instanc
e, pertussis vaccination coverage fell from 80% to 20%, leading to an outbreak in 1979 resulting in 13,000 cases and 41 deaths.  \'93What Would Happen If We Stopped Vaccinations?\'94 }{\i\fs20\insrsid16601275 supra}{\fs20\insrsid16601275  note 91. }}}{
\insrsid10906221   This problem may be compounded when vaccines are mandated for diseases which are not associate
d with high mortality rates, such as chickenpox.  A further complication to the cost-benefit analysis arises when assessing vaccination policy for diseases such as Hepatitis B, which is spread typically through voluntary contact.  In such a case, an indiv
i
dual who feels highly unlikely to engage in the behavior giving rise to the risk of the disease might rationally see very minimal benefit from vaccination, while the state may view widespread vaccination as the most cost-effective method of dealing with t
he disease.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\fs20\super\insrsid16601275 \chftn }{
\fs20\insrsid16601275  Judge Richard Posner has suggested that this difference between sexually transmitted diseases and air- and water-borne diseases may imply a lesser imperative to eliminate sexually transmitted diseases:
\par }\pard \ql \li720\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin720\itap0 {\fs20\insrsid16601275 [T]he externality created by sexually transmitted diseases is smaller than in the case of other contagious diseases
.  Sexually transmitted disease is spread primarily by }{\i\fs20\insrsid16601275 voluntary}{\fs20\insrsid16601275  contact, implying (to the economist) that a person is compensated\'85
for assuming the risk of contracting the disease.  Hence the number of cases of sexually transmitted diseases may be closer to the optimum than in the usual air-borne or water-borne or insect-borne epidemics.
\par }\pard \ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\fs20\insrsid16601275 Posner, Economic Analysis of Law 162.  (6th Ed. 2003).}}}{\insrsid10906221 
\par }\pard\plain \s3\ql \li0\ri0\sb240\sa60\keepn\widctlpar\aspalpha\aspnum\faauto\outlinelevel2\adjustright\rin0\lin0\itap0\pararsid10056933 \i\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid10906221 {\*\bkmkstart _Toc133928192}
{\*\bkmkstart _Toc133934408}Altruism and Free Riding{\*\bkmkend _Toc133928192}{\*\bkmkend _Toc133934408}
\par }\pard\plain \ql \li0\ri0\sl480\slmult1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid10906221 \tab 
Given the continuing policy of vaccinating for diseases that have become relatively rare in recent decades, one might expect individual cost-benefit analyses to increasingly come into conflict with the societal policy.
  Several factors, however, serve to counteract this possibility.  Perhaps most significantly, it is likely that many parents defer on the question of vaccination and accept the cost-benefit analysis of the state (communicated to the individual through th
e vaccination schedule and through doctor\rquote 
s recommendations) as their own.  Along the same lines, many individuals might not strongly consider the pros and cons involved in vaccinating; if the possibility exists for contracting a disease, and a vaccination 
is available, the decision may already be made.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {
\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  Additionally, if vaccination rates are high, these individuals may assume that those in society who have already ma
de the choice to vaccinate have performed a similar cost-benefit analysis.  These individuals choose to vaccinate based simply on vaccination rates in the community.   }{\i\insrsid16601275 See}{\insrsid16601275  John C. Hershey et al., }{
\i\insrsid16601275 The Roles of Altruism, Free Riding, and Bandwagoning in Vaccination Decisions}{\insrsid16601275 , 59 Organizational Behavior and Human Processes 177, 178 (1994).}}}{\insrsid10906221 
  A third possibility implicates a factor that I have not yet mentioned in relation to the individual cost-benefit analysis: altruism.  
\par }\pard \ql \fi720\li0\ri0\sl480\slmult1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\insrsid10906221 Some have proposed that altruism may bridge the gap between incompatible cost-benefit analyses of states and individuals.}{
\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{
\i\insrsid16601275 See, e.g.}{\insrsid16601275 , }{\i\insrsid16601275 id.}{\insrsid16601275  (behavioral survey studying various factors individuals use to make vaccination decisions).}}}{\insrsid10906221 
  Whereas typical medical decisions affect only the patient making the decision, it is pointed out, medical decisions regarding vaccine-preventable diseases usually implicate outside interests.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 Id.}}}{\insrsid10906221   A patient
 thinking only of his own interests may forego vaccination if he feels the risk from vaccination outweighs the personal benefit.  Altruism, it is argued, may present a separate benefit for such an individual.}{\cs17\super\insrsid10906221 \chftn 
{\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  }{\i\insrsid16601275 See id.}{
\insrsid16601275  at 178 (\'93[i]f a patient believes vaccination is 
in his own best interests, then he has two reasons to vaccinate.  One is selfish, in that he will improve his own well being.  The other is altruistic, in that he can improve the health prospects of those around him who might otherwise become infected if 
he is not vaccinated himself\'94).}}}{\insrsid10906221   Though the individual may not consider the ri
sk of contracting the disease high enough by itself to justify vaccination, he may still vaccinate in order to help accomplish the public goal of eliminating the threat of an epidemic.   Public health officials hope that comprehensive vaccination will pro
duce herd immunity.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{
\insrsid16601275  The concept of herd immunity is discussed in Part I.  Note that \'93[i]n economic terms, herd immunity is a positive externality of vaccination.  Altruistic individuals who recognize and value this externality may undergo vacc
ination partly to help others in addition to themselves.\'94  }{\i\insrsid16601275 Id.}{\insrsid16601275   }{\i\insrsid16601275 See also}{\insrsid16601275  Berger, }{\i\insrsid16601275 supra}{\insrsid16601275  note 29 (\'93\lquote [h]erd immunity\rquote 
\'85is the concept that not everybody}{\super\insrsid16601275  }{\insrsid16601275 in a population has to be immunised to protect everyone in that}{\super\insrsid16601275  }{\insrsid16601275 population. As long as a sufficient number 
of children are immunised}{\super\insrsid16601275  }{\insrsid16601275 against each disease for which there is a vaccine, protection}{\super\insrsid16601275  }{\insrsid16601275 against that disease will be conferred on everybody\'94).}}}{\insrsid10906221 
  Thus the individual who may otherwise forego vaccination might undertake it in order to \'93do his part\'94 for the community at large.  Individuals who cannot vaccinate are particularly dependent on this sort of altruistic behavior, as they
 often have no other protection from the disease.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {
\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  The CDC has pointed to this as one of the two most important reasons to vaccinate: 
\par }\pard \s16\ql \li720\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin720\itap0 {\insrsid16601275 There is a small number of 
people who cannot be vaccinated (because of severe allergies to vaccine components, for example), and a small percentage of people don\rquote t respond to vaccines.  These people are susceptible to disease, and their }{\b\insrsid16601275 only}{
\insrsid16601275  hope of protection is that people around them are immune and cannot pass disease along to them.  A successful vaccination program, like a successful society, depends on the cooperation of every individual to ensure the good of all.  

\par }\pard \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\insrsid16601275 \'93Six Common Misconceptions,\'94 supra note 10.}}}{\insrsid10906221 
\par }\pard \ql \li0\ri0\sl480\slmult1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\insrsid10906221 \tab 
Working against this altruistic behavior is the temptation of individuals to enjoy the benefit conferred on them by herd immunity without undertaking the cost of being vaccinated personally.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  In economic terms, \'93
[w]idening vaccine use decreases each individual\rquote s benefit from being vaccinated, but leaves unchanged each individual\rquote s risk from the vaccination itself.\'94  Hershey, }{\i\insrsid16601275 supra }{\insrsid16601275 note 191, at 178.  }}}{
\insrsid10906221    This is widely referred to as \'93free riding,\'94 and greatly undermines the goal of comprehensive vaccination.  Since herd immunity }{\insrsid16601275 is supposed to create}{\insrsid10906221 
 a level of protection sufficient for even those few who are not vaccinated, a small number of free riders might not 
pose a significant problem.  As described earlier in this paper, comprehensive vaccination programs are designed to work even though some members of society cannot be vaccinated.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  \'93Six Common Misconceptions, }{\i\insrsid16601275 supra}{
\insrsid16601275  note 10.}}}{\insrsid10906221   The problem arises when the number of free riders becomes sufficiently high
 to compromise the ability of the society to achieve herd immunity.  Since the average citizen (one with no greater reason to avoid vaccination than any other member of society) could always choose to free ride if immunization were voluntary, herd immunit
y might never be achieved.  This is one of the key arguments advanced in support of government mandated vaccinations.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 
\fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  Hershey, }{\i\insrsid16601275 supra}{\insrsid16601275  note 191, at 178.}}}{\insrsid10906221   
\par }\pard\plain \s3\ql \li0\ri0\sb240\sa60\keepn\widctlpar\aspalpha\aspnum\faauto\outlinelevel2\adjustright\rin0\lin0\itap0\pararsid10056933 \i\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid10056933 {\*\bkmkstart _Toc133928193}
{\*\bkmkstart _Toc133934409}Ex Ante Versus Ex P}{\insrsid10906221 ost{\*\bkmkend _Toc133928193}{\*\bkmkend _Toc133934409}
\par }\pard\plain \ql \fi720\li0\ri0\sl480\slmult1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid10906221 
The concepts of altruism and especially free riding emphasize the importance of ex ante (before the fact) versus 
ex post (after the fact) decision making in the context of vaccination.  One of the main benefits of economic analysis is that it requires decisions to be justified ex ante.  Public health officials, for example, are faced with the decision of whether to 
mandate vaccinati}{\insrsid16601275 on for a particular disease at a time when all adverse effects cannot be known}{\insrsid10906221 
.  They must weigh the possible consequences of allowing a disease to continue against the possible known and unknown adverse effects of a vaccine that }{\insrsid16601275 may have}{\insrsid10906221  j
ust entered the market.  When this decision is made properly, the benefit of the vaccination program will have outweighed the cost.  The benefit is manifested in lower or no occurrences of the disease, while the cost is seen most directly in those childre
n who have actually experienced adverse effects as a result of the vaccine.  If the benefit is greater than the cost from an ex ante perspective, to the economist there should be no second-guessing of the vaccination program.}{\cs17\super\insrsid10906221 
\chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275 
 Suppose, for sake of example, that a vaccination program, if implemented, would save ten lives out of a thousand that would otherwise have perished without the program.  Unfortunately, the vaccine will randomly cause death to five pers
ons out of a thousand.  From an ex ante perspective, the vaccination program should be implemented as it will save five lives overall.  Concerns or complaints from those five persons who die (or their estates) represent ex post objections, and, though unf
ortunate, should not affect evaluations of the soundness of the program.}}}{\insrsid10906221   
\par }\pard\plain \s21\ql \fi720\li0\ri0\sl480\slmult1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid10906221 The economist, of course, is
 not the parent.  Parents who decry mandatory vaccination as the cause of their child\rquote 
s adverse reaction are typically viewing the situation ex post.  That the program has been implemented assumes that the sum of these adverse reactions was an acceptable a
lternative to non-implementation, and should therefore not be allowed to undermine public confidence in the program.  When one surveys the landscape of the vaccination issue, however, objections are usually of the ex post variety.  Since it is harder to a
ppreciate the absence of an epidemic than the presence of a child suffering a vaccine-related injury, it is easy to look at the issue solely ex post.  In the interests of public safety, such reasoning should be avoided.  
\par }\pard\plain \ql \fi720\li0\ri0\sl480\slmult1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid10906221 This is not to imply that all criti
cs of mandatory vaccination are on unsound theoretical footing.  In fact, those whose objections are marked by a distrust of the government authorities in charge of implementing vaccination programs can be seen as questioning only the ex ante judgment of 
t
he officials.  If this is so, they are actually on firmer ground than those who object to the programs because they feel their child was harmed by the vaccine.  Ex ante critiques are valuable because they can bring about change in the system at a time whe
n it can still prove useful.
\par The National Vaccine Injury Compensation Program represents a theoretically sound program under these criteria.  Economically, it represents the idea that some of the costs of mandatory vaccination programs known only ex post wi
ll be compensated by all those who share the benefits ex ante.  The excise tax, paid ex ante by all who receive the vaccine, is used to compensate anyone who experiences certain adverse effects ex post.  This is simply an example of the government distrib
uting the costs of the vaccination program across the spectrum of those who receive the benefit, rather than an ex post complaint by those on whom the costs have fallen. 
\par }\pard\plain \s3\ql \li0\ri0\sb240\sa60\keepn\widctlpar\aspalpha\aspnum\faauto\outlinelevel2\adjustright\rin0\lin0\itap0\pararsid10056933 \i\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid10906221 {\*\bkmkstart _Toc133928194}
{\*\bkmkstart _Toc133934410}Other Issues{\*\bkmkend _Toc133928194}{\*\bkmkend _Toc133934410}
\par }\pard\plain \ql \li0\ri0\sl480\slmult1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid10906221 \tab The modern trend toward more widely-granted exemptions represents govern
ment acquiescence toward a certain degree of free riding.  Should such exemptions proliferate too widely, herd immunity may indeed be lost and a recalculation of the cost-benefit analysis of individuals will be necessary.  In the face of a greater potenti
a
l to contract disease, the benefit of vaccination grows significantly, while the cost of accepting the vaccine remains the same.  Likewise, from the standpoint of the government, the cost of allowing widespread exemptions will eventually overtake the bene
fit of permitting such exemptions if that cost suddenly includes serious risk of epidemic.  
\par \tab The risks associated with non-vaccination can be illustrated through a rather simplified mathematical example.}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 
\fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  This mathematical explanation is a slight variation of that found at CDC, \'93Six Common Misconceptions,\'94 }{\i\insrsid16601275 supra}{
\insrsid16601275  note __.}}}{\insrsid10906221   Suppose a school with 1,000 students is exposed to
 a measles outbreak.  990 of the students have received all of their measles shots, and so are fully immunized.  Suppose further that the measles vaccine is 99% effective; that is, it produces complete immunity in 99% of patients.}{
\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275 
 Note that no vaccine is 100% effective, and vaccination efficacy rates for most childhood vaccinations range from 85 to 95%.  }{\i\insrsid16601275 Id.}{\insrsid16601275 
  As stated in an earlier section, herd immunity is relied upon to protect those who do not develop full immunity from the vaccine.  }}}{\insrsid10906221   Therefore, 10 out of th
e 990 who have been fully immunized will be susceptible to the disease.  In addition, all 10 of the 1,000 students who had not been fully immunized will be susceptible to measles.  Therefore, 20 out of 1,000 students will get the disease.  Although the nu
m
ber of infected students who were vaccinated is equal to the number who were not, this example demonstrates that vaccination can be very effective even if it sometimes does not produce immunity in an individual.  If no one had been vaccinated, 980 more st
u
dents would probably have caught the measles.  It is also important to note that this example assumes an epidemic; in reality, herd immunity would probably be attained at this level of inoculation and none of the 1,000 students would have caught the disea
se. 
\par }{\insrsid470107 
\par }\pard\plain \s1\ql \li0\ri0\sl480\slmult1\keepn\widctlpar\aspalpha\aspnum\faauto\outlinelevel0\adjustright\rin0\lin0\itap0\pararsid10056933 \b\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid10906221\charrsid10056933 
{\*\bkmkstart _Toc133928195}{\*\bkmkstart _Toc133934411}IV.\tab CONCLUSION{\*\bkmkend _Toc133928195}{\*\bkmkend _Toc133934411}
\par }\pard\plain \ql \li0\ri0\sl480\slmult1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid470107 
\par }{\insrsid10906221 \tab 
Vaccines have immeasurably improved our quality of life.  They have led to the eradication of deadly diseases like smallpox and the near elimination of diseases such as diphtheria, polio, and measles.  Outbreaks of vaccine-preventable
 diseases, such as mumps, are infrequent and are also quite newsworthy on the rare occasion that they do occur.  And people like Rafe Hollister can survive a run-in with a rusty saw or an animal bite.
\par \tab The life-saving benefits of vaccination often overshadow the vast economic and personal benefits it has helped provide.  Jonas Salk\rquote 
s cure for polio has spared generations from a life hindered by the devastating physical handicaps of that terrible affliction.  Children no longer must miss vast stretches of sc
hool to overcome a debilitating battle with pertussis (although there is no doubt that some children lament this decline in excused absences from school).  Parents no longer have to spend restless hours worrying as their children suffer the body\rquote 
s natural response to disease.  In economic terms, this translates directly into fewer missed hours of work and less administrative difficulty, leading to a generally more productive society.  
\par 
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\par }\pard \ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\insrsid10906221 
\par }\pard \qc \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\b\insrsid10906221 Jonas Salk
\par }\pard \ql \li0\ri0\sl480\slmult1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\insrsid10906221 
\par 
\par \tab For all the benefits of vaccines, of course, it is important not to ignore the costs.  The National Vaccine Injury Compensation Program is one way of dealing with the economic costs of vaccination, but this may
 provide little solace to the parent of a child who has been injured by a vaccine for a disease that is seemingly in decline.  Side effects with very low probability will sometimes occur; though from a community-wide view this possibility is acceptable, f
or the individual who experiences the adverse effect the vaccination may not have been the best medical decision.  Many who view natural immunity as a rite of passage for children might not desire a means of bypassing the disease entirely.  
\par \tab Some may accus
e public health officials of dreaming for an unreachable day when all diseases are controlled by vaccination.  Zeal on the part of public health officials, however, should not overshadow the actual benefits of vaccination generally.  Soon may come the day
 when diphtheria, like smallpox, will be eradicated globally.  At that point, it can be removed from the vaccination schedule and future generations will reap the benefits of vaccination while undertaking none of the costs.  
\par }\pard \ql \fi720\li0\ri0\sl480\slmult1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\insrsid10906221 This prospect, I think, sheds l
ight on the ultimate solution to vaccination issues that have been discussed in this paper.  Highly communicable and especially terrible diseases should continue on the vaccination schedule until they are virtually eliminated.  The eventual elimination of
 
these scourges will someday make vaccination unnecessary, and the costs of vaccination will drop to zero.  Until that time, officials should seek stricter enforcement of the mandatory vaccination laws and should tighten down on non-medical exemptions.  At
 
the same time, information campaigns should be considered in the interest of reminding the public of the continued importance and relevance of vaccine programs.  Though risks are unavoidable when dealing with vaccines, parents should constantly be reminde
d that immunity depends on a high level of cooperation.  This will hopefully keep immunization rates high, at least for the most harmful diseases. 
\par Meanwhile, public health officials may be wise to consider an alternate stance toward somewhat less-important vaccines such as Hepatitis B and varicella (chickenpox).}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain 
\s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275  Given that these particular vaccines are already on t
he schedule, I think it would be unwise to remove them now.  My analysis applies to comparable vaccines that may arise in the future \endash 
 vaccines for those communicable diseases that do not pose relatively significant health risks.  The definition of such di
seases, of course, would be a matter of debate.  Vaccines for noncommunicable diseases like ear infections would also fall within this rubric.  }}}{\insrsid10906221 
  With such diseases it may be worthwhile to wait longer before placing the vaccines on the recommended schedule.  This will undoubtedly make herd immunity more difficult if not impossible to attain
, while simultaneously announcing to parents that undertaking the vaccine in question is a personal medical decision.  Most of those who choose to vaccinate (and accept the risk of adverse effects from these newer vaccines) will still acquire immunity.  W
i
thout a mandatory program in place, however, one would still expect to see regular occurrences of the disease.  Given the relatively high likelihood of outbreak under these circumstances, a percentage of those who vaccinate will probably get the disease. 
 
They will likely turn to those who did not vaccinate at all and see them as the cause of the outbreak.  In time, social pressures may lead to greater vaccination rates, and the time may be ripe for greater acceptance of mandatory vaccination for the disea
se.  
\par }\pard \ql \fi720\li0\ri0\sl480\slmult1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\insrsid10906221 
One significant benefit to this approach lies in its natural tendency to point out to parents the importance of receiving the more important vaccines.  When some vaccines are mandatory and others }{\insrsid470107 are }{\insrsid10906221 
not, the distinction between the two types of vacci
nes is impossible to neglect.  It would hopefully make parents think more carefully before attempting to gain an insincere exemption.  This approach would fail to satisfy those who want parents to have the option to choose \'93one, ten, or no vaccines,
\'94}{\cs17\super\insrsid10906221 \chftn {\footnote \pard\plain \s16\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs17\super\insrsid16601275 \chftn }{\insrsid16601275 
 Statement of Barbara Fisher, }{\i\insrsid16601275 quoted in}{\insrsid16601275  Ostrom, }{\i\insrsid16601275 supra}{\insrsid16601275  note 56.}}}{\insrsid10906221  but 
it would at least allow an element of choice for some vaccines while hopefully maintaining a sufficient level of immunization for the more important vaccines.  It is also important to remember that parents with serious reservations about any vaccines will
 usually have the option of home schooling.  }{\insrsid470107 Overall, t}{\insrsid10906221 
his approach might have the advantage of winning over those who only partially object to the vaccination schedule, thus helping bring about a greater chance of herd immunity for }{\insrsid470107 diseases associated with }{\insrsid10906221 
less objectionable vaccines. 
\par }\pard \ql \fi720\li0\ri0\sl480\slmult1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\insrsid10906221 
Vaccination certainly is unique among medical treatments, both for its incredible potential and its coercive nature.  It is unfortunate that questionable evidence has led many concerned parents to question the wisdom of vacci
nation programs that still serve important goals.  Given the importance of public support for the achievement of these goals, however, public health officials must account for sometimes questionable concerns in determining vaccination policy.  Greater inf
ormation dissemination, combined with more sharply drawn (and potentially vaccine-specific) guidelines, can hopefully further the important goals of vaccination policy.
\par }}