A recent report indicated that US state legislatures are beginning to pass laws that make it more difficult for parents to obtain so-called personal exemptions to vaccinations before children attend public schools. According to the author, Tara Haelle, “Each US state sets its own vaccination policies, and most will not generally allow children to attend public school unless they have been vaccinated against diphtheria, tetanus and pertussis (whooping cough); hepatitis B; the Haemophilus influenzae bacterium; measles, mumps and rubella; polio; and varicella (chicken pox).” In general, most states require that students meet the Centers for Disease Control and Prevention schedule (pdf) for children between 0 and 6 years old, which is set by the Advisory Committee on Immunization Practices.
All states allow legitimate medical exemptions from the immunization schedule before a child enters school, because of certain medical conditions that might make vaccinations problematic for young children. Some of these medical issues are: allergies to some of the components in the vaccines, immunocompromised conditions, family history of seizures, and other issues outlined in the General Recommendations on Immunization of the Advisory Committee on Immunization Practices. These medical exemptions are extremely rare, but are very important. A licensed medical doctor is the only one that should provide this exemption.
However, “personal exemptions”, which may be philosophical, religious, or just because the parent thinks its better to not vaccinate, has become a huge legal loophole through which vaccine deniers can walk without much difficulty. According to Haelle, “20 states — including California, Washington and Vermont — allow exemptions for personal or philosophical belief, and 48 offer religious exemptions. But exemption rates are growing. In Washington, 6% of children entering kindergarten in 2010–11 had an exemption; in Vermont, the figure was 6.2%, compared with the US average of 1.5%. In California, exemptions rates rose by 25% between 2008 and 2010.” Many of these personal exemptions require nothing more than simply filling out a form and signing it without discussing the exemption with a medical professional.
A recently published article that examined vaccine exemptions, found that more parents get medical vaccination exemptions for their kindergarten children in states in which they are easier to obtain. A perfectly predictable result, based on anecdotal observations of the arguments that I’ve observed on the internet.
The study found that the number of medical exemptions was relatively low during the seven years of the study period, but the rate was more than 6X higher in states with relatively easy medical exemption criteria when compared to states with more difficult exemption standards. As I reported previously, as more parents get vaccine exemptions, herd immunity can be impacted, and children in schools with low immunization levels can face outbreaks of diseases that were once thought rare.
The most interesting results from the study were:
- The authors rated the medical exemption criteria as difficult in only three states: Arkansas, New Mexico, and Wyoming. The criteria were rated as medium in 17 states and easy in 30 states.
- The nationwide rate of medical exemptions ranged from a low of 263 per 100,000 children (0.26%) in 2006-07 to a high of 411 per 100,000 (0.41%) in 2008-09. The national total of exemptions increased from 11,277 in 2004-05 to 13,952 in 2010-11.
- The total number of exemptions for kindergartners over the 7 years came to 87,631.
- The rates of medical exemptions in states with easy or medium criteria were significantly higher than in those with difficult criteria, the researchers found. For “easy” states, the incidence rate ratio (IRR) was 6.4; for “medium” states, it was 4.4. In other words, there were approximately 45% more frequent exemptions in “easy” states than in medium states. (There wasn’t a comparison to “difficult” states, since there were so few of those.)
- Medical exemptions were more numerous in states that had difficult or medium rules for nonmedical exemptions (380.5 and 364.3 per 100,000, respectively) than in states with easy nonmedical exemption rules (221.3 per 100,000).
- Although medical exemption rates are low, other studies show they surpass 1% of kindergarten children in some states, the study reported. As we have seen in other studies, medical exemptions “add to existing pockets of susceptibility [to vaccine-preventable diseases] due to nonmedical exemptions to immunization,” because “immunization exemptors cluster geographically, increasing the possibility for local areas of increased disease incidence.”
The authors commented, “The appropriate use of medical exemptions is important to maintaining sufficient herd immunity to protect those who should not be vaccinated due to medical contraindications. Medical providers, parents, school officials, and state health officials are responsible for ensuring that medical exemptions are actually medically indicated.”
Let me repeat what I’ve written before–I am strongly opposed to ALL personal exemptions to vaccines, and that viewpoint is supported in the United States by the Supreme Court ruling in Jacobson v United States which states that the freedom of the individual must sometimes be subordinated to the general welfare of its citizens and is subject to the police power of the state. In other words, if vaccine deniers want to use public schools, then they must vaccinate. The common good outweighs personal beliefs, especially if that personal belief is unsupported by facts and evidence. Moreover, since the issue usually involves enrollment in public schools, they can choose to enroll their children in private schools, although those schools tend to have tougher requirements for vaccinations, because those schools don’t want their children being exposed to diseases that could be prevented by vaccines. A free public education does not imply a right to harm other children by not vaccinated.
Furthermore, religious exemptions for vaccines should not exist in a secular country. If you want a religious exemption, then please send your child to a religious school, because a public school is a public institution, and according to the Establishment Clause of the First Amendment of the United States Constitution public schools cannot favor one religious group over another. Or over those who don’t care about religion. In fact, the Jehovah’s Witnesses, who are opposed to almost all medical procedures, are not opposed to vaccinations. There are just no mainstream religions that are opposed to vaccinations.
As for medical exemptions, here is basically what is stated in the General Recommendations on Immunization of the Advisory Committee on Immunization Practices (ACIP):
- Contraindications and precautions to vaccination are conditions under which vaccines should not or likely should not be administered. Because the majority of contraindications and precautions are temporary, vaccinations often can be administered later if one or more exist. A contraindication is a condition in a recipient that increases the risk for a serious adverse reaction. A vaccine should not be administered when a contraindication is present; for example, MMR vaccine should not be administered to severely immunocompromised persons. In contrast, certain conditions are commonly misperceived as contraindications (i.e., are not valid reasons to defer vaccination).
- National standards for pediatric vaccination practices have been established and include descriptions of valid contraindications and precautions to vaccination. Persons who administer vaccines should screen patients for contraindications and precautions to the vaccine before each dose of vaccine is administered.
- The only contraindication applicable to all vaccines is a history of a severe allergic reaction (i.e., anaphylaxis) after a previous dose of vaccine or to a vaccine component (unless the recipient has been desensitized; see Special Situations section).
- Severely immunocompromised persons generally should not receive live vaccines. Children who experienced encephalopathy within 7 days after administration of a previous dose of diphtheria and tetanus toxoids and whole-cell pertussis vaccine (DTP), DTaP, or Tdap not attributable to another identifiable cause should not receive additional doses of a vaccine that contains pertussis. Because of the theoretical risk to the fetus, women known to be pregnant generally should not receive live, attenuated virus vaccines (see Special Situations section).
- A precaution is a condition in a recipient that might increase the risk for a serious adverse reaction or that might compromise the ability of the vaccine to produce immunity (e.g., administering measles vaccine to a person with passive immunity to measles from a blood transfusion or administering influenza vaccine to someone with a history of Guillain-Barré syndrome within 6 weeks of a previous influenza vaccination). A person might experience a more severe reaction to the vaccine than would have otherwise been expected; however, the risk for this happening is less than the risk expected with a contraindication. In general, vaccinations should be deferred when a precaution is present. However, a vaccination might be indicated in the presence of a precaution if the benefit of protection from the vaccine outweighs the risk for an adverse reaction. For example a dose of DTaP should be considered for a person in a community with a pertussis outbreak even if that person previously developed Guillain-Barré syndrome after a dose.
- The presence of a moderate or severe acute illness with or without a fever is a precaution to administration of all vaccines.
- A personal or family history of seizures is a precaution for MMRV vaccination.
- The provider should ask the parent or guardian if the child is ill. If the child has a moderate or severe illness, the vaccination should be postponed.
Clinicians or other health-care providers might misperceive certain conditions or circumstances as valid contraindications or precautions to vaccination when they actually do not preclude vaccination. These misperceptions result in missed opportunities to administer recommended vaccines. Among the most common conditions mistakenly considered to be contraindications are diarrhea, minor upper respiratory tract illnesses (including otitis media) with or without fever, mild to moderate local reactions to a previous dose of vaccine, current antimicrobial therapy, and being in the convalescent phase of an acute illness.
In other words, reasons to medically exempt children from vaccines are unusual and should be infrequently given. In fact, as the ACIP states, it’s so rare that sometimes physicians misperceive reasons for not giving vaccinations.
Paul Offit, MD, a strong supporter of vaccinations, and someone who spent 25 years of his life developing a vaccine for rotavirus, a gastrointestinal virus that hospitalized over 55,000 children a year prior to the introduction of the rotavirus vaccine. Dr. Offit, who is absolutely despised by the antivaccination crowd, wrote an editorial in a Philadelphia newspaper critical of a proposed Pennsylvania law that deals with abuse of children. According to Offit, “… Senate Bill 20 makes it clear that any adult who ’causes serious bodily injury,’ either by ‘kicking, biting, stabbing, cutting, or throwing a child,’ or ‘forcefully shakes or slaps a child under one year of age,’ or ’causes serious physical neglect,’ or ’causes a child to be near a methamphetamine lab,’ or ‘operates a vehicle in which a child is a passenger while driving under the influence of alcohol,’ has committed child abuse.” Now, I’m guessing that almost everyone would support this bill, although many vaccine refusers think that shaken babies are actually a vaccine injury (the disgusting levels that antivaccinationists will go to make their case is impossible to comprehend).
So all well and good. Except, according to Offit, the bill also states that “if a child has not been provided needed medical or surgical care because of seriously held religious beliefs of the child’s parents … the child shall not be deemed to be physically or mentally abused.” Wait! What? Offit then states the obvious, “in other words, if parents decide not to give their children antibiotics for meningitis, or insulin for diabetes, or chemotherapy for cancer, or surgery for intestinal blockage, they won’t be held accountable. According to the bill, parents are abusive if they slap their 1-year-old child, but not if they withhold lifesaving therapies.” Offit continues,
The 14th Amendment to the Constitution states that “no state shall … deny to any person within its jurisdiction the equal protection of the laws.” Children whose parents hold certain religious beliefs shouldn’t be afforded less protection than other children. That the commonwealth has allowed children to die from measles, bacterial pneumonia, or leukemia in the name of religion is inexplicable. That it continues to allow such abuse in the face of recent deaths is unconscionable.
Pennsylvania should repeal its religious exemptions for medical neglect. Otherwise, children will continue to suffer and die needlessly.
Bacterial pneumonia and measles are prevented by vaccines, and should never, ever, ever, ever be withheld from children because of “religious” beliefs.
It’s time to stop allowing exemptions, which are nothing more than a cynical method for vaccine denialists to opt out of vaccinating their children, but still putting their children in school, putting other children at risk. The state should not give protection to parents who abuse their children by withholding medical treatment, whether it’s vaccines, insulin, or surgery. That’s it, simple. No exemptions, except under the most narrow of regulations for medical exemptions. No religious exemptions. No personal exemptions. And very narrow medical exemptions approved by several layers of health care professionals to prevent abuse by the denialists.
Vaccines save lives.
- Haelle T. US states make opting out of vaccinations harder. Nature News. 2012 Oct 5. doi: 10.1038/nature.2012.11548.
- Stadlin S, Bednarczyk RA, Omer SB. Medical exemptions to school immunization requirements in the United States–association of state policies with medical exemption rates (2004-2011). J Infect Dis. 2012 Oct 1;206(7):989-92. doi: 10.1093/infdis/jis436. Epub 2012 Aug 29. PubMed PMID: 22936834.
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