Bella Ruud

RCL 138

Section 011

4/14/2019

Increasing Vaccination Rates by Targeting the Newly Developing Group of Unvaccinated

Teenagers
Abstract:

Vaccines have been proven to be extremely useful in not only preventing individual
infection, but also in establishing herd immunity for an entire community of people. However, in
recent years, vaccination rates have been dropping as increasing amounts of parents opt out of
vaccinating their children, putting communities at risk for outbreaks of highly infectious and
devastating diseases like measles. As previous efforts to make vaccine exemptions stricter have
failed and anti-vaccination parents refuse to accept scientific claims that vaccines are safe, a new
option to increase immunizations has emerged: teenagers whose parents opted out of vaccines
but are now doubting their parent’s decision. In order to effectively target this new audience,
four actions should be taken: vaccine education, professional support, minor consent to medical
care laws, and tort law duties to vaccinate.
Introduction:
Almost 100 years ago, more than 15,000 Americans died every year from diphtheria,
a severe nose and throat infection. In the past 15 years, there have only been two cases.
In 1965, rubella, a form of the measles, infected 12.5 million people, claimed the lives of over
2,000 babies, and caused 11,000 miscarriages. Since 2012, there have only been 15 reported
casesi. The reason the world today is not ravaged by infectious diseases such as diphtheria and
rubella, in fact only one bacterial infection, pneumonia, ranks on the top ten causes of death in
modern times, is largely due to the discovery of vaccines, a way to immunize someone so that if
they are infected with a pathogen, their immune system is primed to fight off the infection.
Despite the millions of lives that vaccines have saved over the years, there has been a
recent trend in parents opting out of vaccinating their children, reaching almost 7% in some
statesii. Considering the immense protection that vaccines provide society, it is important to
reverse this concerning trend and increase immunization rates. The most promising way to
increase the amount of people vaccinated in the upcoming years lies in the newly developing
group of 12 to 18-year-olds who are now desiring to be vaccinated after their parents opted out
when they were children, and in order to accomplish this, increased education, support systems,
minor consent to medical treatment laws, and tort law are required.

The Importance of Restoring Vaccination Rates- Herd Immunity:

Vaccines allow for a phenomenon known as “herd immunity”, which essentially means
that a community can be immune to a disease without having 100% vaccination rates. Herd
immunity works like this: Say Person A picks up a microbe that causes bacterial meningitis, for
example, but has a strong enough immune system to keep the infection from causing severe
symptoms, but not eliminate it all together. Person A might not get sick, but he or she could pass
that microbe on to someone else, Person B, who has a compromised immune system, or Person
C, a newborn baby. Person B and C have weaker immune systems and might not be able to fight
off the infection, resulting in contracting the potentially deadly meningitis. However, if Person A
had been vaccinated, he or she would have been able to completely kill the infection and would
not have transmitted the infection to someone with a weaker immune system. If enough people in
a community are vaccinated like Person A, an infectious disease has a very low probability of
reaching people like Person B and Ciii.
 Figure 1 Herd Immunityiv

Herd immunity is necessary because there are people who medically cannot be
immunized against diseases, and are thus dependent on the community to protect them. While
there are many reasons that a vaccine is not an option for a patient, the most common include:
 Severe allergies to vaccine additives
 Below the minimum age requirement
 Highly compromised immune systems
 Pregnant or nursing a newborn
 Nervous system conditions like Guillain Barre Syndromev
In addition, there is a very small fraction of people who receive a full course of immunizations,
but they simply do not work, like the 10% of people who get the measles vaccines and boosters
but remain susceptible to the diseasevi.
 Typically, states see less than 1% of school aged children with medical exemptions for
vaccinesvii. Thus, herd immunity is easily established even if members of society are unable to be
immunized due to health concerns, since 100% vaccination is not necessary. The actual
percentage of people who need to be immunized in order to achieve the protective aspect of herd
immunity depends on how contagious the disease is. For example, measles requires 95%
immunization because it is easily spread, but polio only needs rates around 85%viii. Given the
relatively few cases of medical excuses not to vaccinate, even the high rates necessary for
measles herd immunity should be easily achieved, yet this is not the case. Across the country, 27
states have rates below 95% for the measles vaccine, also known as MMRix. Even worse, there is
a national average of 70.7% for the recommended 7 vaccine series (Diphtheria/tetanus/pertussis,
polio, measles/mumps/rubella, Hemophilus influenzae, Hepatitis B, chicken pox, and
pneumococcal conjugate vaccines), which is far below the herd immunity threshold for any
diseasex.

Exemptions- The Reason for Declining Vaccination Rates:

Despite the benefits that vaccines provide, there are over 30,000 vaccine-preventable
deaths each year and $10 billion spent in medical care to communities with low vaccination
ratesxi. Some of this can be attributed to medical reasons not to vaccinate, but considering that
medical exemption rates typically stay between 0.5% to 1%, there is a larger issue at hand. While
schools typically mandate that children receive certain vaccinations, 18 states allow for “personal
reason” exemptions and 46 allow for “religious reason” exemptionsxii. Originally, states
permitted this because 100% vaccination is not necessary to achieve herd immunity. However,
the issue has grown so much that there are too many people taking advantage of the exemption
system and vaccination rates are dropping below the herd immunity threshold, usually for one of
four reasons: religious, philosophical, desire for more information, or safety concerns.
 Figure 2 Nonmedical Exemption Rates by Statexiii

Religious and philosophical beliefs originate from some disagreement with the principle
of vaccines and injecting foreign proteins and chemicals into the body. Several religious
communities like Christian Scientists, Mennonites, and the Amish do not allow their participants
to receive vaccinesxiv. This becomes a big issue because these types of communities typically
live together in concentrated areas, so pockets of religious groups around the country will be far
more susceptible to a diseases outbreak, even if national herd immunity is met. Philosophical
beliefs are similar in that there is an objection to putting chemicals in the body and a belief in the
natural healing process. However, they are less of an epidemiological concern because they tend
to be more spread out than like-minded religious groupsxv.
The other two reasons stem from questions over the science of vaccines, namely wanting
more information and being concerned over safety. There is a great deal of distrust of
pharmaceutical companies among many of these types of antivaxxers, who do not believe the
doctors and scientific research behind the vaccines and instead rely on anecdotal stories and
experiences from their peers. The media is also fuels the opposition to vaccines where incorrect
data is frequently portrayed or presented in a way that easily leads to misinterpretation. For
example, the media popularized the idea that thimerosal causes brain damage, autism, and
behavioral problems, but it has been removed from vaccines for decades, so even if the findings
were true, the information cannot relevantly be used to argue against vaccinesxvi. This reasoning
for opting out of vaccines is particularly dangerous because it allows the mindset to be spread to
other parents, since emotional stories that play on typical parental fears are often used.

Abuse of the Exemption System and its Consequences:

The original idea behind the exemption system was not ill-intended; it simply allowed
people to choose not to get vaccines because herd immunity could be reached regardless.
However, in the recent years, vaccination rates have been dropping as non-medical exemptions
(both personal and religious) have been on the rise, threatening the state of herd immunity. The
biggest issue is that these exemptions are being abused by people who do not actually have
religious beliefs against vaccines. For example, the New York religious exemption rates rose
significantly from 0.23% to 0.45% from 2000 to 2011xvii. However, this directly contradicts
growing trends in atheism and a shift away from religious beliefs across the countryxviii.
Nationally, the amount of unvaccinated children has quadrupled in the past 17 years, from 0.3%
to 1.3%, which is enough to land “vaccine hesitancy” on the 2019 top 10 list of global health
threatsxix. There are even fake churches that people can sign up for, like the “Congregation of
Universal Wisdom”, to get out of vaccinationsxx.
It is not the case that the increase in exemptions is harmless; studies have shown that
areas with higher exemption rates correspond to more cases of vaccine-preventable infections. A
survey of New York counties revealed that counties with higher exemption rates had on average
33 pertussis cases per 100,000 people compared to counties with lower exemption rates and only
22 pertussis cases per 100,000 peoplexxi. Entire outbreaks can occur in areas with high
concentrations of non-vaccinated people, such as the recent measles outbreak with over 400
confirmed cases in New York City in communities populated by Hasidic Jewsxxii. With proof
that misuse of exemptions is causing community health crises, it is clear that change is needed in
the system.

Failed Attempts to Amend the Exemption System:

It has been long realized that the exemption system is flawed, but little has been done to
actually fix it. Some states have tried to make the exemptions stricter, including California,
Mississippi, and West Virginia that all only accept medical exemptions as valid reasons to opt
out of vaccinationsxxiii. However, for most states, it is very difficult to get these types of laws to
pass, such as Maine, who tried to pass a stricter exemption bill in 2015, but failed because of the
public’s desire for free choice over assured community safety.
Even in states with stricter exemption policies, there are still major issues. In California,
for example, wealthier areas have higher exemption rates despite medical exemptions being the
only exemptions permitted, which should affect wealthy and non-wealthy areas equally.
Investigators found that a doctor had been giving out medical exemptions to anyone, sometimes
without doing any medical tests or observations beforehandxxiv. In these cases, a stricter law
might pass, but will be ineffective if people find a way to cheat the system.

Shifting Focus to Target Unvaccinated Teens Instead of Parents:

A single post in fall of 2018 has the potential to be a pivotal moment in vaccination
history. Ethan Lindenberger, an Ohio 18-year-old, started a Reddit thread asking whether he
could get vaccinated and where he would be able to do so that quickly received over 23,000
upvotes and 1,000 comments providing support and advice from registered nurses on good
resources to turn toxxv. Lindenberger is not alone, and his questions inspired many other minors
to take to Reddit to get help with their desire to be immunized against their parent’s wishes.
Now, there is an entire genre in Reddit dedicated towards teens getting vaccines that they missed
out on as a childxxvi. These changing attitudes provide a promising new target to increasing
vaccination rates.
Many attempts to force people to vaccinate their children have been made, but the
American ideal of individual freedom and personal choice ultimately come out on top. Because
of the current political and social climate, a better option to increase vaccination rates is to target
a new, but growing group of people: teenagers who were not vaccinated as a child, but are
considering doing it now. It is no secret that children often have very different views than their
parents, so many teens might not agree with their parent’s decision against vaccinating, or at
least will not be as strongly against vaccines. Because of this, they might be more likely to get
their own immunizations, and also immunize their children in the future. In order to convince
teenagers to accept vaccines, measures to increase immunization education in schools, provide a
stronger, professional support system, allow for minors to consent to medical decisions, and
establish tort law as a valid means of dealing with the refusal to vaccinate would need to be put
in place. By targeting this group, future vaccination rates could once again be on the rise by
breaking family traditions of opting out of vaccines.

Figure 3. Four Step Plan to Increase Vaccination Rates

The First Step- Increasing Vaccine Education in Schools:

Education is arguably one of the most important ways to combat the drop in vaccination
rates, because the staggering amount of personal exemptions are based off of false claims that
vaccines cause more harm than good. A meta-analysis of over 1.2 million children revealed that
there was no statistical correlation between autism and vaccines, even when analyzing the most
high-risk vaccine, MMRxxvii. However, many people still believe that vaccines are dangerous as
misinformation circulates social media sites, such as the “Stop Mandatory Vaccinations”
Facebook group that claims that Vitamin C will provide measles immunity so that the “dangers”
of the MMR vaccine can be avoided, directly contradicting scientific claims of the safeness of
MMR and lack of effect from Vitamin Cxxviii.
Lindenberger, along with other teens, realized once they got to high school that their
parents’ antivaxxer claims were not based in science, and started to do their own research using
CDC reports and scientific literature as their sourcesxxix. In some cases, the information teens
learn is enough to convince their parents, like 16 year old Danny from Minnesota who was able
to convince his mother to consent to polio and tetanus vaccines after providing her with enough
dataxxx. While this is not typically the case, the first step in getting teenagers to realize that they
need to get vaccinated is to educate them on the benefits and the reasons why claims against
vaccines might be false.
The role of educating teens about immunizations should be filled by the school system
since it will provide the teen an opportunity to learn about vaccines in an academic setting
instead of relying on anecdotal stories and social media claims from home. Even though states
are having difficulties with tightening exemption rules, they would have a much easier time
changing school curriculums to focus on highlighting vaccine benefits. Currently, there is fairly
variable vaccine discussion in schools. For some vaccines, like the flu and HPV shots, there are
over 80% of schools that cover material on it. However, other vaccines like those for meningitis
are only taught in 40% of schools. On top of this, the majority of vaccine material is presented in
high school, but the 11 to 12 years old age range that encompasses most middle schoolers is ideal
for adolescent vaccinationsxxxi. Broadening the discussion to include more vaccines and starting
the material earlier will help develop the mindset that vaccines are necessary for a healthy
community.

The Second Step- Providing Professional Support for Teens Desiring

Vaccination:
Lindenberger and other teens in his situation first turned to Reddit for help. While the
social media community was able to provide him adequate information and advice, there is
clearly no place for teenagers in this situation to turn to with professionals ready to help. For
issues like mental health and teenage pregnancy, there are well-established hotlines and
organizations like SAMHSA and Planned Parenthood for kids in need to turn to when they start
to have questionsxxxii. There are many vaccination resources, but they are primarily geared
towards parents vaccinating their children, not for kids themselvesxxxiii. In this case, teens are left
on their own to figure out if vaccines are right for them.
An organization, with either a website or physical locations, specializing in helping kids
learn and get vaccines would fill this vacuum. A big component of this would be providing clear,
easy to understand data and information on vaccines in one place, because the research is not
always easy to find. Lindenberger, for example had to wade through article after article of dense
scientific literature and CDC reports before reaching his decisionxxxiv. Scientific reports are
difficult for a middle school or high school student to fully understand, and many kids may not
even know reputable sources to begin their information source with. There also is not that much
readily available data on how teens can “catch up” on getting vaccinations. The more work
someone has to do, the less likely they will actually go through with it, so making the
information-gathering process as easy as possible is crucial in getting this teenage population to
accept vaccines.
This proposed organization would also have to offer other forms of support beyond
education. One big issue with targeting this group of people is that they are typically minors, so
help from lawyers to navigate the complexities of receiving medical care against a parent’s
wishes would help many children who want to be vaccinated but cannot because of their parent’s
beliefs. On a similar note, this organization should also offer emotional support because doing
something to contradict one’s parents can cause a lot of tension and conflict. Lindenberger’s
mother, for instance, was reportedly angered by Lindenberger’s decision and felt like he “was
spitting on her”xxxv. Having trained conflict managers and social workers as part of the
organization would be essential to creating a safe home environment for teens getting vaccinated.
Finally, the organization actually having the means to vaccinate people, possibly through a
mobile clinic, would make it safe and easy for kids to find a place to be immunized at.

The Third Step- Allowing Minors to Consent to Their Own Medical Care:
Young children are the most vulnerable to contracting a vaccine-preventable disease
since their immune systems are not fully developed, so vaccines for polio, measles, diphtheria,
and pertussis are recommended for infants around 6 to 15 months old. Other vaccines like those
for HPV and meningitis are recommended for 11 to 12-year-old adolescentsxxxvi. However, these
vaccines are still effective if taken years later, especially to help achieve herd immunity. The
earlier immunized the better, so forcing teens to wait until they are 18 and legal adults puts both
the teen and the community at greater risk. In order to fix this, states should allow minors to
consent to their own vaccines without requiring parental permission.
Many states currently let minors decide on medical care, but there are usually many
restrictions. Several states, such as New York, allow minors who are parents to decide on the
medical care for their children but not themselves. California allows 12-year-olds to seek care
without parental consent, but only for reproductive health care, like STI treatment. Washington
requires that the doctor declare the person in question a “mature minor”xxxvii. Oregon and
Alabama are a bit more general with their rule that 15-year-olds can seek out medical attention,
but the vague wording of the law does not explicitly permit minors get preventative care like
vaccinesxxxviii. Not only are the restrictions themselves wordy and confusing, but the fact that
each state has its own laws makes it harder for teens to figure out where they stand. This could
discourage unvaccinated teens to wait until they turn 18 to seek out immunizations even if they
are eligible at a younger age.
Table 1. Minor Medical Consent Laws in Select States
New York “Any person who is eighteen years of age or older, or is the parent of a child or
has married, may give effective consent for medical, dental, health and hospital
services for himself or herself, and the consent of no other person shall be
necessary.”xxxix
California “A minor 12 years of age and older who may have come in contact with a sexually
transmitted disease may consent to medical care related to the diagnosis and treatment of
the disease”xl
Oregon “A minor 15 years of age or older may give consent to hospital care, medical or surgical
diagnosis or treatment by a physician licensed by the Oregon Medical Board, and dental
or surgical diagnosis or treatment by a dentist licensed by the Oregon Board of Dentistry,
without the consent of a parent or guardian”xli
Alabama “Any minor who is 14 years of age or older, or has graduated from high school, or is
married, or having been married is divorced, or is pregnant, may give effective consent
to any legally authorized medical, dental, health, or mental health services for himself or
herself”xlii

All that state legislatures would have to do is clarify in their pre-existing laws that minors
are also able to decide on their own immunizations or preventative health. Since this still gives
people free choice, it would cause less political uproar than removing personal and religious
vaccination exemptions altogether. Some states have attempted already attempted this for certain
vaccines. In 2017, Texas tried to pass a bill to allow 14-year-olds to consent to vaccines related
to cancer prevention (Hepatitis B and HPV) and Minnesota tried to pass a similar bill for HPV,
but both failed to move out of the committeexliii. However, given that there are now, in 2019,
more teenagers advocating for lowering the consent age like Lindenberger and Danny, there will
likely be increased support in the upcoming years.

The Fourth Step- Using Tort Law as an External Motivator for Teens to Get
Vaccinated:
If educating kids on the medical importance of vaccines does not work, using tort law
could act as a failsafe to provide a different motivator to get vaccinated: financial liability. Tort
law allows people to be financially compensated if someone else harms them through civil court
casesxliv. To have a claim in a tort law case, the plaintiff needs to prove four things: the defendant
owes the plaintiff a legal duty to prevent the harm of others, the defendant violated that duty, the
violation was the direct cause of harm, and the plaintiff suffered damagesxlv. This concept could
be applied to vaccinations, but in this case it would apply to the refusal to get a vaccine, so if
someone spread a vaccine-preventable disease to someone who was medically unable to get
immunized, the affected family could sue for money to pay off medical expenses.
Ultimately, the threat of being sued in the future could serve as the tipping point for teens
whose parents did not vaccinate them. Typically, children are the most vulnerable when it comes
to vaccine-preventable diseases because their bodies are not always strong enough to fight off
infections like polio, measles, and pertussisxlvi. However, once they grow up, the risk of a deadly
infection drops significantly, so the teenager might not feel that vaccination is necessary.
Education on herd immunity could certainly correct this, but adding a financial reason, the threat
of being sued, could act as the deciding factor for unvaccinated teens who do not have strong
opinions either positive or negative towards vaccines.
Tort law has not been applied to many vaccination cases yet, but there have been several
previous court decisions that indicate it has potential to be effective. Courts have long upheld the
idea that people with infectious diseases have a duty to minimize the spread of the disease and
that spreading it is an act of negligencexlvii. In addition, labs and epidemiological studies are
typically able to declare with 95% certainty where the source of the outbreak came, so direct
cause can be shownxlviii. Making the vaccination case special is that the duty would be a “failure
to act” (a failure to get vaccinated,), but most tortious duties require a direct action that causes
harm, not a lack of action. However, there are special cases for certain situations, most notably
the duty of a psychiatrist to inform any potential victims of their patients, where the psychiatrist
is liable if they do not actxlix. The religious freedom aspect has also been addressed before, since
courts have agreed that in choosing to follow a religion, the participant takes on any inherent
“risks” (such as potentially infecting someone who could not be vaccinated) and that following a
religion does not allow the participant to impose costs on to other members of societyl.
To enact this, a duty would need to be passed that would make unvaccinated people liable
in court if they infect someone else who could not be vaccinated for medical reasons. It would
have to be strict and would not allow for religious or personal exemptionsli. However, it would
accept medical reasons to not get vaccinated or special circumstances like demonstrated proof to
try to get the vaccine but an inability to actually do so because of a shortage. This duty would fall
under the rare “failure to act” category, but since it originates from minimizing the harm done to
others, it can be easily argued that purposefully opting out of vaccines endangers the welfare of
others. Most importantly, a tort duty to get vaccinated would be a fair compromise because
people would still have their right to choose whether or not to get vaccinated, but it presents
them with fair consequences if they opt out.

Conclusion:
The newly developing group of teenagers whose parents chose not to vaccinate provides
a unique target to increase vaccination rates and re-establish herd immunity across the country.
Effectively reaching this audience would require four steps. First, education on the benefits of
vaccines would be addressed in schools to reverse any disproven claims made by anti-
vaccination parent. Once teens have been introduced to the importance of herd immunity,
professional support in the form of an organization aimed at getting teenagers vaccinated should
be created. This organization would provide information, legal help, family counseling, and
resources to get the actual vaccines in a central place easy for teens to access. Third, state
legislatures would work to lower medical consent laws so that the target audience could be
expanded to include more minors who want to be immunized. Finally, the establishment of a tort
law duty to get vaccinated would serve as a failsafe motivator for teens who are indifferent to the
medical benefits of vaccines but could be persuaded if financial liability were an issue. While the
full, four step course of actions would provide the greatest benefit, enacting any one of these
steps would certainly make a difference in increasing vaccine rates and decreasing the ongoing
issue of vaccine hesitancy.
Endnotes:

i
Vaccines & Immunizations. (2017, March 10). Retrieved from https://www.cdc.gov/vaccines/vac-
gen/whatifstop.htm
ii
Mellerson, J. L., Maxwell, C. B., Knighton, C. L., Kriss, J. L., Seither, R., & Black, C. L. (2018). Vaccination
Coverage for Selected Vaccines and Exemption Rates Among Children in Kindergarten — United States, 2017–18
School Year. MMWR. Morbidity and Mortality Weekly Report,67(40), 1115-1122. doi:10.15585/mmwr.mm6740a3
iii
Sadarangani, M. (2016, April 26). Herd Immunity: How does it work? Retrieved from
https://www.ovg.ox.ac.uk/news/herd-immunity-how-does-it-work
iv
What is Herd Immunity? (n.d.). Retrieved from https://www.pbs.org/wgbh/nova/article/herd-immunity/
v
Vaccines and Preventable Diseases. (2018, February 12). Retrieved from
https://www.cdc.gov/vaccines/vpd/should-not-vacc.html
vi
Diamond, D. (2015, February 03). Measles Can Kill, And It's Spreading. Sue Parents Who Didn't Vaccinate?
Absolutely. Retrieved from https://www.forbes.com/sites/dandiamond/2015/01/28/measles-is-spreading-and-kids-
might-die-sue-parents-who-didnt-vaccinate-absolutely/#214909927652
vii
Mellerson, J.L., et. al. Vaccination Coverage for Selected Vaccines
viii
Sadarangani, M. Herd Immunity
ix
Mellerson, J.L., et. al. Vaccination Coverage for Selected Vaccines
x
FastStats - Immunization. (n.d.). Retrieved from https://www.cdc.gov/nchs/fastats/immunize.htm
xi
Ciolli A. (2008). Mandatory school vaccinations: the role of tort law. The Yale journal of biology and
medicine, 81(3), 129–137.
xii
McKee, C., & Bohannon, K. (2016). Exploring the Reasons Behind Parental Refusal of Vaccines. The journal of
pediatric pharmacology and therapeutics : JPPT : the official journal of PPAG, 21(2), 104–109. doi:10.5863/1551-
6776-21.2.104
xiii
Raja, T. (2017, June 24). How many people aren't vaccinating their kids in your state? Retrieved from
https://www.motherjones.com/environment/2014/02/vaccine-exemptions-states-pertussis-map/
xiv
Ciolli, A. Mandatory school vaccinations
xv
McKee, C, & Bohannon, K. Exploring the Reasons
xvi
Ibid.
xvii
Ibid.
xviii
Wormald, B., & Wormald, B. (2018, April 25). U.S. Public Becoming Less Religious. Retrieved from
https://www.pewforum.org/2015/11/03/u-s-public-becoming-less-religious/
xix
WHO announces Top Ten Threats to Global Health in 2019. (n.d.). Retrieved from
https://www.vaccineconfidence.org/who=announces-top-ten-threats-to-global-health-in-2019/
xx
Ciolli, A. Mandatory school vaccinations
xxi
McKee, C, & Bohannon, K. Exploring the Reasons
xxii
Scutti, S. (2019, April 09). New York City declares a public health emergency amid Brooklyn measles outbreak.
Retrieved from https://www.cnn.com/2019/04/09/health/measles-new-york-emergency-bn/index.html
xxiii
Writer, J. L. (2019, January 18). Advocates think bill to end most exemptions from childhood vaccinations has a
shot. Retrieved from https://www.pressherald.com/2019/01/18/bill-would-end-non-medical-exemptions-from-
childhood-vaccinations/
xxiv
California's vaccine mandate – loopholes for fraud and bogus exemptions. (n.d.). Retrieved from
https://www.dailykos.com/stories/2018/7/22/1782699/-California-s-vaccine-mandate-loopholes-for-fraud-and-
bogus-exemptions
xxv
Pesce, N. L. (2019, March 06). Anti-vaxxer teen tells Congress why he vaccinated himself against his mom's
wishes. Retrieved from https://www.marketwatch.com/story/these-parents-didnt-vaccinate-their-kids-so-now-the-
kids-are-doing-it-themselves-2019-02-11
xxvi
Macatee, R. (2019, January 31). Teens Are Turning to the Internet for Help to Get Vaccinated Without Their
Parents' Consent. Retrieved from https://www.parents.com/news/teens-are-asking-online-how-to-get-vaccinated-
without-their-parents-consent/
xxvii
New Meta-analysis Confirms: No Association between Vaccines and Autism. (2014, May 19). Retrieved from
https://www.autismspeaks.org/science-news/new-meta-analysis-confirms-no-association-between-vaccines-and-
autism
xxviii
Pilkington, E., & Glenza, J. (2019, February 12). Facebook under pressure to halt rise of anti-vaccination
groups. Retrieved from https://www.theguardian.com/technology/2019/feb/12/facebook-anti-vaxxer-vaccination-
groups-pressure-misinformation
xxix
Pesce, N.L. Anti-vaxxer teen
xxx
Unvaccinated teenagers fight for right to immunization. (2019, March 25). Retrieved from
https://www.spectrumnews.org/news/unvaccinated-teenagers-fight-right-immunization/
xxxi
Dempsey, A. F., & Schaffer, S. (2010). Middle- and high-school health education regarding adolescent vaccines
and human papillomavirus. Vaccine, 28(44), 7179–7183. doi:10.1016/j.vaccine.2010.08.066
xxxii
Teen Health and Wellness. (n.d.). Retrieved from https://teenhealthandwellness.com/static/hotlines
xxxiii
Preteens & Teens | Vaccinate Your Family. (n.d.). Retrieved from https://www.vaccinateyourfamily.org/which-
vaccines-does-my-family-need/preteens-teens/?gclid=Cj0KCQjw7sDlBRC9ARIsAD-
pDFoP4cubbfiuOjlkTfEUu77SSWvwiUo-e8hjjqOYkXu9c68ZDADrzI4aAuG1EALw_wcB
xxxiv
Horton, A. (2019, March 22). Unvaccinated teens are fact-checking their parents and trying to get shots on their
own. Retrieved from https://www.chicagotribune.com/lifestyles/health/ct-anti-vaccine-parents-20190210-story.html
xxxv
Ibid.
xxxvi
Immunization Schedules | CDC. (n.d.). Retrieved from https://www.cdc.gov/vaccines/schedules/index.html
xxxvii
Whyte, C. (n.d.). Can teenagers get vaccinated without their parents' permission? Retrieved from
https://www.newscientist.com/article/2193937-can-teenagers-get-vaccinated-without-their-parents-permission/
xxxviii
Roberts, J., & Roberts, J. (2019, February 11). Unvaccinated children are coming of age–and they want
protection. Retrieved from https://qz.com/1547365/unvaccinated-children-are-coming-of-age-and-they-want-
protection/
xxxix
New York Consolidated Laws, Public Health Law - PBH § 2504. (n.d.). Retrieved from
https://codes.findlaw.com/ny/public-health-law/pbh-sect-2504.html
xl
Code Section. (n.d.). Retrieved from
http://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=FAM§ionNum=6926
xli
2017 ORS 109.640¹ Right to medical or dental treatment without parental consent • provision of birth control
information and services to any person. (n.d.). Retrieved from https://www.oregonlaws.org/ors/109.640
xlii
2013 Code of Alabama :: Title 22 - HEALTH, MENTAL HEALTH, AND ENVIRONMENTAL CONTROL. ::
Title 1 - HEALTH AND ENVIRONMENTAL CONTROL GENERALLY. :: Section 22-8-4 - When minor may
give consent generally. (n.d.). Retrieved from https://law.justia.com/codes/alabama/2013/title-22/title-1/section-22-
8-4/
xliii
Roberts, J. Unvaccinated children are coming
xliv
Hershovitz, Scott. "What Does Tort Law Do? What Can it Do?" Val. U. L. Rev. 47, no. 1 (2012): 99-118.
xlv
Caplan, A. L., Hoke, D., Diamond, N. J., & Karshenboyem, V. (2012). Free to Choose but Liable for the
Consequences: Should Non-Vaccinators Be Penalized for the Harm They Do? The Journal of Law, Medicine &
Ethics,40(3), 606-611. doi:10.1111/j.1748-720x.2012.00693.x
xlvi
Vaccines & Immunizations. (2017, August 18). Retrieved from https://www.cdc.gov/vaccines/vac-
gen/howvpd.htm
xlvii
Caplan, A.L, et. al. Free to Choose
xlviii
Rubenstein Reiss, D. (n.d.). COMPENSATING THE VICTIMS OF FAILURE TO VACCINATE: WHAT ARE
... Retrieved from https://www.lawschool.cornell.edu/research/JLPP/upload/Reiss-final.pdf
xlix
Ibid.
l
Ciolli, A. Mandatory school vaccinations
li
Rubenstein Reiss, D. Compensating the victims