Childhood immunization is a highly charged issue, pitting the needs of public health against the fears of parents, who worry that vaccines can harm rather than help their kids.
It's also an argument that's rapidly coming to a head in New Jersey, as the legislature looks to update regulations requiring mandatory vaccinations for schoolchildren.
Proponents want to ensure that more children are immunized, by tightening the so-call religious exemption that parents can claim. An opposing bill would expand parents' rights to have their children opt out of part or all of a vaccination schedule.
It's a question of public benefit versus independent choice.
Doctors say vaccinating children protects society from diseases like diphtheria, measles and polio, saving several million lives worldwide each year. They also insist that fears linking the shots to auto-immune diseases like autism are unfounded.
Still, a growing number of parents are raising concerns about the possible negative impact these inoculations might have on their kids, and prefer instead to avoid any chance of harm. The controversy is particularly acute New Jersey, which has the highest rate of childhood autism in the nation.
Currently, New Jersey offers two exemptions to parents who want to avoid immunizing their children: religious and medical. While exemptions have grown steadily -- religious exemptions more than doubled to 3,865 students between 2005/06 and 2009/10 -- the overall percentage of unvaccinated children remains low, around 1 percent, and very close to the national average.
New Jersey requires children to be immunized against 13 diseases through a schedule of multiple vaccines that should begin at birth. The state's requirements are based on guidelines from experts, including the national Centers for Disease Control and Prevention, which in January 2011 issued a report that recommended being vaccinated for 17 diseases throughout one's lifetime.
A resolution by Assemblyman Herb Conaway Jr. (D-Burlington), a physician and an attorney, calls on the state health department to rewrite the rules it adopted last summer related to religious exemptions. He and others say parents have exploited the current regulations to obtain exemptions for personal reasons, which is prohibited under state law.
The rising number of exemptions have many in the medical community concerned that the state’s mandatory policy is becoming less so and thus less effective.
The Conaway resolution declares that the new rules aren't consistent with the legislature’s intent when it amended state law in 2002. It instructs the health department to rewrite these regulations within 30 days.
The statute now requires religious exemptions be granted based on a written statement from parents that explains how vaccinating their children conflicts with "the bona fide religious tenets or practices" of the family. The July rule change instructs local officials not to question parents when they request a religious exemption. The resolution says that by failing to require these written statements, the state is putting children, schools and communities at risk.
"Public health science shows that when you do make [vaccines] optional, you get more outbreaks and we all suffer," explained Dr. Drew Harris, who is with the New Jersey Public Health Institute. "If we have breaches in the wall of protection… we’re much more likely to have outbreaks."
Conaway's resolution, originally scheduled for a vote in mid-February, was held up when critics raised concerns about its constitutionality, suggesting it might infringe on parents' religious freedoms. A new vote has yet to be scheduled.
As a concurrent resolution, if the measure is adopted by both the Assembly and Senate, it is considered an expression of the legislature’s opinion and it does not require the governor’s signature to become effective.
A second measure, by Assemblywoman Charlotte Vandervalk (R-Bergen) takes the opposite tack. Considered a hero by vaccine critics, Vandervalk wants to increase the exemptions available to parents by adding one for conscientious objection. The exemption could apply to all or some shots. There are now 20 states that allow some kind of exemption beyond medical or religious.
Vandervalk said her bill, versions of which were stalled in various committees, will soon get a hearing in the Health and Senior Services Committee -- chaired by Conaway. Dozens of legislators joined as co-sponsors on the measure, including some just last week, and more than 15,000 people have signed a petitionsupporting the bill.
"There are so many people who have had bad experiences with vaccines and want a conscientious objection," Vandervalk said, describing the letters she has received from dozens of parents over the past decade. "They want to be able to make the choice."
Concerns about childhood vaccines have existed for years, but these worries gained momentum following a 1998 study published in the prestigious British medical journal The Lancet that suggested a connection between vaccines and autism. But this study, which involved only twelve subjects, was found to be flawed on several levels. All but a few of the researchers involved have since denounced its findings. The journal printed a retraction earlier this year.
"This [study] has caused untold anxiety for parents and serious problems for the public health system in general," Conaway said. "Our immunization policy should be based on the best science available to protect people and reduce the prevalence of diseases in society."
But others, like Vandervalk and parent Sue Collins, who helped found the New Jersey Alliance for Informed Choice in Vaccination, said it is not about this one study. Collins said other research, such as a study involving monkeys and Hepatitis B, have shown dangers. Vandervalk pointed to the recent publication of a book that affirmed many of these fears. They worry most that not enough research has been done to determine the impact of multiple shots in combination, and that the studies on some vaccines are outdated. They urge doctors to consider the weight, health and history of each child individually.
"I hear from parents daily and they are frustrated. They feel pressured, bullied and backed into a corner," Collins said in an email interview. "They do not trust the health department or the government. They feel they are not being listened to and their children are being harmed in the name of pharmaceutical profits."
Public health officials insist that these fears are misplaced. Mercury, an early concern, was removed from almost all vaccines a decade ago. They also note that immunizations have been extensively and sufficiently studied and found to be completely safe.
The CDC also re-examines vaccine policy and issues updated recommendations to public health officials every three to five years. The most recent recommendations were released in January.
The bottom line, doctors say, is that the positives far outweigh any negatives associated with immunizations. And while fear of polio or mumps may seem a thing of the past, public health officials underscore that these diseases have not been eliminated. The CDC reported a major outbreak of whooping cough in California during 2009, and Harris noted a recent outbreak of Hib among unvaccinated children in New Jersey and Pennsylvania that killed four children, some of whom were not vaccinated. Health officials in Boston were battling to contain three suspected cases of measles just this past weekend.
Harris and others believe the Conaway resolution is essential to bring health department regulations back in line with state law and the intention of the legislature. He believes that the new rules, which are based on a 2008 health department memo that included advice from the Attorney General’s office, will result in more religious exemptions being granted without "any justification provided" by parents. He also worries that the rule will make it harder for local officials to effectively protect public health.
Officials at the health department underscore their support for the state’s immunization program and point out that vaccine coverage remains high overall for New Jersey schoolchildren.
"The department strongly supports vaccination as a preventive public health measure that protects not only the children who are immunized but also their families and their communities from infectious diseases," said Dr. Christina Tan, State Epidemiologist.
In a written statement, health officials added: "The department does not investigate parents' religious beliefs if they request a religious exemption from immunization rules for children in schools."
Conaway and others believe that the state is being unnecessarily cautious by changing the rules to drop the written statement requirement. The statute, amended in 2002 does not restrict parents’ First Amendment freedoms, they say, since it does not require parents to claim membership in any particular or organized religion. It does, however, require that they explain the conflict immunizations pose within whatever faith they do hold. They hope the resolution will also be determined to be constitutional and be posted again for a vote soon.
“No documentation other than a truthful statement identifying the personally held religious belief or practice that is in conflict with the mandate must be given,” noted Renee Steinhagen, Executive Director of New Jersey Appleseed Public Interest Law Center, in a preliminary analysis she helped prepare.
"It’s not about a specific church," she added in a telephone interview. "It’s can parents articulate a holistic belief system and demonstrate consistent practice?"
For Harris, the criticisms can become frustrating when looking back to a time before mandatory, widespread immunization programs. "If there is something we can do to prevent disease outbreak, then we need to do that," he said. "Vaccines are saving lives."