© David McNew/Getty ImagesA five-year-old child in California is given the MMR vaccination in preparation for his first day at school
As British health experts become increasingly anxious about declining rates of immunization and the risk of a serious measles epidemic in the UK, the American authorities are convinced that their tougher rules are the answer.
In other cases, parents have been paid $50 (£35) a time to explain to researchers why they are in the tiny minority that is so reluctant to vaccinate their children, in studies probing parents' lingering fears of links between the measles, mumps and rubella (MMR) jab and autism, asthma and attention deficit hyperactivity disorder.
Over the next few months, parents of toddlers across the US will begin registering their children for kindergarten and infant-school intake this September.
School districts post their registration rules online and in local newspapers, and, among the requirements for parents to bring proof of identification when registering, they are, without fail, also asked to bring their child's immunization record showing they have been vaccinated with MMR. No proof, no place at school.
The laws differ slightly from state to state but, overall, obligatory vaccination is so routine most parents and schools automatically accept it.
"It's the law. They have to have had two measles vaccinations to enter school, or even kindergarten," says Marjorie Lapp, a school nurse at Kendall elementary school, near Rochester in upstate New York. "It's a good thing. We don't have many problems with kids getting the jabs. We had a problem with one parent last year where the child's brother was autistic, but nothing has been proven on that point."
Comment: Parents are beginning to question and refuse vaccinations:
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The school has not had a case of measles in the 10 years she has been there. "The benefits of the vaccine outweigh the risks," Lapp says.
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Every state requires proof of immunization before children can enter the state school system, or be eligible for federally funded daycare. As a result, vaccination rates among pupils starting school in the US are typically between 92% and 98%, compared with 78% in England and Wales.
Measles was declared last year to be once again endemic in the UK. Figures published last week confirmed there were 1,348 cases in England and Wales in 2008, a record high, up from 990 in 2007 and just 70 in 2001.
In contrast, in the first six months of 2008 there were just 135 confirmed cases of measles across the US, according to the Centers for Disease Control and Prevention (CDC), the government health data agency.
Even that low figure raised concern in the US, where the population of 300 million is five times bigger than the UK's. American health experts called it the largest outbreak in a decade.
Measles was declared no longer endemic to the US in 2001. "Our vaccination rate is very high and the requirement for immunization before attending school has been going on for decades. The CDC decided that was the best way to get the vaccine to the public," says Dr Anne Gershon, professor of pediatrics at Columbia University Medical Center and president of the Infectious Diseases Society of America.
She says parents who refuse to vaccinate their children have been "led up the garden path" by now-discredited links made between MMR and autism, and by a handful of celebrities "fanning the flames" by speaking out about their fears.
"We have got to regain the public's trust in vaccinations - they do a lot more good than harm. It's no good parents just getting their information from television, and there is so much on the internet that's just wrong," says Gershon.
Comment: More information on the risks of vaccines:
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State exemptions
The "no jab, no school" laws across the US do have caveats, however. In 28 states - including New York, Florida, Kansas, Massachusetts and Illinois - exemptions are allowed for medical or religious reasons. In another 20 states - including California, Texas, Washington, Michigan, Colorado and Ohio - exemptions can be granted for medical, religious or philosophical reasons. Just two states, West Virginia and Mississippi, allow exemptions only for serious medical reasons.
"In New York state, you can't claim exemption for personal philosophical beliefs," explains Jane Zucker, assistant commissioner for the bureau of immunization in the state. "What is allowable is medical exemption in the case of severe allergies that could be life-threatening, with a letter submitted by a doctor, or a letter from the parent declaring it to be against their sincere religious belief."
Despite these loopholes, 98% of children in New York are immunized. Even taking into account private and church schools, the state rate is still 92%. Colorado allows exemptions through parental choice and, there, immunization has slipped to 75%.
"I'm worried about our measles vaccination rate," says paediatrician Dr Robert Brayden, head of the Colorado Children's Immunization Coalition. "When our rate falls, we can be virtually guaranteed that we will have measles re-enter our population. It is, worldwide, extremely contagious, and it is just a plane ride away."
Officials are concerned that measles can be caught by non-immunized Americans holidaying abroad, in Britain for example, or that holidaymakers could bring it to the US. Two-thirds of measles cases in under-19-year-olds in the US last year were found in children whose parents had opted out of vaccination citing religious or philosophical belief.
But, despite a series of reports refuting the alleged link between the MMR vaccine and autism, and the strict laws, significant numbers of American parents remain worried and resist the system.
Tracy Harding, an organic farming consultant in Ashland, Oregon, chose not to vaccinate her two children as babies. She is only now considering taking them for their jabs, at nine and 13 years old. She was one of dozens of parents in a variety of states offered $50 to tell federal researchers why she was afraid to get her children immunized. "It's mistrust of the government and pharmaceutical companies," she says. "Now they are older, I'm considering getting them vaccinated, but for babies it's too much. And I do not want to be mandated to do it. It should not be such a big deal." Neither of her children has caught measles, mumps or rubella, or whooping cough, nor anything more serious than a dose of chicken pox.
Ashland is a liberal town where 28% of parents have chosen exemption from vaccination. "I do not feel that the safety concerns of parents have been well addressed," Harding says. "No one has given a solid explanation for why autism, asthma and attention deficit and hyperactive disorder are increasing. Is it the polluted planet, is it a rise in reporting these things or is it the injections we are giving babies?"
Other states are stricter about exemptions. In Minnesota, for example, a request for religious exemption must be legally notarized. "Only 10 out of 900-plus kids in my school are not vaccinated against measles," says Renata Remington, the school nurse at Pine River elementary school, near Minneapolis. "State law says that if you are in school, you have to have the jab. Any child not being vaccinated for a non-medical reason needs a parental letter signed and notarized, and I have to report it to the state authorities.
"I'm someone who thinks it is OK to opt out of it. But I heard about the increases in measles happening in England and I thought: 'Holy cow, that's close'."
In November 2007, New York state fined a doctor $10,000 (£7,000) and put him under supervision for falsifying certificates to help parents who were concerned about the risks of immunization gain medical exemption from the MMR vaccine, in order for their children to attend school.
Around the same time, parents of 3,000 young pupils in Maryland who were not up to date with their vaccinations received letters from the state courthouse requesting that they attend a hearing, bringing their children. They were then informed that if they did not get their children vaccinated on the spot by the team of medics standing by - or else show proof that the children had already had all their jabs - they faced a $50 fine or 10 days in jail.
West Virginia allows only medical exemptions from MMR vaccination. In that state, pre-schoolers have an immunization rate of more than 96%.
"There are children who cannot take the MMR for medical reasons, so by not allowing any non-medical exemptions we are protecting those children," says Jeff Neccuzi, manager of the West Virginia immunization program. "Our state has taken a stand that we will do all we can to prevent outbreaks. The state provides vaccination free, and we have not seen a case of measles here for 10 years or so."
Dangerous disease
Massachusetts mother-of-two Rachel Magni received hate mail after she went on a television news program to defend her decision not to vaccinate her four-year-old and one-year-old against measles. She says she has been made to feel like a bad parent who is putting others at risk. She has asked the local school for a religious exemption, even though her mainstream Protestant church has no problem with immunization.
"I might get them vaccinated when they are older, when their bodies can tolerate it. You have a responsibility first and foremost for doing what you feel is in your children's best interests," she says. The idea that her children were putting others at risk was "completely idiotic", she adds.
But Jean McDonald, a school nurse at the Glenwood elementary school in Chapel Hill, North Carolina, has a simple message for parents. "The reason a lot of parents don't worry enough is because everyone else is immunized. Some parents forget, because they haven't ever seen it, that measles can be horrendous and that their child is at risk of contracting a terrible disease. If their child catches measles and goes blind or deaf, they would be very sorry."
'A real risk of an epidemic'
Measles is an acute infection caused by a virus, most common in children between one and four. Symptoms include a runny nose, conjunctivitis, fever and a rash. In extreme cases, measles can cause death. Complications include croup, ear infections, pneumonia and eye infection. In fewer than one in 1,000 cases, acute encephalitis occurs, leaving a quarter of those affected with brain damage. Infection during pregnancy can cause the death or premature birth of the baby.
Before the introduction of the measles vaccine in 1968, there were up to 800,000 cases in the UK annually, sometimes causing more than 100 deaths. Uptake of the MMR jab, which protects against measles, mumps and rubella, fell to an all-time low after the Lancet published in 1998 a now discredited study by Andrew Wakefield that suggested the vaccine was linked to autism and bowel disease. In 2006, a 13-year-old boy who was not given the jab became the first person in 14 years to die from measles in Britain.
The number of measles cases in England and Wales hit 1,348 last year - the highest for 13 years, according to the Health Protection Agency. About 3 million children - one in four - have not had both MMR doses, which are necessary to ensure they are fully protected. The HPA warns that without wider uptake of the vaccine, there is a real risk of an epidemic of between 30,000 to 100,000 measles cases.
Comment: More scare tactics to increase MMR vaccinations in children?
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