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Will the Disneyland measles outbreak lead to the end of non-medical exemptions to school vaccine mandates? (It should)

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Well, the ongoing multistate measles outbreak that’s been in the news for the last few weeks continues apace, which means I can’t seem to stay away from the issue for more than a couple of days. For instance, yesterday I learned that five babies at a Chicago-area day care have been diagnosed with the measles. All the babies are under a year old and therefore too young to have received the MMR vaccine yet. At this point, I’m betting that most likely the baby who brought the measles to the KinderCare Day Care with this measles outbreak got it from an older unvaccinated sibling, but time will tell if that’s true. In any case, after all the time advocates of science-based medicine and opponents of the antivaccine movement have been worrying and warning that vaccination rates have fallen perilously low in certain pockets that outbreaks have become possible, it finally seems to be happening, and it’s profoundly disturbing.

On the other hand, if there is a silver lining in this dark stormy cloud it’s that regular people (as opposed to skeptics) are finally starting to pay attention and believe that there’s a problem, so much so that people are starting to show signs of actually wanting to do something about it. More on that in a moment, but first let’s look at the magnitude of the problem, as described yesterday in USA TODAY:

Nearly one in seven public and private schools have measles vaccination rates below 90% — a rate considered inadequate to provide immunity, according to a USA TODAY analysis of immunization data in 13 states.

Hundreds of thousands of students attend schools — ranging from small, private academies in New York City to large public elementary schools outside Boston to Native American reservation schools in Idaho — where vaccination rates have dropped precipitously low, sometimes under 50%. California, Vermont, Rhode Island, Arizona, Minnesota, Florida, Illinois, North Carolina, Virginia and West Virginia also were included in the analysis.

A frequent claim made by antivaccinationists is that there’s no cause for concern because, overall, vaccine uptake is high. However, that’s vaccine uptake averaged out over entire states. As the USA TODAY analysis shows, there are lots of schools in just a 13 state sample with dangerously low MMR uptake, and that’s all that’s needed for outbreaks to begin and be sustained: Populations with MMR uptake too low to maintain herd immunity. Also:

The 13-state sample shows what many experts have long feared: People opposed to vaccinations tend to live near each other, leaving some schools dangerously vulnerable, while other schools are fully protected.

The clusters create hot spots that state immunization rates can mask. In the 32 public elementary schools in Boise, Idaho, for example, vaccination rates for measles in 2013-14 ranged from 84.5% at William Howard Taft Elementary to 100% at Adams Elementary, just 4 miles away.

Some clusters are among people who have philosophical objections to vaccines; other clusters are in poorer neighborhoods, where parents do not stay up to date with their children’s vaccinations.

What was disturbing about this survey went beyond just the finding of low MMR uptake in so many schools and that people opposed to vaccines tend to cluster. USA TODAY reports that a lot of states wouldn’t provide their reporters with school-level data, citing health privacy laws. Of course, one wonders how simply providing school-level vaccine uptake rates would violate health privacy if no student-level information is provided. More disturbing is that several states don’t even keep track of school-level vaccine uptake rates, states such as Maine, Arkansas, Alaska and Colorado. What we also know is that, although the CDC sets a federal goal of 95% of kindergarteners being vaccinated with MMR, in the 2013-2014 school year, 28 states and thousands of schools did not meet that standard.

The finding that vaccine refusers tend to cluster geographically is not a new finding. It’s a finding that has been noted in several studies over the last several years, such as a study from 2008 noting an association between the geographic clustering of nonmedical exemptions and pertussis and a 2013 study with similar findings. Just last month, a study examining children with membership in Kaiser Permanente Northern California involving 154,424 children in 13 counties with continuous membership from birth to 36 months of age also found that underimmunization and vaccine refusal cluster. Wonkblog tried to extend this analysis to all of California and showed a disturbing increase in personal belief exemptions from 2000 to 2013 leading to clusters of undervaccinated children throughout the state.

Although low socioeconomic status is associated with low vaccine uptake due to being medically underserved, by far the largest contributor to pockets of low vaccine uptake appears to be the rise of nonmedical exemptions, exemptions to school vaccine mandates that are based on either religion or “personal belief,” the latter of which, despite being portrayed as some sort of moral or philosophical opposition, basically boils down to parents saying, “I dont’ want to.” Of all the states in the US, only two, Mississippi and West Virginia, do not permit nonmedical exemptions. Twenty states allow philosophical/personal belief exemptions, as I just discussed the other day.

This is a problem that the ongoing measles outbreak might be finally prodding lawmakers to address. For example:

Gov. Jerry Brown, who preserved religious exemptions to state vaccination requirements in 2012, on Wednesday appeared open to legislation that would eliminate all but medical waivers.

The governor’s new flexibility highlighted a growing momentum toward limiting vaccination exemptions partly blamed for the state’s worst outbreak of measles since 2000 and flare-ups of whooping cough and other preventable illnesses.

California Sens. Dianne Feinstein and Barbara Boxer urged state officials to reconsider California’s vaccination policies Wednesday in a letter to Health and Human Services Secretary Diana Dooley.

Brown’s spokesman, Evan Westrup, said the governor “believes that vaccinations are profoundly important and a major public health benefit, and any bill that reaches his desk will be closely considered.”

Earlier, five lawmakers had said they would introduce legislation that would abolish all religious and other personal-beliefs exemptions for parents who do not want their children vaccinated before starting school.

Gov. Brown, unfortunately, betrayed California children a couple of years ago after the California legislature, in an attempt to make personal belief exemptions a little more difficult to obtain, passed a bill that required parents to have a health care professional (doctors, advanced practice nurses, and, unfortunately, naturopaths) provide them with informed consent about the risks of not vaccinating before signing the exemption form every year. What did Gov. Brown do? Basically, when he signed the bill, he added a signing statement instructing the California Department of Public Health to “allow for a separate religious exemption on the form” so that “people whose religious beliefs preclude vaccinations will not be required to seek a health care practitioner’s signature.” Never mind that Brown’s signing statement did not have the force of law and should have had no power to compel the Department of Public Health to add a religious exemption line to the form. Basically, in one fell swoop, Gov. Brown completely neutered the bill, an action he is still defending in the light of measles outbreaks:

The governor’s office says that since the bill took effect, those exemptions have decreased by nearly 20%, from 3.15% of children in the 2013-14 school year to 2.54% in 2014-15.

Brown was criticized by some health experts, however, for exempting parents with religious objections from meeting with a medical professional.

On Wednesday, Brown’s representatives would not directly address whether the religious exemption should be repealed or maintained, but they noted that those are claimed by only about 0.5% of kindergarten students.

Well, two can play the relative decrease game. That 0.5% of kindergarteners would be nearly one-fifth, or 20% of the remaining exemptions. So basically, Gov. Brown facilitated roughly 20% of exemptions by making it unnecessary for those parents to go through even the minimal hurdle of the law to exempt their children from school vaccine mandates. That’s hardly anything to be proud of. In any case, Gov. Brown could potentially single-handedly drive the nonmedical exemption rate 20% lower by repealing his signing statement and instructing the Department of Public Health to do what it should have been doing all along, namely his job as Governor: Enforcing the law as written and passed by the legislature.

It’s interesting that the same Governor who betrayed California children so egregiously by subverting the intent of a law passed by the legislature is now apparently signaling readiness to sign a bill that would eliminate all nonmedical exemptions in the most populous state in the nation. Meanwhile, the legislature through which this bill had to be pushed, with proponents fighting tooth and nail to keep the antivaccine-sympathetic and libertarian-leaning contingent from blocking it or watering it down is actually considering introducing such a bill.

I hope the legislature, if it considers a bill to ban nonmedical exemptions, starts out strong, because, consistent with recent bleatings from some Republicans, there are libertarian groups lining up to fight it:

Matthew B. McReynolds of the Pacific Justice Institute, a conservative Sacramento-based organization that advocates for parental rights and religious freedoms, said removing the exemptions would be an overreaction and a dismissal of legitimate concerns about vaccines by some parents.

“It’s concerning to me that the measles outbreak seems to have prompted some hysteria,” he said, “and this seems like a pretty sweeping approach to what really is a very limited problem that could be addressed in other ways.”

Really? What “other” ways?

Interestingly, Mississippi, which is one of the two states that don’t allow nonmedical exemptions, recently witnessed an attempt to permit nonmedical exemptions via a bill (HB 130) promoted by a local antivaccine group, Mississippi Parents for Vaccine Rights. It failed, the measure having been stripped from a bill designed to codify vaccine exemption policy, but it still has a pernicious component left, specifically a provision that would prevent the Health Department from denying requests for medical exemptions it doesn’t consider valid. Instead, the law stipulates that the opinion of a child’s pediatrician that certain vaccines are medically contraindicated will be final and that the school must take it. You can see why antivaccine activists want this. They can then find their very own Mississippi Dr. Jay Gordons and Dr. Bob Sears to churn out letters stating that vaccines are medically contraindicated for their children. It also allows doctors in bordering states to provide parents with such letters.

I’m guessing that the Disneyland measles outbreak couldn’t have come at a worse time for antivaccinationists in Mississippi. Here they were, having finally gotten a bill to allow personal belief exemptions seriously considered in the state legislature, and its momentum was stopped dead by a major measles outbreak. Good. Mississippi is an example of a state doing it right, and the measles outbreak elsewhere in the country, as bad as it is, at least has the salutary effect of reminding Mississippi legislators of what they are doing right. For example, in the 2013-2014 school year 99.7% of kindergarteners in Mississippi were vaccinated for measles, and only 17 medical exemptions were approved in the whole state.

It’s become increasingly clear that the time has come for the elimination of nonmedical exemptions altogether. Just getting rid of personal belief exemptions isn’t enough, and it would be unfair because the persistence of religious exemptions would privilege religious belief over nonbelief. Since no compelling interest is served by either personal belief or religious exemptions, it’s time to eliminate them. Failing that, at the very least states should track vaccine uptake and personal belief exemptions at the school level and publicly publish these data, the better to allow pro-vaccine parents to avoid schools where vaccine uptake is too low to maintain herd immunity.

Who’d have imagined that in anything I’d be urging the rest of the US to become more like Mississippi?

By Orac

Orac is the nom de blog of a humble surgeon/scientist who has an ego just big enough to delude himself that someone, somewhere might actually give a rodent's posterior about his copious verbal meanderings, but just barely small enough to admit to himself that few probably will. That surgeon is otherwise known as David Gorski.

That this particular surgeon has chosen his nom de blog based on a rather cranky and arrogant computer shaped like a clear box of blinking lights that he originally encountered when he became a fan of a 35 year old British SF television show whose special effects were renowned for their BBC/Doctor Who-style low budget look, but whose stories nonetheless resulted in some of the best, most innovative science fiction ever televised, should tell you nearly all that you need to know about Orac. (That, and the length of the preceding sentence.)

DISCLAIMER:: The various written meanderings here are the opinions of Orac and Orac alone, written on his own time. They should never be construed as representing the opinions of any other person or entity, especially Orac's cancer center, department of surgery, medical school, or university. Also note that Orac is nonpartisan; he is more than willing to criticize the statements of anyone, regardless of of political leanings, if that anyone advocates pseudoscience or quackery. Finally, medical commentary is not to be construed in any way as medical advice.

To contact Orac: [email protected]

276 replies on “Will the Disneyland measles outbreak lead to the end of non-medical exemptions to school vaccine mandates? (It should)”

Orac, did you miss this one case of measles in a daycare center in Santa Monica, California which caused 14 children to be placed in 21 days quarantine. The daycare center is now closed until further notice and school officials are proactive to prevent another major outbreak.

I think I may have covered all the bases about closure and quarantining of attendees…and added a few other comments which you and your readership might find interesting. 🙂

http://abc7.com/news/santa-monica-daycare-to-require-blood-tests-before-reopening/505419/

Need a hand in refuting an MMR point. I have a person claiming that the MMR is only effective on measles genotype A and not the B3 strain currently identified in the Disney outbreak. I suspect this is incorrect/ misleading but can not find a source to refute. Any ideas?

I’m very bothered that where I live (Arizona) clearly isn’t able to enforce it’s existing laws to track vaccination rates in schools (http://www.azcentral.com/story/news/arizona/investigations/2015/02/03/hundreds-arizona-schools-skirting-vaccination-rule/22805897/), but this was already reported for AZ as early as 2012 (http://tucson.com/news/science/health-med-fit/kids-skipping-shots-increases-threat-of-dangerous-outbreak/article_a9d00658-3365-5ba6-9cd8-0ea5e70d8d2b.html) where it was also noted that:

“Dozens more schools have rates below safe levels, but the state is keeping their names secret. The Arizona Department of Health Services refused to release complete data for schools with fewer than 20 kindergarten students because it said parents could figure out how to identify unvaccinated children.”

Now I would really like a statistician or an epidemiologist to explain to me how–for any school with even as few as 5 kindergarten students–let alone 19–that I can easily figure out who is unvaccinated, unless they all are in which case I think some publish shaming is in order.

I strongly agree–it is time to end these non-medical vaccine exemptions before the US becomes a country riddles with outbreaks of measles, mumps, whooping cough and diphtheria.

#2 Guest

This is a classic win-win gambit deployed by anti-vaccine activists:

– if the Disneyland measles virus was genotype A, it would have been a vaccine strain virus and they could claim it was caused by vaccines.

– if the Disneyland measles virus was not genotype A, they could make the claim that it is only effective against genotype A.

In reality, while there are differences between measles genotypes, there is only one measles serotype. Lab experiments and the global measles vaccine efficacy show that the vaccine is effective against all genotypes

“All vaccine strains and their wild-type progenitors are assigned to genotype A. Experiments with monoclonal antibodies have defined antigenic differences between the H proteins of genotype A vaccines and the H proteins of wild-type viruses grouped in other genotypes. However, there is only 1 serotype for measles, and serum samples from vaccinees neutralize viruses from a wide range of genotypes, albeit with different neutralization titers. More importantly, despite the presence of different endemic genotypes, vaccination programs with standard measles vaccines have been successful in every country where they were performed adequately. Suboptimal seroconversion after vaccination is likely the result of inadequate coverage; improper administration, transport, or storage of vaccine; or age of the vaccine recipients”

Rota, P. A., Brown, K., Mankertz, A., Santibanez, S., Shulga, S., Muller, C. P., . . . Featherstone, D. (2011). Global Distribution of Measles Genotypes and Measles Molecular Epidemiology. Journal of Infectious Diseases, 204(suppl 1), S514-S523. doi: 10.1093/infdis/jir118

Sorry, that reference should be

Bankamp, B., Takeda, M., Zhang, Y., Xu, W., & Rota, P. A. (2011). Genetic Characterization of Measles Vaccine Strains. Journal of Infectious Diseases, 204(suppl 1), S533-S548. doi: 10.1093/infdis/jir097

(had two papers up and exported citation from the wrong one)

On Wednesday, Brown’s representatives would not directly address whether the religious exemption should be repealed or maintained, but they noted that those are claimed by only about 0.5% of kindergarten students.

What a stupid defence of an indefensible position. If philosophical exemptions are eliminated, what do you think the speshul snowflake parents are going to get instead? It’s not as though CA will implement a sincere belief clause as NY did. Meanwhile, lawmakers will pat themselves on the back.

Why Brown is saying what he’s saying now: So he can sound sympathetic to vax-dodgers now, before signing the no-belief-exemptions bill when it gets to his desk. Brown is a fiscal conservative who has just seen $60 – $80 million vanish from the state treasury due to this outbreak. He’s also plenty more than smart enough to recognize his own errors and the steps needed to correct them.

BTW, the night the new bill was announced, I immediately wrote to the two authors of it and to my state Senator and to Gov. Brown, with appropriate messages to each.

Orac, correction, important:

You’ve got this part backward: “Since no compelling interest is served by either personal belief or religious exemptions, it’s time to eliminate them.”

The term “compelling interest” denotes “compelling state interest” in legal doctrine, and refers to the level of scrutiny needed to justify any incursion by government into individual liberty.

The lowest level of scrutiny is “rational basis,” which means “does the state have a rational basis (good-enough reasons) to regulate individual behavior in this way?” That would be used for items where the incursion into liberty is small, such as a state-wide ban on smoking in elevators. The state has an obvious rational basis, in preventing fires such as may occur with a smouldering cigarette butt dropped on the floor and going down the elevator shaft; no further explanation than that is needed.

The highest level of scrutiny is “compelling state interest,” which means, “this regulation is a strong incursion into individual liberty, does the state have a compelling (overwhelming) interest with which to justify it?” For example any law that seeks to regulate speech would have to meet that test, before it even got to the level of being tested for constitutionality in court.

Our side’s arguement is that the threat of measles, pertussis, etc., is so severe, that a mandatory vaccination law meets the “compelling state interest” level of scrutiny. It’s the state that has to argue that a law or regulation meets the “compelling state interest” test.

The individual who seeks an exemption does _not_ have to make the case that _they_ have a “compelling interest” in _not_ getting (themselves or their kids) vaccinated. They already have a presumed general liberty interest in doing whatever they darn well please including sneezing germs all over the place: the state’s arguement has to overcome that, by demonstrating that the state has a compelling interest (such as preventing outbreaks of dangerous diseases) in mandatory vaccination.

Not to play Mr. Editor, but your sentence should read something like this: “California has a compelling state interest in preventing dangerous disease outbreaks, that overcomes personal belief or religious exemptions, so it’s time to eliminate them.”

BTW, last I heard, the nationwide case count is up to 152.

Chris @3: If a school has fewer than 20 kindergarteners, it’s probably in a small town. Most small towns have busybodies and gossip mongers who can keep track of such things. It may be as simple as the nurse at the local doctor’s office mentioning, over coffee at the local diner on various dates, that Johnny, Mike, Katy, and Sally have had their shots, so if the school has five kindergarteners and an 80% vaccination rate, then it must be Mary who didn’t get her shots. Or more likely, everybody knows that Mary’s mom and dad are “skeptical” about vaccines, so of course they know that when the school reports an 80% vaccination rate that Mary didn’t get her shots and everybody else did.

Maybe the Arizona Department of Health is being overcautious in setting the threshold at 20, but there is a valid concern here.

FWIW, I live in a small town, but not that small–the two elementary schools in this three-town school district typically have 80-100 kindergarteners each. It’s still small enough that news of this kind travels fast around town.

Instead, the law stipulates that the opinion of a child’s pediatrician that certain vaccines are medically contraindicated will be final and that the school must take it. You can see why antivaccine activists want this.

Ah, but you’re not as insightful as the happily departed Gerg, who “explains” at AoA that this was simply a misstep by “the elites,” who of course don’t actually vaccinate, in their effort to tailor their privilege.

It’s still small enough that news of this kind travels fast around town.

You say that as if it is a bad thing. If legislation isn’t effective, try the court of public opinion.

What’s showing up locally about the Chicago outbreak is “they got it from a recently vaccinated child who is viral shedding!” and pointing to the baby who became sick after her MMR in Baltimore as proof.

That and the old “108 deaths from MMR” canard.

New AV nonsense:

MMR is only effective on measles genotype A and not the B3 strain

I think I’m kind of au courant with antiv-accine nonsense and myths, but this is a new one on me. I started seeing it on..oh, Monday? and now it is all over. I am curious as who started this one.

In any case:

“There is only one antigenic type of measles virus. Although studies have documented changes in the H glycoprotein, these changes do not appear to be epidemiologically important (i.e., no change in vaccine efficacy has been observed).”

http://www.cdc.gov/vaccines/pubs/pinkbook/meas.html

Science Mom also has a good explanation — next slide pleae.

Orac, don’t sit on the fence like that. Tell us how you really feel about pedantry.

/not serious

Topically, my Google-fu is failing me, and I couldn’t track it down on Facebook, but I recall someone sharing an article suggesting that the answer to anti-vaccine parents was not to eliminate exemptions or otherwise cut down on un-/under-vaccination (because FREEEEEDOMMMMM!!!), but instead to deny publicly-funded health services to delinquent families. (Or something to that effect; my memory’s a little hazy and as I noted above I haven’t been able to track down the article to confirm.)

Suffice to say, this strikes me as a rather bad idea. Affluent anti-vaccine parents aren’t likely to feel the pinch. You know who will? People in poverty who aren’t necessarily anti-vaccine but have a hard time finding the money or time to get their children to doctors’ appointments for immunizations.

Punishing the poor for the sins of the wealthy. Really classy stuff.

Science Mom, responding to the “why the measles vaccine is protective against all measles genotypes question:

….’s complicated. The vaccine strain is A but is cross protective for all the other strains. What is most important is that the epitopes of the different strains are relatively conserved. What that means is the areas of the virus which actually attach to our cell surfaces are similar enough so that a vaccine for one strain will protect us from others.

Since the advent of molecular techniques and molecular epidemiology, we are able to get entire gene sequences for these organisms. This has allowed us to see where the strain differences occur and where they are circulating. It’s also a good idea to watch for significant mutations which could lead to lowered vaccine protection. But that is not the case here. It’s as it has been and that is the majority of cases are unvaccinated.

In that comment stream she also links to several papers.

Where does this “108 deaths from MMR” nonsense come from? Are they pulling that from VAERS?

There are already a couple of petitions on White House (dot) gov asking for no religious or personal belief exemptions, so I won’t reinvent the wheel and create another one. However, I’d like to petition POTUS and the Congress to pass legislation (or sign an Executive Order) mandating immunizations for all federal employees, all children attending daycare that is paid for with federal dollars, and all college students receiving federal financial aid. Only medical exemptions will be allowed through an affidavit by a licensed healthcare provider.
Enough is enough with this stupidity. Thousands of dollars are being wasted on these outbreaks (measles, mumps, whooping cough, influenza) when they could be used for other things. If anti-vaccine people don’t want to vaccinate, fine. But they are not allowed to smooch off the rest of us anymore. No public schools. No college financial aid. No good-paying federal jobs.
Who’s with me?

I’m getting tired of this canard that recently vaccinated children are “shedding” measles. I’ve been unable to find a reference to even one case where an asymptomatic recently vaccinated child infected another child with vaccine-strain measles.

Rebecca: of course that’s where it’s coming from. Don’t you know that every report in VAERS is conclusive evidence of causation?

No good-paying federal jobs.
Who’s with me?

Sounds fair. I’d love to watch some GS-14 line up in front of the corpsmen for shots.

Yes, the “108 deaths from MMR” is drawn from VAERS. I have also seen people quoting one or more reports from the National Vaccine Injury Compensation Program Statistical Report (the most recent is February 2); since the start of the program in 1988, there have been:

19 death claims filed for the measles vaccine alone;
57 death claims filed for the MMR
1 death claims filed for the MMRV

One reading-comprehension-impaired meme I saw said that the death claims were for just one month.

108 dead, but what about all the little Hulks and Wonder Women running around since they got their vaccines? Won’t somebody please think of the children?

Back in 2012, then Representative Richard Pan MD sponsored legislation in California, AB2109, which strengthened California’s ridiculously lax vaccine exemption laws. Our host covered it in detail, which you can read by clicking on the link above.

Pan moved on to the California Senate; he is now sponsoring a bill that would remove the Personal Belief Exemption entirely. The bill isn’t yet available electronically; I will keep you up to date.

@Eric #10–there’s a bigger issue of public health and safety for the child who needs to be in a school with high vaccination rates here. You mention and I agree that most electively non vaccinating parents seemed rather proud of their brilliance and like to tell everybody how they’ve chosen not to vaccinate. I disagree with health departments worrying about parents figuring this out. If health departments are not deliberately trying to identify the non vaccinating students, then they shouldn’t be liable for any breach of confidentiality if people figure it out from the data. what I have noticed in Arizona with a notification from the health department about whooping cough in schools is that the official notice will say that a child in your child’s school has whooping cough. They refuse to further delineate what grade or classroom that child is in. I find this inexcusable as if you are in the same classroom with that child for 8 hours and they’ve been coughing the whole time you’re at least is exposed as immediate family members are at their home. But for other infections such as a strep throat, the school will send home a note only for the children in the classroom of the child with strap and then it will specifically say that a child in your child’s classroom has strep. I’m really tired of public health departments bending over backwards to try and accommodate the confidentiality of electively non vaccinating parents when there is no law anywhere that says they have to be this accommodating.

Predictably, Bob Sears went ballistic.

https://www.facebook.com/permalink.php?story_fbid=843560165682469&id=116317855073374

DR. BOB’S DAILY:
FORCED VACCINATIONS FOR CALIFORNIANS ARE ON THEIR WAY
I never thought I’d see the day. Maybe I was naive. Maybe I was too optimistic. But California Senators Pan and Allen are introducing legislation that will further restrict a parent’s choice. We can thank Pan for last year’s Personal Belief Exemption form requiring a doctor’s signature, but at least that still put the choice in the hands of parents.

These Senators are taking advantage of the measles hysteria to push an agenda which violates the long-established and sacred value of informed consent and a parent’s right to make all health care decisions for their child. The measles “epidemic” is already on the decline, and will soon die out as they all do. AND THEY KNOW IT. Yet, many in the media and the government continue to stir up panic and hysteria and falsely make it looks as if measles is continuing to escalate and the ONLY solution is forced vaccination. Talk about misinformation.

What puts Californians at risk is that we have a Democratic majority in our state senate. Last year’s PBE law was voted very clearly along party lines – Republicans tried to fight it. Now, our rights will be taken away by the Democratic majority, and any Republican who tries to fight it will be labeled as anti-vaccine. So, we are screwed.

In the months to come, I will post ways you can contact your California senators and representatives. I won’t clog the “Daily” with too much of it. But this is important. Never thought I’d see the day. If this law passes, it will, of course, only apply to public school education. Yet, many private schools will follow suit. Perhaps some private schools will remain a haven for some families who want a choice. And home-schooling rates will probably fly through the roof.

More to come. For now, make some calls to your senators.
Dr. Bob

I sincerely hope advocates for public health learned effective strategies and tactics from the AB 2109 fight, and this bill will go through.

Sear’s isn’t uspet about parents losing their right to make all health care decisions for their child–they won’t–he’s upset that choosing to exercise that right will no longer consequence free.

If Pan’s bill passes parents will still be able to decline having their kids vaccinated: those kids simply will no longer be eligible for enrollment in public schools. No one’s going to break down the door and ‘forcibly’ innoculate them.

Sear’s isn’t uspet about parents losing their right to make all health care decisions for their child–they won’t–he’s upset that choosing to exercise that right will no longer consequence free.

Pan moved on to the California Senate; he is now sponsoring a bill that would remove the Personal Belief Exemption entirely.

And he has signaled that he’s willing to consider retaining a religious exemption.

How can someone support a “religious exemption” when no major religion (and the vast majority of minor ones) have no issue with vaccines?

@Lawrence:

If you’re a politician, coming off as anti-religious-freedom (even if you definitely are not) doesn’t do wonders for your PR machine. Sadly, most politicians are more interested in their poll numbers than in actually making good policy.

(You’re right – I can’t think of a religion off the top of my head which categorically refuses vaccines. Jehovah’s Witnesses haven’t been anti-vaccine since the 1960s, though you’ll still find some anti-vaxxers among them. Heck, even Christian Scientists aren’t anti-vaccine anymore. I wonder about Scientology?)

Right from donkey’s mouth:
(from Bob Sears, via Liz Ditz #28)

What puts Californians at risk is that we have a Democratic majority in our state senate. Last year’s PBE law was voted very clearly along party lines – Republicans tried to fight it.

So much for antivax beliefs being the apanage of leftish hippies…

How can someone support a “religious exemption” when no major religion (and the vast majority of minor ones) have no issue with vaccines?

As has been discussed ad nauseam, the state doesn’t rule on orthodoxy. It’s quite straightforward for a Catholic to obtain a religious exemption in New York State to vaccines propagated on MRC-5 and WI-38, for example.

If I were a politician, I would preface pro-vaccine statements with “As my friend the Archbishop remarked the other day…”

Orac: “On the other hand, if there is a silver lining in this dark stormy cloud it’s that regular people (as opposed to skeptics) are finally starting to pay attention and believe that there’s a problem, so much so that people are starting to show signs of actually wanting to do something about it.”

Unusually for Orac, this is optimistic. And wrong. Americans like the measles now, and don’t care if other kids get sick or die. Heck, most of the anti-vaxxers will cheerfully sacrifice their own kids. Although, as I said, I wonder how many of those kids would end up in the CPS system if they became disabled from measles. Imperfection is one thing those families can’t tolerate. And most of the public is just too stupid to think that disease is a bad thing.

@ KayMarie:

My thoughts exactly:
if his more middle-class clients have to pay for non-governmentally sponsored schools, they may not have enough to pay him out-of-pocket.

-btw-
AoA is linking to Democracy Now’s presentation which features Paul Offit, Dorit Reiss and Mary Holland.

PRN will post Holland’s response to Offit ( Gary Null Show today) later; with Tenpenny. ( Non-existent) lord almighty! I think desperation is not attractive,even over the internet air

.

Eric @10 — Chris Hickie followed up on this aspect already, but the medical confidentiality law (HIPAA) is very strict; it’s unlikely that a school nurse would even say casually that Johnny and Mikey had their shots already. I have a close associate who’s a health care professional, and I never hear a word about any of her patients except with all identifying details removed.

So there’s even less reason why states should withhold aggregate data. If the system works, this kind of inference should be impossible.

Melanie’ Marvelous Measles, according to an article at Salon is getting a well-deserved pounding in reviews at Amazon. The comments I read at Salon are uniformly hammering anti-vaxers.

Apologies if someone has commented on this previously.

The measles “epidemic” is already on the decline, and will soon die out as they all do. AND THEY KNOW IT. Yet, many in the media and the government continue to stir up panic and hysteria and falsely make it looks as if measles is continuing to escalate and the ONLY solution is forced vaccination. Talk about misinformation.

The only misinformation is from Bobo himself. The number of cases is over 150 which has increased from the 100 cases earlier this week. Furthermore, a passel of babies too young for vaccination have been infected. If only Bobo wasn’t so innumerate. And there is no forced vaccination being discussed, only in Bobo’s fevered, drama-queen head. It’s mandatory vaccination for public school but even as he suggested, there should be plenty of private schools to accommodate all the speshul snowflakes and their super above-average, privileged parental units.

Chris @27: I understand your reluctance to protect anti-vaxers to an extent beyond what the law appears to require. But keep in mind that some kids have medical contraindications to vaccines. Consider this variation in the small-town kindergarden class: Everybody in town knows that Mary has some kind of medical issue (though, because of HIPAA, only her parents, doctors, nurses, and possibly her siblings know exactly what it is). They don’t necessarily know that as a consequence, Mary can’t get the MMR vaccine. Until, that is, the school reports an 80% vaccination rate, and it’s obvious that Mary didn’t get the vaccine.

The point is that because of how HIPAA is worded, the health department has to take the small town rumor mill into account. If anybody can figure out from publicly available information that Mary (or any other specific child) is not vaccinated, than some piece of that information should not have been public. If somebody can figure it out without directly asking Mary or her parents and getting an answer from them, HIPAA does not allow it, no matter how they figured it out. A similar issue has arisen with state legislation that would require abortion providers to identify (among other info) the county of residence of their patients: it conflicts with HIPAA because somebody back in Overshoe County can correlate Jane Smith’s trip to Big City with the fact that a clinic in Big City performed an abortion on somebody from Overshoe County that day.

@NH

“I’m getting tired of this canard that recently vaccinated children are “shedding” measles.”

Not only do they shed, the shedding children can now give autism to unvaccinated children! From Mothering today (one of these days I need to stop lurking and actually comment there) :

“My concern is my own children being exposed to the shedding from their live-virus vaccinations. I’ve known people firsthand whose unvaxed, typical children regressed into autism after being exposed to another child’s shedding of live virus vaccinations.”

She later expands:

“Older brother got the vax, took a bath with young toddler sister, sister got sick, regressed and is fairly severely on the spectrum – and it was hard to deny it was the vax – it happened so quickly. This family (the mom) works at the office of a local DAN doctor.”

And there are actually people agreeing with her on the rational that illnesses can trigger autism and vaccinated children can shed the vaccine causing illness!

http://www.mothering.com/forum/47-vaccinations/1482290-do-you-worry-about-your-kids-being-exposed-shedding.html

The new link being spread around by those who are anti-vaccine is this one http://www.ncbi.nlm.nih.gov/pubmed/11858860

“Detection of measles vaccine in the throat of a vaccinated child.”

Apparently this is sufficient evidence to show that vaccinated children are constantly shedding measles germs to other children.

@Ren

Federal legislation that requires vaccinations for students or kids at day care receiving Federal dollars might run into challenges under states’ rights arguments. I’d agree that requiring them for Federal employees, however, could work.

Re: Dr. Bob

I would wager that forced disarmament of children attending schools is not something he would argue against, even though the right to bear arms is written into the Constitution. So why isn’t Dr. Bob arguing against laws and regulations that prohibit kids from bringing guns and knives to schools?

But the absurdity of his free-dumb argument aside, remember: school is a privilege, not a right. Privileges come with responsibilities. If you do not want to uphold those responsibilities, then you do not get the privilege.

It comes down to Rights & Responsibilities…..

If a parent has an exemption for their child, they also agree that they will abide by the terms of that exemption – which means that they agree to keep their child out of school in the case of an outbreak.

They really don’t have recourse – since they signed the form.

I cannot imagine any exemption (including a genuine medical exemption) which does not explain to the parent(s) that their child(ren) will be barred from attending school, in the event of a measles outbreak.

Let’s face it, these selfish parents who opt for a personal belief exemption or a religious exemption, and who are quite willing to expose other children, lack a moral compass and lack empathy.

One other good thing about this measles outbreak is that many people are taking serious steps to counter the anti-vaccine message. For example, see this article:

http://www.cbc.ca/asithappens/features/2015/02/05/doctor-says-he-reported-queens-anti-vaccine-teaching-three-years-ago/

Three years ago, a doctor reported an adjunct professor of kinesiology who was promoting anti-vaccine messages in her course, Nothing was done. But now, when students at Queens reported this instructor, the university has sat up and taken notice.

You can tell for sure she’s a hard-core antivaxer – one of her slides links to the infamous Wakefield-CDC Whistleblower-Tuskegee experiment video, and states that it will be on the test!

I should have also stated that the youngsters with real medical exemptions, are punished because they are being punished because of their medical conditions.

There is no nurse and no school nurse who would ever identify an unvaccinated child, because they, like doctors, are devoted to the principles of patient confidentiality.

For any policy wonks out there willing to opine, I have a couple questions about a subject about which I know little…
Could private insurance companies stipulate in their insurance plans that they will not cover hospitalizations related to vaccine-preventable illnesses in unvaccinated patients lacking medical exemption? Is there a legal barrier here – religious discrimination, etc.? There have been several suggestions on the boards here regarding how to motivate vaccination apart from tightening school exemptions, screening Disneyland admissions, and of course, general public shaming…er, I mean educating. The valid concern of course is always that any financial penalties would disproportionately affect low income patients. If it were solely private insurers stipulating this and not, say, Medicaid, this would partially alleviate concerns about low income family impact perhaps?
Anyway, if insurers dump Snowflake’s parents with the constant risk of the $30K hospital bill, they may be inclined to vaccinate purely as a financial decision, or at least, keep their kids out of school by choice during outbreaks. On one hand, it seems like private insurers would have a financial incentive to do something like this. But I suppose such a policy would risk driving away the affluent SoCal populations that are otherwise statistically healthy, as well as reliable high premium payers.

Hmmm that was an awkward statement:

^ “I should have also stated that the youngsters with real medical exemptions, are punished because they are being denied access to their school programs.

What are the prospects for containing the measles outbreak?
Yes, it’s good to see so much pro-vaccination sentiment. The people who do get their children have been pretty quiet compared to anti-vaxxers – but now they’re speaking up.

@Ren #20:

mandating immunizations for all federal employees, all children attending daycare that is paid for with federal dollars, and all college students receiving federal financial aid. Only medical exemptions will be allowed through an affidavit by a licensed healthcare provider.

But…but…but that’s the same as dragging them off to the FEMA camps!

@Liz Ditz #29:

We can thank Pan for last year’s Personal Belief Exemption form requiring a doctor’s signature

Pan?! Oh, wait, the senator. not the Greek god of fear and terror. OK. That’s alright then. No irrational fear involved.

@Laura

It’s tough. Schools and day cares would have to proactively keep out unvaccinated kids, really, rather than waiting for one to show symptoms. Vaccination right now will help, but people need to remember that there is a lag time between vaccination and when immunity is developed. For MMR, I think that’s somewhere around a few days. Also, if kids are completely unvaccinated, there’s that minimum window of 4 weeks between shots to ensure maximum efficacy from the second dose.

Found it in the wild; have screenshot:

From a fact-challenged anti-vaccination activist who has been featured in this blog

There are 24 different measles genotypes or strains. The CDC finally did molecular characterization to determine the genotype implicated in the Disney outbreak, labeled “B3.”
MMR only targets “A.”
MMR is utterly USELESS and does absolutely NOTHING for the 23 other strains.
This REFUTES the following:
1. Unvaccinated children are spreading measles
2. Everyone needs to be vaccinated
3. The measles vaccine protects against measles
4. They will make more to sell

We need a vaccine against stupidity.

Why yes, lady, we do. The kind of stupidity you are exhibiting.

I’ve had acquaintances and friends make comments about how vaccinated people can get and spread measles, too – m essence trying to suggest it’s not necessarily the fault of the unvaxed. While it is correct, I believe, that the MMR is not quite 100% effective for measles, but pretty dang close, it’s still the unvaccinated that fuel the flame of an outbreak, right? In a perfect world, if the only people that were NOT vaccinated were those who couldn’t for valid medical reasons, then the occurrence of measles infections would be small – am I understanding that correctly?

This is a really common defense I’m seeing from those who downplay the outbreak and I want to make sure I can refute it plainly and accurately!

Laura, you are fortunate to have a New York residence, which aside from the two States (Mississippi and West Virginia), which only have valid medical contraindications, has a restrictive “sincerely held religious belief exemption”. There are relatively few parents who are able to meet the courts’ burden of proof that they have “sincerely held religious beliefs”.

Here’s Dr. Jay Gordon’s first comment on a recent Science Based Medicine blog:

http://www.sciencebasedmedicine.org/appeal-to-brady-bunch-vaccine-fallacy/#comment-335482

Scroll down to see the additional comments from Dr. Jay, where he is on record stating:

– His “opinions about vaccines” are NOT evidence-based.

– He bases his ignorant “opinions” on the anecdotal stories he hears from his vaccine-phobic parents.

– He brags that he “administered 35 MMR vaccines in one day, which is more than the total number of MMR vaccines which (he) administered during all of 2014”.

See the many comments from other posters which inform the reader that Dr. Jay is listed on Dr. Bob Sears’ “Vaccine Friendly Doctors” list…code for pediatricians who do not adhere to the American Academy of Pediatrics “Standards of Care” for timely and complete vaccinations, according to the CDC/AAP Recommended Childhood Vaccine Schedule.

Dr. Gordon likes to think his comments are “civil”; they are not when he devolved into insulting comments, directed at me.

Dr. Gordon will never, ever admit he was mistaken about the availability of the varicella vaccine under a “compassionate use protocol” for children who were undergoing cancer treatment, circa late 1970s…while the vaccine was still undergoing clinical trials in Japan where the vaccine was developed. Not only was he mistaken with that statement, Dr. Jay refuses to acknowledge that children who are undergoing cancer treatment are still not eligible for the live attenuated varicella or live attenuated measles vaccine. (See page 2, Section 8):

http://www.immunize.org/catg.d/p4060.pdf

Jessica:

As far as I can see you are understanding it correctly.

A single case of measles in an unprotected population is expected to cause 12-18 other cases (the measles basic reproduction number, IIRC).

But, again IIRC, 2 doses of measles vaccine provides 99% immunity in a population. So in a fully vaccinated population, a single case of measles will spread to only 1 out of every hundred people.

So yes, in a perfect world, measles transmission would occur at a very low rate. (So low, that in fact if a sustained global campaign to vaccinate occurred, we would eventually wipe out measles, as we managed with smallpox.)

You can see that from the CDC’s graph of reported measles cases from 2001. The CDC remarks on each year in which the number of cases exceeds 100. Most of them appear to be fuelled by unvaccinated populations, whether in the US or elsewhere in the world (and then brought to the US courtesy of modern travel).

To elaborate a bit on my above post, it’s clear, then, that even the slowly-faltering rate of MMR uptake in the US is sufficiently high that special circumstances were required (e.g. measles hitting a large pocket of unvaccinated Amish in 2014) for measles to even breach 100 cases in any given year this century!

Quite the contrast with years past.

All the more reason, then, to prevent further decline in MMR vaccination.

Incidentally, while trying to look up the nature of the Disneyland cases (i.e. proportion of vaccinated vs. unvaccinated people infected), I did this Google search.

While, unfortunately, vaxtruth and the National Vaccine MisInformation Center came up on the first page, so did this very post – ahead of them, no less!

Not sure if that’s meaningful or not, but it might be a good sign.

Composer99: The measles outbreak (384 confirmed measles cases), in Ohio which was caused by some unvaccinated Amish people traveling to the Philippines where they contracted measles and returned home to infect other unvaccinated people in their rather closed society, was (relatively) easy to contain.

The Amish people who were exposed to the “index cases” were quite amenable to receiving MMR vaccine to contain, then stop the outbreak:

http://www.odh.ohio.gov/features/odhfeatures/Measles%202014.aspx

This current measles outbreak is far more difficult to contain/stop because it has resulted in confirmed measles cases in multiple States…and because we are dealing with some hardcore anti-vaccine parents.

In other words, what is the risk of measles becoming endemic again in the USA?
From http://abcnews.go.com/Health/measles-return-permanently-us/story?id=28699739
“Measles was declared “eliminated” from the U.S. 15 years ago by the U.S. Centers for Disease Control and Prevention but recent outbreaks have health experts concerned that the disease could make a more permanent return to the U.S. if vaccination rates fall.
Dr. Stephen Morse, an infectious disease expert at Columbia University Mailman School of Public Health, said for measles to become permanent — that is, become “endemic” — again to the U.S., measles immunizations would have to drop below 90 percent.
“It is highly contagious,” Morse said of measles, noting that every infected person could infect another 10 to 20 non-immune people. “You could have sporadic cases anytime [immunization levels] fall below something that approaches 90 to 95 percent.”

Also in this story: someone with measles got onto an Amtrak train from NYC to Albany.
Ithaca has lots of anti-vaxxers.

re #34

How can someone support a “religious exemption” when no major religion (and the vast majority of minor ones) have no issue with vaccines?

Depends:
If it’s a “sincerely held religious belief exemption”., you support it BECAUSE no major religions have issues with vaccines. Thus, you can pass a nicely restrictive exemption policy while seeming ‘moderate’ ‘reasonable’, and not pissing off powerful lobbies.

If it’s an easy-to-get, undocumented religious belief exemption. you support it so you can appear pro-vax enough to fool enough people and still dogwhistle the “sacred value of ia parent’s right to make all health care decisions for their child.” crowd. Dr. Bob’s not stupid, here. His words are very carefully chosen to appeal to both the Christian Conservatives AND the Tea Baggers. As Rachel Maddow pointed out last night, these constituencies often don’t see eye to eye, and ‘vaccine freedom’ is a symbolic issue that can unite them. By “symbolic”, I mean it’s symbolic to these groups as they don’t care about vaccine policy or public health, don’t really believe vaccines cause harm, etc. Of course it’s a very real issue if you’re immunocompromised, but these folks could care less about you.

Here is a link to an article from the San Jose Mercury News on religion and vaccines:http://www.mercurynews.com/science/ci_27437392/why-religions-dont-oppose-vaccines
Note that it points out that even christian science does not forbid vaccines “Christian Science: There are some faith-healing groups — of which the Church of Christ, Scientist (Christian Science) is the most prominent — that believe prayer can heal, making vaccines unnecessary. But the church does not oppose vaccinations.”
the article goes thru a long list of major religions. It notes again that the Amish religion does not prohibt vaccines, its only the opinion of some members, so it appears in both cases the organized bodies are more open than many members.
It seems that only fringe groups take a position as an organized religious body against religion. Interestingly articles have pointed out that the elites tend to be more against vaccines than the masses.

@Todd

“Federal legislation that requires vaccinations for students or kids at day care receiving Federal dollars might run into challenges under states’ rights arguments. I’d agree that requiring them for Federal employees, however, could work.”

The federal government has been quite successful at getting states to go along with things like blood alcohol levels and speed limits if highway improvement money is withheld. I see a similar situation with medicaid money: require universal vaccination (with exemptions for medical reasons, of course) or lose medicaid cash.

I’ve had acquaintances and friends make comments about how vaccinated people can get and spread measles, too – m essence trying to suggest it’s not necessarily the fault of the unvaxed.

This tends to hinge on one of three items:

1. The frankly absurd notion of contagious vaccine “shedding.” This will typically be accompanied by frantic waving at PMID 20822734.

2. Transmissible measles disease due to vaccination, which has but a single, inadequately documented exemplar in known history (PMIDs 2563426, 2563820). Measles disease itself due to vaccination in the immunocompetent barely has a leg to stand on (see, e.g., here and following).

Trying to rely upon the immunocompromised doesn’t hold water, either (e.g., PMID 23531102).

3. Transmission due to secondary vaccine failure, of which the use of the phrase “Measles Mary” is pathognomic. This is a reference to PMID 24585562 and is usually conflated with other NYC outbreaks because the dimwits trotting it out can’t be bothered to so much as read the title. There were zero tertiary cases. In fact, the reason it made scientific news is because there were four secondary cases (one immunocompromised, IIRC) out of over 100 contacts.

It’s desperate failure writ large.

Thanks, Composer! I’m glad I had it mostly right, it means it’s becoming ingrained!

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