Evidence Briefs: Public Health Topics
Infectious Disease
The Problem:
Tuberculosis is a classic public health scourge. Globally, there are over 9 million new cases of TB each year. World Health Organization: Tuberculosis Fact Sheet. The risks associated with TB have increased with the emergence of more virulent and drug-resistant strains of the disease. In the United States, the rate of TB incidence and associated mortality declined precipitously for most of the 20th century. In 1900 TB was the second leading cause of mortality accounting for over 10% of deaths; by 1980s deaths attributed to TB were in the hundreds. CDC: MMWR: Achievements in Public Health: Infectious Disease. In the early 1990s, however, incidence of TB began to increase again due to the HIV/AIDS epidemic and the synergistic risks of co-infection. Although these increases appear to have leveled off in the last few years, the risks associated with drug resistant strains continue to make TB an important public health challenge. CDC: MMWR: Trends in Tuberculosis.
The Law:
There are numerous legal measures for controlling the spread of TB. Law authorizes surveillance and specifies treatment requirements like Directly Observed Therapy (DOT). The most extreme and controversial legal measures involve the involuntary detention of individuals who are suspected or known to have infectious TB. In the United States, state statutes (Ca. Health & Safety Code § 121366) and regulations (New Jersey, N.J. Admin. Code § 8:57-5.7 et seq) define the procedural and substantive requirements for detaining an individual who presents a putative risk to the community as the carrier of an infectious disease. A sizable body of case law has also developed providing guidance about how and when an individual can be detained against their will to protect the public from disease. One of the seminal cases interpreting state power over coercive tuberculosis control measures is Green v. Edwards, 263 S.E. 2d 661 (1980).
The Evidence:
Coker systematically reviewed studies assessing the effect of detention of individuals with TB on public health. R.J. Coker. Public Health Impact of Detention of Individuals with Tuberculosis: Systematic Literature Review. Public Health (2003) 117, 281–287. Twenty-two studies fit the inclusion criteria. One of the studies employed a molecular finger printing design and found evidence that removing some infected individuals from the population would significantly decrease population incidence. Other modeling studies, however, suggested that the presence of coercive measures might increase transmission by decreasing the proportion of infected individuals that seek treatment. Observational and case control studies were few and small. According to Coker, there is insufficient evidence to sustain inferences about the effects of detention on population health.
The Bottom Line:
According to the author of a peer-reviewed systematic review, there is insufficient evidence at this time to conclude that detention of individuals with infectious tuberculosis improves population health.
Publication Date: 12/07/2009
The Problem:
Vaccine coverage for preventable disease is an essential public health goal. Low vaccine coverage rates enable otherwise avoidable outbreaks of harmful diseases. CDC: Vaccines and Immunizations.
The Law:
State vaccination laws require children to be immunized prior to entering school. National Vaccine Program Office: Immunization Laws. Subject to instances where exemptions apply, these laws require written proof of a child’s immunization status provided from a health provider. For examples of state vaccination laws, see Colorado (6 CCR 1009-2), Iowa (Iowa Administrative Code), Nebraska (173 NAC 3) and Massachusetts (105 CMR 220.000).
The Evidence:
In a systematic review, a Community Guide expert panel reviewed the evidence concerning the effectiveness of requiring vaccinations as a condition of matriculation into child care, secondary school or college. Briss PA, Rodewald LE, Hinman AR, et al. Reviews of evidence regarding interventions to improve vaccination coverage in children, adolescents, and adults. Am J Prev Med 2000;18(1S):97-140. The review identified nine studies in the U.S. and Canada that measure the impact of these requirements. Of the nine studies, seven examined the impact of school laws; one examined vaccination mandates for child care, and one looked at requirements for college attendance. Six studies measuring the effect of vaccination requirements on the incidence of specific diseases (e.g., measles) found an inverse relationship suggesting that laws reduce rates of the targeted diseases. Three studies also observed a positive relationship between mandated immunization programs and rates of vaccination among the target populations. On the basis of this evidence, the reviewers concluded that there is sufficient evidence that school vaccination requirements are an effective public health intervention aimed at increasing vaccination coverage and decreasing the incidence of certain diseases.
The Bottom Line:
In the judgment of a Community Guide expert panel, there is sufficient evidence supporting the effectiveness of requiring vaccinations as a condition for attending child care facilities and schools.
Additional Information:
The Centers for Disease Control and Prevention has compiled and provided online access to all state vaccination laws.
The Immunization Action Coalition also has online maps showing specific legal requirements for the fifty states.
Additional Resources: Centers for Disease Control and Prevention, Immunization Action Coalition
Origin: Arizona State University News, December 8, 2010
Additional URL(s):
ASU: Professors awarded public health law research grant
PHLR: What is effective "legal triage" in a public health emergency?
Publication Date: 12/07/2009
The Problem:
Vaccine coverage for vaccine preventable disease is an essential public health goal. Vaccination against specific diseases is particularly important for high risk populations, which may include individuals of a certain age (e.g., greater than 68 years for Pneumococcal Polysaccharide) or with specified medical conditions (e.g., HIV/AIDS for influenza). CDC: General Recommendations on Immunization.
The Law:
Laws and policies require vaccination (subject to enumerated exceptions) as a condition of certain jobs. In some states, state law or hospital policies require hospital staff to be vaccinated against influenza. In Rhode Island, for example, health care workers with direct patient contact must be vaccinated for measles, mumps, and rubella. RI Code R. 14-090-007. Illinois requires rubella vaccinations for nursery workers. Ill. Admin. Code tit. 77, § 250.1820.
The Evidence:
In a systematic review, a Community Guide expert panel attempted to systematically review the evidence concerning the impact of requiring vaccinations outright or as a condition of specified activities such as employment as a healthcare worker. Ndaiye SM, Hopkins DP, Shefer AM, et al. Interventions to improve influenza, pneumococcal polysaccharide, and hepatitis B vaccination coverage among high-risk adults: a systematic review. Am J Prev Med 2005;28(5S):248-79. The reviewers were unable to locate any studies that measured the impact of these laws in the U.S. As a result, the reviewers concluded there is insufficient evidence to currently evaluate the effectiveness of these laws and policies as public health measures aimed at protecting vulnerable populations against specific diseases.
The Bottom Line:
In the judgment of a Community Guide expert panel, there is insufficient evidence to assess the effectiveness of requiring vaccinations as a condition for specified jobs as a means of reducing incidence of specific diseases among particularly vulnerable populations.
Additional Information:
The Centers for Disease Control and Prevention has compiled and provided online access to state laws requiring or encouraging vaccination of health care workers.
Additional Resources: Centers for Disease Control and Prevention
Publication Date: 12/07/2009
The Problem:
Vaccine coverage for preventable disease is an essential public health goal. Low vaccine coverage rates enable otherwise avoidable outbreaks of harmful diseases. CDC: Vaccines and Immunizations.
The Law:
To increase vaccination rates among specified adult populations, states authorize or require hospitals to create standing orders. Standing orders allow healthcare workers without prescription authority to prescribe and or administer vaccines under defined circumstances. Without standing orders, such vaccinations would be barred by laws regulating medical practice and the scope of patient-doctor relationships. Laws that provide standing order authority to non-physicians apply to registered nurses (Rev. Code Wash. § 18.79.260, Washington), pharmacists (N.D. Admin. Code 61-04-08-03, North Dakota) and physician assistants (ORS § 677.515, Oregon)
The Evidence:
In a systematic review, a Community Guide expert panel reviewed 11 studies assessing the use of standing orders to deliver vaccines to specified adult populations. Briss PA, Rodewald LE, Hinman AR, et al. Reviews of evidence regarding interventions to improve vaccination coverage in children, adolescents, and adults. Am J Prev Med 2000;18(1S):97-140. Of the 11 studies, six measured the impact of standing orders as an isolated intervention and five measured the effectiveness of standing orders in conjunction with other interventions. The reviewers identified a median 28 percent increase in vaccination among targeted populations following the adoption of standing order policies. The panel viewed all the results as strong evidence that standing orders improve vaccination coverage in adults as standalone intervention or as part of broader multifaceted interventions.
The Bottom Line:
In the judgment of a Community Guide expert panel, there is strong evidence supporting the effectiveness of standing orders as a public health intervention aimed at increasing vaccination rates.
Additional Information:
The Centers for Disease Control and Prevention has compiled and provides online access to all state vaccination laws.
The Immunization Action Coalition also provides online access to maps showing specific legal requirements for the fifty states.
Additional Resources: Centers for Disease Control and Prevention, Immunization Action Coalition
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Public Health Law Research is a national program of the Robert Wood Johnson Foundation. It is housed at the Temple University Beasley School of Law.