Sep 07 2017

Eliminating Personal Belief Exemptions for Vaccines

ExImmunMap15-TuesdayIn the US routine childhood vaccination is required for entry into public school, and in some states even private school. This is a reasonable public health policy. Vaccination not only protects the individual against common infectious diseases, but when enough people get vaccinated this creates community immunity (often referred to as herd immunity) which protects everyone.

Any parent knows first hand that children are seething vectors for germs. Their concept of hygiene, generally speaking, is often not the same as the average adult. Put a large group of children together in a close environment like a school, and you have basically created a disease factory.

Further, some children cannot be vaccinated for medical reasons. They may have a chronic illness that makes their immune systems too weak to handle the vaccine, or they have an intolerance to vaccines. For these children, if they want to attend school, their only protection is the community immunity that results from all the more healthy children being vaccinated. 

Vaccine Exemptions and SB277

Over the decades those with a belief system that lead them to anti-vaccine views have persistently lobbied their state governments to allow for exemptions to mandatory vaccination laws. Much of this lobbying has come from the Christian Scientists, who are often anti-vaccine. They have mostly lobbied for religious exemptions to vaccines, but this has often extended to more permissive non-medical exemptions in general.

America also highly values personal freedom as a general cultural feature. In order to balance the public good and personal freedom the laws do not mandate vaccination for all children – only if you want to enter the school system and mix your child with other children in large groups. If you don’t want your child to be vaccinated, you can home school them.

Whether or not this is the optimal balance of freedom and public good is a matter of debate, but that is where we are. The fight now, when it comes to state vaccination laws, centers around how permissive to make the rules that allow parents to seek exemption from the vaccination requirement to enter school.

All states allow for medical exemptions if children have a medical condition that is a contraindication to vaccination. This is non-controversial. There are three other levels of exemption we can consider: more permissive medical exemptions, religious exemptions, and personal belief exemptions.

Of these religious exemptions are perhaps the most controversial. Even among proponents of science-based medicine, it is unclear if this is a fight we think we can win. We should try, but not necessarily go down with that ship. Eliminating religious exemptions in states that have them is likely to meet the most opposition. Personal belief exemptions (PBE) are the most vulnerable. They are essentially parents saying that they don’t want to vaccinate their kids, and make mandatory vaccine policies an illusion. Definitely we can and should eliminate PBEs in all states.

However, after the Disneyland measles outbreak the political calculus on this issue definitely changed. As we have been predicting on SBM for years, it will likely take a significant return of previously eliminated infectious diseases before the public wakes up about the need for mandatory vaccination. That is exactly what happened. In the wake of the Disney outbreak, California passed SB277, which went into effect on July 1, 2016, and which eliminated all non-medical exemptions, including religious and PBE.

At the same time, however, the bill expanded medical exemptions, giving doctors more leeway in granting it. Previously a medical exemption requires a vaccine contraindication, and now it can include a family history of a reaction to vaccines and other softer indications.

Now it has been a full year since SB277, and JAMA has published an article reporting the results. Overall, the results are good. Non medical exemptions significantly decreased, from 2.37% to 0.56%. However, at the same time medical exemptions increased from 0.17% to 0.51%. Overall vaccine exemptions decreased from 2.54% to 1.06%.

So – bottom line is that SB277 worked. It decreased vaccine exemptions by more than half. These percentages may all seem very low, but it makes a big difference for two main reasons. First, the higher the vaccination rate the more effective is community immunity. Getting a few more percent of kids vaccinated can make a huge difference. Second, these numbers are statewide, and are not evenly distributed. There are pockets of vaccine refusal, and likewise those pockets can be significantly decreased by eliminating PBE.

Of concern, however is the tripling of the rate of medical exemptions. These increased in areas where PBE decreased, and so there does appear to be some substitution. However, it is difficult to interpret exactly what that means. Some parents with children with legitimate reasons for medical exemptions may have used the PBE option because it was easier. A medical exemption requires a letter from a doctor. Now they have to go through that extra step.

But of course some parents who really are just vaccine hesitant may have sought a medical exemption for a questionable reason to replace their PBE. Researchers would have to gather further information in order to resolve this. It also suggests that SB277 can be tightened further, perhaps narrowing the range of what constitutes a legitimate medical exemption, to keep vaccine rates high.

We also know from other studies states with more permissive exemption laws have lower vaccine rates and higher risk of vaccine-preventable diseases. In addition to whether or not they allow religious or personal belief exemptions, states differ on how difficult it is to obtain such exemptions. States that make it harder have higher vaccine compliance.

Overall the data is clear – if we want to optimally protect the public from outbreaks of vaccine-preventable diseases, and to eliminate and perhaps even eventually eradicate some of those diseases, we need to have strong mandatory vaccination laws. Personal belief exemptions all have to go. Religious exemptions should go too, but that will be more of a fight. In those states who allow for religious exemptions, it should be difficult to obtain them (like requiring parental education about the importance of vaccines). Further, medical exemptions should be evidence-based, and not overly permissive.

SB277 was a great step forward, but we can’t stop there. Of the 50 states, 47 of them allow for some combination of religious and personal belief exemptions. There is a lot of work to do.

25 responses so far

25 Responses to “Eliminating Personal Belief Exemptions for Vaccines”

  1. ScubaSharkyon 07 Sep 2017 at 12:15 pm

    Minor correction: Walt Disney WORLD is in Florida. DisneyLAND is in California. 🙂

  2. Steven Novellaon 07 Sep 2017 at 3:56 pm

    Thanks – fixed.

  3. Bill Openthalton 07 Sep 2017 at 5:51 pm

    France’s new Health Minister wants to make 8 additional childhood vaccines compulsory (until now only Diphtheria, Tetanus and Polio vaccination is compulsory). They’re upgrading hemophilus influenza B, whooping cough, hepatitis B, measles, mumps, rubella, meningococcus C and pneumococcus vaccines from “recommended” to “compulsory”. According to the government ( http://www.gouvernement.fr/argumentaire/8-nouveaux-vaccins-obligatoires-pour-les-enfants-de-moins-de-2-ans ), only 70% of children currently get all the vaccines (10 shots between 0 and 2 years of age). The measure is quite contested in a country where 41% of the population doesn’t trust the safety of vaccines.

  4. michaelegnoron 07 Sep 2017 at 10:44 pm

    Steven:

    [if we want to optimally protect the public from outbreaks of vaccine-preventable diseases, and to eliminate and perhaps even eventually eradicate some of those diseases, we need to have strong mandatory vaccination laws. Personal belief exemptions all have to go.]

    And there’s no question that devout Christian practice improves health and reduces anti-social behavior, which is an enormous social benefit.

    Therefore,

    if we want to optimally protect the public from outbreaks of non-Christian life, and to eliminate and perhaps even eventually eradicate some of behaviors associated with non-Christian life, we need to have strong mandatory Christian practice laws. Personal belief exemptions all have to go.

    I’m starting to like these new “personal belief exemptions all have to go” laws. I’ve got a whole list of things I’m going to force you to do, for your own good and the good of society.

    Hey, this totalitarian stuff isn’t so bad after all…

  5. michaelegnoron 07 Sep 2017 at 10:48 pm

    Steven,

    I point out the irony of an atheist, who holds to the deadliest belief system in modern times (100 million murders and counting), announcing that, for the good of society, personal beliefs are now going to be regulated.

    You atheists need to sign up immediately at your local church. Public health is at stake. It’s the law.

  6. michaelegnoron 07 Sep 2017 at 11:01 pm

    If preventing the spread of deadly disease is justification for constraining prsonal freedom, why is it legal for a person with AIDS to have sex with an uninfected person?

  7. wellerpondon 07 Sep 2017 at 11:30 pm

    michaelegnor,

    Regarding your last point:

    https://www.quora.com/Is-it-illegal-to-knowingly-infect-someone-with-HIV

  8. RickKon 07 Sep 2017 at 11:55 pm

    The redder the state, the lower the life expectancy.

    Hmm.. Wrong again, Michael.

    But you’re not here to make any accurate or substantive points. You’re just here to provoke people who are trying to have an adult conversation.
    https://m.youtube.com/watch?v=h8JKZgwqH3g

  9. bachfiendon 07 Sep 2017 at 11:56 pm

    wellerpond,

    Well, Egnor doesn’t care about ‘facts’. He just trots out whatever nonsense he thinks supports his worldview and ideology.

    I was wondering what had happened to Michael Egnor. Perhaps he was missing the public attention he craves? Since EvolutionNews doesn’t accept comments, it’s impossible to determine how many people read his frequent threads there.

  10. michaelegnoron 08 Sep 2017 at 12:40 pm

    @wellerpond:

    Of course it is illegal to knowingly infect someone with a disease. That’s assualt, battery, etc. That’s irrelevant to my point.

    My point is:

    If it is justifiable on public health grounds to “eliminate personal belief exemptions” from vaccines in order to prevent the spread of disease, why isn’t it justifiable to legally constrain HIV positive people from sexual contact with HIV negative people? A much stronger public health case can be made for draconian measures to prevent AIDS than for draconian measures to prevent measles.

    Please understand: I support vaccination, and I am inclined to agree that vaccination should be mandatory, as a matter of public health. What perplexes me is that the same kind of vigilence is not invoked in the control of AIDS, which seems to have a political constituency that exempts it from ordinary public health measures, such as quarantine, tracking of contacts, etc.

    It just strikes me as incongruous that we’re calling the police on a mother who’s concerned about autism, while a orgy of HIV infected and uninfected people goes on next door unmolested.

    I guess it’s better to have two standards, than no standards at all.

  11. BurnOuton 08 Sep 2017 at 1:55 pm

    [Please understand: I support vaccination, and I am inclined to agree that vaccination should be mandatory, as a matter of public health. What perplexes me is that the same kind of vigilence is not invoked in the control of AIDS, which seems to have a political constituency that exempts it from ordinary public health measures, such as quarantine, tracking of contacts, etc.]

    You can’t easily quarantine cases of an infection that lasts the rest of one’s life. If you care about preventing HIV infection, you need to be sure that public health measures don’t prevent patients from seeking treatment. I would be concerned about a draconian strategy for this reason. So what is it exactly that you think we should do?

    [It just strikes me as incongruous that we’re calling the police on a mother who’s concerned about autism, while a orgy of HIV infected and uninfected people goes on next door unmolested.]

    OK, but nobody is calling the police since there’s no law against refusing vaccines. Regarding orgies:
    how exactly do you want to regulate sexual activity of HIV patients?

  12. michaelegnoron 08 Sep 2017 at 2:33 pm

    burn:

    [I would be concerned about a draconian strategy for this reason. So what is it exactly that you think we should do? Regarding orgies:how exactly do you want to regulate sexual activity of HIV patients?]

    I’m not a big fan of ‘regulating activities’ in general, in part because of privacy issues and in part because of logistical issues.

    What I want is consistency. If you are going to criminalize vaccine refusal, which is exactly what Steven advocates, why not criminalize other, much more dangerous, behavior that disseminates diseases much deadlier than measles?

    The reason is obvious. You have two standards: one for folks who don’t like thimerisol, another for men who like sex with men.

    The latter is orders of magnitude more deadly than the former (there are few behaviors as destructive to personal and group health as promiscuous homosexuality). Why be draconian with the former, and not with the later?

  13. Beamupon 08 Sep 2017 at 3:03 pm

    You might want to take note of the fact that the original post explicitly includes the observation that home schooling is an alternative. “If you want to use this particular public service, you must vaccinate” is not even close to “criminaliz[ing] vaccine refusal.” I observe that you’ve already been called on this, yet you continue to repeat the strawman.

    And more generally, constraining a person’s activities in a public setting where they are exposing everyone around their child to an avoidable risk, where said “everyone” has no opportunity to object, is fundamentally different from constraining private activity between two consenting adults.

    Furthermore the entire concept of comparing public health measures around measles and HIV is pretty darn ridiculous, given that the former is an exceedingly infectious airborne virus and the latter spreads orders of magnitude less readily. Plus there isn’t an HIV vaccine. When the available countermeasures are so different, and the patterns of spread are so different, it would be an exceedingly ignorant public health organization which tried to approach them the same way.

  14. RickKon 08 Sep 2017 at 3:49 pm

    Michael is a totalitarian at heart – always has been. So he’s naturally in favor of tracking and registries and forced limitations on sexual activity.

    He knows there’s a difference between denying certain services to people who refuse vaccination, and creating a government registry of people’s sex partners. But again, he’s just here to poke not to discuss.

  15. bachfiendon 08 Sep 2017 at 4:38 pm

    ‘The reason is obvious. You have two standards: one for folks who don’t like thimerisol, another for men who like sex with men’.

    Another one of Michael’s extremely stupid Egnorisms. Thimerisol is no longer used in childhood vaccines. It’s used in multidose vaccines in some situations.

    Michael is advocating quarantine for men whom he think are ‘unclean’ spreading disease, even worse, spreading disease via sex, which makes Michael even more uncomfortable.

    Obviously, if someone has an infectious disease capable of being spread to another person, such as measles or tuberculosis, then that person should be quarantined, either voluntarily or by compulsion, until that person is no longer infectious. And that includes HIV-positive individuals with open tuberculosis, which might be for the rest of the person’s life if it’s a strain resistant to all antibiotics.

  16. michaelegnoron 08 Sep 2017 at 6:35 pm

    bach:

    Should an HIV positive person who persists in having sex with uninfected people be quarantined?

  17. bachfiendon 08 Sep 2017 at 7:04 pm

    Michael,

    ‘Should an HIV positive person who persists in having sex with uninflected people be quarantined?’

    Yes, in gaol. It should be (and is) a criminal offence.

    There will, of course, be exceptions. Suppose the uninfected person is consenting, and is aware of the risks? You can’t legislate against people taking risks that affect only themselves. You can’t prohibit the use of excessive alcohol consumption or cigarette smoking if it’s only affecting the addicts. You can’t ban mountain climbing. Suppose the uninfected person is also taking prophylactic anti-HIV medication? Suppose the HIV positive person is on treatment, and has a very low but still detectable viral burden?

    You, as a conservative, want to think in terms of polar options. Real life is a matter of greys, nuances.

  18. michaelegnoron 08 Sep 2017 at 8:59 pm

    It’s not a criminal offense for a person with AIDS to have sex with an uninfected person, unless there is intent to transmit the disease.

    The hysteria against vaccination refusal, along with the astonishing permissiveness for deadly sexual behavior, reminds me of when Mayor Bloomberg of New York was on his “get rid of large soda cups” crusade, and at the same time, marching in gay pride parades, which celebrate much deadlier behavior than drinking soda.

  19. bachfiendon 08 Sep 2017 at 9:24 pm

    Michael,

    ‘It’s not a criminal offence for a person with AIDS to have sex with an uninfected person, unless there is intent to transmit the disease’.

    Evidence please? It’s my understanding that it’s an offence for a person not to disclose HIV status if positive to a potential sexual partner.

    Having ‘intent’ is difficult to prove. ‘Intent’ isn’t necessary for certain acts to be regarded as criminal and able to be successfully prosecuted in a court of law. If you kill someone (and there’s no legal justification for it, such as self-defence), if there was intent on your part to kill, then it’s murder. If there was no intent to kill, then it could be manslaughter. Or unlawful action causing death.

  20. michaelegnoron 08 Sep 2017 at 9:32 pm

    Here’s what get me:

    We have a massive epidemic of sexually transmitted diseases. AIDS, syphilis, gonorrhea, herpes, stuff you’ve never heard of. Multiple infections in each victim. A massive epidemic, probably unprecedented.

    http://www.huffingtonpost.com/dr-jonathan-mermin/have-stds-reached-crisis_b_12577246.html

    Tens of millions of people infected annually. Deaths, sterility, cancer.

    What is Steven whining about? What does he want to use as a pretext to deny basic human rights?

    Measles. A few soccer moms who fear autism. Lock ’em up!

    Tens of millions of infections, many permanently disabling and some deadly: birds tweeting…

    If you want to get serious about public health, ignore the soccer moms.

    For STD’s: Mandatory testing, mandatory reporting, mandatory abstinence, quarantine if necessary, criminal sanctions for people who knowingly expose others to infection.

    If you want to get serious…

  21. michaelegnoron 08 Sep 2017 at 9:35 pm

    But you don’t want to get serious. You want to beat the sh*t out of a few religious people who you think are anti-science.

    You don’t give a sh*t about public health. Not when you attack the tiny fringe who don’t like vaccines, and ignore the tens of millions who persistently spread very dangerous diseases without any legal sanction at all.

  22. bachfiendon 08 Sep 2017 at 10:22 pm

    Michael,

    ‘For STD’s (sic): Mandatory testing, mandatory reporting, mandatory abstinence, quarantine if necessary, criminal sanctions for people who knowingly expose others to infection’.

    Sounds ‘easy’, doesn’t it? Unless you make it compulsory to test everyone regularly (which would be extremely expensive), all you’d be doing is profiling, targeting segments of the population you don’t like and forcing them to hide and avoid treatment, which would be counterproductive.

    Where do you have the idea that Steven Novella thinks that HIV infection should be ignored? Evidence please?

    It’s a fair stretch to get from the idea that children without medical exemption for immunisation who haven’t been immunised against the common childhood infections shouldn’t be allowed to attend public schools and kindergartens to the idea that homosexuals with HIV infection should be incarcerated.

  23. chikoppion 08 Sep 2017 at 10:36 pm

    [michael egnor] We have a massive epidemic of sexually transmitted diseases.

    You don’t give a sh*t about public health. Not when you attack the tiny fringe who don’t like vaccines, and ignore the tens of millions who persistently spread very dangerous diseases without any legal sanction at all.

    A five year old can’t protect themselves from contracting whooping cough or polio from an unvaccinated classmate. The “fringe who don’t like vaccines” are subjecting other children to risk without consent.

    Adults choose to assume the personal risk of sexual contact through informed consent.

    The difference is whether or not the party exposed to the risk is able to consent to that risk.

  24. RickKon 09 Sep 2017 at 12:18 pm

    Michael said: “You don’t give a sh*t about public health.”

    No, we just care more about personal liberty than you. Denying government handouts to those that don’t vaccinate is not an infringement of liberty. Quarantining and tracking people is.

    But you focus on the “religious” element of the debate because your epistemology is entirely tribal.

    Killing or detaining people is fine if they’re the other tribe according to Mr. The- Inqusition-was-too-Timid Egnor.

  25. BillyJoe7on 09 Sep 2017 at 6:32 pm

    Michael Egnor,

    You are all over the place here.

    First of all, this post is about religious and personal belief exemptions from vaccinations. It is not about controlling STDs. Taking action on one doesn’t preclude taking action on the other. We can do both. But this post is about the former.

    Secondly, there is almost no connection between taking action against religious and personal belief exemptions from vaccinations and limiting the spread STDs. They are different problems with different solutions. Only your personal disgust regarding promiscuous and homosexual behaviour prevents you from seeing this.

    Thirdly, you have to get past your personal bias against what you call promiscuous sexual activity and you have to get past your bias against sexual activity by homosexuals. Homosexuals who are going to have sex whether you like it or not. Homosexuals and heterosexuals who are going to have sex with multiple partners whether you like it or not. Personal disgust is no basis for sensible public policy.

Trackback URI | Comments RSS

Leave a Reply

You must be logged in to post a comment.