Vaccine refusal and vaccine hesitancy: Can we change the terms of the debate?

In early 2008, a measles outbreak occurred in San Diego, California. Notably, the San Diego outbreak was able to spread through two generations of secondary infection due to a cluster of unvaccinated children in the same school—children whose parents had decided that the risks of vaccines outweighed the risks of vaccine-preventable diseases, and who constituted a tight social network of like-minded families. In this study, I discuss the epidemiological and policy implications of vaccine refusal “networks”, and propose new approaches to community-based promotion of vaccination. The study addresses three related research goals: First, I describe how refusal rates have changed over time, and how refusal rates vary by state exemption regimes, by disease, and by socio-demographic characteristics. Next, I open the “black box” of the decision to delay or refuse vaccines using the tools and perspectives of behavioral economics, social network theory, and psychological approaches to heuristics and biases. I look in particular at the role of social networks, both place-based and virtual, and of the media in creating the informational cascades that drive up refusal rates. Finally, I evaluate four specific policy and program interventions related to vaccine refusal: mandatory ceilings on allowable exemptions at the county or school district level; mandatory reporting of exemption rates to parents; reframing of the vaccine refusal issue by clinicians and health educators to emphasize the “free-riding” aspect of the vaccine refusal decision; and a community-based approach that works to increase vaccination rates at the community level through changing norms and attitudes.