This blog post was authored by Javier Saladich, a Summer Research Intern at the O’Neill Institute. Javier is a third year law student at ESADE Business and Law School in Barcelona, Spain. Any comments or questions can be emailed to


In light of recent measles outbreaks in Europe and the United States and a European Court of Justice decision in a vaccine-liability case, this blog post considers the importance of public health laws and messaging to strengthen societal consensus and compliance with vaccination programs. It argues that governments and public health advocates should continue to counter the growing presence of the reactionary anti-vaccine discourse, which threatens to erode community immunity and public health gains.

Vaccination and the importance of societal consensus

There are very few public health issues in relation to which societal consensus is taken as granted, but none as misleading as vaccination. Every so often, new data reminds us of the fragility of such consensus and the peremptory challenge non-vaccination and incomplete vaccination pose to public health, including recent outbreaks of measles in Europe and the United States. Even though anti-vaccine responses can be traced back to a purported atavistic fear of chemicals, as brilliantly portrayed by Eula Biss in her essay On Immunity, the devastating consequences of infectious epidemics throughout history and the steady effectiveness of vaccines finally brought parents and societies together around a sort of collective trust in each other’s child vaccinated status. This allowed for what the medical community calls the “immunization of the herd”, a social contract whereby the group stays protected only insofar as no significant share of members opts out.

Concerning measles outbreaks in Europe and the United States

The core of this status quo, though, has come under question in recent decades. Take measles, for instance. Immunization coverage to prevent measles outbreaks – 95% is needed, according to global standards – has fallen to risky levels in some communities within the United States. Even more worryingly, up to 15 European Union/European Economic Area (EU/EEA) member states are not complying with the minimum threshold. These countries’ failure to have their population immunized despite availability of safe and affordable vaccines has been closely followed by the WHO, which launched a 2017 campaign with the goal of showcasing “immunization’s role in sustainable development and global health security”.

In the United States, measles outbreaks are due to an insufficient rate of infant vaccination. While 2016 data shows vaccination coverage of roughly 91% population, coverage is distributed unevenly throughout the country. Under US law, states are free to adopt non-medical exemptions based on personal and religious beliefs, which contributes to lower coverage in many communities. Recent studies show that despite the improving levels of vaccination, unvaccinated persons appealing to state-level exemptions tend to cluster geographically in schools and communities, “so vaccine-preventable disease outbreaks can still occur”. For example, in 2014/5, a measles outbreak traced to Disney theme parks in California sickened 147 people. A 2016 outbreak originating in rural Minnesota has sickened more than 70 people to date.

In Europe, measles are still endemic. Italy and Romania the two major hotspots, with thousands of new reported cases. Why are higher-income countries, often considered as leaders in public health, still experiencing outbreaks of preventable diseases?

The anti-vaccine movement: weakening societal consensus and public health

An important contributing factor is the anti-vaccine movement, which promulgates messages that vaccines are unnecessary and harmful. In some ways, vaccines have been victims of their own success. Low incidence of measles outbreaks thanks to vaccine inoculation has been used by these groups to spread the belief that there is no longer a public health threat that justifies this intervention. The intersection of the traditional anti-vaccine movement and winning populist parties, whose discourse openly questions the safety of vaccines and in turn the whole pharmaceutical industry, could be another reason. Yet, these theories have been repeatedly dismissed by public health advocates and the international community, who recently endorsed a joint resolution to support vaccination.

The Disney outbreak in late 2014, highlighted the problem of misinformation and complacency, in the air since 2000, when measles ceased to be a native infection in the U.S. After the 2014 outbreak many hesitant parents soon understood that these seemingly eliminated threats were not over, but just waiting for vaccination rates to drop again.

However, this may not always be the case. Minnesota’s measles outbreak originated in a large Somali immigrant community that had been successfully targeted by anti-vaccine theories, including personal visits from Andrew Wakefield, who founded the modern anti-vaccination movement. This situation in Minnesota reveals how misinformation that conjures fear and emotion can take hold, with serious ramifications for the public’s health.

Strengthening public health laws and public confidence

Following major measles outbreaks in Western countries, political leaders have strengthened legal requirements for vaccinations. In California, where the Disney outbreak started, tough new legislation was passed, which removes non-medical exemptions (religious and personal beliefs) from the requirement to vaccinate children prior to their enrollment in kindergarten. In France, the Macron administration has promised to reverse low-vaccination rates and it will follow the path of California and Italy, by enforcing vaccination and making it a prerequisite to access public schools. To date, France has shown the worst performance in vaccination (around 75%). In France, there is a strong negative perception of vaccines, aggravated by bureaucratic and a confusing legislation, which labels only three vaccines as mandatory and the rest recommended.

Although legislative efforts are a step in the right direction, laws should be accompanied by public health education aiming to counter misinformation around the safety and necessity of vaccines. The need for pedagogy is evidenced by the recent controversy surrounding the European Court of Justice’s judgment on a liability claim for Hepatitis B vaccine harm. At the request of French Supreme Court, the EU’s highest court made a preliminary ruling, which has been wrongly interpreted as endorsing liability of vaccine manufacturers for vaccine-related injuries in the absence of scientific proof of causation. Instead, the ruling confirms that, in the absence of medical or scientific consensus on a specific cause of harm, causation may be established based on serious circumstantial evidence. The court noted that a mere temporal relationship between the vaccine and the harm would not be enough. Controversy emerged among public health experts, who fear this decision may be manipulated by the anti-vaccination movement. This reinforces the importance of public education and messaging to create a counter-narrative strong enough to impede manipulation of this ruling and other scientific questions.

It’s time for policy-makers to deploy not only an enforceable agenda for immunization, but also a persuasive battery of arguments to convince families that vaccines are safe, effective, and necessary for personal and public health. To this end, the credibility of institutions such as the Centers for Disease Control and Prevention and the WHO should be reinforced against bizarre conspiracy theories. Primary health care providers and pediatricians, who work at the front line of children’s health care, should be empowered to educate misinformed parents on the risks that non-vaccination entails.