The American Academy of Pediatrics gets hard core on vaccine exemptions—finally

It’s hard for me to believe that it’s been approximately 16 years since I first discovered that there was such a thing as antivaccinationists. Think of it this way. I was around 37 or so when, while wandering around Usenet (remember Usenet?), I found the newsgroup misc.health.alternative (or m.h.a. for short), a discussion group about, appropriately enough, alternative medicine. It was there that I first encountered the claim that vaccines cause autism, sudden infant death syndrome, autoimmune diseases, and a panoply of just about every chronic disease known to humankind. Much like when I had first discovered Holocaust denial a couple of years before that, I was floored that such beliefs existed. Given the evidence, I couldn’t believe that there were people out there who thought vaccines were harmful.

The more I engaged with the antivaccine fringe on m.h.a, the more I came to realized just how far off the deep end many antivaccinationists are and just how full of conspiracy theories. By the time I started my blog in December 2004, I had become pretty well-versed in antivaccine misinformation and tropes and how to combat them. Then, in June 2005, I wrote my first big refutation to a major antivaccine article by Robert F. Kennedy, Jr in—to their eternal shame—Salon.com and Rolling Stone, and my course was set. Dealing with antivaccine pseudoscience became one of the most common topics on this blog and has remained so ever since. Unfortunately, over the years, the antivaccine movement didn’t go away. It got louder and better at social medial, which is why in comparison I often feel that skeptics are outgunned, even though we have science on our side.

My thinking on what the best policy is to ensure maximal vaccine uptake and therefore maximal protection of children from vaccine-preventable diseases, as well as protection of children who can’t be vaccinated for medical reasons, which brings me to the American Academy of Pediatrics (AAP) position paper on vaccine hesitancy and refusal, published about a week ago in Pediatrics. In this paper, the AAP advocates eliminating nonmedical exemptions to vaccine mandates:

Children who are philosophically exempted from vaccination not only are at greater risk of developing vaccine-preventable disease but also put vaccinated children and medically exempt children who live in the same area at risk.33–35 Vaccine-preventable diseases occurring in vaccinated children may result from waning immunity after immunization or may be attributable to an ineffective immune response to vaccine initially. In January 2015, a measles outbreak occurred in California, where an estimated 3.1% of kindergartners had a nonmedical exemption from receiving the measles–mumps–rubella (MMR) vaccine.36 The majority of cases occurred in children who either had not received measles vaccine (45%) or had unknown vaccination status (38%).37 Of the cases in unvaccinated children, 43% of parents cited philosophical or religious objects to vaccine. An additional 40% of unvaccinated children could not receive the vaccine because they were too young. This outbreak, which spread to multiple states, has sparked intense debate about vaccine exemptions and the government’s role in limiting nonmedical exemptions. Whether the 2015 outbreak and legislation resulting from this outbreak will have a long-lasting effect on public policy and parental choices is not clear at this time. For these reasons, we believe the better approach is to work to eliminate all nonmedical exemptions for childhood vaccines, a position that is shared by the American Medical Association and the Infectious Diseases Society of America and is currently the basis of a policy statement being developed by the AAP.

In the US, states mandate that certain vaccines, usually the vaccines on the CDC recommended immunization schedule, are required before children can be enrolled in school. There is no “forced vaccination,” as antivaccinationists like to mischaracterize it, but there are consequences for parents who don’t vaccinate. They won’t be able to enroll their children in day care or public school unless they are up-to-date on their vaccines.

There are, of course, exceptions. These come in two varieties. First there are medical exemptions. If a child is, for instance, immunosuppressed because he has cancer and is receiving chemotherapy, then certain live attenuated virus vaccines are not safe to administer. Then, of course, there are what are referred to as personal belief exemptions (PBEs), which come in two flavors: religious exemptions and philosophical exemptions. To me philosophical exemptions boil down to “I don’t wanna.” However, if religious exemptions are granted, it’s very problematic not to grant philosophical exemptions because such a policy not only privileges religious beliefs above nonreligious beliefs but can put the government in the position of deciding what is and is not a religion.

Be that as it may, PBEs have been a major problem over the last decade or so. As the antivaccine movement became more vocal, PBEs became more common, particularly in states that made it easy to get them. As a result, there were more and more pockets where vaccine uptake decreased to the point where herd immunity was compromised. This led to a number of attempts to make it more difficult to obtain nonmedical exemptions, because there is good evidence that lax standards for nonmedical exemptions are associated with increased pertussis incidence. Usually, the strategy has been to require that the parents have a doctor sign their exemption form after receiving counseling about the dangers of not vaccinating. California tried that strategy with AB 2109, although Governor Jerry Brown watered it down with a signing statement. My own state of Michigan has instituted a policy that requires parents seeking nonmedical exemptions to visit their local health department for state-sanctioned counseling before they can have an exemption. In neither case were parents prevented from receiving a PBE, but the process was just made intentionally more difficult, with counseling that might persuade some fence sitters to vaccinate. Policies like this work, too. In Michigan, for instance, vaccine exemptions declined after they became more difficult to obtain.

This brings me back to my evolving view. Steve Novella recalls a time when the Vaccine Committee at the Institute for Science in Medicine was debating what our position should be regarding vaccine mandates. While we all agreed that in an ideal world there would be no nonmedical exemptions, there was a huge disagreement between what I like to refer to as the pragmatists (which included me) and those in favor of no compromise. The question was over whether or not opposing nonmedical exemptions should be our only position or whether we should include an option in which we advocated that states that do allow non-medical exemptions should make them as difficult as possible to obtain. The concern was that the political calculus was such that banning nonmedical exemptions was not feasible in most states. And it was.

In retrospect, I still don’t think that was the wrong compromise. However, since the Disneyland measles outbreak, the political calculus has changed, at least in California, which led to the passage of SB 277, a law that did eliminate nonmedical exemptions. However, I must disagree with Steve, who thinks the political climate is such that now is a good time to lobby for eliminating nonmedical exemptions. I have no problem with doing that, but I am not nearly as optimistic as Steve that progress will be made. That’s because, unfortunately, in the rest of the country the political calculus appears not to have changed that much; it’s hard not to note that, as of yet, no other state has emulated California, and there are now only three states that do not allow nonmedical exemptions. So I still think that eliminating nonmedical exemptions is the ideal policy, but that in states that still allow nonmedical exemptions, PBEs should be made as difficult as possible to obtain. Still, it’s good to see the AAP come down on the side of children here, and I actually do hope that Steve is correct that the political will is finally coalescing. Unfortunately, the extreme pushback from antivaccine activists in California might deter other state legislatures from fallowing suit.

The AAP also discusses strategies for dealing with vaccine hesitancy. As I’ve discussed this issue in depth recently, I’ll try to restrain my more “Oracian” tendencies towards logorrhea. I will note, however, that the AAP reiterates that the vast majority of vaccine-hesitant parents are reachable with information and persuasion. They’ve just been misinformed. It’s only a relatively small percentage who are hardcore antivaccine who are unpersuadable. The AAP also notes that countering vaccine hesitancy is hard and a source of pediatrician dissatisfaction with their jobs:

Providing vaccine information is time consuming. Kempe et al56 found that 53% of physicians spend 10 to 19 minutes discussing vaccines with concerned parents, and 8% of physicians spend 20 minutes or more with these parents. They also reported that pediatricians experienced decreased job satisfaction because of time spent with parents with significant vaccine concerns. Physicians have several options to deal with this problem, ranging from scheduling longer well-care visits, with some loss of overall efficiency; simply not having the discussion and acceding to a parent’s request to defer, delay, or skip a vaccination; or dismissing such families from their practice. Permitting alternative vaccine schedules reduces vaccine timeliness and complicates an already complex vaccine schedule.57 A study by Robison et al3 demonstrated that children whose parents chose to limit vaccinations had more total visits for immunizations and by both 9 and 19 months of age were substantially less likely to be caught up on their immunization series. The additional time and costs associated with longer and more frequent well-child and immunization visits for parents with vaccine concerns are substantial, and by decreasing the efficiency of primary care providers, they may have a significant effect on access to health care services for all children.

When discussing vaccines with primary care pediatricians over the years, I’ve acknowledged that I couldn’t do their job and one reason would be all the dealing with antivaccine and vaccine-averse parents. I can see how draining that could be. On the other hand, we should value pediatricians who can do this well because, as the AAP puts it:

With all the challenges acknowledged, the single most important factor in getting parents to accept vaccines remains the one-on-one contact with an informed, caring, and concerned pediatrician.58 In a study reported in Pediatrics, parents of more than 7000 children 19 to 35 months of age were surveyed to determine whether they believed vaccines were safe and what influence their primary care providers had on their decisions to vaccinate.45 Nearly 80% of parents stated that their decision to vaccinate was positively influenced by their primary care provider. The study concluded, “Health care providers have a positive influence on parents to vaccinate their children, including parents who believe that vaccinations are unsafe. Physicians, nurses, and other health care professionals should increase their efforts to build honest and respectful relationships with parents, especially when parents express concerns about vaccine safety or have misconceptions about the benefits and risks of vaccinations.” In another study, Smith et al59 clearly demonstrated that parents whose children were vaccinated listed their pediatrician as a strong influence on their decision to vaccinate. A well-informed pediatrician who effectively addresses parental concerns and strongly supports the benefits of vaccination has enormous influence on parental vaccine acceptance.

I must admit that this passage annoyed me not because it is incorrect but because it is insufficiently inclusive. It only mentions pediatricians. What about advanced practice nurses (APRN)? What about nurses? My wife is a pediatric primary care APRN. She vaccinates at least as many children as any pediatrician and she has become quite good at dealing with the vaccine-averse. The point still resonates, though. An informed, caring, and concerned provider can make a huge difference.

The AAP position paper is welcome in that it’s a lot more hard line than previous AAP statements. For example:

The decision to dismiss a family who continues to refuse immunization is not one that should be made lightly, nor should it be made without considering and respecting the reasons for the parents’ point of view.44 Nevertheless, the individual pediatrician may consider dismissal of families who refuse vaccination as an acceptable option. In all practice settings, consistency, transparency, and openness regarding the practice’s policy on vaccines is important.

I’ve always been conflicted on the ethics of dismissing parents who won’t vaccinate, but I can definitely see a rationale justifying such an action if such parents are taking up too much of a pediatrician’s time and potentially exposing his other patients, particularly those who can’t be vaccinated.

One thing that’s missing from the AAP statement is a discussion of pediatricians who promote antivaccine misinformation, such as “Dr. Bob” Sears, who not only promotes antivaccine pseudoscience but is basically selling highly dubious medical exemptions online to help parents get around SB 277. The AAP needs to come out forcefully to condemn such physicians in no uncertain terms and then to take action to show that their words are more than just words. That action would be to expel such pediatricians from their organization.

Overall, however, that quibble aside, the AAP statement is welcome, as it strongly emphasizes the importance of vaccination and advocates unequivocally for the strongest policies to encourage it.