Who knew? Tightening up requirements for waivers for school vaccine requirements increases vaccine uptake! (Part two)

Well, it’s finally done.

The grants that have been taking up so much of my time are finally with the grants office and, hopefully, won’t have too many errors flagged as they go through the validation process. So it’s time to get back into that blogging thing again, even though I’m admittedly tired. So I’ll start out slow. No Orac-ian epics today, just another rather satisfying bit of news mirroring a previous post that I did last week about how making it more difficult to obtain personal belief exemptions to school vaccine requirements works. In states where PBEs are difficult to obtain or not permitted vaccine uptake rates are high or higher.

I saw this gratifying outcome in my very own state, where as of January 1, 2015, the Michigan Department of Community Health issued a new rule that required parents seeking PBEs for their children to go to the local health department office and be educated by a local health worker about vaccines and the diseases they are intended to prevent, after which they would be required to sign the universal state form that includes an explicit statement of acknowledgement that parents understand they may be putting their own children and others at risk by refusing the shots. Initial data from 2015 suggest that this tightening of vaccine waiver rules has had an effect. Vaccine waiver rates fell from 4.6% in 2014 to 2.8% in 2015. Of course, Michigan being Michigan, there are wingnuts in our legislature who want to reverse that in the name of “freedom.” Or should I say, “Freedumb!”?

California is another experiment in what happens when vaccine exemptions are made more difficult to receive, but a more extreme example. Like Michigan, California had a problem with areas where vaccine exemption rates were high and, as a consequence, were prone to outbreaks of vaccine-preventable diseases. About a year ago, there was an outbreak that got worldwide news attention centered at—where else?—Disneyland that finally spurred lawmakers to act. Introduced by Sens. Richard Pan and Ben Allen, passed by the California legislature after much controversy (and no shortage of rhetoric likening it to Nazi genocide of the Jews), and signed into law by Governor Jerry Brown in July, basically eliminates nonmedical exemptions to school vaccine mandates as of the 2016-2017 school year.

Already, it seems to be working. At least, initial numbers suggest this is the case:

California’s new, more stringent law on childhood vaccinations, SB 277, doesn’t fully kick in until July 1. But it started protecting the public months ago when parents heard from schools and doctors that they would no longer be able to claim a “personal belief exemption” from immunizations if they wanted to enroll their children.

The proof is in the numbers. The percentage of fully vaccinated kindergartners entering the state’s schools in 2015-2016 was the highest in a decade: 92.9%, up from 90.4% last year. State health officials say the measles outbreak at Disneyland a year ago might have scared a few parents off the vaccination fence, but SB 277, combined with another bill from 2012 that required parents to talk to a pediatrician before obtaining an exemption, had more to do with it.

The law from 2012 referred to in this article is California AB 2109, a law upon which the Michigan Department of Community Medicine based its rule change on. Michigan actually improved upon it. The California law allowed parents to receive counseling from any physician and some other health care professionals, like nurse practitioners. The Michigan rule, in contrast, requires that parents receive their counseling from the health department. Thus, in California, parents seeking PBEs were free to seek out woo-friendly and anti-vaccine friendly physicians for their “counseling,” while in Michigan parents seeking PBEs receive the same standardized information from a script and must sign a statement explicitly acknowledging that they are potentially endangering their children.

What these numbers suggest is that a significant part of the problem with unvaccinated children comes not from parents who are truly antivaccine (although certainly they are a major problem) but from sheer human nature. In California, for instance, it was much easier just to sign a vaccine waiver than to have one’s children fully vaccinated or to sign the waiver with a promise to finish vaccinating:

The vaccination rebound validates the suspicion that the falling rates were caused in part by procrastination, not politics. Schools encouraged an increase in partially immunized students by allowing parents to sign a form promising they would finish the vaccinations, but the promise wasn’t well enforced. This year, the percentage of such enrollees dropped by the same amount the overall immunization rate increased.

When one option is much easier than another, even though it’s the wrong option, there will always be some who will choose the easier option. It’s human nature. Rules like the one now enforced in Michigan seek to make the effort required to obtain vaccine waivers closer to the level of effort required to have one’s children vaccinated, and it’s working. It appears to be working in California as well. However, what will be far more interesting is to see the effect of SB 277 next year, after the law has fully kicked in and only medical exemptions are required. Already antivaccine pediatricians like Dr. Bob Sears are preparing for an influx of business to sell medical exemptions, but it’s likely that the effects of this will be small. Fortunately, there aren’t many pediatricians like Sears.

None of this should come as a surprise. As far back as 2006, I was discussing research that showed that ease of obtaining vaccine exemptions correlated—of course!—with increased vaccine exemption rates, which correlated with higher incidences of pertussis. Basically pertussis was returning in states with lax vaccine laws. Experience since then has validated that observation. More recently, a systematic review of studies of state vaccine exemption laws and vaccine exemption rates concluded that vaccine exemption rates have been increasing and tend to occur in clusters. It also concluded that easier state-level exemption procedures are correlated with increased exemption rates and increase the risk of vaccine-preventable diseases.

None of what is happening in Michigan and California is a surprise. Unfortunately, in today’s political climate the widespread adoption of SB 277-like bans on nonmedical exemptions to school vaccine mandates is highly unlikely. This is particularly true since right wing “freedom” warriors have conflated personal freedom with “health freedom” and the freedom to refuse vaccines, even leading Presidential candidates like Donald Trump, Rand Paul (who has suspended his campaign), and Ben Carson to pander to this view. Actually, neither Trump nor Paul are pandering. They appear to really believe antivaccine views. “Freedom” and “parental rights” have become antivaccine dog whistles.

In an ideal world, PBEs would not be permitted. That’s not likely to happen any time soon in the current political climate. (Witness the nastiness that happened in California as SB 277 moved towards passage.) However, the Michigan experience suggests that a smart “middle way” requiring parents to visit the health department for a counseling session and to sign a form explicitly acknowledging that they are endangering their children might do almost as much good.