Making salient ethics arguments about vaccine mandates: A California case study

Vaccine mandates can take many forms, and different kinds of mandates can implicate an array of values in diverse ways. It follows that good ethics arguments about particular vaccine mandates will attend to the details of individual policies. Furthermore, attention to particular mandate policies-and to attributes of the communities they aim to govern-can also illuminate which ethics arguments may be more salient in particular contexts. If ethicists want their arguments to make a difference in policy, they should attend to these kinds of empirical considerations. This paper focuses on the most common and contentious vaccine mandate reform in the contemporary United States: the elimination of nonmedical exemptions (NMEs) to school and daycare vaccine mandates. It highlights, in particular, debates about California's Senate Bill 277 (SB277), which was the first successful recent effort to eliminate NMEs in that country. We use media, secondary sources, and original interviews with policymakers and activists to identify and evaluate three ethics arguments offered by critics of SB277: parental freedom, informed consent, and children's rights to care and education. We then turn to one ethics argument often offered by advocates of SB277: harm prevention. We note, however, that three arguments for mandates that are common in the immunization ethics literature-fairness/free-riding, children's rights to vaccination, and utilitarianism-did not play a role in debates about SB277.

Eliminating nonmedical exemptions: a radical shift in how childhood vaccine mandates govern

INTRODUCTION

Every state in the US has had school vaccine mandates for decades, and all except West Virginia and Mississippi offered nonmedical exemptions (NMEs) in addition to medical exemptions. Several states recently eliminated NMEs, and others have attempted to do so. These efforts are transforming America's immunization governance.

AREAS COVERED

What we call the 'mandates & exemptions' regime of vaccination policy from the 1960s and 1970s functioned to orient parents toward vaccination, but did not coerce or punish them for not vaccinating. The article identifies how policy tweaks in the 2000s - including education requirements and other bureaucratic burdens - delivered enhancements to the 'mandates & exemptions' regime. Finally, the paper illustrates how the recent elimination of NMEs, first in California and then in other states, represents a radical transformation of America's vaccine mandates.

EXPERT OPINION

Today's 'unencumbered vaccine mandates' (mandates without exemptions) directly govern and punish non-vaccination, unlike the 'mandates & exemption' regime that aimed to make it harder for parents to avoid vaccination. This kind of policy change introduces new problems for implementation and enforcement, especially within America's underfunded public health system, and in the context of post-COVID public health political conflicts.

Measuring Multiple Dimensions and Indices of Nonvaccination Clustering in Michigan, 2008-2018

Michigan experienced a significant measles outbreak in 2019 amidst rising rates of nonmedical vaccine exemptions (NMEs) and low vaccination coverage compared with the rest of the United States. There is a critical need to better understand the landscape of nonvaccination in Michigan to assess the risk of vaccine-preventable disease outbreaks in the state, yet there is no agreed-upon best practice for characterizing spatial clustering of nonvaccination, and numerous clustering metrics are available in the statistical, geographical, and epidemiologic literature. We used school-level data to characterize the spatiotemporal landscape of vaccine exemptions in Michigan for the period 2008-2018 using Moran's I, the isolation index, the modified aggregation index, and the Theil index at 4 spatial scales. We also used nonvaccination thresholds of 5%, 10%, and 20% to assess the bias incurred when aggregating vaccination data. We found that aggregating school-level data to levels commonly used for public reporting can lead to large biases in identifying the number and location of at-risk students and that different clustering metrics yielded variable interpretations of the nonvaccination landscape in Michigan. This study shows the importance of choosing clustering metrics with their mechanistic interpretations in mind, be it large- or fine-scale heterogeneity or between- and within-group contributions to spatial variation.

Immunization Noncompliance: Gauging the Cause, Effect, and Management in the School Setting

Immunization noncompliance is a public health issue. Vaccines have been noted as one of the most effective public health interventions against the spread of infectious disease. However, there is an increase in the number of nonmedical exemptions and vaccine hesitancy. This has been linked to a decrease in the fear of contracting vaccine preventable diseases to public concerns regarding vaccine safety. Research has shown that decreased vaccine coverage lessens the effect of herd immunity placing those who are unvaccinated or unable to be vaccinated at increased risk of contracting vaccine preventable diseases. These factors have led to legislative action with some states implementing stricter exemption laws and stronger enforcement of vaccine mandates. Within the school setting, the school nurse is in a unique position working within both the educational and healthcare domains. The monitoring of immunizations is a key and vital factor in ensuring the health and safety of the school community.