In the last half-century, childhood vaccines have been a great blessing, greatly decreasing death and disability due to infectious diseases. Most grandparents today are old enough to recall the scourges of polio, whooping cough, and other childhood infectious diseases. Visions of children languishing in iron lungs in institutions and of the braces and wheelchairs of victims of paralytic polio come to mind. Some may even suffer or know adults with the fatigue, pain, and muscle weakness of post-polio syndrome, which affects twenty to forty percent of polio survivors many years after the attack.[1] And who can forget the distinctive “whoop” of pertussis, which gives “whooping cough” its name? Yet, today, thanks to routine immunizations, few medical personnel outside developing countries have ever seen a polio victim or witnessed an infant struggling against pertussis's ravaging cough.
Most childhood immunizations are given in infancy. Adolescents routinely receive only a booster for tetanus. Yet the protection afforded by some vaccines decreases over time. Thanks to television news and documentaries, the best-known and most dramatic example of this is probably meningococcal meningitis, which can cause death in hours or leave its young survivors amputees. Other diseases, like diphtheria, are less severe in adolescents, but may cause uncomfortable and persistent symptoms and extended illness, requiring absence from school. Other infections, such as those causing sexually transmitted diseases, put many adolescents at special risk as they respond to raging hormones in this era of casual sex.
Increasingly, vaccines are or are becoming available for each of these categories of disease. The Food and Drug Administration soon will consider whether to recommend vaccination of adolescents against meningitis and the virus causing genital warts and increased risk of cervical cancer, along with a booster for pertussis.[2]
Decisions of this type usually involve assessing the risk and benefits of the immunization. Like any medicine or treatment, vaccines are not without risk, yet their risk is usually much lower and less serious than the risk of disease. For example, vaccines may cause pain or inflammation at the injection site, fever, or allergic responses, while, as noted above, the disease may be disabling or life-threatening. A small number of vaccines, such as smallpox vaccine, bring with them a low, but measurable risk of death and should be used only when risk of disease is significant, such as in first responders or after a biological attack.
Decisions on whether to mandate immunizations should be based on specific situations, such as those that make infection more likely, and the nature of the disease they are designed to prevent. Highly contagious and fulminate diseases that strike without warning, such as meningococcal disease, put those nearby at risk. It is reasonable to mandate vaccination against such diseases for those attending school or university, entering the military, or accepting employment in situations where many people spend extended time together. In some cases, it may be reasonable to grant exemptions for those with moral or religious objections to vaccination. This is especially true for diseases unlikely to spread in an environment where most are immunized or for which effective post-exposure prophylaxis is available. Meningococcal disease may be such a condition, since a decision not to be vaccinated is a decision to risk personally contracting the disease, but is unlikely to pose a significant risk to those exposed to that individual, since a drug is available to prevent the disease and most would have received the vaccine. In the rare situations in which exemptions might put others at high risk, mandating vaccination of students should not greatly limit the education of those with moral or religious objections in this era of home schooling and distance learning.
Except for those in the military, who enter voluntarily and require high readiness for immediate deployment, it is harder to justify mandating immunization against diseases likely to bring significant symptoms and require extended recovery. In these cases the FDA should refrain from mandating vaccination, but should make a recommendation whether to inform the public of the vaccine’s benefits and make it available on a voluntary basis.
Vaccines, such as those against sexually transmitted diseases, could greatly decrease the frequency and effects of these diseases. The FDA should evaluate whether to inform the public and recommend vaccination on a voluntary basis. However, the FDA should make clear which groups are at risk and of what disease(s). Those not engaging in high-risk behaviors would not benefit from this type of vaccine, unless it has other benefits. For example, the hepatitis B vaccine may be wise for medical personnel and others at risk of blood contact who would not otherwise benefit from it if they were sexually abstinent or monogamous.
The future of vaccination is bright. The number of vaccines available continues to increase. Immunizations can prevent an increasing array of infectious diseases. New types of vaccines against diseases, such as cancer and diabetes, may be on the horizon. New methods of vaccination may even arise with the advent of genetic engineering and nanotechnology. Wisdom is needed in evaluating which immunizations to recommend, at what life stage, and to which risk groups. Mandated vaccination should be limited to those diseases and situations where disease in an individual puts those with whom they come into contact at significant risk of serious illness.
References
[1] Christine A. Maxey, “Living With Post-Polio Syndrome,” HealthLink, July 28, 2001 http://healthlink.mcw.edu/article/996372413.html (accessed April 18, 2005).
[2] Anita Manning, “Here Come the Vaccines,” USA Today, March 7, 2005 http://www.usatoday.com/news/health/2005-03-07-vaccines-usat_x.htm (accessed April 18, 2005).