Dorit Rubinstein Reiss – an index of contributions to this website

Dorit Rubinstein Reiss

Dorit Rubinstein Reiss – Professor of Law at the University of California Hastings College of the Law (San Francisco, CA) – is a frequent contributor to this and many other blogs, providing in-depth, and intellectually stimulating, articles about vaccines (generally, but sometimes moving to other areas of medicine), social policy and the law. Her articles usually unwind the complexities of legal issues with vaccinations and legal policies, such as mandatory vaccination and exemptions, with facts and citations. I know a lot of writers out there will link to one of her articles here as a sort of primary source to tear down a bogus antivaccine message.

Professor Reiss writes extensively in law journals about the social and legal policies of vaccination–she really is a well-published expert in this area of vaccine policy, and doesn’t stand on the pulpit with a veneer of Argument from Authority, but is actually an authority. Additionally, Reiss is also member of the Parent Advisory Board of Voices for Vaccines, a parent-led organization that supports and advocates for on-time vaccination and the reduction of vaccine-preventable disease.

Below is a list of articles that Dorit Rubinstein Reiss has written for this blog, organized into some arbitrary and somewhat broad categories for easy reference. This article will be updated as new articles from Professor Reiss are added here.

Continue reading “Dorit Rubinstein Reiss – an index of contributions to this website”

California SB277 lawsuit update – judge rejected Torrey-Love

California SB277 lawsuit

On August 15, 2017 Judge Charles D. Wachob from the Placer County Superior court granted the state’s demurrer to the California SB277 lawsuit (known as Torrey-Love).  In lay terms, dismissed the suit without leave to amend. Demurrer is generally granted when, assuming all the facts plaintiffs claimed are true, the court sees no legal basis for the suit, in technical terms, no cause of action. Continue reading “California SB277 lawsuit update – judge rejected Torrey-Love”

California vaccination rates – record high thanks to SB277

California vaccination rates

About two years ago, California’s governor, Jerry Brown, signed SB277 into law, which mandated that all school age children must have all vaccines appropriate for their age before they could enter private or public schools. The law nearly eliminated the ability to get personal belief exemptions (PBE), which allowed parents to object to vaccinations for almost any reason. As a result of this law, it was predicted that the California vaccination rates for school age children would increase substantially, while reducing the incidence of vaccine preventable diseases.

Those of us who have been keen observers and supporters of SB277 were hoping for the best – that the vaccination rate in the state would show increases quickly. First results, released by the California Department of Public Health in April 2017 (pdf), showed a significant increase in the percentage of California’s kindergarteners who were fully vaccinated (for their age group). The vaccination rate for kindergartners rose from 92.8% to 95.6%.

But, there was even more data from that report that supported California vaccination rates. With the advent of the new law, 97.3% of California’s kindergartners have received both MMR vaccinations, up from 94.5% in 2016 and 92.6% in 2014. The same was shown for the Tdap vaccine (for diphtheria, tetanus and pertussis or whooping cough), which went from 94.2% in 2015 to 96.9% in 2016.

Continue reading “California vaccination rates – record high thanks to SB277”

SB277 RICO lawsuit – Bad arguments and conspiracy theories updated

SB277 RICO lawsuit

In previous posts I addressed three of the lawsuits filed against SB277, all of which suffered defeats, at least for the moment: WhitlowBuck, and Torrey-Love. There was a fourth lawsuit, however, filed in July 2016 that I did not address until now – the SB277 RICO lawsuit from Travis Middleton.

This lawsuit had, in my view, the lowest chances from the start, and I was not sure how to cover it in the best manner, given its writing. But I think it’s time, since although a formal decision has not come down, a recommendation to dismiss the SB277 RICO lawsuit was filed.  Continue reading “SB277 RICO lawsuit – Bad arguments and conspiracy theories updated”

Appeal to false authority – who is Tetyana Obukhanych

There are so many annoying issues about the antivaccination cult, that most of us can’t even keep up with it. If only they would provide evidence published in high quality, peer reviewed journals (yes, a high standard, but if we’re talking about public health, a high standard is required), the fake debate would move into a real scientific discussion. One of their favorite feints against real evidence is to push people, like Tetyana Obukhanych, who appear to have great credentials, but once you dig below the surface, not much is there.

One of the most irritating problems I have with the antivaccination movement  is their over-reliance on false authorities, where they trumpet the publications or commentary from someone who appears to have all of the credentials to be a part of the discussion on vaccines, but really doesn’t. Here’s the thing – it simply does not matter who the authority is or isn’t, all that matters is the evidence.

For example, Christopher Shaw and Lucija Tomljenovic, two researchers in the Department of Ophthalmology at the University of British Columbia, have, for all intents and purposes, sterling credentials in medicine and science. However, they publish nonsense research (usually filled with the weakest of epidemiology trying to show population level correlation between vaccines and adverse events) in low ranked scientific journals.

Now the anti-vaccine world has a new hero – Tetyana Obukhanych. Continue reading “Appeal to false authority – who is Tetyana Obukhanych”

Vaccine legislation in the USA – a state by state analysis

vaccine legislation

One of the most successful pieces of vaccine legislation in recent years has been SB277 in California, which eliminated personal belief exemptions (PBE), that allowed a parent to exclude a child from immunization requirements for school based on the parent’s personal beliefs, including religious objections.  These PBEs had been used and abused by anti-vaccine parents to exempt their school-aged children from most, if not all, vaccines.

Other than California, only West Virginia and Mississippi have such strict prohibitions on these PBEs that they are effectively not allowed as a method to refuse vaccines before a child enters school. But many other states are considering vaccine legislation that could improve vaccine uptake. Unfortunately, there are also states on the other side of the equation that are considering laws that reduce restrictions on personal belief exemptions.

The National Vaccine Information Center (NVIC), which seems to conflate “information” with misinformation about vaccines, claims that there are 134 vaccine bills being considered in 35 states. I wish!

I thought we would could take a look at current vaccine legislation being considered by various states that could potentially increase vaccine uptake in those states. Then we’ll take a look at those states pushing legislation that might decrease vaccine uptake. This should provide real information about what’s going on with these laws, instead of the alternative facts from the vaccine deniers at NVIC.

Continue reading “Vaccine legislation in the USA – a state by state analysis”

California vaccine uptake – big increase because of new law

California vaccine uptake

About two years ago, California’s governor, Jerry Brown, signed SB277 into law, which mandated that all school age children must have all vaccines appropriate for their age before they could enter private or public schools. The law nearly eliminated the ability to get personal belief exemptions (PBE), which allowed parents to object to vaccinations for almost any reason. The new law does allow for medical exemptions, that is, children who have some medical condition that contraindicates a vaccine may be exempted from these rules. As a result of this law, it was predicted that the California vaccine uptake for school age children would increase substantially, while reducing the incidence of vaccine preventable diseases.

Those of us who have been keen observers and supporters of SB277 were hoping for the best – that the vaccination rate in the state would show increases quickly. And it did.

Data released this week (pdf), from the California Department of Public Health, showed an exceptional increase in the percentage of California’s kindergarteners who were fully vaccinated (for their age group) – it rose from 92.8% to 95.6%. But, there’s even more astonishing data underneath that. With the advent of the new law, 97.3% of California’s kindergartners have received both MMR vaccinations, up from 94.5% in 2016 and 92.6% in 2014. The same was shown for diphtheria, tetanus and pertussis (whooping cough) vaccine – it went from 94.2% in 2015 to 96.9% in 2016. There should be cheering in the streets of California for the success of SB277.

The increase in vaccine uptake for all mandated vaccines is dramatic – not only does it show that SB277 has stemmed the overuse of personal belief exemptions that was slowly reducing California vaccine uptake, but it also has increased that uptake to levels far above historical. This graph illustrates how well the law has worked in a short period of time:

California vaccine uptake

The best part of the law is that it’s increasing vaccine uptake in areas of the state where the overuse of PBEs was pushing the vaccination rate down. Most California’s counties have vaccination rates above 95%, which is considered the level at which the herd effect for measles vaccinations prevent the rapid spreading of the disease. Furthermore, only 4 relatively small counties in California have rates below 90%.

California vaccine uptake

California state Senator Richard Pan (D-Sacramento), who is also a pediatrician and who was one of the primary supporters of SB277, tweeted out “Great News.” Obviously he’s ecstatic with this data on California vaccine uptake across the state.

Dr. Pan was interviewed by the Los Angeles Times, and said,

Measles certainly hasn’t gone away. We need to be sure to have our immunization levels high enough. The fact that this class and the state overall has now achieved this level is one further step to restore the community immunity we had before.

He also noted that the data shows the significant increase in very young children, kindergartners. He mentioned that there are still significant number of older children who are not vaccinated because of the lax requirements in previous vaccine laws, which made PBEs very easy to get. SB277 also requires 7th graders to be completely up-t0-date on their vaccines, so all children should eventually be caught up with their vaccines. Unfortunately, many students who have passed that 7th grade vaccination checkpoint may be insufficiently vaccinated. Or not vaccinated at all.

The University of California (UC) system has stated that it will require vaccines for all new enrollees at its 10 campuses (along with the UC Hastings College of Law which has decided to comply with the UC requirements). Like the state law, it eliminates all personal belief exemptions, but does allow medical ones. Eventually, this mandate will cover the over 230,000 students in the system.

The anti-vaccine forces have tried several tactics to block implementation of the new law. Opponents of SB277 filed a lawsuit last summer claiming the law violated California children’s right to an education under the state’s Constitution. A judge denied their demand for an injunction against the law –  the plaintiffs eventually withdrew their case. These opponents also failed to gather enough signatures last year to put a referendum on the November ballot to overturn the law.

There are reasons to cheer all of this news out of California regarding immunization rates. But that’s just one state, albeit the largest and arguably the most influential state in the country. Other than California, only two other states have laws that have eliminated personal belief exemptions for immunizations – Mississippi and West Virginia, both of which have high vaccine uptake. And the easy availability of personal belief exemptions have lead many states to have vaccination rates of the MMR vaccine that are far below the 95% target. This graphic shows which states have significant deviations from the 95% standard for MMR vaccine (thanks to BuzzFeed News):

Sadly, it may not be possible for a lot of states to copy California’s success with vaccines. One of the worst performing states for the MMR vaccine is Colorado, and, according to BuzzFeed News,

Vaccine advocates in Colorado are envious of their counterparts in California. “We are watching California very closely, and kudos to them for getting that bill through,” Stephanie Wasserman, executive director of the Colorado Children’s Immunization Coalition, told BuzzFeed News.

She believes it would be very difficult to enact similar legislation in Colorado, which has libertarian conservatives who reject government mandates on vaccines, as well as liberal enclaves like Boulder where many parents seek out alternative health care and see vaccines as a tool of Big Pharma.

Libertarian conservatives and liberals on the same side of the fence on vaccines? The problem with both groups is that they ignore the health of children just to be “politically virtuous” about vaccines. Except they are scientifically and medically wrong.

So let’s give an ovation for hard working politicians of California, who decided that the health of the state’s children was the paramount consideration for vaccinations. Dr. Pan and many other state legislators decided that the most effective way of increasing the California vaccine uptake was to reduce the availability of personal belief exemptions. And they were right – California’s immunization rate has increased appreciably because of SB277.

Vaccines save lives.

California SB277 expected to drop vaccine preventable disease rates

California sb277

California SB277 makes immunization mandatory for children attending schools in the state by removing personal belief exemptions for vaccination. These personal belief exemptions were abused by parents in pockets of California, causing immunization rates in some communities to fall precipitously. California SB277 should correct that abuse. The new vaccine requirements should increase the vaccination rate, as long as someone doesn’t find some loophole to abuse the system, because anti-vaccine parents tend to be a resourceful group.

California joined two other states, West Virginia and Mississippi, with the most stringent requirements for vaccination for children before they can enter school. West Virginia State Law does not allow for non-medical exemptions to immunization requirements. Mississippi only allows medical exemptions (as does California), which allows parents to request an exemption for their child if there is a medical condition that contraindicates a vaccine. All three states require physician certification of medical exemptions.

Interestingly, West Virginia legislators strengthened vaccination laws in 2015 by extending vaccination requirements to preschoolers. And it created the position of state Immunization Officer, who is responsible for ruling on the validity of requested medical exemptions in an unbiased manner. Maybe California could implement such a position.

The results of these strict enforcement of exemptions are significant reduction in incidence of diseases. For example, Mississippi has not had a case of measles since 1992, and West Virginia since 2009. On the other hand, there was a relatively large measles outbreak at Disneyland in 2015, where 134 individuals (mostly Californians, though residents of six other states and two countries) were infected with the disease.

The drop in disease rates in California will be much more apparent in California, which has 9 million children in school, compared to 737 thousand in Mississippi and 382 thousand in West Virginia. Diseases like chickenpox and measles are highly infectious, so high immunization rates should block any spread of the disease

California SB277 became effective on July 1, 2016, so this is the first school year where the mandatory vaccine requirements were in place. Unfortunately, because of that prior abuse of personal belief exemptions in California, there are still communities at risk for vaccine preventable diseases.

A measles outbreak in the Orthodox Jewish community in parts of Los Angeles struck 20 individuals. And when county health officers started tracking down the 2000 people who were in contact with measles patients, they found that over 10% of them were not vaccinated.

A recent mumps outbreak in Los Angeles has stricken seven adult males who lacked vaccination to the disease (usually from the MMR vaccine). And last month, there was an outbreak of mumps amongst college students in Southern California. Hopefully, as we increase the vaccine uptake in California, the risk of these type of outbreaks will become lower and lower.

Unfortunately, there is a loophole (I told you) in the California SB277 – the medical exemption only requires a letter from a physician, and it’s not further scrutinized as is done in West Virginia. And because there are numerous anti-vaccine doctors who ignore real science for their beliefs, there appears to be a growing cottage industry forming to make medical exemptions somewhat easily available.

According to the garrulous Orac, it seems that medical exemptions are for sale. Orac mentions a Dr. Tara Zandvliet, who charges $120 per child for medical exemptions for vaccines. She describes what constitutes a valid, in her opinion, medical exemption for vaccines:

Hyper immune conditions
Including, but not limited to:

  • Asthma
  • Allergies to food, bee stings, medicines that include hives/swelling/wheezing (hay fever does not count)
  • Eczema
  • Hives

Autoimmune Conditions
Including, but not limited to:

  • Celiac
  • Crohn’s
  • Ulcerative Colitis
  • Lupus
  • Sjogrens
  • Scleroderma
  • Mixed connective tissue
  • Hashimoto or Graves thyroid (not regular low thyroid)
  • Psoriasis
  • Vitiligo
  • Vasculitis
  • Antiphospholipid antibody
  • Multiple Sclerosis
  • Rheumatoid arthritis (not old age or overuse arthritis)
  • Wegeners
  • Type 1 diabetes (child type)
  • Eosinophilic esophagitis
  • Documented autoimmune only – not suspected autoimmune such as fibromyalgia, chronic fatigue, Lyme or endometriosis. Those will not qualify.

Immune Cancers
Including, but not limited to:

  • Lymphoma
  • Leukemia
  • Multiple myeloma

Immune deficiencies
Including, but not limited to:

  • SCID
  • Agammaglobulinemia
  • Documented diseases only. Not “getting sick a lot”.

Genetic conditions associated with worse outcomes

  • Studies are still pending, but include MTHFR, Some HLA subtypes.

Vaccine reactions

  • Vaccine reactions must be related to the vaccine within about a week, and must be immediate and not caused by anything else. These reactions include but are not limited to:
  • Seizure
  • Anaphylaxis
  • Leg swelling causing hospitalization
  • Difficulty breathing
  • Encephalitis, including high-pitched cry and developmental regression
  • Coma
  • Severe lethargy
  • Fevers over 103
  • Bad reactions do NOT include fevers under 103, sore leg, cranky, getting sick a lot after, getting asthma after, having allergies after vaccination.

This is a ridiculous list. Children with type 1 diabetes, for example, are more susceptible to and more at risk of complications from vaccine preventable diseases. If Dr. Zandvliet had any idea about diabetes, she would be strongly recommending vaccines for those children. Ironically, the only treatment for type 1 diabetes is 3-4 times daily injections of insulin, whose package insert (pdf) would make any anti-vaxxer faint – vaccines should be a walk in the park for any child with diabetes. And should be  required.

Dr. Zandvliet also states that MTHFR gene mutation is a risk factor for vaccines. But that’s simply not true, and no reliable source says that this gene mutation is a serious contraindication for vaccines.

Furthermore, her list of vaccine reactions actually may or may not be related to vaccines. The whole list is dependent upon parental memory and post hoc logical fallacies.

Finally, as Orac points out, the actual list of real contraindications for vaccines is rather limited – severe allergic reaction to the vaccine or its components, which will be obvious to anyone, is the major one. But I suppose, to get the vaccine medical exemption, people will try to make that claim. And because California relies upon the word of the physician rather than an independent, unbiased party, like West Virginia’s Immunization officer, there will be no way to dismiss this problem.

But there is some good news. Late last year, the California Medical Board started actions to pull the license of Dr. Robert Sears, a notorious anti-vaccine physician, who wrote a medical exemption for a 2 year old child. In a post in CityWatch, Bob Gelfand wrote:

The charges against Sears cannot help but create a stultifying effect on pediatricians who have been merchandising themselves as anti-vaccine practitioners, and on those who have been considering doing so. They are all thinking things through very carefully at the moment. The upside to writing slightly spurious vaccine exemptions is to build one’s medical practice and to gain the gratitude of anti-vaccine parents. The downside is the possible loss of one’s career.

By the way, continuing a narrative that bothers me about the anti-vaccine movement, it feels like only white privileged types are going to be able to get these “for sale” medical exemptions. Dr. Sears practices in a swanky part of Southern California, and caters to wealthy parents. Of course, Dr. Zandvliet charges $120 for her “services” in providing medical exemptions. I’ve seen numerous other “ads” from physicians in the expensive areas of California saying that they’ll consider writing medical exemptions for children.

The problem with this industry is that it has a negative impact on the California SB277 – the law may not be as effective as we want, although I’ve got a feeling that a lot of people who used personal belief exemptions are not going to be bothered by trying to find a pediatrician to write an exemption, once their own physician says, “NO!”

As long as California SB277 increases the uptake rate for childhood vaccines, despite the exemption industry, the overall effect should be strongly positive. But we all await data from California on the exemption rate and vaccination rate – as I always say, it’s the evidence that matters, and hopefully we’ll get some good evidence soon.

 

Index of articles by Prof. Dorit Rubinstein Reiss

Dorit Rubinstein Reiss

Editor’s note – this index of articles by Dorit Rubinstein Reiss has been updated and published here. The comments here are closed, and you can comment at the new article. 

 

Dorit Rubinstein Reiss – Professor of Law at the University of California Hastings College of the Law (San Francisco, CA) – is a frequent contributor to this and many other blogs, providing in-depth, and intellectually stimulating, articles about vaccines (generally, but sometimes moving to other areas of medicine), social policy and the law. Her articles usually unwind the complexities of legal issues with vaccinations and legal policies, such as mandatory vaccination and exemptions, with facts and citations. I know a lot of writers out there will link to one of her articles here as a sort of primary source to tear down a bogus antivaccine message.

Professor Reiss writes extensively in law journals about the social and legal policies of vaccination–she really is a well-published expert in this area of vaccine policy, and doesn’t stand on the pulpit with a veneer of Argument from Authority, but is actually an authority. Additionally, Reiss is also member of the Parent Advisory Board of Voices for Vaccines, a parent-led organization that supports and advocates for on-time vaccination and the reduction of vaccine-preventable disease.

Below is a list of articles that Dorit Rubinstein Reiss has written for this blog, organized into some arbitrary and somewhat broad categories for easy reference. Of course, she has written articles about vaccines and legal issues in other locations, which I intend to link here at a later date. This article will be updated as new articles from Dorit are added here.

Continue reading “Index of articles by Prof. Dorit Rubinstein Reiss”

SB277 lawsuit ruling – suit from A Voice for Choice dismissed by court

sb277 lawsuit ruling

To remind readers, in November 2016 a fourth lawsuit attacking California’s SB277, the law that removed the personal belief exemption from school immunization requirements, was filed in a district court in California. On January 13, 2017, after a hearing, the state’s motion to dismiss the lawsuit was granted. This is another SB277 lawsuit ruling that has supported the state of California.

The decision gave leave to amend, because the standard for doing so is very lax – as the decision explains, “[l]eave to amend should be granted unless the district court ‘determines that the pleading could not possibly be cured by the allegation of other facts.’” But the court left very little room for a successful amendment. It’s unknown yet whether plaintiffs would appeal.

Basically, the court followed the extensive jurisprudence in United States courts supporting school immunization laws, based on their role in protecting the public health.

This post starts by explaining more in detail the court’s decision. Then it addresses – shortly, because that’s not the focus of the case now –  two issues the court did not address in detail: why the plaintiffs’ argument of unconstitutional conditions is unconvincing and the problems with the plaintiffs’ effort to distinguish previous Supreme Court cases.  Continue reading “SB277 lawsuit ruling – suit from A Voice for Choice dismissed by court”