Because I give full-throated support to the development, manufacturing and use of vaccines, one might think I was some sort of promoter of the pharmaceutical industry. In fact, I care about vaccines generically, and do not care about the system that gets vaccines into the hand of physicians. Frankly, pharmaceutical companies have the money and means to investigate new vaccines and improve old ones, which means it’s our only choice.
Maybe it would be better if the CDC or WHO were responsible for vaccines (and more or less, they are, but not for the manufacturing), but governments come and go, and there would be varying levels of support for the research. I could imagine a time where an antivaccination candidate running for US President would demand the cessation of government support of vaccine research and manufacturing, thus ending supplies of vaccines to US citizens. That would be a horrible scenario. But let’s assume that the 90-95% of Americans who vaccinate won’t vote for someone that delusional.
Pharmaceutical companies have done many wonderful things for humanity, and part of the reason we can live longer, while still being productive, is almost exclusively a result of pharmaceutical and medical innovations, especially over the past 20 years. I’m not going to list out every single revolutionary invention out of the pharmaceutical industry, but in the areas of cancer medications, antibiotics, vaccines, cardiovascular and orthopedic devices, and a few other areas, Big Medical (because it’s really more than just pharma) allows you to live longer and better.
(more…) «Drug company withholds critical data…»
Currently in the United States, the Advisory Committee on Immunization Practices (ACIP) recommends that preteen girls and boys aged 11 or 12 are vaccinated against HPV. The immunization is also recommended for teenage girls and young women up to the age of 26 who did not receive it when they were younger, and teenage boys and young men up to the age of 21.
As I reported recently, the HPV vaccine uptake has not been as a high as many would like in the US. A recent retrospective epidemiological study of HPV cancers in Alberta, Canada, published in the Canadian Medical Association Journal OPEN, seemed to indicate that HPV related cancers have increased substantially in the study years from 1975 to 2009, prior to the widespread use of the HPV vaccine in Canada. This is another indicator that increasing the rate of HPV vaccination is important.
(more…) «Rising rates of HPV-related cancer–Gardasil…»
Genital human papillomavirus (HPV) is the most common sexually transmitted infection (STI) in the USA. There are more than 40 HPV sub-types that can infect the genital areas of males and females. These same HPV types can also infect the mouth and throat. They are transmitted from personal contact during vaginal, anal or oral sex.
Some HPV subtypes, such as HPV-6 and HPV-11, can cause warts around the genitals or anus, but have low (but not 0) risk of causing cancers. However, the higher risk subtypes, such as HPV 16 and 18, not only cause approximately 70% of cervical cancers, but they cause most HPV-induced anal (95% linked to HPV), vulvar (50% linked), vaginal (65% linked), oropharyngeal (60% linked) and penile (35% linked) cancers. HPV is estimated to be the cause of nearly 5% of all new cancers across the world.
According to the CDC, roughly 79 million Americans are infected with HPV–approximately 14 million Americans contract HPV every year. Most individuals don’t even know they have the infection until the onset of cancer.
(more…) «Gardasil (HPV vaccine) coverage and…»
In Dorit Reiss’ critical analysis of the legal tools that could be employed to improve vaccination uptake, she outlined six different legal strategies that could be employed. Do you have a favorite? Do you think one might actually work to increase vaccinations? Vote, and comment below if you have other thoughts.
Many of us are concerned at the rise of cases of preventable diseases and the role played in that by the decision by a minority of parents not to vaccinate their children. One question is what, if any, legal tools are available to address non-vaccination. This article attempts to map out the available tools.
Note that the focus of this article is what the law can do, not what the law should do. The fact that a legal tool is available – i.e. Constitutional, can be enacted or used by the courts – doesn’t automatically mean it should be. I would, in fact, argue that some of the tools discussed here shouldn’t be used in the context of immunization – in most circumstances, forced vaccination and criminal law are inappropriate. But mapping out what’s available seems like a useful first step in the discussion of what the law should do. The goal of this post is to provide a menu of options and a more or less logical way to classify them. My hope is that setting out what’s possible would help us think through what is desirable.
Based on what I write, you’d think I was all about vaccines and thoroughly mocking the ignorance of the antivaccination world. And, apparently, I’m paid to do that. Sadly, I do not have a new BMW M5 in my driveway. I’d rather write about evolution, but there’s a direct correlation between not vaccinating and harm to children from vaccine preventable diseases, so it seems more important to me than arguing about the stupidity of creationism.
I tend to be the cranky one on the interwebs with respect to vaccines. I’m the mean, angry uncle who turns on the sprinklers when the antivaccine parents walk their dogs in front of my house. Extra benefit–their dogs don’t poop on my lawn. See, I’m the curmudgeonly neighbor of the pro-science/pro-vaccine world.
I realize my tone, filled with sarcasm and mockery, may blur my message, which is always based on real science, anti-cherry picking, and appropriately weighing evidence from experts vs. invented data from non-experts. But there are websites, which are important to my own personal mission of understanding vaccines and infectious diseases, that provide the same high value information but without the snark. I know, some of you like snark, as do I.
Here are some of the best websites on the internet that engage in the debate (there’s no debate, vaccination is safe and effective, as shown by a couple of mountains worth of evidence) about vaccines. But are on a different planet of niceness compared to me.
Voices for Vaccines. This blog (with lots of supporting information) tells personal stories through the voices of those who vaccinate. You cannot helped but be touched by the stories. VacLiars (see, I cannot resist) hates Voices for Vaccines, so there’s that. But it’s a good place if you’re looking for a calm voice in the screaming about vaccines. One of the managers of this website, Karen Ernst, has written a very popular post here. And she was nice. One of the scientific advisory board members (all of whom have impressive credentials in pediatrics and/or infectious diseases) is Paul Offit, who invented a vaccine that saves hundreds of thousands of lives every year. I don’t have to say anything more.
Shot of Prevention. One of the older websites that is pro-vaccine (by old, I mean 4 or 5 years), Shot of Prevention focuses on practical parenting issues with regards to vaccinating and diseases. What I love about Shot of Prevention is that its writers come from all walks of life, and really gives the reader a broad perspective on immunization.
Red Wine and Apple Sauce. This website has a different appeal, but it’s an outstanding resource for a thoughtful analysis of immunizations. Tara Haelle, who is a science journalist and writes nearly all of the articles, discusses more than just vaccines, but numerous current topics that are important to parents. She writes long detailed articles, filled with links that support her points, and she should be on anyone’s list for getting information about vaccines.
The Value of Vaccination–A Conversation. A relatively new entrant into the conversation about vaccines, Value of Vaccination focuses in a different way–the stories are more personal, with the perspective almost exclusively from the viewpoint of a parent or individual. It features conversations that show us what the value of vaccination is and how it makes our lives better.
PKIDs Online. PKIDs, officially Parents of Kids with Infectious Diseases, probably would not describe themselves as a “pro-vaccine” website, but they really are pro-vaccine. They tell the personal stories of parents of children who have chronic infectious diseases, most of which are vaccine preventable.
Vaccine Education Center. Run by the Children’s Hospital of Philadelphia (known by almost everyone as CHOP), it is one of the top websites for information about vaccines. Yes, Paul Offit is involved again. Well, when you’re one of the leading experts in immunization of children, and you’re on the faculty of CHOP, that’s what happens.
Vaccine News Daily. This website, more or less, aggregates news articles about vaccines, while giving a brief, but useful, summary of the information. It’s a good way to keep up with what’s going on in the vaccine world.
I Speak of Dreams. Although not necessarily about vaccines, I Speak of Dreams is an important resource in myths (and debunking of said myths) about autism. And because vaccines and autism has been a manufactured issue since the late 1990′s, anyone who discusses myths about autism has to spend an inordinate amount of time debunking the myths of vaccines and autism. If I might remind everyone, there is no correlation between vaccines and autism.
All of these websites have non-cranky writers. Well mostly. And most of them are much more patient with comments than I am, because I have no patience when it’s clear that a commenter doesn’t get what constitutes evidence and what doesn’t.
I’m sure I missed an important website or two. This article isn’t static, I can make changes whenever I want, so drop me a comment. Besides, I’d want to know about your website!
All 50 US states (along with several territories and DC) require mandatory vaccination for children entering public (and frequently, private) schools. This system has essentially ended most vaccine preventable diseases in the USA, including measles, polio, chickenpox, and many others. It is considered one of the 10 greatest achievements in public health. Vaccines should probably be number 1 on the list. Overall, the immunization mandate has established a strong herd effect, which has generally ended transmission of these diseases.
Even though vaccination is mandatory, there are ways around it, if you choose. Every state allows medical exemptions, which is based on a proven risk for a child to not be vaccinated with one or more vaccines. For example, some vaccines are produced in chicken eggs, and a tiny percentage of children are allergic. Medical exemptions are absolutely critical to the well being of the child, and no pro-science (pro-vaccine) writer or researcher would be opposed to those types of exemptions.
But most of the exemptions are personal belief exemptions (PBE), which fall into one of two groups–religious exemptions, that is, the parent “claims” that their religion is opposed to vaccines; or personal exemptions, which are simply based on the fact that the parents are opposed to vaccination for whatever reason that hits their brain after 20 minutes of Googling “facts.” Most states allow both types of exemptions, some only allow religious exemptions, and one state, Mississippi, allows only medical exemptions. As a progressive, there is little positive I can say about Mississippi, but this is a major positive. So congrats Mississippi for caring about children, at least in this one important way.
(more…) «California’s vaccine exemption law–prevalence and…»
Updated 21 July 2014.
As the push to legalize marijuana for personal or medical use gains traction in the USA, the “pro-pot” arguments become more enthusiastic and more off the beaten track of real science. I suspect, like legal same sex marriage, social norms have changed, and legal marijuana is something that will become commonplace across the country, except in some deeply conservative areas. The Federal Government has shown little enthusiasm in enforcing Federal law, which retains the highest authority in regulating certain drugs, in states that allow legal marijuana.
I personally have no issue with smoking marijuana, since other “drugs”, like alcohol, are completely legal and socially acceptable. I think that legalizing marijuana will reduce much of drug trafficking, reduce the burden of law enforcement and penal system costs, and have other beneficial effects to society. I still want regulations such as control over public smoking (I don’t want second hand cannabis smoke wafting over me or my children, as much as I don’t want to inhale other people’s tobacco smoke), there needs to be regulations about when it might be illegal to be high (I don’t want my Delta Airlines pilot to be smoking weed before flying my jet, and I don’t want automobile drivers to be under the influence), and I want age regulations no different than there is for alcohol. But I think those are reasonable boundaries for legalization of cannabis that would be reasonable to most people. But this isn’t the point of this article.
What troubles me about the “debate” about legalization of cannabis is that the pro-pot side seems to make claims about various medical benefits that appear to be only tenuously supported by real scientific evidence. The reasons for doing this is probably, though I can only speculate, to make it appear that marijuana is some miracle product, so let’s speed up the legalization of it. It’s like the Food Babe telling us that kale is the miracle food, except that kale isn’t illegal. It does taste awful (but not the point).
(more…) «Medical uses of marijuana–hitting the…»
Until recently, I didn’t think there was much of an issue about patients or parents paying for vaccines. My perspective is certainly USA-based, but it would be interesting to see how people are paying for their vaccines.
One of the most tiresome discussions that a scientific skeptic has when debunking and refuting pseudoscience or junk science (slightly different variations of the same theme) is what constitutes real evidence. You’d think that would be easy, “scientific evidence” should be the gold standard, but really, there is a range of evidence from garbage to convincing. So this is my guide to amateur (and if I do a good job, professional) scientific evidence. This is a major update of my original article on this topic, with less emphasis on Wikipedia, and more detail about scientific authority and hierarchy of evidence.
In today’s world of instant news, with memes and 140 character analyses flying across social media pretending to present knowledge in a manner that makes it appear authoritative. Even detailed, 2000 word articles that I write are often considered to be too long, and people only read the title or the concluding paragraph. This happens all the time in the amateur science circles specifically. For example, many people only read the abstract and, even there, only the conclusion of the abstract for scientific articles.
THE most popular article I ever wrote on this blog was one that thoroughly refuted a crazy meme that bananas kill cancer (which is an update of the original banana article). Hysterically, it was based on a complete misunderstanding of a study by “Japanese scientists” (the lead author was, in fact, an American, but whenever you see something that tries to claim authority by using unnamed, but smart sounding, scientists, be wary). Moreover, the conclusion made by the meme-author was based on ignorance about why a growth factor called “tumor necrosis factor” (TNF) that doesn’t do what it sounds like it does, about how a banana would never produce TNF, about how TNF would be broken down in the digestive system, about how it couldn’t be transported from the digestive system to the blood, and about how if you could eat enough bananas, if they did contain TNF, to have a biological effect, it would have to be more bananas than you could possibly eat, and the TNF effects would make you really sick. The banana meme did not have one single accurate assumption. None.
But still, it’s a popular belief. Just go to Facebook, and you’ll find someone promoting it. Like all anti-science memes, it’s a zombie, it reanimates from the dead and spreads its pseudoscience every few months, and I get thousands of hits from people trying to confirm the meme. Well, that’s actually good. I did the hard work of digging into the article and trying to figure out if this whole TNF thing was real.
There’s an irresponsible antivaccination group called Nurses Against Mandatory Vaccines whose sole purpose is to oppose vaccinating nurses and other healthcare workers against vaccine preventable diseases. They claim that they are opposed to mandatory vaccination, yet if you look into their propaganda, they use all of the refuted tropes and lies found throughout the antivaccination movement.
These so-called nurses, whose profession is generally dedicated to protecting, maintaining and assisting people to live healthy lives, are so blinded by their antivaccine myths that they would rather risk harming patients and their co-workers rather than get a safe and effective vaccination. These nurses have arrogant and ignorant beliefs, no different than global warming deniers and creationists, that put at risk patients who are too young to be vaccinated. Immunocompromised patients who cannot be vaccinated. Certain cancer patients who are at risk to almost every disease. Instead of protecting life, they willingly choose to cause harm
I do not know why these “nurses” have such callous disregard for human life. It disgusts me. It nauseates me. These “nurses” are not nurses–they are vile, ignorant fools.
But there is a group that stands with patients and the honorable profession of nursing. A group that represents all that is wonderful and helpful about dedicated nurses. A group that thinks that patient care supersedes believing in ridiculous myths. Nurses Who Vaccinate. Check them out. Help them out. And give them your support in whatever way you can.
Suddenly, there has been a lot of noise about the price of vaccines. Well, there’s always been over-exaggerations and outright misinformation about vaccine prices and profits from the antivaccination gang, and they must be embarrassed by the quality of their arguments. OK, I doubt that. But there is noise out there.
But when the criticism comes from the “pro-vaccine” world, I needed to stand up and see what was being said. In my world of vaccines, I believe that anyone, especially children, who needs vaccines should get them for free. This is true in the USA (which leads the world in this one facet of healthcare), thus, any argument about vaccines costing too much falls rather flat to me. I hate dropping anecdotal data on my readers, but the fact is my health insurance plan, by no means some corporate executive level concierge plan, pays for all vaccines. In fact, I asked for one vaccination out of indication (meaning I was about 10 years too young to receive it), and the insurance company paid for it immediately and without question.
In the USA, the Affordable Care Act (best known as Obamacare) mandates vaccinations for adults and children with no out-of-pocket costs. Medicaid pays for vaccines. Medicare pays for vaccines, though the rules for payment are unnecessarily bureaucratic and confusing, unless the member is in Medicare Advantage. Maybe not as of today, but certainly soon, the cost of vaccines shouldn’t matter to the average rich or poor or middle-class American. And considering the number of lives saved by vaccines, this is an incredible and modern aspect of the USA health care system.
(more…) «Prices of vaccines–an uncomfortable discussion»
One of the important hypotheses of vaccination is to make sure that all family members or others who may encounter a newborn child be vaccinated, especially since many vaccinations are not indicated for infants for a couple of months after birth–those newborns are very susceptible to vaccine preventable diseases until they themselves are vaccinated with the DTaP vaccine (which also protects against tetanus and diphtheria).
This protective “cocoon,” especially important with whooping cough (Bordetella pertussis), theoretically blocks the transmission of the disease to a newborn by creating a protective circle of vaccinated individuals around the newborn. A teenage sibling could catch the disease and accidentally infect the infant. Pertussis is bad enough for a teenager, but it can be deadly to a baby.
Even though the evidence for cocooning is growing, there are some flaws to the idea that are still being investigated in various parts of the world. One of the concerns is that asymptomatic carriers of pertussis (who have been vaccinated) might transmit the disease through a cocoon. However, scientists have known that the current version of pertussis vaccine, called acellular pertussis, isn’t as effective as it should be, but it is still better than not vaccinating. Much better. But that is a potential hole in the protective cocoon that needs to be understood better through research.
(more…) «Why we vaccinate–so mom will…»
I’ve written over 640 articles over the past 2 ½ years, 3-4 a week. It’s fun, mostly. About 360 of those articles are on vaccines, vaccination, and you know, those who don’t like vaccines.
When I started, I wanted to write about all kinds of topics that always rub us skeptics the wrong way: creationism, global warming denialism, UFO’s, the Loch Ness Monster, Sasquatch, the Loch Ness Monster having an affair with Sasquatch, everything but the kitchen sink causing or curing cancer (seriously, it’s that bad with cancer), and, near the bottom of the list, vaccines. Why at the bottom of the list? I naively believed that vaccines were a settled question. You know, vaccinate or really horrible diseases will return. I guess I was wrong.
This is just a “sense of the readers” poll. So choose wisely. I might go in that direction.
Anecdotally, it has always seemed like the HPV quadrivalent vaccine, known as Gardasil or Silgard, was the most despised vaccine on the market. Although I write about almost every vaccine, I seem to write more about Gardasil, countering all kinds of silly claims. Despite several large case-controlled epidemiological studies, some of which I’ve discussed previously, there is some pervasive fear that the HPV vaccine is dangerous. You don’t know how many times I’ve read “I vaccinate my kids, but never that Gardasil stuff.”
Just for review, forget that Gardasil saves lives by preventing cancer. The HPV quadrivalent vaccine specifically targets human papillomavirus (HPV) subtypes 16 and 18, that cause not only approximately 70% of cervical cancers, but they also cause most HPV-induced anal (95% linked to HPV), vulvar (50% linked), vaginal (65% linked), oropharyngeal (60% linked) and penile (35% linked) cancers. It also targets HPV6 and HPV11, which account for approximately 90% of external genital warts. The viruses are generally passed through genital contact, almost always as a result of vaginal, oral and anal sex.
There is substantial clinical evidence that once a population is vaccinated against HPV, the rates of infection drop, which should lead to lower risk of various cancers. There is no other way to say this but Gardasil is very safe and very effective at preventing cancers.
But science is irrelevant, if you can spread fear. The antivaccination cult at GreenMedInfo, home of the vaccine denying lunatic Sayer Ji, cherry-picked a whole laundry list of “peer-reviewed”, many of marginal if not laughable quality, trying to “prove” that Gardasil is dangerous. One article, of slightly better quality, use a bit of dumpster diving into the fairly useless VAERS database that showed an overabundance of reporting of venous thromboembolic events, though, because of the quality of data, they authors were unable to establish any firm correlation between the HPV quadrivalent vaccine and those events.
(more…) «HPV vaccine is unrelated to…»
If you’re a regular reader of this blog, you would think that I spend a lot of time discussing autism spectrum disorders (ASD). But the goals of this blog is weed out and debunk pseudoscientific beliefs, especially some of the more popular ones. Probably the most ridiculous had been the fraudulently invented and eventually thoroughly debunked link between vaccines and autism. That belief is completely dead, right? Well, not really. Irrational and, frankly cult-like, groups like Age of Autism refuse to give up. Of course, the Age of Autism is so deluded by their illogical and unscientific beliefs, they oppose funding for genetic research into autism.
Not everyone in the world of ASD has that fanatical hold onto the “vaccines cause autism” trope. Most real scientists accept that the likely cause of ASD is some combination of genetics and environment. But that hasn’t stopped people from claiming that everything, but the kitchen sink, causes ASD. About three years ago, Emily Willingham, Ph.D., whom I consider to be one of the leading ASD scientific experts on this planet, wrote a hysterical, but still appropriate, article about all the popular causes of ASD. Older mothers. Older fathers. Depressed mothers. Fingers. Facial features. Facial features?
Dr. Willingham wrote about around 50 different causes of ASD, including refrigerator mothers (but not kitchen sink mothers)–it has nothing to do with actual refrigerators. That article was very important to me, because it formed the basis of my skepticism about popular beliefs regarding correlation and causality. It’s not just ASD, but other areas, like cancer causes and cures, which seem to attract the everything-but-the-kitchen-sink science.
As you may be aware, there was a relatively large measles outbreak in New York City (pdf), hitting 26 individuals according to the New York City Department of Health. Some have stated that the outbreak was small, but compared to the historical average of around 60 measles cases per year for the whole United States, and when it was thought that we had “defeated” measles in the USA, 26 is a surprisingly large number.
In light of these outbreaks, the New York State Department of Health (DOH) announced that it has updated its immunization requirements for school attendance to meet the revised standards recently published by Advisory Committee on Immunization Practices (ACIP), which is a group of medical and public health experts that have developed vaccine and immunization recommendations to reduce the incidence and prevent disease amongst America’s children. The goal of these recommendations is to reduce the incidence of vaccine preventable diseases.
The new 2014 standards did not add any new vaccines for school entry; however, they did update the number of doses required and the minimum intervals between doses. Generally, ACIP makes several recommendations a year, and state health departments “catch up” with the newest recommendations when they set the standard for the upcoming school year.
According to said Acting State Health Commissioner Howard Zucker, MD, JD, “immunizations protect children from serious childhood diseases, like whooping cough and measles, and have an excellent track record of safety and effectiveness. I encourage parents to talk to their children’s healthcare provider and work with their school’s health services to ensure that all immunizations are up-to-date.”
New School Immunization Requirements
The new requirements, which apply to daycare, head start, nursery, pre-kindergarten and grades kindergarten through 12, represent the best evidence and data available to public health researchers, and is the first update to the New York State requirements in over a decade.
- Students entering kindergarten or 6th grade in the 2014-2015 school year will now be required to have two doses of the varicella (chicken pox) vaccine and 3-5 doses of poliomyelitis vaccine. The updated varicella and polio vaccination requirements will be phased in over the next seven years and will be required for all grades by the 2020-2021 school year.
- For all other required vaccines, students in day care, head start, nursery, pre-kindergarten and grades kindergarten through 12 will be required to have age-appropriate doses in accordance with the ACIP schedule (pdf).
- A student who is in process is defined as one who has had the first dose of vaccine in all of the required immunization series and has appointments to complete the series in accordance with the ACIP catch up schedule.
- Students may present proof of immunity by serology (blood test) for the following immunizations: measles, mumps, rubella, hepatitis B, varicella, and poliomyelitis.
- Medical exemptions to immunizations must be reissued annually. The written exemption must identify the immunization exempted, the medical contraindication for the exemption, and the length of time the immunization is contraindicated. A sample medical exemption form is available one the website.
- Any child who has been vaccinated according to the ACIP recommendations, which are followed by most health care providers, should not need further vaccinations in order to attend day care or school.
New York State and City allow for legitimate medical exemptions to some or all of these vaccines, but they require certification and renewal each year. The state and city also allow religious exemptions, but recent court decisions (also here) have empowered school administrators to restrict or disallow those exemptions.
I cannot be sure that the New York State Department of Health was responding to outbreaks of measles and whooping cough to re-examine its vaccine requirements, but it would make sense. And hopefully it, along with the reduction or elimination of nonsense religious exemptions (there are simply no legitimate anti-vaccine religious groups), will reduce or eliminate outbreaks of vaccine preventable disease.
In the recent Burwell v. Hobby Lobby Stores, Inc. (Hobby Lobby) decision, a majority of the Supreme Court ruled that the Department of Health and Human Services (HHS)’s requirement that qualifying employer health plans under the the Patient Protection and Affordable Care Act of 2010 (ACA) include coverage for all FDA approve contraceptives cannot be applied to at least certain corporations stating religious objections. The Court found that the regulations violated the Religious Freedom Restoration Act of 1993 (RFRA)’s prohibition on burdening exercise of religion. The majority made every effort to make that decision narrow as possible – but it still has concerning implications for the future, and Justice Ginsburg’s ringing dissent raises very important questions.
When the Skeptical Raptor asked me to write about this decision, we intended that I will discuss how it affects religious exemptions to vaccination. But this decision is too important to stop there, so while I also address the vaccination aspect, my discussion is about the decision generally.
From my point of view – as a secular individual who believes reproductive freedom is crucial to women’s equality – the decision has some positives, but also much to be concerned about (I hope the analysis will also be useful to those whose views are different from mine, however). It’s not, however, a decision that turns the United States into a theocracy, as some of the more impassioned posts I’ve seen on Facebook suggest. In some ways, actually, just the opposite.
(more…) «Hobby Lobby and Religious Exemptions:…»