California, Vermont consider tougher vaccine-exemption rules
■ Physician organizations are concerned about the rising number of parents who skip immunizing their children for personal or philosophical reasons.
Recent outbreaks of vaccine-preventable diseases and a growing immunization opt-out rate are pushing physician organizations in California and Vermont to seek greater restrictions on exemptions from school-entry immunization requirements.
Every state allows exemptions for children with medical contraindications verified by a physician, and all but two states let parents with religious objections skip immunizing their children.
An additional 20 states allow exemptions based on parents' philosophical or personal beliefs. Requirements for securing personal-belief exemptions vary by state but are often as easy as signing a form.
Signing a form at the child's school is all it takes to obtain a personal-belief exemption in California, which researchers say has some of the loosest opt-out rules in the country. A California Assembly bill proposed in February would change that, requiring parents to obtain the signature of a physician, nurse practitioner or physician assistant affirming that the health professional provided “information regarding the benefits and risks of the immunization and the health risks of the communicable diseases” covered by the state's vaccine mandates. A similar requirement — the first of its kind in the nation — took effect for personal-belief exemptions in Washington state in July 2011. The Washington State Medical Assn. supported the measure. Despite Washington's action to encourage immunization, the state's health department said in April that pertussis has reached "epidemic" levels there, with 640 cases of whooping cough reported in 23 counties so far in 2012.
The California bill would help reduce the risk of disease outbreaks by requiring parents to become informed before opting out, said Rep. Richard Pan, MD, MPH, the state Assembly member who proposed the legislation, AB 2109.
“Parents are on the front line when it comes to protecting the health of their children and their communities,” Dr. Pan said. “This bill empowers them with up-to-date, accurate information about immunizations. As a pediatrician, I have spent my career making sure families, physicians and public officials are working in unison to build healthier communities. AB 2109 strengthens this relationship through education to help save our children from infectious outbreaks that can only be prevented by working together.”
A 2010 pertussis outbreak in California caused more than 9,000 infections, 800 hospitalizations and 10 deaths, Dr. Pan said. The state's education department reported in November 2011 that about 11,500 kindergartners had personal-belief exemptions, a 25% rise from the number during the two previous years.
“This bill doesn't take away a parent's right to exempt [his or her child from] immunizations,” said Paul Phinney, MD, president-elect of the California Medical Assn., which supports the bill. “It just makes sure parents are fully informed and make a good decision.” (See clarification)
The effect of opt outs
Vaccine exemption policies have an effect on opt-out rates and disease outbreaks, research shows. The 28 states that have religious-only exemptions saw their opt-out rates remain stable between 1991 and 2004, according to an Oct. 11, 2006, study in The Journal of the American Medical Association. But the 20 states that also allow personal-belief opt outs saw exemptions grow by 61%, to 2.54%, during the same period. Meanwhile, the 15 states with the easiest exemption process, including California, saw their rate jump 48%, to 2.51%, during that time. The religious-only opt-out states had pertussis rates two times lower than did states that also granted personal-belief exemptions. The hassle-free exemption states had pertussis rates 90% higher than the states where opt outs are the hardest to obtain.
“It's hard to say what effect one specific requirement such as the California proposal would have,” said Dr. Saad Bin Omer, PhD, MPH, lead author of the JAMA study and a faculty member at the Emory University Vaccine Center in Atlanta. “What we can say with reasonable confidence is that if you look at a scale of different kinds of requirements and divide them up into easy, difficult or moderate, we do in fact see a difference in both how much the rates of exemptions increase year to year and, more important, on actual disease.”
But the bill, AB 2109, which has been referred to the Committee on Health and scheduled for a hearing on April 17, already has provoked strong objections from vaccine skeptics. The measure has drawn protests, and alternative-vaccine schedule proponent Robert Sears, MD, has urged his followers to speak out against the bill.
“What gravely concerns me is that some doctors will refuse to sign this form,” Dr. Sears said in a post to his website, AskDrSears.com. “I know how doctors think. Many doctors strongly believe that vaccines should be mandatory, and that parents should not have the right to decline vaccines. Some doctors are willing to provide care to unvaccinated kids, despite this difference in philosophy. But now the power over this decision will be put directly into doctors' hands. He or she can simply refuse to sign the form. Doctors who oppose vaccine freedom of choice have been frustrated for years over this issue. Finally, they will have the power to impose their beliefs on their patients. Patients will be forced to find another doctor, submit to vaccines or get kicked out of school.”
CMA's Dr. Phinney, a Sacramento pediatrician, said Dr. Sears' concern is largely unfounded. Though some physician practices have fired parents who refuse to vaccinate their children, they remain a minority.
“It's difficult to predict what's going to happen in any individual patient encounter, but that's not the approach I'd take, and I don't think it's the approach that some 90% of the pediatricians across the state would take, either,” Dr. Phinney said. “We're advocates of the children and try to teach parents what we believe is in the best interests of the child. In essence, we're in partnership with the parent and work with them within their belief system on behalf of the child. Throwing up your hands and refusing to deal with the issue [of vaccine refusal] is just not how we do things.”
Physicians in Vermont, meanwhile, are seeking to eliminate the state's personal-belief exemption. Rep. George Till, MD, author of the House version of the bill, said it is important to act soon.
“We don't want to wait until we're in the middle of a crisis,” he said. “As elected officials, we have an obligation to protect the public health.”
The Vermont Medical Society supports the legislation, which passed the state Senate on March 1. Contentious hearings were held before the House Committee on Appropriations in the last week of March. The committee voted 6-4 to keep the personal-belief exemption and instead have the state health department to do more parental outreach on the importance of immunization. A compromise measure similar to the bill in California that would maintain the personal-belief exemption but require a health professional's signature also is being considered.
Advocates of broader exemptions also have been active in statehouses around the country. Eight states — Kansas, Massachusetts, Minnesota, Mississippi, New Jersey, New York, South Dakota and West Virginia — are considering legislation to add religious or personal-belief exemptions or to make such exemptions easier to secure. The American Medical Association has policy opposing religious or philosophical exemptions from school-entry immunization mandates.