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The case for mandatory vaccinations

REUTERS/Brian Snyder
Parents who oppose vaccinations and opt not to inoculate their children are asking society to bear the costs of their choices.

Should vaccinations be mandatory? Measles outbreaks and recent remarks by presidential hopefuls Sen. Rand Paul of Kentucky and New Jersey Gov. Chris Christie that they should be voluntary have thrust this question into the center of American politics and policy debate. Perhaps mandatory vaccinations have become a surrogate for a broader view about freedom and the role of the state in society, similar to the one surrounding mandatory health insurance at the center of the controversy with the Affordable Care Act. Yet there is a powerful ethical case for why vaccines should be mandatory – with no opt-out for religious or personal conscience reasons.

There are a host of reasons some oppose vaccinations. There is the misinformed and discredited urban legend that vaccinations cause autism. Or some claim that the human body is stronger if it fights off disease on its own or that vaccines are not natural. These assertions amount to a broad-scale rejection of modern science that ignores human progress and the benefits that medicine has brought to the world in terms of increased life expectancy, decreased infant mortality, and improvements in the quality of life. But the core arguments rest upon libertarian grounds – that individuals have a right to reject vaccinations if they wish – or religious claims – that some procedures simply violate their right to free exercise of religion.

When it comes to choices by adults, John Stuart Mill’s “On Liberty” is perhaps the most articulate defense of personal liberty penned in the West. He argues against paternalism and makes the case that the state and others have no right to interfere in our lives to protect us against ourselves. Yet Mill held out an exception: Intervention is permitted to prevent us from committing harm to others.

Harming others, and other externalities

Vaccinations are not just about the health of a single individual; they are about preventing individuals from making choices that will harm others. Society, as British legal philosopher H.L.A. Hart once said, is not a suicide pact. Governments have a right to prevent the destructive actions of some from hurting others.

Mandatory vaccinations are only partially about paternalism; they are also about public costs and expenditures. A personal decision not to get vaccinated has externalities. Your decision not to get vaccinated means others and the government may have to bear the costs in terms of paying for additional health-care expenditures to treat themselves or deal with the societal costs of your decision. In reality, it is not about personal choice: It is about you asking society to bear the costs of your decision that you impose upon others. Personal choices not to vaccinate do not mean that individuals have internalized the costs of that choice.

From an economics perspective, mandatory vaccinations address a free rider problem. Maybe it is OK for me to eschew a vaccination and I am willing to take the risk of getting sick. A single choice by a single person is no big deal. But multiply that choice by millions and we get a public-health crisis. This is no different from one bank making one sub-prime loan to one person. Singularly it’s no big issue, but on a large scale we got the mortgage meltdown of 2008.

Parents who oppose vaccinations and opt not to inoculate their children are asking society to bear the costs of their choices in ways described above. But they are also imposing their ethical or religious views about vaccinations upon children who may have no choice over whether they wish to be vaccinated. In declining to vaccinate their children, they are potentially making an irrevocable and irreversible decision about the children’s health. We do not know what children would have consented to if given the choice as an adult, and therefore we are potentially, if not actually, denying them the ability to make a decision over how they would want to be treated if they were given the option to make their own health decisions.

Balancing religious views against the public interest

Finally, there are those who object to vaccines on religious grounds. When it comes to children, the law has long recognized that a parent’s religious views need to be balanced against the legitimate public interest and interest of minors in terms of the their health when it comes to procedures such as blood transfusions. There are limits to parental choices that must be balanced against the health and moral right of children to speak for themselves where they to make the choice as a rational adult.

schultz portrait
David Schultz

When it comes to adults, the law once distinguished between religious belief and practice. While many discredit this distinction, it is still valid in many cases. The law can place some limits upon the extent of your religious practices to serve compelling secular interests. Laws against polygamy and rules that reject the right of individuals not to comply with civil-rights laws based on religious grounds are two examples. Those defending the right to refuse vaccinations on religious grounds ultimately are employing the same arguments used by those who are currently seeking legislation to give individuals the right to refuse to provide services to same-sex couples.

Additionally, because allowing individuals to refuse vaccinations on religious grounds imposes costs on others, such objections amount to society subsidizing religion, a violation of the First Amendment’s Establishment clause.

Personal liberty and the liberty of all

Mandatory vaccinations might intrude on some concept of personal liberty. Yet that personal liberty must be read in concert with the like liberty of all. Those rejecting vaccinations are social free riders — benefiting from practices they would expect all others to follow. One person can afford not to get vaccinated because others are.

Finally, personal liberty against a vaccination must be considered in light of the degree of bodily intrusion and state interests in promoting public health. Such a balance weighs in favor of mandatory vaccines.

David Schultz is a Hamline University professor of political science and the author of “Election Law and Democratic Theory” (Ashgate, 2014) and “American Politics in the Age of Ignorance” (Macmillan, 2013). He blogs at Schultz’s Take


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Comments (46)

  1. Submitted by Tom Christensen on 02/05/2015 - 08:45 am.

    The screwed up GOP.

    They won’t make a move on climate change because “They are not scientists”. Now, take a proven scientific fact, vaccines work, and they choose to claim they know more than medical science, which has a proven track record. We have a surgeon general and a Center for Disease Control so why do we need politicians passing out their two cents (or less) worth of fiction? The GOP continues in their leaderless mode where they all know the answers. Their answers, over time, have mostly been proven to be wrong.

    • Submitted by RB Holbrook on 02/05/2015 - 11:16 am.


      They’re not just Republican. Anti-vaxxers are spread across the political spectrum pretty evenly, although the state with highest percentage of unvaccinated children is good old blue Oregon.

      Mississippi leads the nation in the number of children who are vaccinated. Their law does not allow religious or “conscience” exemptions.

      • Submitted by Jonathan Ecklund on 02/05/2015 - 03:52 pm.


        Yes, there are more than enough anti-vaxxers on the liberal side of the political spectrum. Honestly, I’d be willing to guess that over 51% of anti-vaccination folks would consider themselves liberal or progressive.

        I will say that i’ve never met an establishment Republican who’s been anti-vaxx. The conservatives I know who are remotely anti are all among the libertarian set. The liberals I am aware of who do this tend to be wealthy and believe that they are inherently better than.

        • Submitted by RB Holbrook on 02/06/2015 - 09:07 am.

          Also true

          I think you’re correct. There are also a considerable number of anti-vaxxers among the more hard core evangelical types. It’s a combination of anti-intellectualism and an innate mistrust of anyone outside their circle of believers.

          There is, as you and Ms. Kohls point out, a lot of anti-corporate sentiment driving the anti-vaxx liberals. My impression is they tend to be conspiracy buffs. I would expect a lot of overlap between lefty anti-vaxxers and 9/11 truthers.

          • Submitted by Jonathan Ecklund on 02/06/2015 - 11:13 am.

            I completely agree

            And I think it means there will be some strange bedfellows in the 2016 election cycle. See: Rand Paul.

        • Submitted by chuck holtman on 02/06/2015 - 05:15 pm.

          Both right and left.

          The anti-vaxx stance on the left, I think, rests on the recognition of a huge corporate interest in avoiding the massive liability that might result from a link between vaccinations and improbable but serious occurrences such as neurological disorders, combined with a distrust of the pronouncements of government and the medical community that both are susceptible to capture by those powerful corporate interests.

          The anti-vaxx stance on the right, I think, rests in part on the recent, engineered return to clan-based thinking that denies connection or responsibility to the broader community, and in part on some sort of murky conspiratorial thinking about social experiments and social control.

          The left anti-vaxx stance is more reasonable because the assumptions on which it rests are generally correct: when the financial interests of the powerful are in play, the pronouncements of those in authority give overdue deference to such interests and should be examined critically. However, when one carefully reviews the universe of information and motives concerning measles vaccination, it seems to me, the reasonable person finds more than enough to overcome the initial assumption and make the case for vaccination.

  2. Submitted by Pavel Yankovic on 02/05/2015 - 09:14 am.


    Jehovah’s Witnesses then be mandated to accept blood transfusions in life saving situations? Just curious about how you feel about this, Mr. Schultz.

    • Submitted by Matt Haas on 02/05/2015 - 09:40 am.

      I would say

      Children yes, adults no. Beyond that it is irrelevant to the discussion unless the transfusion would be to cure a communicable disease, which they could conceivably pass on to the public at large. As to the first part, parents should have a great deal of control over their children’s upbringing, playing God and deciding whether they live or die should not be among them. (Before anyone bothers to attempt to send this on a tangent, children I speak of are ones that are alive and independent, not codependent embryos)

    • Submitted by RB Holbrook on 02/05/2015 - 09:43 am.


      I won’t answer for Professor Schultz, but I would draw the distinction that a refusal to accept a blood transfusion affects only the person who makes the refusal. A refusal to vaccinate lets communicable disease spread to others.

    • Submitted by Phil Dech on 02/05/2015 - 10:32 am.

      r.e. transfusion

      This particular situation is, I believe, well settled in case law. An adult Jehovah’s Witness cannot be compelled to accept a blood transfusion, but a child, who has not reached the age of autonomy, can be given blood products against their parents’ wishes, if it is clearly of significant medical benefit and considered the standard of care.

  3. Submitted by Bill Schletzer on 02/05/2015 - 09:28 am.

    Instead of a global mandate…

    …why not just make it a mandate to attend a public school. That way all the Republicans homeschooling their kids and teaching them GOP science can suffer the consequences of their decisions when they get together with other homeschoolers. Places like Disneyland should be able to require it too.

    Question: do the vac truthers deny all vaccines or just MMR? Do they deny polio vaccine just on principle?

    • Submitted by Ron Gotzman on 02/05/2015 - 11:45 am.

      Real change…

      Why not give all the families public money so they can decide to what school to send their kids? You cannot get more public than that.

      That way the effects of those who are suffering from union education will be diminished.

      • Submitted by Logan Foreman on 02/07/2015 - 04:01 pm.

        No way

        The MN constitution provides state money only for public education. If you want to go to a cherry picking private school, pay it yourself.

  4. Submitted by Dimitri Drekonja on 02/05/2015 - 09:39 am.

    Refusing a blood transfusion has much less societal cost– your lack of blood will not be spread to others. Sure, it might prolong a hospital stay, and it does lead to death occasionally (I’ve watched patients bleed to death because they clearly articulated their belief that to accept blood would doom their soul to everlasting damnation). Plus, adults have the ability to refuse medical care that may be beneficial– as long as they have the capacity to make such a decision (understand the risks/benefits, the consequences, able to articulate their objection, etc). Kids do not have that capacity– certainly not infants. Thus, they are a protected class under medical ethics, and there is a high bar to refuse proven beneficial treatments. Higher in some states than in others.

  5. Submitted by Jake Holman on 02/05/2015 - 11:41 am.

    Assuming the vaccinations are effective

    Then it seems to me that the only people at risk of getting sick are those who are not vaccinated. So those who refuse vaccinations are only hurting themselves, right?

    If that’s not the case, then why are we requiring people to get ineffective vaccinations?

    • Submitted by Pavel Yankovic on 02/05/2015 - 01:49 pm.

      You must…..

      be talking about the influenza vaccine. My wife works in a health care facility and it is required. She is recovering from a nasty case of influenza which I caught as well. So much for the vaccine.

      • Submitted by Jonathan Ecklund on 02/05/2015 - 03:54 pm.

        So much for the vaccine

        Indeed, while the vaccine this year was less effective than in years past, it still would have reduced your symptoms- even if it keeps your temperature down a degree or two extra, that means the difference between at-home bedrest and a hospitalization. So, don’t stop getting an annual flu vaccine- even a 25% chance you don’t get the flu is still better than nothing.

      • Submitted by Neal Rovick on 02/05/2015 - 04:10 pm.

        Surely you’re not conflating the yearly flu vaccine with measles vaccine.

        Measles virus has been historically stable and is 93 to 97 percent effective, regardless of what year it is given.

        Flu viruses varies widely by year, and the vaccine is different every year based on the best guess of medical authorities 9 months prior as flu season based on their best guess as to what strains of flu will predominate that year. Much more variability by year and a wide range of effectiveness over the years.

    • Submitted by Peter Stark on 02/05/2015 - 02:31 pm.

      Other Vulnerable People

      It isn’t just those who choose not to be vaccinated who are at risk. Many people are not vaccinated because they cannot be vaccinated: 1) Individuals with auto-immune disorders, 2) People receiving chemotherapy or radiation treatments, 3) children who have not yet reached the appropriate age for a given vaccine.

      I’m sure other people could come up with more examples. As the father of a very young child, I would be absolutely furious if my kid got the measles because a bunch of anti-vaxxers decided that they wanted to coexist peacefully with deadly diseases we eradicated decades ago.

      And Prof. Schultz’ free rider problem still exists, regardless of who is harmed. If I have to pay and get vaccinated, and that means you can skate without getting vaccinated, you’ve effectively stolen from me.

    • Submitted by Matt Haas on 02/05/2015 - 03:01 pm.


      People who cannot receive them, as they are to young or whose health conditions leave their immune systems compromised. But you already knew that, and agree I’m sure with That quack in Arizona whose advice for parents of a child with leukemia was to never leave the house as it was not his problem whether their child could be exposed to measles from his unvaccinated spawn. Classy guy.

    • Submitted by Neal Rovick on 02/05/2015 - 03:18 pm.

      Only hurting themselves?


      One dose of measles vaccine protects 93% of patients, while two doses protect 97%, Wallace says.

      But even with a vaccine failure rate of only 3%, a large measles outbreak can end up infecting a lot of fully vaccinated people, Wallace says.

      To illustrate why, Wallace suggested considering a scenario in which 1,000 people are exposed to measles, with 900 fully vaccinated and 100 unvaccinated.

      Doctors would expect 90% of the unvaccinated people — or 90 people — to get sick. They would also expect 3% of the vaccinated people — or 27 people — to get sick, for a total of 117 people.

      Clearly, the vaccinated people here are much better protected. But the percentage of patients were vaccinated in this scenario is 23% — about the same proportion that health officials tend to see in real outbreaks, Wallace says.

      “People look at these numbers and they say the vaccine doesn’t work,” Wallace says. “It does work… Nothing in the numbers we’re seeing from the current outbreak suggest the vaccine isn’t working as well as it always has…..

      So the “personal choice” affects those too young to get vaccinated, those who have genuine religious objections to vaccinations, and 3 to 7% of the vaccinated population.

  6. Submitted by Rosalind Kohls on 02/05/2015 - 02:57 pm.

    Big Pharma

    There is another group of people who don’t want their kids to be vaccinated. They believe the big pharmaceutical companies which develop and sell the vaccines are in the same class as Wall Street, Big Oil and Big Tobacco companies. They do not want e-e-evil Big Pharma to profit from selling vaccines. That is why there are so many blue states and blue counties with a lot of anti-vaxxers in them.

    • Submitted by Jonathan Ecklund on 02/05/2015 - 03:56 pm.

      I think there is a correlation there, for sure, but I think it’s not so much that they don’t want the Pharma companies to get rich, but that they inherently don’t trust them in the first place. Their own confirmation bias against corporations in general pushes them towards a denial of vaccines.

  7. Submitted by Neal Rovick on 02/05/2015 - 03:09 pm.

    Only hurting themselves?

    ….In a country of more than 313 million, a couple hundred infections doesn’t sound like a lot — and it’s not. But you need only take a look across the Atlantic to find out how quickly measles can spread out of control. In 2007, there were just 44 infections in France, a country where vaccination is recommended but not required. Over the next four years, more than 20,000 additional cases were recorded. Nearly 5,000 of these patients required hospitalization, and 10 of them died.

    As the containment efforts illustrate, the fact that there haven’t been any recent deaths in the United States doesn’t mean measles isn’t having a real impact on the economy or on public health. One of the reasons Madoff oversaw an effort in Massachusetts to contact everyone who might have been exposed was to make sure they were OK. Another was to identify anyone who wasn’t vaccinated so they could “isolate themselves and be out of work and out of school.”

    The state isn’t releasing estimates for the total cost of these two infections, but a 2010 study in Pediatrics quantified the expense of containing a 2008 outbreak in San Diego in which 11 children were infected — and another 839 people were exposed. That cost the public sector $124,517, an average of more than $10,000 per infection. These are costs borne by all of us: Every tax dollar spent containing measles is a dollar not spent on other public health initiatives.

    Maybe you’re not particularly civic-minded. If so, consider this: Forty-eight children too young to be vaccinated in San Diego had to be quarantined at an average cost of $775 per family. Another infant had to be hospitalized after being infected — a harrowing ordeal for that child’s parents and one that rung up almost $15,000 in medical costs.

    All of this is worth remembering the next time parents who don’t vaccinate their children tell you they’re making a purely personal choice. This is, of course, technically true, in the same sense that driving after having a few beers is a personal choice. As the mother of the 10-month-old hospitalized in San Diego said, if people want to make that choice, they should go live on an island with its own schools and doctors: “Their own little infectious disease island.”…

  8. Submitted by Nancy Hokkanen on 02/05/2015 - 03:21 pm.

    One-size-fits-all mandates harm health of vaccine-sensitive

    Chart of Contraindications and Precautions to Commonly Used Vaccines

    Adversomics: The Emerging Field of Vaccine Adverse Event Immunogenetics
    Gregory A. Poland, MD, Inna G. Ovsyannikova, PhD, and Robert M. Jacobson, MD
    “Immune, inflammatory, idiosyncratic, and other responses to a vaccine are determined by a host of known and unknown factors, including individual characteristics… attention now needs to turn toward understanding genetic susceptibility to vaccine-related AEs.”

    List of peer-reviewed published studies on adverse events

    • Submitted by Susan McNerney on 02/05/2015 - 05:45 pm.

      There will always be medical exemptions

      Nobody is suggesting a vaccine mandate that does not have science-based medical exemptions. The people who truly cannot tolerate vaccines (a relatively small number) are in fact dependent on everyone else getting vaccinated to avoid getting sick.

  9. Submitted by Thomas Swift on 02/05/2015 - 03:34 pm.

    People make many decisions that put themselves and others at risk, do you propose mandating anything that meets that definition? What of AIDS? Many have died for the decision of others to engage in behaviors that are known to spread that deadly disease. What sort of legislation do you propose to deal with that?

    • Submitted by Jonathan Ecklund on 02/05/2015 - 03:58 pm.


      …you don’t get AIDS by walking into a room that someone else with AIDS was in an hour prior. Or by riding in an elevator with someone with AIDS. Or by looking at someone with AIDS. Cripes.

      • Submitted by Thomas Swift on 02/05/2015 - 05:20 pm.

        So it’s a matter of how easily ones bad choices can effect others? What about consequences? Measles isn’t usually fatal. AIDS is 100% fatal; there is no cure.

        If we’re gonna legislate behaviors, how about starting with the deadly ones first?

        • Submitted by Susan McNerney on 02/05/2015 - 05:52 pm.

          AIDS is not 100% fatal.

          AIDS is actually a manageable disease for the majority of patients. It’s still very serious, but that’s very old information you have if you believe it is 100% fatal (except in the way that life is 100% fatal).

          In any case, if there were a vaccine for HIV, it might be another one that should go on the “required” list.

          As for measles not being “usually” fatal (in first world countries, that is), fatality is only one negative outcome. Measles has a high hospitalization rate, high cost to society, and can do terrible damage to infants, even if they survive.

          Speaking of which, news just came across the wire as I type this: 5 infants in an Illinois daycare have just been diagnosed with measles.

        • Submitted by Bill Gleason on 02/06/2015 - 01:58 pm.

          Facts about AIDs

          Perhaps you should do a little more investigation of the facts about AIDs fatality, Mr. Swift?

          Here’s a start:

          Life Expectancy for North Americans with HIV Reaches Historic High

          Although HIV infection was once considered a certain death sentence, research published today shows that the average person infected with HIV in North America can expect to live to the age of 63. Gay men with HIV can expect to live even longer, to an average age of 77, according to the findings published in PLOS One.

          In 2009, the average life expectancy for a 20-year-old American man in the general population was exactly the same—77, the study reported.

          “[It is] nothing short of miraculous, given where we were 20 years ago,” said Dr. Mark Smith, who treats people with HIV and also serves as president of the California HealthCare Foundation. “It’s a stunning success story for biomedical science and has contributed greatly to our understanding of other viruses and disease processes as well.”


          I point out – proudly – that this development is the result of stunning successes by scientists in the US and worldwide, much of it funded by NIH.

          • Submitted by Jonathan Ecklund on 02/06/2015 - 04:36 pm.

            Speaking of NIH

            We need to undo the sequester and restore (and INCREASE) funding of the NIH.

          • Submitted by Tom Anderson on 02/10/2015 - 07:51 pm.

            Is there any cost

            To this remarkable life expectancy? Has HIV just become that less deadly or do the persons who have it require, say, medical attention? If gay men with HIV can expect to live to 77, doesn’t that mean that they will live longer than most Americans in general? How long will a gay man live without HIV?

    • Submitted by richard owens on 02/05/2015 - 06:03 pm.

      Public Health:

      It’s a concept.

    • Submitted by Rachel Kahler on 02/06/2015 - 09:57 am.


      1. HIV (the virus that causes AIDS) has no vaccine, unlike measles, mumps, rubella, chicken pox, polio, and other potentially deadly and relatively easily communicable diseases.
      2. People who knowingly expose others to HIV without their consent have been (and should be) criminally prosecuted.

      “Freedom” in any society will never mean complete freedom to do anything you want without consequences from others.

    • Submitted by Bill Gleason on 02/06/2015 - 01:47 pm.

      What sort of legislation would you propose, Mr. Swift,

      to stop others from engaging in behaviors known to spread the deadly disease of AIDs?

      Another fact about AIDS of which you may be unaware is that it is readily spread by heterosexual sex.

      For example:

      In 1999, for the first time, heterosexual sex accounted for a larger proportion of diagnoses than sex between men. [in the UK]


      • Submitted by Thomas Swift on 02/09/2015 - 09:43 am.

        You failed to include a critical part of your cite, Bill

        “Since 2005, the number of people who acquired HIV through heterosexual contact has declined while new HIV diagnoses among MSM have continued to increase. –

        In other words, you’ve cited an old, irrelevant statistic from a country we are not examining.

        In the US (the country we are attending in this discussion), more than 70% of HIV transmission is directly attributable to unsafe homosexual sex between males.

        Further, the difference between hetero and homosexual behavior is not even close.

        For male homosexual encounters account for “an average of one transmission occurred for every 71 exposures”

        Heterosexual encounters account for “1 transmission per 1,250 exposures”

        Spreading disinformation isn’t helpful to anyone.

        I’m not sure we can legislate this problem away, but it’s clear that normalizing risky behaviors is not in the best interests of public health.

        • Submitted by Bill Gleason on 02/09/2015 - 04:49 pm.

          Further information about heterosexual transmission of AIDs

          The Effectiveness of Condoms in Reducing Heterosexual Transmission of HIV
          Family Planning Perspectives
          Volume 31, Number 6, November/December 1999

          “Heterosexual intercourse is the primary mode of HIV infection worldwide. In the United States, male homosexual contact and intravenous drug use account for the majority of HIV infections, but transmission via heterosexual contact continues to increase. Heterosexual contact with an infected partner is the greatest risk factor for women and, consequently, for their newborn children. In 1988, 2% of male AIDS cases and 30% of female cases reported in the United States were attributed to heterosexual contact.2 By 1998, this percentage had risen to 7% for men and 38% for women.”


          Another noteworthy feature of this study that should interest Mr. Swift is that condom usage – one form of birth control – is remarkably effective in decreasing the spread of AIDs.


          “Conclusions: Consistent use of condoms provides protection from HIV. The level of protection approximates 87%, with a range depending upon the incidence among condom nonusers. Thus, the condom’s efficacy at reducing heterosexual transmission may be comparable to or slightly lower than its effectiveness at preventing pregnancy.”

  10. Submitted by Ilya Gutman on 02/05/2015 - 09:56 pm.


    I am afraid that Mr. Schultz is wrong in one of his core assumption that the main reason for not vaccination is libertarian or religious approach to life. In fact, the major reason is the false belief in vaccination harm and that is why the lowest level of vaccination is in California and Oregon, both liberal bastions. It is also interesting that some commenters here blame Republicans right away without even thinking – a very liberal approach to life.

    So what should be done? Mandatory immunization may seem too harsh… so not allowing not immunized kids to attend any public school or space or event may be a better way… Basically, in order for a child to come to any amusement park, cruise ship, theater performance, plane, or anything else of that nature, the parents will have to show a proof of child’s immunization… That will allow people to make their own choices and will not endanger the other people.

    • Submitted by Matt Haas on 02/06/2015 - 09:30 am.


      You might mention that to Rand Paul and Chris Christie. I’m sure they had no idea they were liberal stalwarts.

  11. Submitted by Ray Lewis on 02/05/2015 - 11:13 pm.

    Public Health

    is science based, but also has ethical and social justice implications when individual lifestyle and choice impact society.

    Ebola, measles and flu are infectious outbreaks, and the concept of “herd immunity” is a proven “population health” based approach.

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