Issue: December 2019

November 19, 2019
6 min read

Q&A: More vaccine-preventable diseases lead to more pro-vaccine bills

Issue: December 2019

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Photo of Neal Goldstein
Neal D. Goldstein

An increased incidence of vaccine-preventable diseases is associated with an increase in proposed bills restricting vaccine exemptions, according to study findings published in JAMA Pediatrics.

Specifically, researchers found that each standard deviation increase in vaccine-preventable diseases per 100,000 people was associated with 54% more proposed bills (95% CI, 27%-88%).

Neal D. Goldstein, PhD, MBI, assistant research professor of epidemiology at Drexel University Dornsife School of Public Health, and colleagues analyzed instances of vaccine-preventable diseases reported to the National Notifiable Diseases Surveillance System. They included diphtheria, hepatitis A and B, Haemophilus influenzae type B, influenza, measles, pneumococcal disease, meningococcal disease serotypes A, B, C, Y and W-135, mumps, pertussis, tetanus, varicella and rubella and congenital rubella syndrome in the analysis.

The researchers linked reported vaccine-preventable diseases to proposed bills related to state vaccination exemption laws from 2011 to 2017. They aggregated reports for all states between 2010 and 2016 to allow for a 1-year lag time and account for potential upticks in disease to elicit a legislative response.

The states reported an average of 25 vaccine-preventable diseases per 100,000 people, and there were 175 total proposed vaccine exemption-related bills. Of the bills, 83 (47%) restricted exemptions, whereas 92 (53%) expanded exemptions. When limited only to bills that would expand exemptions, vaccine-preventable diseases were not associated with bill proposals. However, the researchers found significant associations between both types of bills when they restricted vaccine-preventable diseases only to pertussis.

Goldstein and colleagues cited medical coverage and increased public awareness as potential explanations for these associations. Infectious Diseases in Children spoke with Goldstein about the study’s wider implications, including the influence of public opinion and guidance from clinicians on vaccine exemption legislation. – by Eamon Dreisbach

Q: What was the impetus for this study?

A: We were looking at legislation in particular and had a previous study that was published last year in the American Journal of Public Health. We asked the question, “What is the current state of vaccine exemption legislation in the United States?”

We were particularly interested in proposed legislation to get a general sense of what trends are out there right now at a state level. What we saw was concerning in that there were more bills being proposed at the state level that would enable exemption, or to put it another way, anti-vaccination.

The positive of this study was that those bills rarely made it into law, and that those that were proposed and made it into law were overwhelmingly pro-vaccination or restricted the ability to exempt from school entry vaccine requirements. We did that study and then naturally the question came up, especially with what we saw in California a few years ago with the Disneyland measles outbreak, “What prompts legislators to act to raise these bills — to prepare them, to debate them and to enact them into law ultimately?”


We thought one potential mechanism for this is disease outbreak. So, you have more disease, then you have media coverage of that, which potentially leads to advocacy efforts and garners enough support that legislators will act upon it. The recent measles outbreak in New York is an excellent example of that. We saw all these cases of measles, and then we saw the state subsequently remove nonmedical exemptions.

Q: What do these results say about public reaction to vaccine - preventable disease, and how that may affect legislation?

A: From a positive perspective, it shows it increases the awareness of this at the public level. Even if we do see people exempting themselves or their children, the coverage of this raises the public awareness. I suspect that for people who are truly on the fence about vaccinating, this is an opportunity to convince them to vaccinate because in this worst-case scenario, they get disease.

That’s an important message that could come out of this. It also shows me that legislators will listen to their constituents if they are vocal enough to say, “We want laws that will promote vaccination in our in our states.”

Q: What are the implications of this research for pediatricians or clinicians?

A: This is a good example of raising public awareness. I think when awareness is higher, people are more inclined to have this conversation with their health professional and the health professional is that frontline worker. For the people who are truly on the fence, this is a great opportunity.

If they have re-engaged, if they have access to the provider and if they're engaged in care, then they should be able to move the hesitant people to become vaccinated or to vaccinate their kids. The challenging population now is those who are digging their heels in and are truly anti-vaccine. They don't care about the science and don't care about any evidence because they are convinced of their own misinformation.

Those individuals may not visit what we would consider “mainstream” health care professionals. They may be more likely to visit fringe practitioners who will reinforce their misinformation, unfortunately. Those are the folks who are challenging to engage. For the general health care practitioner, this increased awareness is an opportunity for them to have that vaccination conversation, early and often when they see these families.


Q: What are the implications for children?

A: Although we talked about legislation broadly, this really is school entry vaccination requirements that we're talking about. That varies state by state, and it's tough to make generalizations based on this. But typically, what we can say is that public and private schools and often daycare centers fall under these legislative requirements.

This is focusing on kids as soon as they're born into the point where they are ready to go into daycare or going to school. One of the challenging areas that we still have — and this is something we saw recently with California — were laws on the books that say there are no nonmedical exemptions, that there are loopholes in the law that will affect children.

This could be that parents are just going to say, “Well, I'm going to homeschool my child where we won't have these vaccine requirements.” Or maybe they'll say, “OK, if I can only get a medical exemption, I'm going to seek out one of these fringe practitioners who will support my point of view on this and therefore won't vaccinate their children.”

As such, these children then remain vulnerable to getting infection and potentially exposing other children. The real challenge is that because these parents tend to all have a similar mindset, they also tend to be of a certain socioeconomic position, and they're more likely to congregate or to lead in similar areas.

That's really what provides the fuel for the fire of infectious disease outbreaks. It's not that you just have random people here and there for a given state. It's when they congregate together, and then their children who are unvaccinated are congregating together, that you have the opportunity for a measles outbreak.

Q: What actions can clinicians and legislators take to confront anti-vaccine confirmation bias?

A: That's the current challenge of public health, “How do we counter this misinformation?” How do we break down this distrust and mistrust of established institutions like the CDC?

For the individuals who are on the fence, I think there's hope that studies like ours and the overall media coverage will raise the awareness for the individuals who have dug their heels in and are really anti-vaccine. I think this is an opportunity for public health to engage their counterparts in other disciplines, such as psychology, sociology and even economics. Talking about the economics of a disease outbreak is a nice motivator where we don't even have to talk about the science of how vaccines work.


There’s a lot to be learned from each other’s disciplines on how to motivate individuals to do things. Law is just one way of doing it. And I certainly wouldn’t say that law is the only way of doing it. It’s not the magic bullet that we're looking for.

Law in my mind is more of last resort, because what we see is that it took a disease outbreak, or many disease outbreaks, to prompt a legislative response and by that point, people have already gotten sick. So really the opportunity here is for public health to engage individuals in other disciplines.

Q: Where should research look next?

A: You could put really any disease that you want, or any health outcome that you want, in this model, and you can say, “How do areas of mental health impact mental health legislation?” How does firearm violence impact the proposed firearm related bills?

It’s another interesting perspective to look at how law can affect constituents, or the other way around — how constituents can impact law. Because really the lawmaker is their elected representative, and in an elected democracy, that's the way that this process should be happening. There should be something that affects the constituents and subsequently a legislative response to that.


Goldstein ND, et al. JAMA Pediatr. 2019;doi:10.1001/jamapediatrics.2019.4365.

Disclosures: Goldstein reports funding from the NIH unrelated to this study.