Journal of Translational Science

Research Article ISSN: 2059-268X

Pilot comparative study on the health of vaccinated and

unvaccinated 6- to 12-year-old U.S. children
Anthony R Mawson1*, Brian D Ray2, Azad R Bhuiyan3 and Binu Jacob4
Professor, Department of Epidemiology and Biostatistics, School of Public Health, Jackson State University, Jackson, MS 39213, USA
1

President, National Home Education Research Institute, PO Box 13939, Salem, OR 97309, USA
2

Associate Professor, Department of Epidemiology and Biostatistics, School of Public Health, Jackson State University, Jackson, MS 39213, USA
3

Former graduate student, Department of Epidemiology and Biostatistics School of Public Health, Jackson State University, Jackson, MS 39213, USA
4

Abstract
Vaccinations have prevented millions of infectious illnesses, hospitalizations and deaths among U.S. children, yet the long-term health outcomes of the vaccination
schedule remain uncertain. Studies have been recommended by the U.S. Institute of Medicine to address this question. This study aimed 1) to compare vaccinated and
unvaccinated children on a broad range of health outcomes, and 2) to determine whether an association found between vaccination and neurodevelopmental disorders
(NDD), if any, remained significant after adjustment for other measured factors. A cross-sectional study of mothers of children educated at home was carried out
in collaboration with homeschool organizations in four U.S. states: Florida, Louisiana, Mississippi and Oregon. Mothers were asked to complete an anonymous
online questionnaire on their 6- to 12-year-old biological children with respect to pregnancy-related factors, birth history, vaccinations, physician-diagnosed illnesses,
medications used, and health services. NDD, a derived diagnostic measure, was defined as having one or more of the following three closely-related diagnoses: a
learning disability, Attention Deficient Hyperactivity Disorder, and Autism Spectrum Disorder. A convenience sample of 666 children was obtained, of which 261
(39%) were unvaccinated. The vaccinated were less likely than the unvaccinated to have been diagnosed with chickenpox and pertussis, but more likely to have been
diagnosed with pneumonia, otitis media, allergies and NDD. After adjustment, vaccination, male gender, and preterm birth remained significantly associated with
NDD. However, in a final adjusted model with interaction, vaccination but not preterm birth remained associated with NDD, while the interaction of preterm
birth and vaccination was associated with a 6.6-fold increased odds of NDD (95% CI: 2.8, 15.5). In conclusion, vaccinated homeschool children were found to have
a higher rate of allergies and NDD than unvaccinated homeschool children. While vaccination remained significantly associated with NDD after controlling for
other factors, preterm birth coupled with vaccination was associated with an apparent synergistic increase in the odds of NDD. Further research involving larger,
independent samples and stronger research designs is needed to verify and understand these unexpected findings in order to optimize the impact of vaccines on
childrens health.

Abbreviations: ADHD: Attention Deficit Hyperactivity Disorder; Haemophilus influenzae type b disease, hepatitis B, measles, mumps,
ASD: Autism Spectrum Disorder; AOM: Acute Otitis Media; CDC:
and rubella. Between 1995 and 2013, new vaccines against five other
Centers for Disease Control and Prevention; CI: Confidence Interval;
diseases were added for children age 6 and under: varicella, hepatitis A,
NDD: Neurodevelopmental Disorders; NHERI: National Home Education pneumococcal disease, influenza, and rotavirus vaccine.
Research Institute; OR: Odds Ratio; PCV-7: Pneumococcal Conjugate
Vaccine-7; VAERS: Vaccine Adverse Events Reporting System. Although short-term immunologic and safety testing is performed
on vaccines prior to their approval by the U.S. Food and Drug
Introduction Administration, the long-term effects of individual vaccines and of
the vaccination program itself remain unknown [8]. Vaccines are
Vaccines are among the greatest achievements of biomedical
science and one of the most effective public health interventions of the acknowledged to carry risks of severe acute and chronic adverse effects,
20th century [1]. Among U.S. children born between 1995 and 2013, such as neurological complications and even death [9], but such risks
vaccination is estimated to have prevented 322 million illnesses, 21 million are considered so rare that the vaccination program is believed to be
hospitalizations and 732,000 premature deaths, with overall cost savings of safe and effective for virtually all children [10].
$1.38 trillion [2]. About 95% of U.S. children of kindergarten age receive There are very few randomized trials on any existing vaccine
all of the recommended vaccines as a requirement for school and daycare recommended for children in terms of morbidity and mortality, in
attendance [3,4], aimed at preventing the occurrence and spread of targeted
infectious diseases [5]. Advances in biotechnology are contributing to the
development of new vaccines for widespread use [6].
*Correspondence to: Anthony R Mawson, Professor, Department of
Under the currently recommended pediatric vaccination schedule Epidemiology and Biostatistics, School of Public Health, Jackson State
[7], U.S. children receive up to 48 doses of vaccines for 14 diseases University, Jackson, MS 39213, USA, E-mail: [email protected]
from birth to age six years, a figure that has steadily increased since
the 1950s, most notably since the Vaccines for Children program Key words: acute diseases, chronic diseases, epidemiology, evaluation, health
policy, immunization, neurodevelopmental disorders, vaccination
was created in 1994. The Vaccines for Children program began with
vaccines targeting nine diseases: diphtheria, tetanus, pertussis, polio, Received: March 22, 2017; Accepted: April 21, 2017; Published: April 24, 2017

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 Mawson AR (2017) Pilot comparative study on the health of vaccinated and unvaccinated 6- to 12-year-old U.S. children

part because of ethical concerns involving withholding vaccines from been fueled by the fact that the U.S. is experiencing what has been
children assigned to a control group. One exception, the high-titer described as a silent pandemic of mostly subclinical developmental
measles vaccine, was withdrawn after several randomized trials in west neurotoxicity, in which about 15% of children suffer from a learning
Africa showed that it interacted with the diphtheria-tetanus-pertussis disability, sensory deficits, and developmental delays [27,28]. In 1996
vaccine, resulting in a significant 33% increase in child mortality [11]. the estimated prevalence of ASD was 0.42%. By 2010 it had risen to
Evidence of safety from observational studies includes a limited number 1.47% (1 in 68), with 1 in 42 boys and 1 in 189 girls affected [29].
of vaccines, e.g., the measles, mumps and rubella vaccine, and hepatitis More recently, based on a CDC survey of parents in 20112014,
B vaccine, but none on the childhood vaccination program itself. 2.24% of children (1 in 45) were estimated to have ASD. Rates of other
Knowledge is limited even for vaccines with a long record of safety and developmental disabilities, however, such as intellectual disability,
protection against contagious diseases [12]. The safe levels and long- cerebral palsy, hearing loss, and vision impairments, have declined
term effects of vaccine ingredients such as adjuvants and preservatives or remained unchanged [30]. Prevalence rates of Attention Deficit
are also unknown [13]. Other concerns include the safety and cost- Hyperactivity Disorder (ADHD) have also risen markedly in recent
effectiveness of newer vaccines against diseases that are potentially decades [31]. Earlier increases in the prevalence of learning disability
lethal for individuals but have a lesser impact on population health, have been followed by declining rates in most states, possibly due to
such as the group B meningococcus vaccine [14]. changes in diagnostic criteria [32].
Knowledge of adverse events following vaccinations is largely It is believed that much of the increase in NDD diagnoses in
based on voluntary reports to the Vaccine Adverse Events Reporting recent decades has been due to growing awareness of autism and more
System (VAERS) by physicians and parents. However, the rate of sensitive screening tools, and hence to greater numbers of children
reporting of serious vaccine injuries is estimated to be <1% [15]. These with milder symptoms of autism. But these factors do not account
considerations led the former Institute of Medicine (now the National for all of the increase [33]. The geographically widespread increase in
Academy of Medicine) in 2005 to recommend the development of a ASD and ADHD suggests a role for an environmental factor to which
five-year plan for vaccine safety research by the Centers for Disease virtually all children are exposed. Agricultural chemicals are a current
Control and Prevention (CDC) [16,17]. In its 2011 and 2013 reviews focus of research [34-37].
of the adverse effects of vaccines, the Institute of Medicine concluded
A possible contributory role for vaccines in the rise in NDD
that few health problems are caused by or associated with vaccines, and
diagnoses remains unknown because data on the health outcomes of
found no evidence that the vaccination schedule was unsafe [18,19].
Another systematic review, commissioned by the US Agency for vaccinated and unvaccinated children are lacking. The need for such
Healthcare Research and Quality to identify gaps in evidence on the studies is suggested by the fact that the Vaccine Injury Compensation
safety of the childhood vaccination program, concluded that severe Program has paid $3.2 billion in compensation for vaccine injury since
adverse events following vaccinations are extremely rare [20]. The its creation in 1986 [38]. A study of claims compensated by the Vaccine
Institute of Medicine, however, noted that studies were needed: to Injury Compensation Program for vaccine-induced encephalopathy
compare the health outcomes of vaccinated and unvaccinated children; and seizure disorder found 83 claims that were acknowledged as being
to examine the long-term cumulative effects of vaccines; the timing of due to brain damage. In all cases it was noted by the Court of Federal
vaccination in relation to the age and condition of the child; the total Claims, or indicated in settlement agreements, that the children had
load or number of vaccines given at one time; the effect of other vaccine autism or ASD [39]. On the other hand, numerous epidemiological
ingredients in relation to health outcomes; and the mechanisms of studies have found no association between receipt of selected vaccines
vaccine-associated injury [19]. (in particular the combined measles, mumps, and rubella vaccine)
and autism [10,40-45], and there is no accepted mechanism by which
A complicating factor in evaluating the vaccination program is vaccines could induce autism [46].
that vaccines against infectious diseases have complex nonspecific
effects on morbidity and mortality that extend beyond prevention of A major challenge in comparing vaccinated and unvaccinated
the targeted disease. The existence of such effects poses a challenge children has been to identify an accessible pool of unvaccinated
to the assumption that individual vaccines affect the immune system children, since the vast majority of children in the U.S. are vaccinated.
independently of each other and have no physiological effect other Children educated at home (homeschool children) are suitable
than protection against the targeted pathogen [21]. The nonspecific for such studies as a higher proportion are unvaccinated compared
effects of some vaccines appear to be beneficial, while in others they to public school children [47]. Homeschool families have an
appear to increase morbidity and mortality [22,23]. For instance, both approximately equal median income to that of married-couple families
the measles and Bacillus CalmetteGurin vaccine reportedly reduce nationwide, somewhat more years of formal education, and a higher
overall morbidity and mortality [24], whereas the diphtheria-tetanus- average family size (just over three children) compared to the national
pertussis [25] and hepatitis B vaccines [26] have the opposite effect. average of just over two children [48-50]. Homeschooling families
The mechanisms responsible for these nonspecific effects are unknown are slightly overrepresented in the south, about 23% are nonwhite,
but may involve inter alia: interactions between vaccines and their and the age distribution of homeschool children in grades K-12 is
ingredients, e.g., whether the vaccines are live or inactivated; the most similar to that of children nationwide [51]. About 3% of the school-age
recently administered vaccine; micronutrient supplements such as population was homeschooled in the 2011-2012 school year [52].
vitamin A; the sequence in which vaccines are given; and their possible
The aims of this study were 1) to compare vaccinated and
combined and cumulative effects [21].
unvaccinated children on a broad range of health outcomes, including
A major current controversy is the question of whether vaccination acute and chronic conditions, medication and health service
plays a role in neurodevelopmental disorders (NDDs), which broadly utilization, and 2) to determine whether an association found between
include learning disabilities, Attention Deficit Hyperactivity Disorder vaccination and NDDs, if any, remained significant after adjustment
(ADHD) and Autism Spectrum Disorder (ASD). The controversy has for other measured factors.

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 Mawson AR (2017) Pilot comparative study on the health of vaccinated and unvaccinated 6- to 12-year-old U.S. children

Methods A number of homeschool mothers volunteered to assist NHERI

promote the study to their wide circles of homeschool contacts. A
Study planning number of nationwide organizations also agreed to promote the study
To implement the study, a partnership was formed with the in the designated states. The online survey remained open for three
National Home Education Research Institute (NHERI), an organization months in the summer of 2012. Financial incentives to complete the
that has been involved in educational research on homeschooling for survey were neither available nor offered.
many years and has strong and extensive contacts with the homeschool Definitions and measures
community throughout the country (www.nheri.org). The study
protocol was approved by the Institutional Review Board of Jackson Vaccination status was classified as unvaccinated (i.e., no
State University. previous vaccinations), partially vaccinated (received some but not
all recommended vaccinations) and fully vaccinated (received all
Study design recommended age-appropriate vaccines), as reported by mothers.
The study was designed as a cross-sectional survey of homeschooling These categories were developed on the premise that any long-term
mothers on their vaccinated and unvaccinated biological children ages 6 effects of vaccines would be more evident in fully-vaccinated than in
to 12. As contact information on homeschool families was unavailable, partially-vaccinated children, and rare or absent in the unvaccinated.
there was no defined population or sampling frame from which a Mothers were asked to use their childs vaccination records to indicate
randomized study could be carried out, and from which response the recommended vaccines and doses their child had received.
rates could be determined. However, the object of our pilot study was Dates of vaccinations were not requested in order not to overburden
not to obtain a representative sample of homeschool children but a respondents and to reduce the likelihood of inaccurate reporting; nor
convenience sample of unvaccinated children of sufficient size to test was information requested on adverse events related to vaccines, as
for significant differences in outcomes between the groups. this was not our purpose. We also did not ask about dates of diagnoses
We proceeded by selecting 4 states (Florida, Louisiana, Mississippi, because chronic illnesses are often gradual in onset and made long after
and Oregon) for the survey (Stage 1). NHERI compiled a list of the appearance of symptoms. Since most vaccinations are given before
statewide and local homeschool organizations, totaling 84 in Florida, age 6, vaccination would be expected to precede the recognition and
18 in Louisiana, 12 in Mississippi and 17 in Oregon. Initial contacts diagnosis of most chronic conditions.
were made in June 2012. NHERI contacted the leaders of each statewide
Mothers were asked to indicate on a list of more than 40 acute and
organization by email to request their support. A second email was
then sent, explaining the study purpose and background, which the chronic illnesses all those for which her child or children had received
leaders were asked to forward to their members (Stage 2). A link was a diagnosis by a physician. Other questions included the use of health
provided to an online questionnaire in which no personally identifying services and procedures, dental check-ups, sick visits to physicians,
information was requested. With funding limited to 12 months, we medications used, insertion of ventilation ear tubes, number of days
sought to obtain as many responses as possible, contacting families in the hospital, the extent of physical activity (number of hours the
only indirectly through homeschool organizations. Biological mothers child engaged in vigorous activities on a typical weekday), number
of children ages 6-12 years were asked to serve as respondents in order of siblings, family structure (mother and father living in the home,
to standardize data collection and to include data on pregnancy-related divorced or separated), family income and/or highest level of education
factors and birth history that might relate to the children's current of mother or father, and social interaction with children outside the
health. The age-range of 6 to 12 years was selected because most home (i.e., amount of time spent in play or other contact with children
recommended vaccinations would have been received by then. outside the household). Questions specifically for the mother included
Recruitment and informed consent pregnancy-related conditions and birth history, use of medications
during pregnancy, and exposure to an adverse environment (defined
Homeschool leaders were asked to sign Memoranda of Agreement as living within 1-2 miles of a furniture manufacturing factory,
on behalf of their organizations and to provide the number of member hazardous waste site, or lumber processing factory). NDD, a derived
families. Non-responders were sent a second notice but few provided diagnostic category, was defined as having one or more of the following
the requested information. However, follow-up calls to the leaders
three closely related and overlapping diagnoses: a learning disability,
suggested that all had contacted their members about the study. Both
Attention Deficit Hyperactivity Disorder (ADHD) and Autism
the letter to families and the survey questions were stated in a neutral
Spectrum Disorder (ASD) [53].
way with respect to vaccines. Our letter to parents began:
Dear Parent, This study concerns a major current health question: Statistical methods
namely, whether vaccination is linked in any way to children's long-term Unadjusted bivariate analyses using chi-square tests were
health. Vaccination is one of the greatest discoveries in medicine, yet performed initially to test the null hypothesis of no association between
little is known about its long-term impact. The objective of this study vaccination status and health outcomes, i.e., physician-diagnosed acute
is to evaluate the effects of vaccination by comparing vaccinated and and chronic illnesses, medications, and the use of health services. In
unvaccinated children in terms of a number of major health outcomes most analyses, partially and fully vaccinated children were grouped
Respondents were asked to indicate their consent to participate, to together as the vaccinated group, with unvaccinated children as the
provide their home state and zip code of residence, and to confirm that control group. The second aim of the study was to determine whether
they had biological children 6 to 12 years of age. The communications any association found between vaccination and neurodevelopmental
company Qualtrics (http://qualtrics.com) hosted the survey website. disorders remained significant after controlling for other measured
The questionnaire included only closed-ended questions requiring factors. Descriptive statistics on all variables were computed to
yes or no responses, with the aim of improving both response and determine frequencies and percentages for categorical variables and
completion rates. means ( SD) for continuous variables. The strength of associations

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 Mawson AR (2017) Pilot comparative study on the health of vaccinated and unvaccinated 6- to 12-year-old U.S. children

between vaccination status and health outcomes were tested using odds Partial versus full vaccination
ratios (OR) and 95% Confidence Intervals (CI). Odds ratios describe the
strength of the association between two categorical variables measured Partially vaccinated children had an intermediate position between
simultaneously and are appropriate measures of that relationship in a the fully vaccinated and unvaccinated in regard to several but not
cross-sectional study [54]. Unadjusted and adjusted logistic regression all health outcomes. For instance, as shown in Table 4, the partially
analyses were carried out using SAS (Version 9.3) to determine the vaccinated had an intermediate (apparently detrimental) position in
factors associated with NDDs. terms of allergic rhinitis, ADHD, eczema, and learning disability.
Gender differences in chronic illness
Results
Among the vaccinated (combining partially and fully vaccinated
Socio-Demographic characteristics of respondents
children), boys were more likely than girls to be diagnosed with a
The information contained in 415 questionnaires provided data chronic condition significantly so in the case of allergic rhinitis
on 666 homeschool children. Table 1 shows the characteristics of (13.9% vs. 7.2%, p = 0.03; OR 2.1, 95% CI: 1.1, 4.1), ASD (7.7% vs. 1.9%,
the survey respondents. Mothers averaged about 40 years of age, p = 0.006; OR 4.3, 95% CI: 1.4, 13.2), and any neurodevelopmental
were typically white, college graduates, with household incomes disorder (14.4% vs. 6.7%, p = 0.01; OR 2.3, 95% CI: 1.2, 4.6) (Table 5).
between $50,000 to $100,000, Christian, and married. The reasons for
homeschooling for the majority of respondents (80-86%) were for a Use of medications and health services
moral environment, better family relationships, or for more contact
The vaccinated (combining the partially and fully vaccinated) were
with their child or children.
significantly more likely than the unvaccinated to use medication for
The children as a group were similarly mostly white (88%), with allergies (20.0% vs. 1.2%, p <0.001; OR 21.5, 95% CI: 6.7, 68.9), to have
a slight preponderance of females (52%), and averaged 9 years of age. used antibiotics in the past 12 months (30.8% vs. 15.4%, p <0.001; OR
With regard to vaccination status, 261 (39%) were unvaccinated, 208 2.4, 95% CI: 1.6, 3.6), and to have used fever medications at least once
(31%) were partially vaccinated, and 197 (30%) had received all of the (90.7% vs. 67.8%, p <0.001; OR 4.6, 95% CI: 3.0, 7.1). The vaccinated
recommended vaccinations. All statistical analyses are based on these
were also more likely to have seen a doctor for a routine checkup in the
numbers.
past 12 months (57.6% vs. 37.2%, p <0.001; OR 2.3, 95% CI: 1.7, 3.2),
Acute illness visited a dentist during the past year (89.4% vs. 80.5%, p <0.001; OR
2.0, 95% CI: 1.3, 3.2), visited a doctor or clinic due to illness in the past
Vaccinated children (N=405), combining the partially and fully
year (36.0% vs. 16.0%, p <0.001; OR 3.0, 95% CI: 2.0, 4.4), been fitted
vaccinated, were significantly less likely than the unvaccinated to have
with ventilation ear tubes (3.0% vs. 0.4%, p = 0.018; OR 8.0, 95% CI: 1.0,
had chickenpox (7.9% vs. 25.3%, p <0.001; Odds Ratio = 0.26, 95%
Confidence Interval: 0.2, 0.4) and whooping cough (pertussis) (2.5% 66.1), and spent one or more nights in a hospital (19.8% vs. 12.3%, p =
vs. 8.4%, p <0.001; OR 0.3, 95% CI: 0.1, 0.6), and less likely, but not 0.012; OR 1.8, 95% CI: 1.1, 2.7) (Table 6).
significantly so, to have had rubella (0.3% vs. 1.9%, p = 0.04; OR 0.1,
Table 1. Characteristics of the respondentsa
95% CI: 0.01, 1.1). However, the vaccinated were significantly more
likely than the unvaccinated to have been diagnosed with otitis media Mean (SD) a
(19.8% vs. 5.8%, p <0.001; OR 3.8, 95% CI: 2.1, 6.6) and pneumonia Age (n=407) 40.59 (6.7)
(6.4% vs. 1.2%, p = 0.001; OR 5.9, 95% CI: 1.8, 19.7). No significant Number (%)a
Race
differences were seen with regard to hepatitis A or B, high fever in
White 382 (92.5%)
the past 6 months, measles, mumps, meningitis (viral or bacterial),
Non-White 21 (7.6%)
influenza, or rotavirus (Table 2).
Total 413
Chronic illness Education
High School Graduate or Less 35 (8.5%)
Vaccinated children were significantly more likely than the Some College 114 (27.5%)
unvaccinated to have been diagnosed with the following: allergic College Graduate 187 (45.2%)
rhinitis (10.4% vs. 0.4%, p <0.001; OR 30.1, 95% CI: 4.1, 219.3), other Post-Graduates 78 (18.5%)
allergies (22.2% vs. 6.9%, p <0.001; OR 3.9, 95% CI: 2.3, 6.6), eczema/ Total 414
atopic dermatitis (9.5% vs. 3.6%, p = 0.035; OR 2.9, 95% CI: 1.4, 6.1), a Total Gross Household Income
learning disability (5.7% vs. 1.2%, p = 0.003; OR 5.2, 95% CI: 1.6, 17.4), < $49,999 123 (30.8%)
$50,000-100,000 182 (45.5%)
ADHD (4.7% vs. 1.0%, p = 0.013; OR 4.2, 95% CI: 1.2, 14.5), ASD (4.7%
> $100,000 95 (23.8%)
vs. 1.0%, p = 0.013; OR 4.2, 95% CI: 1.2, 14.5), any neurodevelopmental
Total 400
disorder (i.e., learning disability, ADHD or ASD) (10.5% vs. 3.1%, p
Religious Affiliation
<0.001; OR 3.7, 95% CI: 1.7, 7.9) and any chronic illness (44.0% vs. Christianity 375 (91.2%)
25.0%, p <0.001; OR 2.4, 95% CI: 1.7, 3.3). No significant differences Non-Christianity 36 (8.8%)
were observed with regard to cancer, chronic fatigue, conduct disorder, Total 411
Crohns disease, depression, Types 1 or 2 diabetes, encephalopathy, Marital Status
epilepsy, hearing loss, high blood pressure, inflammatory bowel Married 386 (93.7%)
disease, juvenile rheumatoid arthritis, obesity, seizures, Tourettes Not Married 26 (6.3%)
syndrome, or services received under the Individuals with Disabilities Total 412
Education Act (Table 3). Missing observations are excluded.
a

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 Mawson AR (2017) Pilot comparative study on the health of vaccinated and unvaccinated 6- to 12-year-old U.S. children

Figure 1. The overlap and distribution of physician-diagnosed neurodevelopmental disorders, based on mothers reports

Table 2. Vaccination status and health outcomes Acute Conditions

Vaccinated (n=405) Unvaccinated (n=261) Total (n=666) Chi-square P-value Odds Ratio (95% CI)
Chickenpox
Yes 32 (7.9%) 66 (25.3%) 98 (14.7%)
38.229 < 0.001 0.26 (0.2 - 0.4)
No 373 (92.1%) 195 (74.7%) 568 (85.3%)
Otitis media
Yes 80 (19.8%) 16(5.8%) 96 (14.4%)
26.643 < 0.001 3.8 (2.1 - 6.6)
No 325 (80.2%) 245 (94.2%) 507 (85.6%)
Pneumonia
Yes 26 (6.4%) 3 (1.2%) 29 (4.4%)
10.585 < 0.001 5.9 (1.8 - 19.7)
No 379 (93.6%) 258 (98.8%) 637 (95.6%)
Whooping cough
Yes 10 (2.5%) 22 (8.4%) 32 (4.8%)
12.326 < 0.001 0.3 (0.1 - 0.6)
No 395 (97.5%) 239 (91.6%) 634 (95.2%)
Rubella
Yes 1 (0.3%) 5 (1.9%) 6 (0.9%)
4.951 0.037 0.1 (0.01 - 1.1)
No 404 (99.6%) 256 (98.1%) 660 (99.1%)

Table 3. Vaccination status and health outcomes Chronic Conditions

Chronic Disease Vaccinated (n=405) Unvaccinated (n=261) Chi-square P-value Odds Ratio (95% CI)
Allergic rhinitis
Yes 42 (10.4%) 1 (0.4%)
26.21 < 0.001 30.1 (4.1 - 219.3)
363 (89.6%) 260 (99.6%)
Allergies
Yes 90 (22.2%) 18 (6.9%)
29.44 < 0.001 3.9 (2.3 - 6.6)
No 315 (77.9%) 243 (93.1%)
ADHD
Yes 19 (4.7%) 3 (1.0%)
6.23 0.013 4.2 (1.2 - 14.5)
No 386 (95.3%) 258 (99.0%)
ASD
Yes 19 (4.7%) 3 (1.0%)
6.23 0.013 4.2 (1.2 - 14.5)
No 386 (95.3%) 258 (99.0%)
Eczema (atopic dermatitis)
Yes 38 (9.5%) 9 (3.6%)
8.522 0.035 2.9 (1.4 - 6.1)
No 367 (90.5%) 252 (96.4%)
Learning Disability
Yes 23 (5.7%) 3 (1.2%)
8.6803 0.003 5.2 (1.6 - 17.4)
No 382 (94.3%) 258 (98.9%)
Neurodevelopment Disorder
Yes 42 (10.5%) 8 (3.1%)
12.198 < 0.001 3.7 (1.7 - 7.9)
No 313 (89.5%) 253 (96.9%)
Any Chronic Condition
Yes 178 (44.0%) 65 (24.9%)
24.8456 < 0.001 2.4 (1.7 - 3.3)
No 227 (56.0%) 196 (75.1%)

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Table 4. Partial versus full vaccination and chronic health conditions

Partially Vaccinated Fully Vaccinated Total
Unvaccinated (n=261) Chi-Square P-value
(n=208) (n=197) (n=666)
Chronic Conditions
Allergic rhinitis
Yes 1 (0.4%) 17 (8.2%) 25 (12.7%) 43 (6.5%)
29.6306 < 0.001
No 260 (99.6%) 191 (91.8%) 172 (87.3%) 623 (93.5%)
Allergies
Yes 18 (6.9%) 47 (22.6%) 43 (21.8%) 108 (16.2%)
27.4819 < 0.001
No 243 (93.1%) 161 (77.4%) 154 (78.2%) 558 (83.8%)
ADHD
Yes 3 (1.2%) 8 (3.9%) 11 (5.6%) 22 (3.3%)
7.1900 0.075
No 258 (98.8%) 200 (96.1%) 186 (94.4%) 644 (96.7%)
ASD
Yes 3 (1.2%) 11 (5.3%) 8 (4.6%) 22 (3.3%)
6.7109 0.034
No 258 (98.8%) 197 (94.7%) 189 (95.4%) 644 (96.7%)
Eczema (atopic

dermatitis)
Yes 9 (3.5%) 18 (8.7%) 20 (10.2%) 47 (7.1%)
8.8683 0.012
No 252 (96.5%) 190 (91.3%) 177 (89.8%) 619 (92.9%)
Learning Disability
Yes 3 (1.2%) 11 (5.3%) 12 (6.1%) 26 (3.9%)
8.8541 0.012
No 258 (98.8%) 197 (94.7%) 185 (93.9%) 640 (96.1%)
NDD
Yes 8 (3.1%) 21 (10.1%) 21 (10.7%) 50 (7.5%)
12.2443 0.002
No 253 (96.9%) 187 (89.9%) 176 (89.3%) 616 (92.5%)
Any Chronic Condition
Yes 65 (24.9%) 94 (45.2%) 84 (42.6%) 243 (36.5%)
25.1301 < 0.001
No 196 (75.1%) 114 (54.8%) 113 (57.4%) 423 (63.5%)

Table 5. Chronic conditions and gender among vaccinated children

Male Female Total Odds Ratio
Chi-square P-value
(n=194) (n=209) (n=403) (95% CI)
Allergic rhinitis
Yes 27 (13.9%) 15 (7.2%) 42 (10.4%)
4.8964 0.0269 2.1 (1.1 - 4.1)
No 167 (86.1%) 194 (92.8%) 361 (90.0%)
Allergies
Yes 50 (25.8%) 40 (19.1%) 90 (22.3%)
2.5531 0.1101 1.5 (0.91 - 2.4)
No 144 (74.2%) 168 (80. 9%) 313 (77.7%)
ADHD
Yes 13 (6.7%) 6 (2.9%) 19 (4.7%)
3.2856 0.0699 2.4 (0.90 - 6.5)
No 181 (93.3%) 203 (97.1%) 384 (95.3%)
ASD
Yes 15 (7.7%) 4 (1.9%) 19 (4.7%)
7.5810 0.0059 4.3 (1.4 - 13.2)
No 178 (92.3%) 205 (98.1%) 384 (95.3%)
Eczema
Yes 19 (9.89%) 19 (9.1%) 38 (9.4%)
0.0582 0.8094 1.1 (0.6 - 2.1)
No 175 (90.2%) 190 (90.9%) 365 (90.6%)
Learning Disability
Yes 14 (7.2%) 9 (4.3%) 23 (5.7%)
1.5835 0.2083 1.7 (0.7 - 4.1)
No 180 (92.8%) 200 (95.7%) 380 (94.3%)
NDD
Yes 28 (14.4%) 14 (6.7%) 42 (10.4%)
6.4469 0.0111 2.3 (1.2 - 4.6)
No 166 (85.6%) 195 (93.3%) 361 (89.6%)
Any Chronic Condition
Yes 94 (48.5%) 83 (39.7%) 177 (43.9%)
3.1208 0.0773 1.4 (1.0 - 2.1)
No 100 (51.5%) 126 (60.3%) 226 (56.1%)

Factors associated with neurodevelopmental disorders association remained significant after adjustment for other measured
factors. As noted, because of the relatively small numbers of children
The second aim of the study focused on a specific health outcome with specific diagnoses, NDD was a derived variable combining
and was designed to determine whether vaccination was associated children with a diagnosis of one or more of ASD, ADHD and a learning
with neurodevelopmental disorders (NDD) and, if so, whether the disability. The close association and overlap of these diagnoses in the

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 Mawson AR (2017) Pilot comparative study on the health of vaccinated and unvaccinated 6- to 12-year-old U.S. children

Table 6. Vaccination status, medication use and health services utilization

Vaccinated (n=405) Unvaccinated (n=261) Total (n=666) Chi-square P-value Odds Ratio (95% CI)
Medication Use
Medication for Allergy
Yes 81 (20.0%) 3 (1.2%) 84 (12.6%)
51.170 < 0.001 21.5 (6.7 - 68.9)
No 324 (80.0%) 258 (98.8%) 582 (87.4%)
Used antibiotics in the past 12 months
Yes 124 (30.8%) 40 (15.4%) 164 (24.7%)
20.092 < 0.001 2.4 (1.6 - 3.6)
No 279 (69.2%) 220 (84.6%) 499 (75.3%)
Used fever medication 1+ times
Yes 350 (90.7%) 173 (67.8%) 523 (81.6%)
53.288 < 0.001 4.6 (3.0 - 7.1)
No 36 (9.3%) 82 (32.2%) 118 (18.4%)
Using fitted ear drainage tubes
Yes 12 (3.0%) 1 (0.4%) 13 (2.0%) 5.592
0.018 8.0 (1.0 - 66.1)
No 389 (97.0%) 260 (99.6%) 649 (98.0%)
Used medication for ADHD
Yes 7 (1.7%) 3 (1.2%) 10 (1.5%)
0.346 0.556 -
No 398 (98.3%) 256 (98.8%) 654 (98.5%)
Used medication for Seizures
Yes 4 (1.0%) 1 (0.4%) 5 (0.8%)
0.769 0.653 -
No 400 (99.0%) 258 (99.6%) 658 (99.2)
Health Services Utilization
Emergency Department visit in the past 12
months
Yes 38 (9.5%) 23 (9.0%) 61 (9.3%)
0.047 0.828 -
No 364 (90.5%) 234 (91.0%) 598 (90.7%)
Sick visit to doctor in the past year
Yes 145 (36.0%) 41 (16.0%) 186 (28.2%)
31.096 < 0.001 3.0 (2.0 - 4.4)
No 258 (64.0%) 216 (84.0%) 474 (71.8%)
Ever spent one or more nights in the hospital
Yes 80 (19.8%) 32 (12.3%) 112 (16.8%)
6.267 0.012 1.8 (1.1 - 2.7)
No 325 (80.2%) 228 (87.7%) 553 (83.2%)
Seen doctor for checkup in past 12 months
Yes 233 (57.6%) 97 (37.2%) 330 (49.6%)
26.336 < 0.001 2.3 (1.7 - 3.2)
No 172 (42.4%) 164 (62.8%) 336 (50.4%)
Seen dentist in the past 12 months
Yes 362 (89.4%) 210 (80.5%) 572 (85.9%)
10.424 < 0.001 2.0 (1.3 - 3.2)
No 43 (10.6%) 51 (19.5%) 94 (14.1%)

study is shown in the figure above (Figure 1). The figure shows that Adjusted analysis
the single largest group of diagnoses was learning disability (n=15)
After adjustment for all other significant factors, those that
followed by ASD (n=9), and ADHD (n=9), with smaller numbers
remained significantly associated with NDD were: vaccination (OR 3.1,
comprising combinations of the three diagnoses.
95% CI: 1.4, 6.8); male gender (OR 2.3, 95% CI: 1.2, 4.3); and preterm
Unadjusted analysis birth (OR 5.0, 95% CI: 2.3, 11.1). The apparently strong association
between both vaccination and preterm birth and NDD suggested the
Table 7 shows that the factors associated with NDD in unadjusted possibility of an interaction between these factors.
logistic regression analyses were: vaccination (OR 3.7, 95% CI: 1.7, 7.9);
In a final adjusted model designed to test for this possibility,
male gender (OR 2.1, 95% CI: 1.1, 3.8); adverse environment, defined as
controlling for the interaction of preterm birth and vaccination,
living within 1-2 miles of a furniture manufacturing factory, hazardous
the following factors remained significantly associated with NDD:
waste site, or lumber processing factory (OR 2.9, 95% CI: 1.1, 7.4); vaccination (OR 2.5, 95% CI: 1.1, 5.6), nonwhite race (OR 2.4, 95%
maternal use of antibiotics during pregnancy (OR 2.3, 95% CI: 1.1, 4.8); CI: 1.1, 5.4), and male gender (OR 2.3, 95% CI: 1.2, 4.4). Preterm birth
and preterm birth (OR 4.9, 95% CI: 2.4, 10.3). Two factors that almost itself, however, was not significantly associated with NDD, whereas
reached statistical significance were vaccination during pregnancy the combination (interaction) of preterm birth and vaccination was
(OR 2.5, 95% CI: 1.0, 6.3) and three or more fetal ultrasounds (OR 3.2, associated with 6.6-fold increased odds of NDD (95% CI: 2.8, 15.5)
95% CI: 0.92, 11.5). Factors that were not associated with NDD in this (Table 8).
study included mothers education, household income, and religious
affiliation; use of acetaminophen, alcohol, and antacids during
Discussion
pregnancy; gestational diabetes; preeclampsia; Rhogham shot during Following a recommendation of the Institute of Medicine [19] for
pregnancy; and breastfeeding (data not shown). studies comparing the health outcomes of vaccinated and unvaccinated

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 Mawson AR (2017) Pilot comparative study on the health of vaccinated and unvaccinated 6- to 12-year-old U.S. children

Table 7. Unadjusted analysis of potential risk factors for neurodevelopmental disorders

NDD
Yes No Total*
Vaccination Status Chi-Square P-value OR (95% CI)**
(N=50) (N=616) (N=666)
Vaccinated 42 363 405 3.7 (1.7 - 7.9)
12.198 <0.001
Not Vaccinated 8 253 261 Ref
Race
Non-White 9 71 80 1.7 (0.7 - 3.6)
1.8208 0.177
White 41 544 585 Ref
Child's Gender
Male 32 283 315 2.1 (1.1 - 3.8)
5.9471 0.015
Female 18 331 349 Ref
Adverse Environment
Yes 6 27 33 2.9 (1.1 - 7.4)
No 40 523 563 5.8706 0.053 Ref
Do not know 4 66 70 0.8 (0.3 - 2.3)
Medication during

Pregnancy - Antibiotics
Yes 10 61 71 2.3 (1.1 - 4.8)
4.950 0.026
No 40 555 595 Ref
Medication during

Pregnancy Vaccinated
Yes 6 32 38 2.5 (1.0 - 6.3)
3.965 0.057
No 44 583 627 Ref
Preterm birth
Yes 12 37 49 4.9 (2.4 - 10.3)
22.910 < 0.001
No 38 578 616 Ref
Ultrasound
None 3 71 74 Ref
5.898 0.052
1-3 times 30 419 449 1.7 (0.5 - 5.7)
> 3 times 17 124 141 3.2 (0.92 - 11.5)
*Numbers may not add to column totals due to missing or incomplete data.
**Note that Odds Ratios are the cross-product ratios of the entries in the 2-by-2 tables, and are an estimate of the relative incidence (or risk) of the outcome associated with the
exposure factor.

Table 8. Adjusted logistic regression analyses of risk factors and NDD* invited to participate in the study by the leaders of their homeschool
Adjusted Model with Interaction organizations. Data from the survey were also used to determine
Adjusted Model (Model 1)
(Model 2) whether vaccination was associated specifically with NDDs, a derived
Vaccination Status diagnostic category combining children with the diagnoses of learning
Vaccinated 3.1 (1.4 - 6.8) 2.5 (1.1 - 5.6) disability, ASD and/or ADHD.
Not Vaccinated Ref Ref
Race With regard to acute and chronic conditions, vaccinated
Non-White 2.3 (1.0 - 5.2) 2.4 (1.1 - 5.4) children were significantly less likely than the unvaccinated to have
White Ref Ref had chickenpox and pertussis but, contrary to expectation, were
Child's Gender significantly more likely to have been diagnosed with otitis media,
Male 2.3 (1.2 - 4.3) 2.3 (1.2 - 4.4) pneumonia, allergic rhinitis, eczema, and NDD. The vaccinated were
Female Ref Ref also more likely to have used antibiotics, allergy and fever medications;
Preterm birth to have been fitted with ventilation ear tubes; visited a doctor for a
Yes 5.0 (2.3 - 11.1) NS health issue in the previous year, and been hospitalized. The reason for
No Ref hospitalization and the age of the child at the time were not determined,
Preterm birth but the latter finding appears consistent with a study of 38,801 reports
and Vaccination
interaction to the VAERS of infants who were hospitalized or had died after
No interaction Ref receiving vaccinations. The study reported a linear relationship between
Preterm and Not in the model the number of vaccine doses administered at one time and the rate of
6.6 (2.8 - 15.5)
Vaccinated hospitalization and death; moreover, the younger the infant at the time
*Number of observation read 666, number of observations used 629. NDD=47, Not NDD of vaccination, the higher was the rate of hospitalization and death
= 582 [55]. The hospitalization rate increased from 11% for 2 vaccine doses
to 23.5% for 8 doses (r2 = 0.91), while the case fatality rate increased
children, this study focused on homeschool children ages 6 to 12
significantly from 3.6% for those receiving from 1-4 doses to 5.4 % for
years based on mothers anonymous reports of pregnancy-related
those receiving from 5-8 doses.
conditions, birth histories, physician-diagnosed illnesses, medications
and healthcare use. Respondents were mostly white, married, and In support of the possibility that the number of vaccinations
college-educated, upper income women who had been contacted and received could be implicated in risks of associated chronic illness, a

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 Mawson AR (2017) Pilot comparative study on the health of vaccinated and unvaccinated 6- to 12-year-old U.S. children

comparison of unvaccinated, partially and fully vaccinated children in These observations have suggested that eradication of vaccine serotype
the present study showed that the partially vaccinated had increased but pneumococci can be followed by colonization of other bacterial species
intermediate odds of chronic disease, between those of unvaccinated in the vacant nasopharyngeal niche, leading to disequilibria of bacterial
and fully vaccinated children, specifically for allergic rhinitis, ADHD, composition (dysbiosis) and increased risks of otitis media. Long-term
eczema, a learning disability, and NDD as a whole. monitoring has been recommended as essential for understanding
the full implications of vaccination-induced changes in microbiota
The national rates of ADHD and LD are comparable to those of structure [67].
the study. The U.S. rate of ADHD for ages 4-17 (twice the age range of
children than the present study), is 11% [31]. The study rate of ADHD The second aim of the paper focused on a specific health outcome
for ages 6 to 12 is 3.3%, and 4.7% when only vaccinated children are and sought to determine whether vaccination remained associated
included. The national LD rate is 5% [32], and the study data show with neurodevelopmental disorders (NDD) after controlling for
a rate of LD of 3.9% for all groups, and 5.6% when only vaccinated other measured factors. After adjustment, the factors that remained
children are included. However, the ASD prevalence of 2.24% from a significantly associated with NDD were vaccination, nonwhite race,
CDC parent survey is lower than the study rate of 3.3%. Vaccinated male gender, and preterm birth. The apparently strong association
males were significantly more likely than vaccinated females to have between both vaccination and preterm birth and NDD suggested the
been diagnosed with allergic rhinitis, and NDD. The percentage of possibility of an interaction between these factors. This was shown in a
vaccinated males with an NDD in this study (14.4%) is consistent with final adjusted model with interaction (controlling for the interaction of
national findings based on parental responses to survey questions, preterm birth with vaccination). In this model, vaccination, nonwhite
indicating that 15% of U.S. children ages 3 to 17 years in the years race and male gender remained associated with NDD, whereas preterm
2006-2008 had an NDD [28]. Boys are also more likely than girls to be birth itself was no longer associated with NDD. However, preterm birth
diagnosed with an NDD, and ASD in particular [29]. combined with vaccination was associated with a 6.6-fold increased
odds of NDD.
Vaccination was strongly associated with both otitis media and
pneumonia, which are among the most common complications of In summary, vaccination, nonwhite race, and male gender
measles infection [56,57]. The odds of otitis media were almost four- were significantly associated with NDD after controlling for other
fold higher among the vaccinated (OR 3.8, 95% CI: 2.1, 6.6) and the factors. Preterm birth, although significantly associated with NDD
odds of myringotomy with tube placement were eight-fold higher than in unadjusted and adjusted analyses, was no longer associated with
those of unvaccinated children (OR 8.0, 95% CI: 1.0, 66.1). Acute otitis NDD in the final model with interaction. However, preterm birth and
media (AOM) is a very frequent childhood infection, accounting for vaccination combined was strongly associated with NDD in the final
up to 30 million physician visits each year in the U.S., and the most adjusted model with interaction, more than doubling the odds of NDD
common reason for prescribing antibiotics for children [58,59]. The compared to vaccination alone. Preterm birth has long been known as
incidence of AOM peaks at ages 3 to 18 months and 80% of children a major factor for NDD [68,69], but since preterm infants are routinely
have experienced at least one episode by 3 years of age. Rates of AOM vaccinated, the separate effects of preterm birth and vaccination
have increased in recent decades [60]. Worldwide, the incidence of have not been examined. The present study suggests that vaccination
AOM is 10.9%, with 709 million cases each year, 51% occurring in could be a contributing factor in the pathogenesis of NDD but also
children under 5 years of age [61]. Pediatric AOM is a significant that preterm birth by itself may have a lesser or much reduced role in
concern in terms of healthcare utilization in the U.S., accounting for NDD (defined here as ASD, ADHD and/or a learning disability) than
$2.88 billion in annual health care costs [62]. currently believed. The findings also suggest that vaccination coupled
with preterm birth could increase the odds of NDD beyond that of
Numerous reports of AOM have been filed with VAERS. A search vaccination alone.
of VAERS for Cases where age is under 1 and onset interval is 0 or
1 or 2 or 3 or 4 or 5 or 6 or 7 days and Symptom is otitis media [63] Potential limitations
revealed that 438,573 cases were reported between 1990 and 2011, We did not set out to test a specific hypothesis about the association
often with fever and other signs and symptoms of inflammation between vaccination and health. The aim of the study was to determine
and central nervous system involvement. One study [64] assessed whether the health outcomes of vaccinated children differed from
the nasopharyngeal carriage of S. pneumoniae, H. influenzae, and those of unvaccinated homeschool children, given that vaccines have
M. catarrhalis during AOM in fully immunized, partly immunized nonspecific effects on morbidity and mortality in addition to protecting
children with 0 or 1 dose of Pneumococcal Conjugate Vaccine-7 against targeted pathogens [11]. Comparisons were based on mothers
(PCV7), and historical control children from the pre-PCV-7 era, reports of pregnancy-related factors, birth histories, vaccinations,
and found an increased frequency of M. catarrhalis colonization in physician-diagnosed illnesses, medications, and the use of health
the vaccinated group compared to the partly immunized and control services. We tested the null hypothesis of no difference in outcomes
groups (76% vs. 62% and 56%, respectively). A high rate of Moraxella using chi-square tests, and then used Odds Ratios and 96% Confidence
catarrhalis colonization is associated with an increased risk of AOM [65]. Intervals to determine the strength and significance of the association.
Successful vaccination against pneumococcal infections can lead to If the effects of vaccination on health were limited to protection
replacement of the latter in the nasopharyngeal niche by nonvaccine against the targeted pathogens, as is assumed to be the case [21], no
pneumococcal serotypes and disease [66]. Vaccination with PCV-7 has difference in outcomes would be expected between the vaccinated and
a marked effect on the complete microbiota composition of the upper unvaccinated groups except for reduced rates of the targeted infectious
respiratory tract in children, going beyond shifts in the distribution diseases. However, in this homogeneous sample of 666 children there
of pneumococcal serotypes and known potential pathogens and were striking differences in diverse health outcomes between the
resulting in increased anaerobes, gram-positive bacteria and gram- groups. The vaccinated were less likely to have had chickenpox or
negative bacterial species. PCV-7 administration also correlates highly whooping cough, as expected, but more likely to have been diagnosed
with the emergence and expansion of oropharyngeal types of species. with pneumonia and ear infections as well as allergies and NDDs.

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 Mawson AR (2017) Pilot comparative study on the health of vaccinated and unvaccinated 6- to 12-year-old U.S. children

What credence can be given to the findings? This study was not vaccinated and unvaccinated homeschool children, reduced odds of
intended to be based on a representative sample of homeschool chickenpox and whooping cough were found among the vaccinated,
children but on a convenience sample of sufficient size to test for as expected, but unexpectedly increased odds were found for many
significant differences in outcomes. Homeschoolers were targeted for other physician-diagnosed conditions. Although the cross-sectional
the study because their vaccination completion rates are lower than those design of the study limits causal interpretation, the strength and
of children in the general population. In this respect our pilot survey was consistency of the findings, the apparent dose-response relationship
successful, since data were available on 261 unvaccinated children. between vaccination status and several forms of chronic illness, and
To eliminate opportunities for subjectivity or opinion in the data, the significant association between vaccination and NDDs all support
only factual information was requested and the questions involved the possibility that some aspect of the current vaccination program
memorable events such as physician-diagnosed diseases in a child. could be contributing to risks of childhood morbidity. Vaccination
With regard to minimizing potential bias in the information provided also remained significantly associated with NDD after controlling for
by mothers, all communications with the latter emphasized neutrality other factors, whereas preterm birth, long considered a major risk
regarding vaccination and vaccine safety. To minimize recall bias, factor for NDD, was not associated with NDD after controlling for
respondents were asked to use their childs vaccination records. the interaction between preterm birth and vaccination. In addition,
To enhance reliability, closed-ended questions were used and each preterm birth coupled with vaccination was associated with an apparent
set of questions had to be completed before proceeding to the next.
synergistic increase in the odds of NDD above that of vaccination
To enhance validity, parents were asked to report only physician-
alone. Nevertheless, the study findings should be interpreted with
diagnosed illnesses.
caution. First, additional research is needed to replicate the findings
Mothers reports could not be validated by clinical records because in studies with larger samples and stronger research designs. Second,
the survey was designed to be anonymous. However, self-reports about subject to replication, potentially detrimental factors associated with
significant events provide a valid proxy for official records when medical the vaccination schedule should be identified and addressed and
records and administrative data are unavailable [70]. Had mothers been underlying mechanisms better understood. Such studies are essential
asked to provide copies of their childrens medical records it would in order to optimize the impact of vaccination of childrens health.
no longer have been an anonymous study and would have resulted
in few completed questionnaires. We were advised by homeschool Competing Interests
leaders that recruitment efforts would have been unsuccessful had we
insisted on obtaining the childrens medical records as a requirement The authors declare that they have no financial interests that had
for participating in the study. any bearing on any aspect of the conduct or conclusions of the study
and the submitted manuscript.
A further potential limitation is under-ascertainment of disease in
unvaccinated children. Could the unvaccinated have artificially reduced Author contributions
rates of illness because they are seen less often by physicians and would
AM designed the study, contributed to data analysis and
therefore have been less likely to be diagnosed with a disease? The
interpretation, and drafted the paper. BR designed the study,
vaccinated were indeed more likely to have seen a doctor for a routine
contributed to data collection, and edited the paper. AB contributed to
checkup in the past 12 months (57.5% vs. 37.1%, p < 0.001; OR 2.3,
data analyses and edited the paper. BJ contributed to data analyses and
95% CI: 1.7, 3.1). Such visits usually involve vaccinations, which non-
editing. All authors read and approved the final version of the paper.
vaccinating families would be expected to refuse. However, fewer visits
to physicians would not necessarily mean that unvaccinated children Funding sources
are less likely to be seen by a physician if their condition warranted it.
In fact, since unvaccinated children were more likely to be diagnosed This study was supported by grants from Generation Rescue,
with chickenpox and whooping cough, which would have involved a Inc., and the Childrens Medical Safety Research Institute, charitable
visit to the pediatrician, differences in health outcomes are unlikely to organizations that support research on childrens health and safety.
be due to under-ascertainment. The funders had no role or influence on the design and conduct of the
research or the preparation of reports.
Strengths of the study include the unique design of the study,
involving homeschool mothers as respondents, and the relatively Acknowledgments
large sample of unvaccinated children, which made it possible to
compare health outcomes across the spectrum of vaccination coverage. The authors thank all those who contributed critical comments,
Recruitment of biological mothers as respondents also allowed us to suggestions and financial support for the project. We also thank the
test hypotheses about the role of pregnancy-related factors and birth collaborating homeschool organizations and especially the mothers
history as well as vaccination in NDD and other specific conditions. who participated in the survey.
In addition, this was a within-group study of a demographically
homogeneous population of mainly white, higher-income and college-
Disclaimer
educated homeschooling families in which the children were all 6-12 This study was approved by the Institutional Review Board of
years of age. Information was provided anonymously by biological Jackson State University and completed prior to Dr. Mawsons tenure-
mothers, obviously well-informed about their own childrens vaccination track appointment at Jackson State University.
status and health, which likely increased the validity of the reports.

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J Transl Sci, 2017 doi: 10.15761/JTS.1000186 Volume 3(3): 12-12