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Disease Control and the Individual

The price of disease prevention in the group may be injury to an occasional individual. The fact that polio vaccine prevents thousands of cases of paralytic polio is little comfort to the rare individual who gets polio from the vaccine. Most mandatory immunization laws contain exceptions for individuals who have a high probability of being injured by an immunization. Many of these laws also exempt persons who have religious objections to immunization. The U.S. Constitution allows mandatory immunization of religious objectors, but most states do not take advantage of this power.

The effectiveness of the immunization laws depends on compliance by physicians and parents. If physicians give medical exemptions to a large percentage of their patients, the level of immunity in their school system might drop low enough to support a disease epidemic. The physician might be liable for the results of the disease in any child he or she exempted improperly. The physician also might be liable for injuries to children who are not the physician's patients who would not have been exposed to the disease but for the physician's improper behavior.

Herd immunity is important because an infectious disease epidemic must have a large group of susceptible people to continue its spread, just as a fire must have fuel. (See Chapter 28.) If enough people are immune to the disease, the epidemic will die out. Although some people remain susceptible, they are diluted sufficiently that the probability of an infected person's contacting a susceptible person is low. If the disease has a short period of infectivity, the infected persons will become noninfectious before they have a chance to spread the disease.

Compulsory immunization laws take advantage of herd immunity to control or eliminate certain diseases from the community. Most of these laws are directed at children because school entry is the only opportunity to ensure immunization status for patients without regular medical care. School children are the best vectors or the major reservoir of disease for many diseases. Many communicable diseases are less serious in school-age children. Rubella is benign in the children who carry it but can be devastating to a fetus. Immunizing children against rubella prevents the exposure of women in their childbearing years and thereby prevents congenital rubella. Mumps, too, is much more serious in adults than in children.

Immunization programs have suffered from fears of legal liability and increased vaccine costs. (See Chapter 28.) Immunization levels for many diseases are at lower levels than they were in 1978. In 1978 the CDC set the goal of eliminating measles by October 1982. In 1990, there were more than 20,000 cases, more than at any other time in the previous 20 years because of falling immunization levels and the problem of infections in children who are too young to be reached by school-entry-driven programs. Most children, even indigent children, will see a physician during the first few years of life, but many of those physicians do not see to it that the child is properly immunized. The physician may send the child to the health department for immunizations, but parents may never follow up to take the child to be immunized.

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