Feudtner and Marcuse (2001) also proposed consideration of a broader range of policy options to accommodate a greater degree of autonomy in immunization decisions. The current emphasis on universal immunization recommendations and state mandates may not be appropriate or necessary. The experience of the 15 states that allow philosophic exemptions to required immunization illustrates that the availability of exemptions does not appear to be directly related to levels of immunization coverage. In 2000, although some states that allow philosophic exemptions had some of the lowest immunization rates, other states offering exemptions had some of the highest rates (Marcuse, 2001). An alternative approach might allow for a range of priorities (e.g., mandatory, recommended, or elective), based on an evaluation of the immunization objectives and tradeoffs associated with specific vaccines.

Feudtner and Marcuse (2001) acknowledged the challenges of reaching consensus regarding immunization policies with their broader approach to these issues, but they argued that more explicit attention to a wider range of conflicting views and values is needed to maintain public trust in immunization and other public health programs.

Conclusions

The committee’s assessment of the significance of concerns about possible immune system dysfunctions as a result of multiple immunizations took several factors into account: the burden of the possible adverse outcomes of autoimmune diseases such as type 1 diabetes and allergic diseases such as asthma; indications of the extent of the concern about multiple immunizations; and views regarding the framework for immunization policy-making.

Although parents appear to value immunization, a substantial minority believes that multiple immunizations could be harmful. Autoimmune and allergic diseases are common in the United States, after all, and the incidence of these conditions appears to be increasing. As represented by type 1 diabetes and asthma, these conditions are life-threatening if not adequately treated and are associated with substantial health care costs. Given also the prevalence of allergic diseases, specifically asthma, a relatively small increase in risk may lead to a significant public health impact.

A better understanding of parents’ perceptions of risk and decision-making may be necessary to prevent decreases in immunization rates and increases in vaccine-preventable disease. Current approaches to immunization policy-making emphasize epidemiological and economic considerations, but may benefit from greater attention to ethical issues, including personal liberty and equity in allocation of the benefits and burdens of immunization. With new vaccines in development and discussions of the wider use of existing vaccines, more flexible approaches to immunization policies—especially regarding priorities—may be needed. Thus, the committee concludes that concern about multiple



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