Low Immunization Rates in the United States
By Asia Haslam and Harper Forsgren
Published Summer 2021
Special thanks to Hannah Pitt for editing and research contributions
Summary+
Vaccination hesitancy has been a concern for some time in the United States, but it is an issue that has become increasingly prevalent in the past 20 years. This hesitancy and mistrust of vaccinations has translated into lowered immunization rates for children and adults. The reduction in vaccination rates is driven mainly by concerns over safety, perpetuation of misinformation about vaccinations, and the increased polarization of immunizations in the United States. Low vaccination rates can cause serious consequences including re-emergence of dangerous diseases, economic consequences for communities, and furthered perpetuation of political divides. The US government and many public health organizations have utilized several strategies to increase vaccination rates, but rates still remain lower than recommended by the Centers for Disease Control and Prevention (CDC). This issue of low immunizations has been especially highlighted by the 2020 Covid-19 pandemic, which brought much of the anti-vaccination dialogue to the forefront of public attention.
Key Takeaways+
Key Terms+
Vaccination–A biological preparation that improves immunity to a particular disease. It typically contains an agent that resembles a disease-causing microorganism. The agent stimulates the body’s immune system to recognize the pathogen as foreign, destroy it, and “remember” it, so the immune system can recognize and destroy any of these microorganisms it encounters at a later date.1
Immunization–“The creation of immunity, usually against an infectious disease, especially treatment (as by vaccination) of an organism for the purpose of making it immune.”2
Vaccine hesitancy–A refusal to vaccinate or a delay in vaccination among those who have access to vaccinations.3
Community immunity–Also known as “herd immunity.” Where enough of a population is immune to an infectious disease that its spread is unlikely.4
Immunocompromised–Also called immunosuppressed. Having a weakened immune system. “Patients who are immunocompromised have a reduced ability to fight infections and other diseases.”5
Conspiracy theory–“An effort to explain some event or practice by reference to the machinations of powerful people, who attempt to conceal their role (at least until their aims are accomplished).”6
CDC–A United States governmental organization that works to protect the American public and promote the health and wellbeing of those in the US.7
MMR–Measles, mumps, and rubella.8
Pertussis–Also known as whooping cough. Pertussis is a very contagious respiratory disease that is known for violent and uncontrollable coughing fits.9
Context
Vaccinations, interchangeably known as immunizations, work by activating the body’s immune system with a weaker strain of the microorganism that leads to a specific illness, causing the body to create antibodies that will recognize and terminate the foreign invader before it fully infects the body.10 The ability to train the body to recognize and fight against diseases has been vital in stopping the spread and magnitude of illnesses such as polio, tetanus, diphtheria, measles, and many more.11 Though the widespread benefits of each immunization would be difficult to synthesize, the example of polio is an excellent case study in highlighting the effectiveness of vaccines. In the late 1940s, over 35,000 people per year were disabled by polio, an illness known for its high paralysis and death rates; however, since the creation and widespread administration of the vaccine in the 1950s–1960s, polio has been almost eradicated from the United States, with less than 10 reported cases per year.12
Not only do immunizations protect the individual who receives the vaccination but also the widespread administration of immunizations is proven to protect the whole of society with what is called “herd immunity.” Herd immunity, or community immunity, occurs when enough of the population is immune to a specific illness that the likelihood of anyone catching the illness—even those who are unable to receive immunizations for medical reasons—is low.13 The exact percentages of who needs to be immune to achieve herd immunity varies between illnesses, but in highly contagious illnesses such as measles it can be as high as 95% of the population.14
Even before the 2020 Covid-19 pandemic renewed the vaccination dialogue in mass media, many health experts were concerned about the increasingly shrinking rates of immunizations for individuals in the United States.15 Vaccination rates are low for both children and adults, which has been brought forward as a concern from public health entities such as the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO).16, 17 Though the United States’ immunization rates may seem fairly high in comparison to the worldwide average, the stats are quite low in the context of the US’s well-developed health infrastructure. Generalized data demonstrates that the United States’ vaccination rates are similar to the rates in Canada but are lower than most Western European nations such as France, Germany, and the United Kingdom.18 Thus, though the United States may not have the lowest percentages of vaccination administration worldwide, it does rank low in comparison to other high-income nations.19
Vaccination rates in the United States as a whole have been rising slowly since 2001.20 In 2000, the nationwide percentage of children who received the recommended four doses of the Diphtheria, Tetanus, and Pertussis (DTaP) immunization was around 81.7%; other immunizations such as the Measles, Mumps, and Rubella (MMR) and the Hepatitis B immunizations were 90.5% and 90.3%, respectively.21 In 2017, the percentage of individuals who received the full four-dose round of the DTaP vaccine rose to approximately 83.2%. MMR vaccination rates in 2017 were around 91.5%, and the Hepatitis B vaccine rates were 91.4%.22 However, this increase is not consistent in all areas of the US, likely due to variations in state vaccination laws. For example, West Virginia’s vaccination rates hover above 98% for MMR, DTaP, and Varicella, yet Colorado’s rates range from 86 to 90% for these different vaccinations.23 These rates have a negative correlation with the number of exemptions allowed, illustrating that states with more exemptions have lower vaccination percentages.
The 2020 Covid-19 pandemic exacerbated the issue of vaccine hesitancy greatly. The pandemic itself thrust the fields of public health and epidemiology into the public eye, and information that once was obscure to many is now common household dialogue.24 With this newfound resurgence of interest in disease transmission came a fresh wave of naysayers in regards to Covid-19 health advice—including recommendations on vaccinations.25 Increased interest in disease, low health literacy, and easy access to quick and potentially unvetted information through social media has escalated the discussion beyond what it was before.26, 27 This escalated discussion in turn influences the hesitancy of many citizens of the United States in getting vaccinated.
Contributing Factors
The two main groups of people who do not vaccinate in the United States are those who are unable to access vaccinations and those who choose not to vaccinate—whether that be for medical or non-medical reasons. Those that have access to vaccines but choose not to vaccinate themselves or their children at the recommended times are referred to as “vaccine hesitant,”28 and these individuals will be the focus of this brief. Others do not have access to vaccinations due to concerns about cost or lack of infrastructure. However, these individuals make up a small percentage of those who do not vaccinate and will only be discussed briefly.
Non-medical Exemptions
An important factor contributing to low vaccination rates in parts of the US is the granting of non-medical exemptions. West Virginia, the state with the highest rates of vaccinations nationwide, does not legally allow exemptions for either religious or philosophical reasons; Colorado, the state with the lowest average vaccination rates nationwide, allows both religions and philosophical exemptions.29 Most states allow for non-medical exemptions to the rule that all children must be vaccinated in order to attend public school.30 West Virginia, Mississippi, and California are the only three states who currently do not allow non-medical exemptions for any reason.31 These exemptions may be requested for religious and/or philosophical reasons. For example, some Hasidic Jews—a small subgroup of the larger Jewish population—have religious concerns about vaccinations due to religious teachings that promote hesitancy in engaging in modern medicine and as such choose to apply for religious exemptions.32 For others, personal beliefs may lead individuals to apply for philosophical exemptions. However, what is classified as a valid religious and/or philosophical reason is oftentimes not specified in legislation, and there is not a list of religious organizations who should be granted exemptions over other groups.33 Because the wording “non-medical exemptions” is purposefully vague, healthcare providers are oftentimes left to determine whether a stated reason for requesting an exemption is valid.
Due to legislative practices in place in the United States, there are only four groups of people who may not be vaccinated: children who are immunocompromised and receive medical exemptions, children who receive non-medical exemptions for personal or religious beliefs, children who are homeschooled, and those who immigrate into the United States without documentation.34
Safety Concerns
Concerns about the safety of vaccines have been a topic of conversation since the arrival of vaccinations themselves.35 Moreover, the information that is perpetuated is usually highly linked to misinformation that is found in media outlets.36 Though there are always risks associated with any medical intervention, the adverse side effects of immunizations are usually minor, such as soreness, fever, stiffness, headaches, and fatigue.37 Other, more common side effects such as allergic reactions can occur but are extremely rare.38 However, in the perpetuation of safety concerns throughout society, individuals tend to focus on more frightening side effects, oftentimes linking vaccinations to deathly side effects and chronic ailments.
A common belief regarding vaccines is that they may increase the chance of a child being diagnosed with autism. While the claim has been disproven numerous times by credible medical professionals,39 this popular misconception persists, stemming from a 1998 study that claimed to have found a link between the MMR vaccination and developmental disorders such as autism.40 Though the majority of the authors have since retracted the paper’s interpretation and the study has been redacted by the journal that published it due to a low sample group, a previously undisclosed conflict of interest, and falsified data,41 its negative consequences on public opinion of vaccines remain prominent.42 For example, in the United Kingdom before the study was published, vaccination rates for MMR were estimated to be around 92–95%. After the publication of the study, vaccination rates were estimated to have fallen to approximately 60–80%.43 Although vaccination rates have increased since the study's findings were retracted and the MMR vaccine was altered, the belief that there is a strong link between vaccines and autism remains prevalent in many countries.44
Other safety concerns, spread by media or word-of-mouth, persist despite a clear lack of evidence. One such common misperception is the belief that the DTaP vaccine causes Sudden Infant Death Syndrome (SIDS), an argument linked to evidence that most cases of SIDS occur during the same age range when three shots of the DTP vaccine are given to an infant. However, no scientific connections have been made regarding the truth or validity of these claims.45 Additionally, other claims are made that vaccinations actually give an individual the sickness they were trying to prevent. These claims are based on anecdotes of the flu vaccination giving people the flu; however, this claim is widely based on scientific misconceptions. People often mislabel gastrointestinal illness and the stomach bug, caused by the norovirus, as the “flu,” whereas the flu is actually a respiratory illness.46 Therefore, receiving the flu vaccination is not the cause for contracting another illness or the flu itself.
In early 2021, multiple Covid-19 vaccinations were released to the public. Most notably were Pfizer and Moderna, which were the first to be released and as such garnered much of the publicity.47 Though the vaccination was made available, many individuals were hesitant to receive it; a December 2020 study stated only 58% of Americans who took the survey said they would take the vaccination, and 31% stated they were unsure at the time if they would.48 Concerns about the safety of these vaccinations was at the top of the list for why individuals were hesitant or unwilling to take the vaccine. Many of these concerns stemmed from individuals worrying that the vaccines had been produced too rapidly and there were not adequate trials conducted on them before distributing them, leading many to wonder if there would be long-term effects that were not discovered at the time.49 These worries once again resurfaced in April 2021, when the CDC halted the distribution of the Johnson & Johnson vaccination due to rare blood clots.50 Though these clots were not common and the halting of the vaccination was precautionary, the action fueled the argument that the Covid-19 vaccinations were more harmful than the actual disease.
Ideological Viewpoints
Those that tend to be vaccine hesitant often identify as being on the two opposite poles of the political and ideological spectrum. In the United States, anti-vaccine sentiment has historically been attributed to those who identify as liberal, or ideologically “left-wing.” Conversations on this end of the spectrum were focused on the safety of vaccinations and uneasiness of having manufactured substances injected into the body.51 On the other side of the ideological spectrum, vaccine-hesitant individuals who promote more conservative, or “right-wing” ideologies oppose the idea of mandatory vaccinations due to the belief that legislation mandating immunizations is an overreach by the government and a direct imposition to the individual freedoms delegated to United States citizens in the Constitution.52, 53 Though the reasoning for vaccine hesitancy varies between these two ends of the ideological spectrum, one common thread between the ideology of the far right and the far left is distrust of scientists, government entities and experts, and/or the pharmaceutical industry.54
The Pew Research Center conducted a review of research in 2015 to determine the personal beliefs about vaccinations by those living in the United States. In one study mentioned in the review, it was determined that 12% of those who self-identified as liberal believed that childhood vaccines such as MMR were unsafe, while only 10% of those who identified as conservative believed these vaccinations were unsafe.55 However, a poll conducted by Pew in 2014 illustrated that only 64% of conservative individuals believed that vaccination requirements should be mandated by the government, whereas 74% of liberal individuals believed that there should be a mandate for immunizations.56
The partisan split of vaccination willingness versus hesitancy reached a climax in 2021 with Covid-19 vaccination. Whereas previous data on vaccinations tended to be a bit more murky in regards to political ideology, data on the Covid-19 vaccinations provides clear evidence of a political divide. In a March 2021 survey conducted by CBS News, approximately 33% of Republicans stated they would not get a Covid-19 vaccine in comparison to 10% of Democrats.57 Additionally, an NPR poll revealed that 47% of people who took the survey who reported supporting former President Donald Trump in the 2020 elections stated they would not receive the vaccine, whereas only 10% of those who supported President Joe Biden in the 2020 election stated the same.58
Spread of Misinformation through Media
Internet
The availability of unsubstantiated information, which has become much more common as content becomes more accessible through the internet, is another reason for vaccine hesitancy. The creation of the internet in 1989 opened the doors for increased internet usage and quick distribution of information.59 However, the internet may also lead to the perpetuation of false information because much of the information posted on the internet is not “fact-checked” before it is published.60, 61 The lack of regulation has led to the increasing popularity and spread of unfounded theories, including those persuading others against vaccination. The most common claims on anti-vaccination websites are that vaccines contain toxins and cause illnesses.62 Most of these sites also encourage alternative, homeopathic treatments, which are not a viable substitute to many vaccines.63
The material people may find while searching for information on immunizations varies with the search terms they choose to use. In 2009, a study examined search results in the United States for three terms: “vaccine,” “vaccination,” and “immunization.”64 A search for “vaccination” produced links that belonged to anti-vaccination websites 71% of the time, whereas “vaccine” produced anti-vaccination links only 25% of the time. “Immunization,” on the other hand, produced only pro-vaccination links.65 Though there are differences in meaning to these two words, the terms are oftentimes used synonymously. However, the term “vaccination” holds a more negative connotation than the term “immunization” in the public eye.66 This information indicates that the function of search engines is a high contributor to the spread of misinformation about vaccines, which then leads individuals to be unwilling to get immunized.
When conducting an internet search, the wording used can drastically change the type of information you will receive. The term 'vaccination' is known to produce more hits that are against vaccines, whereas the term 'immunization' is known to produce hits that are for vaccines.
Social Media
Social media platforms such as Facebook, Instagram, Twitter, Pinterest, and YouTube have created mediums for the creation and distribution of anti-vaccination content. In a survey conducted on first-time mothers about vaccination knowledge, approximately 36% of individuals reported using the internet as one of their main sources of information for vaccinations; only 22.5% reported that their healthcare provider was a primary source of information.67 Social media platforms tend to be a place where many people access internet information, and many spread either “misinformation,” which is an inadvertent drawing of conclusions based on incomplete or wrong information, or “disinformation,” which is a more deliberate spread of false ideas, through these sites.68 False news stories are 70% more likely to be shared than true stories, and data indicates that true stories take about 6 times longer to reach the same amount of people as false stories do.69 This spread of inaccurate information, whether knowingly or unknowingly, often stems from the fact that much of the information found on social media comes from sources that are not traceable nor come from credible sources.70
Researchers have found Facebook to be one of the most prominent platforms to promote what is termed as “anti-vax” content.71 Facebook platforms create a venue where users can participate in groups, share content on their public feeds, and interact with others who share similar beliefs and opinions. Researchers mapping the anti-vaccination movement over Facebook have asserted that discourses surrounding the movement suggest a theme of “conspiracy-style beliefs and thinking.”72 Additionally, studies conclude that anti-vaccination content distributed through Facebook groups tends to establish echo-chambers, which subsequently lead to increased polarization of ideas from those who participate in the groups.73
Though Facebook tends to be the most prevalent social media platform for acquiring and sharing anti-vax content, other platforms also spread anti-vaccination sentiment. In a 2015 analysis on the content found on Pinterest, researchers discovered that approximately 74% of the pins about vaccinations they analyzed portrayed immunizations in a negative light.74 Additionally, studies on the perpetuation of vaccination information over Twitter indicate that vaccination content can be spread through hashtags, one of the most common being the tag #VaccinateUS. Researchers studying the content found that approximately 38% of the Tweets with the hashtag #VaccinateUS promoted negative ideas about vaccinations.75 The spread of negative and/or untrue information about vaccinations skews public opinion and subsequently leads individuals to opt out of vaccinating due to the stories they hear.
Lack of Access
In the United States, there are those who may have a desire to get immunized but who have limited access to vaccinations. One common concern is convenience. If a health clinic where immunizations are administered is too far away or the operating hours are inconvenient, those who would like to get vaccinated may not be able to do so.76 The CDC reported that in 2018, the proportion of teenagers who had all recommended doses was 15 percentage points lower for those in rural areas than for those in urban areas. Additionally, the proportion of teenagers who had received the meningococcal vaccine were 20 percentage points lower for those in rural areas than urban areas.77 There are many possible reasons for this trend, including decreased access to hands-on education for rural populations due to decreased ratios of public health providers to rural cities and greater distance from areas where these immunizations could be administered.
Another concern that can decrease the likelihood of receiving the recommended vaccinations is the cost of immunizations, especially for those who have inadequate health insurance. The CDC lists the cost of the MMR vaccine without insurance as $21.22 at a state health department and $75.04 in the private sector.78 Though many individuals in the United States are covered with health insurance, approximately 7.9% of people in the United States reported having no health insurance in 2018, and the percentage of children who were uninsured was approximately 5.5%, or approximately 4.3 million children.79 Illustrations of this phenomenon can be seen in the disparities between high-income and low-income individuals; a 2003 data set revealed that the percentage of those with up-to-date vaccine coverage was approximately 87.7% for middle-income families but only 79.8% for those in near poverty and 74.9% for those in severe poverty.80 Though researchers have found that the correlation between low socioeconomic standing and lower vaccination rates has decreased over time, they still conclude that it is a problem that continues to affect individuals in the United States.81
Consequences
Contraction of Disease
Individuals who are not vaccinated have a higher likelihood of acquiring certain diseases due to the fact that their immune systems are not properly equipped to fight against the illness.82 In one study on the transmission of varicella (chickenpox) in a childcare center, researchers found that only 14% of vaccinated children developed varicella, whereas 88% of unvaccinated children got the disease.83 These results show that children who did not receive immunizations were more likely to contract the disease.
Loss of Community Immunity
One of the most prevalent and highly discussed consequences of low vaccination rates is the loss of herd immunity in communities nationwide. Though the percentage of individuals needing to be vaccinated in order to reach herd immunity varies from illness to illness, many illnesses require a percentage around 90% or above to reach community immunity.84 Public health experts promote the maintenance of community immunity because it keeps even those who cannot receive immunizations safe from developing preventable illnesses.85 This protection is possible because fewer individuals have the ability to receive and pass on the illness to others, which subsequently lowers the number of people getting sick who can pass that sickness to others. Immunocompromised persons, such as people who have undergone chemotherapy, those with HIV/AIDS, and those who have undergone a transplant,86 may be unable to get vaccinated with some specific types of immunizations because their immune systems may be too fragile for even a weakened form of a disease-causing microbe.87 An estimated 2.7% of the US population was reported to be immunosuppressed in 2013, which would equate to an estimated 662,000 people immunocompromised in 2020 if this rate has remained constant.88 Additionally, children under the age of 15 to 18 months have not completed their basic rounds of immunizations and may thus be susceptible to illnesses.89 Though there are not exact numbers of how many children fall into this age bracket, there are likely a few million.90 When those who are able to receive immunizations fail to get vaccinated, it puts these infants and those who are immunocompromised at greater risk of contracting potentially fatal illnesses.
The graphic “Progress of Disease with and without Herd Immunity” demonstrates the spread of disease with and without herd immunity. When herd immunity is intact, those who are unvaccinated are considered safe from contracting specific diseases; however, when herd immunity is compromised, those who are unable to receive their immunizations are in danger of contracting diseases such as measles, mumps, rubella, and polio.91
Re-emergence of Dangerous Diseases
Diseases that are nearly eradicated from the United States, including whooping cough (pertussis), mumps, and measles, can return if enough members of a population refrain from getting vaccinated.92 This issue occurred recently with a resurgence of measles in the United States.93 Although measles was eradicated in the US in 2000, 1,282 cases were confirmed in 2019,94 which is the greatest number of cases reported in the US since 1992. Measles is one of the most infectious diseases and requires between 93 to 95% of the population to be vaccinated in order for herd immunity to be reached.95 In the 2018–2019 school year, 28 of 49 states had lower than 95% coverage for their kindergarteners.96 This gap indicates that herd immunity may be falling in many areas of the US and exposing individuals to measles and its life-threatening complications.
Economic Consequences
Lowering vaccination rates in the US have evident health consequences, but those health consequences are also connected to economic repercussions for both individuals who acquire the illness and the public sector who must manage disease outbreaks. Reductions in immunizations often lead to increases in cases of a particular disease. These increases in turn lead to an increased need for medications, treatments, and doctor’s visits. For an individual with adequate insurance in the US, trips to an instacare usually result in a $25–$75 copay.97 Without any insurance, a trip to the urgent care is estimated to cost anywhere from $71 to $125.98 These estimates are vague and variant, but they illustrate the expense of a single trip to a medical facility without factoring in any other necessary testing, medications, or other procedures that may be necessary for fully treating the illness.
The public health costs of monitoring and managing cases for diseases likely to cause an outbreak are also very high. In a report on Colorado’s management of two measles cases in 2016, researchers estimated that a public health agency’s response to a single case of measles had the potential to cost from as little as $5,655 to as high as $181,679 depending on the severity of case(s), how long the individual was symptomatic, and how many individuals the infected person was in contact with before diagnosis.99 Included in this cost was the price to pay for the salaries of individual workers, the time and equipment involved in tracing the movements of the individual, the effort to determine who was in contact with that individual, and the time to contact each person who was at risk for further monitoring.100 Though the exact cost of tracing varies from state to state, it can generally become quite expensive.101 Much of the funding allocated to community health centers comes from Medicaid, the federal Community Health Center Fund (CHCF), and other government grants.102 The government, in turn, provides funding for these grants and programs by using taxpayer money.103 Therefore, the refusal of one individual to receive an immunization can possibly result in economic repercussions across society as a whole.
Continued Politicization of Immunizations
Individuals who do not vaccinate themselves are more likely to subscribe to anti-vaccination rhetoric, something that policymakers capitalize on in order to receive support from those audiences. The political climate of the United States both influences and is influenced by polarized rhetoric, and vaccinations continue to be a hot topic in the political sphere. Those seeking the support of vaccine-hesitant individuals may play toward the public’s concern for the safety of vaccinations, or those who believe in the effectiveness of vaccines may not promote their stance heavily because they do not want to lose any of their base that disagrees with pro-vaccine sentiment.104, 105
This politicization was seen during the 2015–2016 campaign cycle for the United States presidential election, where candidates perpetuated many varying arguments about vaccinations in order to win the support of specific constituents. Then-candidate Donald Trump alluded to the idea that immunizations lead to autism and recommended spacing out the vaccination schedule, contrary to the CDC’s recommendation.106 Candidate Rand Paul stated that vaccinations should be a personal decision, whereas Democratic nominee Hilary Clinton received increased media scrutiny for her strong statement in favor of immunizations.107 The vaccine conversation that occurred in the months leading up to the 2016 presidential election was a case study, reflecting the fact that many involved in politics are required to take a stand on the necessity of immunizations. Ultimately, their stance will influence the support they receive from the American public.108
The politicization of immunizations has reached a new high in the United States with the emergence of the global Covid-19 pandemic in the early months of 2020. In the United States, the response to the pandemic has been incredibly polarized. For many states, a large factor of this polarization is a distrust in science and experts, which has been observed as being more prevalent among those who identify with political conservatism, religious orthodoxy, and conspiracy ideation.109 The polarization of these ideologies, mixed with the increasing partisanship in the US government, will likely lead to the perpetual politicization of vaccinations for years to come. In May 2020, a 30-minute video called “Plandemic” was distributed through many media platforms but was especially popular on Facebook. In this documentary, discredited scientist Judy Mikovits claims that vaccine companies will “kill millions, as they already have with their vaccines” if a Covid-19 immunization becomes mandatory.110 Though the documentary was removed by YouTube for violating its usage agreement by perpetuating false information on the pandemic,111 many individuals continue to believe and spread this information.
Practices
Government Policy
One practice that has been implemented in an effort to increase vaccination rates is the creation of public policy aimed at removing the ability to receive non-medical exemptions for children attending schools.112 Legislation is seen as an effective form of addressing market failures, as many argue that self-regulation is not sufficient in order to propagate the better good of society.113 Because an inadequate distribution or low administration of vaccinations can be seen as a market failure, outside legislation can be effective in regulating this market and ensuring vaccinations are administered. One suggested legislative change is to require all children in the United States who are not immunocompromised to be vaccinated against certain diseases before entering kindergarten.
Currently, there are just three states in the US that have laws like this, which only allow exemptions for medical reasons for children entering kindergarten: West Virginia, Mississippi, and California.114 California’s bill, Senate Bill 277 (SB277) is the most widely publicized and scrutinized legislative act. In 2016, the bill was passed to eliminate the ability for individuals to acquire non-medical exemptions due to the high prevalence of “doctor-shopping”—a term used to describe individuals who would specifically seek out doctors who would grant non-medical exemptions—in the state.115
Impact
In a study conducted on the effects of the policy in California, researchers determined that implementation of the policy increased the percentage of those vaccinated in 2017 from approximately 93% (in the synthetic control group) to 97.5% in the treatment group.116 The rise in immunization rates that accompanied the policy to eliminate non-medical exemptions demonstrates the assertion that these non-medical exemptions likely lead to lower rates of vaccinations for school-aged children.
For the 2017–2018 school year, the three states who implemented these laws had a much higher average vaccination rate than states that allowed non-medical exemptions. Due to the nature of this legislation applying to an entire state, it is difficult to perform a randomized-controlled trial determining the effect of non-medical exemptions on vaccination rates. However, there appears to be a significant correlation between allowed exemptions and vaccination rates.117, 118, 119
Gaps
Though the current data shows this sort of legislative mandate is successful at raising vaccination rates, receiving sufficient votes to eliminate non-medical exemptions for vaccines in many states is difficult. This is largely due to the fact that many feel it is a breach of constitutional rights to mandate vaccinations, and as such legislators are wary to support such laws as it may put their political standing in jeopardy with their constituents.120 Additionally, legislation that applies to children who attend school (including daycare) fails to include those who are homeschooled. These children are not affected by laws that require them to be vaccinated in order to attend school.121 Therefore, any changes to school vaccination requirements would not increase vaccination rates among this group. Legislation applying only to children entering school would also fail to increase vaccination rates among those who are already in school or who have finished school.
Educating the Public
Because the rampant spread of misinformation is such a strong contributor to vaccine hesitancy, and ultimately low immunization rates, one of the main practices is public education about vaccinations.122 Major public health organizations such as the CDC, NIH, and WHO, as well as local community public health organizations, have put in much time and effort to create and disseminate accurate information on vaccinations, their risks, and their benefits.123
Other organizations have been working to lessen the prevalence of falsehoods on social media. During the Covid-19 pandemic, Instagram added a feature in which every post or story that mentions Covid-19 also has a link to the WHO website that discusses the disease.124 Instagram also blocked specific searches on sites that would lead to inaccurate Covid information in an attempt to make sure the information people find in their searches are more likely to be accurate.125 Both the active propagation of credible resources and the steps taken to decrease the spread of misinformation is meant to decrease vaccine hesitancy and increase the number of immunizations distributed.
Impact
Unfortunately, solid data on the effectiveness of this intervention is extremely hard to find since there are so many different organizations who work to put out quality information on the subject. Additionally, once information is placed on the internet, it is nearly impossible to track who accesses the information and even more difficult to measure how many people thoroughly read and are impacted by the information they accessed. However, education does have a degree of importance because many people are genuinely looking for answers to health questions online or in the media. Of Americans that are online, 70% of those who look for health information online say that the information they encounter online affects their treatment decisions.126 It can reasonably be assumed that disseminating accurate, credible, and well-researched information is a good practice in fighting misinformation.
Gaps
In many instances, the issue has less to do with lack of access to accurate information and more to do with the choice many individuals make to disbelieve the accurate information that is readily available to them.127 This belief is often based not on a knowledge of the risks, costs, and benefits of vaccination but on “emotion, culture, religion, and sociopolitical context.”128 Therefore, efforts to educate the public will never completely solve the problem of vaccine hesitancy because access to accurate information is typically not an issue for them.129
Additionally, attempts by the government to give information about vaccines also works to reinforce ties between the US government and vaccinations. This source could deter those who already distrust the government.
Preferred Citation: Haslam, Asia and Harper Forsgren. “Low Immunization Rates in the United States.” Ballard Brief. July 2021. www.ballardbrief.byu.edu.
Viewpoints published by Ballard Brief are not necessarily endorsed by BYU or The Church of Jesus Christ of Latter-day Saints
