No, eliminating religious exemptions to school vaccine mandates will not endanger immunosuppressed children

In response to low vaccine uptake, more and more states have been considering passing laws that would eliminate all exemptions to school vaccine mandates other than medical exemptions. It started in California in the wake of the Disneyland measles outbreak five years ago. Led by Senator Richard Pan, the California legislature passed SB 277, which eliminated all personal belief and religious exemptions to school vaccine mandates and allowed only medical exemptions. It worked. Last year, that law was strengthened with SB 276 and SB 714. Last year, as a result of several measles outbreaks, other states have been considering eliminating nonmedical exemptions, be they religious or personal belief exemptions. For example, New York banned religious exemptions last year, and out-of-state antivaxxers have descended upon Trenton because the New Jersey state legislature is also considering eliminating religious exemptions. To oppose this bill (and others like it) mothers like Liz Rovegno are claiming that children like her son Keanu would die if they were “forced” to be vaccinated. It’s a message that could sound convincing to legislators.

Unfortunately, a New Jersey newspaper, Asbury Park Press, published a letter by Ms. Rovegno that uses exactly this argument, even going so far as to publish it under the headline Removal of NJ’s religious exemption for vaccines could kill our son:

Our son Keanu has congenital heart disease, had life-saving open heart surgery and will need further heart surgeries. Keanu’s organ placement is abnormal, causing an issue with his intestines called malrotation for which he may also need surgery.

Keanu is severally immunocompromised in that he has no thymus and polysplenia. The thymus is where T cells go to mature, hence he is deficient in mature T cells. Polysplenia, or multiple spleens, results in no spleen function. The spleen is where B cells go to mature, hence he is deficient in mature B cells. Without mature T and B cells he cannot fight infections. Keanu is so severely immunocompromised that doctors have ordered prophylactic antibiotics every day for the rest of his life.

The inserts of some vaccines, including the MMR, state they are contraindicated in those with “cellular immune deficiencies.” Clearly Keanu falls into this category but his very rare condition does not meet the state Department of Health criteria to qualify for a medical exemption.

It sounds as though Keanu likely has DiGeorge syndrome, which does include congenital heart disease, missing thymus, and T-cell immune abnormalities, although it could be another syndrome. Whatever the specific congenital syndrome Keanu has, he’s obviously immunocompromised. That’s exactly contraindication number one to vaccination with live attenuated virus vaccines like the MMR or rotavirus vaccines. If there’s one contraindication to vaccination that’s medically valid and universally agreed upon, it’s that severely immunocompromised children should not receive live virus vaccines.

Indeed, if you look at the New Jersey guidelines for obtaining medical exemptions, they explicitly invoke accepted reasons, including immunodeficiency:

In order to obtain a medical exemption, N.J.A.C. 8:57-4.3 requires a written statement to be submitted to the school, preschool, or child care center by a physician licensed to practice medicine or osteopathy, or an advanced practice nurse who is licensed in any jurisdiction in the United States indicating that the immunization is medically contraindicated for the child for a specific period of time, and the reason(s) for the medical contraindication, based upon valid reasons as enumerated by the Advisory Committee on Immunization Practices (ACIP) of the United States Public Health Service or the American Academy of Pediatrics (AAP) guidelines.

These guidelines are accessible on the CDC and AAP website at https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/contraindications.html or https://redbook.solutions.aap.org/redbook.aspx.

Among the reasons:

A vaccine should not be administered when a contraindication is present; for example, MMR vaccine should not be administered to severely immunocompromised persons (1). However, certain conditions are commonly misperceived as contraindications (i.e., are not valid reasons to defer vaccination).

Severely immunocompromised persons generally should not receive live vaccines (3). Because of the theoretical risk to the fetus, women known to be pregnant generally should not receive live, attenuated virus vaccines (4)

In the table later on the page, we see this contraindication further specified:

• Known severe immunodeficiency (e.g., from hematologic and solid tumors, receipt of chemotherapy, congenital immunodeficiency, long-term immunosuppressive therapy or patients with HIV infection who are severely immunocompromised)
• Family history of altered immunocompetence

It sounds very much as though Keanu qualifies for a medical exemption to live virus vaccines. On the other hand, I think I know what’s going on here. If Keanu actually has DiGeorge syndrome, here are the recommendations, published in 2014:

Children with partial DiGeorge syndrome (pDGS) should undergo immune system assessment with evaluation of lymphocyte subsets and mitogen responsiveness in order to determine whether they should be given live viral vaccines. Those with ≥500 CD3 T cells/mm3, ≥200 CD8 T cells/mm3, and normal mitogen response should receive MMR vaccine and VAR (weak, low).*

My guess? Either Keanu’s parents didn’t want to have his immune system tested to see if he could safely take the MMR vaccine and other live virus vaccines, or he didn’t meet the criteria above for a medical exemptions (i.e., his immunodeficiency is not severe). On the other hand, the evidence for the above recommendation was listed as lower quality. In other words, there’s room for disagreement, and I bet that most doctors would be OK with a medical exemption for a child like Keanu. (I’m not a pediatrician, though, and am welcome to correction.) Moreover, immunodeficiency is in general not a contraindication to vaccination with vaccines not containing live virus; so none of the considerations above applies to inactivated vaccines, which contain no live virus but rather just protein from killed virus or bacteria chosen to provoke a protective immune response.

I have the sneaking suspicion here that this is not about the MMR or Keanu’s ability to safely handle live attenuated virus vaccines. Here’s what it’s about:

We exercise the religious exemption because vaccinations go against the very core of our religious beliefs. However, if the religious exemption is removed in the name of herd immunity our son’s only option to stay in public schools will be to be vaccinated, which could kill him.

Again, it’s not about live attenuated virus vaccines. It’s about all vaccines. Religion was simply a convenient reason for Liz Rovegno to do what she wanted to do anyway based on her antivaccine views: Not vaccinate Keanu at all. Invoking a religious exemption was simply the easiest way for her to refuse to vaccinate Keanu without the state of anew Jersey objecting. Getting a medical exemption would have required a letter from Keanu’s doctor and possibly tests to assess his immune system..

And, make no mistake, Liz Rovegno is hard core antivaccine. All it takes to see that is a brief perusal of her Facebook page. For instance, just the other day, she was promoting the sequel to the antivaccine propaganda film VAXXED:

Just yesterday, she posted this:

And there are memes like this aplenty:

There’s a lot more where this came from on her page. I quickly became nauseated as I scrolled further down..

There is, of course, a dark irony here. Children with congenital immunodeficiencies are exactly one of the kinds of children who most rely on herd immunity to avoid becoming ill. Yet, Liz Rovegno is doing her damnedest to spread fear, uncertainty, doubt, and loathing of vaccines by promoting antivaccine misinformation. If her disinformation were to be believed by more parents, it could result in a decline in vaccination rates, which would threaten herd immunity, which would directly threaten her son Keanu. In a rational world, she’d be urging everyone to vaccinate their children, as the vast majority of parents of children with compromised immune systems do, if only out of pure self-interest and concern for the son whom she loves. Instead she’s doing the exact opposite.

Finally, shame on whatever editor at Asbury Park Press decided that it would be a good idea to let someone like Liz Rovegno print a letter promoting antivaccine misinformation. Her letter basically promotes the antivaccine propaganda message that deceptively claims that the elimination of nonmedical personal belief and religious exemptions means the elimination of all exemptions to school vaccine mandates. It doesn’t. Antivaxxers have a long list of “contraindications” to vaccination that (they think) should merit medical exemptions, most of which are not based in science. Conflating children like Keanu, who likely has a legitimate contraindication to vaccination because of his congenital immunodeficiency, with all the children with bogus “contraindications” to vaccination and trying to convince legislators that children like Keanu will be put at risk of death if they have to be vaccinated is propaganda, not science.