Bills to eliminate non-medical exemptions to school vaccination requirements are pending in state legislatures. Bills to add non-medical exemptions are pending as well. Some bills make it harder to claim an exemption. Others discourage vaccination by requiring “misinformed consent.” Still others try to weaken the authority of public health officials to combat vaccine-preventable diseases. Today, we look at a number of bills currently before the state legislatures and how they might affect immunization of school children.
All states require students to have been vaccinated against certain diseases to attend school and all states allow medical exemptions to vaccination. Unfortunately, every state except three allows religious or personal belief exemptions, even though neither is constitutionally required. While West Virginia and Mississippi have allowed only medical exemptions for some time, California repealed its non-medical exemptions less than two years ago, over the strenuous objections of anti-vaccination groups.
Mississippi would have been eliminated from that list in 2017 had one of two bills passed. House Bill 1439 established a conscientious belief exemption to vaccination and House Bill 1457 recognized both religious and philosophical exemptions. Fortunately, both bills died in committee this week.
Senate Bill 52 and Assembly Bill 1810 would make New York the fourth state by repealing the religious exemption, leaving only medical exemptions. However, just across the border, a New Jersey bill would allow parents to exempt a child “for any reason,” effectively making the state’s existing religious exemption unnecessary. A Rhode Island bill would reinstate the personal belief exemption there.
Oklahoma allows parents to exempt a child merely by signing a statement “objecting to the immunization of the child.” Sen. Ervin Yen, a cardiac anesthesiologist, has introduced a bill eliminating this broad exemption, leaving only medical exemptions valid. A bill filed in Arkansas to do away with religious and philosophical exemptions was, unfortunately, withdrawn by its author.
In Iowa, a bill would add an exemption for children of parents who oppose immunization due to “personal conviction.” A Hawaii bill would add to the state’s religious exemption by permitting a philosophical exemption because, as the bill’s preamble says,
the legislature also finds that individuals may object to vaccines due to philosophical objections, which include concerned parents who want to wait until their child’s immune system is more functional.
They got one thing right. Waiting “until their child’s immune system is more functional” is certainly based on philosophy, not science.
If you find this sort of legislative “alternative facts” depressing, you will be cheered by a bill in Pennsylvania that relies on real facts. While retaining the religious exemption, the bill eliminates those based on “strong moral or ethical convictions.” The bill’s sponsor explains that the state has the second lowest vaccination rate in the country, but doing away with the philosophical exemption would reduce the number of non-medical exemptions by more than half.
Short of actually getting rid of non-medical exemptions, pending state legislation would make it more trouble to claim one, which can be an effective strategy in increasing vaccination rates.
Minnesota law allows parents to exempt their children from school immunization requirements based on “conscientiously held beliefs” by simply signing a notarized statement. Companion bills (House File 96 and Senate File 143) would require parents to specify which vaccines they want to exempt and to say why the exemption is sought. (It would be interesting to see if of the reasons had any basis in fact.) They would also need a statement from a physician verifying that he or she reviewed the risks and benefits of vaccines and would have to acknowledge that their child could be excluded from school during an outbreak.
Religious exemptions are currently allowed in New York, but there is no established protocol for claiming them. To remedy this, a bill directs the Commissioners of Health and Education to work together on rules for this and hopefully introduce some stringency in the matter.
Two bills have been filed in Texas to ensure parents realize the risks of not vaccinating their children. Texas permits “conscience” exemptions, “conscience” being defined as “including a religious belief.” Per House Bill 241, sponsored by a legislator who is an RN, to take advantage of the conscience belief, a parent would have to submit a form from a health care practitioner stating that the practitioner has provided the parent with “information on the risks and benefits of immunization.” As an alternative, under House Bill 126, a parent would have to complete an internet-based “immunization education module” that presents “evidence based information” consistent with that provided by the CDC. The state could charge a fee for developing and maintaining the module.
Similarly, in Connecticut, if House Bill 6971 passes, parents would be required to attend a science-based educational session regarding the efficacy and safety of vaccines if they sought a religious exemption from immunization for their children.
An Iowa bill takes a different tack by requiring some back up before a religious exemption can be claimed. Iowa law allows religious exemptions only when immunizations conflict with the tenets and practices of a “recognized religious denomination.” The bill adds a requirement that the religious leader of a local congregation where the exemption applicant is a member in good standing sign the application and state that the immunizations actually do conflict with the religion’s tenets and practices.
Undermining student immunization
On the other hand, a number of bills seek to undermine school immunization requirements. One way to do this is to prevent public health officials from questioning medical exemptions, no matter how dubious their provenance or rationale. In Mississippi, current law permits a local health official to refuse a medical exemption if, in his or her opinion, it would cause undue risk to the community. House Bill 1456 would have prevented further inquiry, making the physician’s decision absolute. (The bill died in committee.) As a public health official explained when a similar bill failed last year, the state feared that out-of-state physicians were sending in exemptions for children under dubious circumstances. Assembly Bill 1810, pending in New York, provides that a medical exemption signed by a physician, nurse practitioner or physician’s assistant “shall prevail,” eliminating questions from local authorities.
Another way to undermine public health officials is to take away their authority to determine vaccination requirements. In New Hampshire, the commissioner of health can issue regulations regarding vaccination against diseases other than those specified by the legislature. House Bill 361 eliminates this provision, leaving immunization requirements within the sole discretion of the legislature. (As regular readers of SBM are aware, I tend to take a dim view of the scientific literacy of the average state legislator.) House Bill 362 prevents the legislature itself from establishing school immunization requirements for diseases that are “noncommunicable in a child care or school setting” including hepatitis B. Likewise, Rhode Island Senate Bill 47 prevents the department of health from setting vaccination standards for diseases that aren’t transmitted “in the school environment” and requires the department to hold public hearings before making any further changes in the vaccination schedule.
Imposing onerous “misinformed consent” requirements on health care providers can discourage vaccination. In Oklahoma, the “Parental Rights Vaccine Act” bill (companion Senate Bill here) requires informed consent prior to vaccination, which is defined, as a minimum, as giving parents a Vaccine Information Statement and “information concerning” the National Vaccine Injury Compensation Program. Each of these requirements is superfluous because, as with any medical procedure, informed consent is already required before vaccination, federal law already requires that health care practitioners give patients a VIS on each vaccine prior to administration and each VIS already includes information on the Vaccine Injury Compensation Program (see, e.g., this meningitis VIS).
There is one particularly troubling addition to this “minimum” requirement for informed consent. The practitioner must make “available for review” the CDC’s Epidemiology and Prevention of Vaccine-Preventable Diseases: Vaccine Excipient and Media Summary. Epidemiology and Prevention of Vaccine-Preventable Diseases (known as the “pink book”) is a 512-page reference work on all things vaccine for health care practitioners. The “Vaccine Excipient and Media Summary” is one subpart of an appendix to the “pink book.” It is a chart of the ingredients in each vaccine. Not an explanation of why they are necessary, not a risk-benefit determination, not an indication of how much of each is actually in the vaccine. Just those scary-sounding chemical names, like “aluminum hydroxide” and “formaldehyde,” one after another.
It’s not hard to see where this is going. Taking vaccine ingredients out of context and misrepresenting them as harmful is a favorite tactic of the anti-vaccination crowd. So is overemphasizing risk.
Misinformed consent bills have also been filed in Texas and Oregon. In Texas (where one of the sponsors is a veterinarian, who should know better), in addition to providing risks and benefits and a copy of the VIS, the practitioner must tell parents about procedures available under the National Vaccine Injury Act to seek:
possible recovery for unreimbursed expenses for certain injuries arising out of the administration of certain vaccines.
Practitioners must also provide a copy of the Vaccine Excipient and Media Summary to parents. Oregon Senate Bill 579 goes even further. The entire 512-page “pink book” must be made available for review, as well as notice of how to file a petition for a claim under the National Vaccine Injury Act. Anything to overwhelm parents with information most of them are not competent to interpret and to undermine confidence in vaccination by emphasizing the possibility of adverse reactions, however remote.
Finally, some physicians have decided not to see unvaccinated patients, a decision that recently received some support from the American Academy of Pediatrics. Texas House Bill 1070 would take away their right to make that decision, no matter what the circumstances, by prohibiting health care practitioners from refusing to provide services to a patient if he or she is unvaccinated for a particular disease. Penalties include withholding payments from public health insurance programs.
Well-funded anti-vaxx lobbyists
The anti-vaccination lobby is up and running, opposing any bill that eliminates exemptions, makes them harder to get or adds new vaccination requirements. They even oppose collecting more vaccination statistics, a position that belies their claims they are concerned only about vaccine safety.
I first learned about some of these bills in an email from the Alliance for Natural Health, an organization supported by the dietary supplement industry and physicians who eschew evidence-based medicine.
From there, I went to the National Vaccine (Mis)Information Center’s “Advocacy Portal,” an obviously well-funded effort that lists several dozen bills and facilitates lobbying by the NVIC’s flying monkeys. In fact, as far as I know, this is the only comprehensive list of vaccination bills publicly available anywhere, a sad commentary on the lack of resources for the science-minded. If we were really in the pocket of Big Pharma, it should have bought us a nice “advocacy portal” like the NVIC’s, where we could take the opposite position on these bills and have a fancy internet-based system for lobbying. Sadly, that’s not the case. Until we have resources to match groups like the NVIC and Alliance for Natural Health, please use your own resources to contact state legislators to let them know what you think about these bills.