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


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?