You may soon be required to accept mandatory education on the risks of vaccination exemption, with an emphasis on vaccination as a “community prevention tool,” before being allowed to opt your children out of vaccinations for “non-medical reasons,” according to an article in the Wall Street Journal (requires a subscription to read the article). Colorado and Washington are planning to institute mandatory counseling this year. Missisippi already allows only medical exemption and other states are considering similarly restrictive schemes.
“Non-medical reasons” is a way of saying personal choice or philosophical reasons. Should it become difficult to opt out of vaccines for non-medical reasons, this could make things very tough for parents who choose not to vaccinate. Obtaining a medical exemption generally requires parents to have a written statement of proof from a physician that their child has an illness that precludes vaccination (few illnesses do) or that she or he has had a previous vaccination reaction serious enough to warrant skipping them in the future – which given the limited existing definition of what qualifies as a vaccine reaction serious enough to justify this, can be hard to prove.
While I am not opposed to parents receiving education on vaccination pros and cons, as well as the pros and cons of choosing not to vaccinate — which actually could be of value to parents — I am concerned that the information will be biased, based on convention medical rhetoric that denies any and all problems with vaccinations. And if the ability to choose not to vaccinate for non-medical reasons is removed and parents can't prove a non-medical reason, is this not essentially the equivalent of mandating vaccinations?
This move is being predicated on the association between a drop in vaccination rates and an increase in pertussis and measles rates in a number of states. However, this is only a small part of the story. The fact is that the pertussis vaccine is much less effective than expected, as demonstrated by Centers for Disease Control statistics:
Valid vaccination history was available for 1,829 of 2,006 (91.2%) patients aged 3 months–19 years. Overall, 758 of 1,000 (75.8%) patients aged 3 months–10 years were up-to-date with the childhood diphtheria and tetanus toxoids and acellular pertussis (DTaP) doses. Receipt of Tdap was documented in 97 of 225 (43.1%) patients aged 11–12 years and in 466 of 604 (77.2%) patients aged 13–19 years. Estimated DTaP coverage in Washington among children aged 19–35 months was 93.2% for ≥3 doses and 81.9% for ≥4 doses in 2010; Tdap coverage in adolescents aged 13–17 years was estimated at 70.6% …Increased rates of pertussis among adolescents aged 13–14 years who were fully vaccinated with acellular vaccines in childhood suggests early waning of immunity after vaccination with Tdap vaccine. Studies are ongoing to evaluate Tdap duration of protection in adolescents. Centers for Disease Control and Prevention
Previously thought to confer practically lifelong protection, or at least protection until adulthood when pertussis infection causes no more than a mild annoying and persistent cough, we now know that the current vaccine preparation confers only about 5 years of immunity with nearly 50% having waned in half that time. A large percentage of the kids in the recent Washington State pertussis outbreak were vaccinated against pertussis.
Does a state have a right to mandate vaccination when it comes to a conflict between individual choice and potential public health issues?
As a physician I am not at all anti-vaccine. They save lives. No question. I personally came quite literally face-to-face with diphtheria when providing medical care in Haiti. I counted my lucky stars that I was protected against this often deadly disease through the vaccinations I had received.
A decrease in immunization rates could mean that more of our kids contract “vaccine preventable diseases.” It is likely that the current measles outbreak in California is due to a decline in measles vaccination rates. This is a reality we have to face. However, parents are declining the vaccine in unprecedented numbers because they are afraid that there is an association between the MMR vaccination, of which measles is a component, and autism. While a causal link has not been identified, in my clinical experience as a doctor I have seen children whose symptoms of autism began within weeks of the MMR vaccine. None of their parents were opting out of vaccinations or even questioned vaccine safety. They were following the rules.
As a mom and physician I have many unanswered questions. And so do many parents that I hear from whose questions and concerns have not been adequately addressed by their pediatricians and family doctors.
I have followed the vaccine debate for 3 decades, and chose to opt out of the whole cell pertussis vaccinations for my own children over 20 years ago because of safety issues. I empathize with parents who are concerned about vaccine safety. There are legitimate reasons that educated, intelligent, caring parents are concerned about vaccinating their children and are even opting out. When my children were young, I was told that the pertussis vaccine was totally safe. It was replaced several years later with a new form of the vaccine, the acellular pertussis, because the whole cell version was in fact found to be associated with neurologic events including seizures. We'd been told there was no such association, though it had already been discontinued in Japan and several European countries in favor of the safer acellular version. I picketed with other families at the CDC 25 years ago, asking for the truth. It was not forthcoming. So who are parents supposed to trust? And how can they trust the information that might be delivered in mandatory education sessions?
Lawmakers, health policy drivers, and physicians would be wise to listen to and address parents' concerns. Further polarizing parents with increasingly restrictive laws will only keep parents from sending their kids to the doctor's office. And if the consequence of choosing no vaccines is no school — well, increasing numbers will simply choose that option.
It appears that very soon, at least in some states, parents will be required to listen to programming on the importance of vaccinations. Will state governments and physicians similarly be required to listen to and try to understand parents' concerns? I believe we all have the same goal – healthy children. But who gets to decide what that means?
What do you think?