School vaccination requirements: historical, social, and legal perspectives.

Though school vaccination has been an important component of public health practice for decades, it has had a controversial history in the United States and abroad. Subject to exceptions, including individual medical, religious, and philosophical objections, modern state school vaccination laws mandate that children be vaccinated prior to being allowed to attend public or private schools. State school vaccination requirements are widely thought to serve important public health purposes. However, they also provoke popular resistance. Historical and modern examples of the real, perceived, and potential harms of vaccination, governmental abuses underlying its widespread practice, and strongly-held religious beliefs have led to fervent objections among parents and other "antivaccinationists" on legal, ethical, social, and epidemiological grounds. Historic and modern legal, political, philosophical, and social struggles surrounding vaccination are vividly reflected in legislative and judicial debates on the powers, and limits, of government to compel school vaccination policies. At the crux of public debate are core concerns about the tradeoffs between public health benefits and the infringements on individual and parental freedoms arising from the systematic vaccination of millions of school age children in the United States. Public health authorities argue that school vaccination requirements have led to a drastic decrease in the incidence of once common childhood diseases. Antivaccinationists tend to view the consequences of mass vaccination on an individualistic basis, focusing on alleged or actual harms to children from vaccinations for which government vaccination requirements are at fault. In this article, we discuss this debate through an examination of the historical and contemporary aspects of immunization requirements as a condition of school attendance. Part II provides a brief history of vaccination as a medical and public health practice, using smallpox disease as the primary case study, and subsequently addresses corresponding societal and individual objections to the proliferation of vaccination programs. Part III reviews the subsequent legislative and judicial reactions to these policies. Did state and local lawmakers second guess the need for school vaccination laws, and, if so, for what reasons? How did courts construe these laws? Our judicial examination includes a review of the various legal and constitutional objections to school vaccination policies, including those based on religious beliefs under the First Amendment, equal protection theories, and due process concerns. The historical and modern legal and social contexts supports a contemporary discussion of views about school vaccination requirements in Part IV. We examine the modern debate through a scholarly discussion of available evidence of the public health effectiveness of school vaccination programs. We compare (1) childhood immunization rates and (2) rates of vaccine-preventable childhood diseases before and after the introduction of school vaccination requirements. These data suggest that school vaccination requirements have succeeded in increasing vaccination rates and reducing the incidence of childhood disease. Finally, we discuss modern antivaccination arguments. Like arguments from the past, modern antivaccination sentiment is fueled by general distrust of government, a rugged sense of individualism, and concerns about the efficacy and safety of vaccines.