Friday, February 8, 2013

Vermont Rolls Up Its Sleeves Again

Last year, Vermont legislators debated a bill that tried to eliminate religious and philosophical exemptions from school immunizations. It was rather hotly contested, with anti-vaccine activists up in arms and the misnamed National Vaccine Information Center urging people to write to their state congresscritters to oppose the bill. In the end, a sort of compromise was reached. The bill was signed into law, but with rather significant revisions. Parents in Vermont can still get a religious or philosophical exemption for their child, but they must sign a statement indicating that they have reviewed the educational material provided to them and that they understand that their decision increases the risk of disease for their child and those around them, including children with special health needs in the child's school who may suffer serious complications if infected. It's one of the more strongly worded laws requiring education before an exemption is granted. It would have been better if the law had passed as originally written, but baby steps.

Well, it looks like the sponsor of that bill is back in action this year. Rep. George Till (D-Chittenden) and others have introduced two new bills (H.114, full text available here, and H.138, full text here) that are more narrowly focused. While still addressing the concerns of religious and philosophical exemptions, the bills focus on pertussis immunization and individual schools, respectively.

H.114 - An Act Relating to Immunization Against Pertussis

Let's start with H.114, An Act Relating to Immunization Against Pertussis. This very short bill would change the immunization requirement and exemption laws as follows:
  1. Exemptions for religious or philosophical reasons would no longer be granted for the pertussis vaccine to children enrolled in a child care facility or public school. Only medical exemptions would remain.
  2. All adults working in a child care facility or public school who has contact with children in such facilities must provide evidence that their pertussis immunization is current and up to date.
Over the past several years, we have seen the number of pertussis cases dramatically increasing across the country.

CDC Pertussis Surveillance, 1990-2011
Vermont is one of the states that has been hit particularly hard in the past year, going from 94 cases in 2011 to 645 cases in 2012, or about 100.4 cases/100,000 people, giving them the second highest incidence of pertussis in the country. For a comparison, the national incidence for 2012 was just 13.4/100,000. Dr. George Till, the only medical doctor in the Vermont state legislature, has ample justification, then, to be concerned.

The outbreaks of pertussis that we've been seeing have been the result of a variety of causes: low vaccine uptake, lapsed adult boosters and waning vaccine immunity in teens. The evidence so far has suggested that children, especially in the 10-13-year-old range, need more frequent boosters to ensure immunity. We have also seen that adults need to get boosters, too.

Till's bill would help improve the public health impact of pertussis in his state to some degree. However, it appears that private schools are not covered by this bill, so parents of those students could still get religious or philosophical exemptions. The impact of that, however, may be offset by requiring adults working in public schools and, more importantly, child care facilities to keep up to date on their boosters. I highlight the child care facility part because these often have infants, who are too young to be fully immunized and are at the greatest risk from infection, and young children who may be the siblings of infants.

This is an important legislative measure that may help reduce some of the impact of pertussis. But only some. Recent research into pertussis outbreaks has identified another factor that may be playing a role in the increase we've seen: mutation. According to an article in MedPage Today, Mutations in Pertussis May Account for Rise in Cases, the immunity granted by the pertussis vaccine may have created a selective pressure on the bacteria to mutate and find new ways to infect and spread. In some cases, pertactin, a virulance factor that is used in the vaccines to produce immunity, was missing. This means that the body's natural defenses can't recognize the bacteria and mount a quick response to prevent illness. This type of mutation is similar to what happens naturally: sufficient numbers of the population are infected with a strain, develop immunity and stop spreading that strain. But another strain, for which the majority of the population has not developed immunity, continues to spread and takes over the niche that was left by the dominant strain. Evolution in action. If this is true, it means we'll need to develop new formulations of the vaccine, or perhaps even go back to using the whole-cell pertussis vaccine, which is known to produce better, longer-lasting immunity.

H.138 - An Act Relating to Immunization Rates of Students Attending Public Schools

Where H.114 focused on the pertussis vaccine statewide, H.138 focuses on immunization rates at individual schools for specific vaccines. Again, this bill is short and has two changes to the state immunization laws and applies only to public schools, excluding child care facilities:
  1. If the immunization rate for a required vaccine at a particular school drops below 90%, then religious and philosophical exemptions from immunization requirements will be suspended for that school for the particular vaccine until their rate returns to 90%+ uptake.
  2. Adults who work at and come into contact with children at a school where the religious and philosophical exemptions have been suspended will need to provide evidence that they are up to date for the immunization in question.
This bill resonates with me a lot. What I like about it is that, although it still allows for religious and philosophical exemptions (thereby placating some vaccine refusers), it helps to prevent what we see in certain communities, where pockets of low vaccine uptake develop. Being limited to public schools, however, keeps this bill from going far enough, in my opinion. Independent schools (i.e., private schools) are not covered, so we could still have sub-par immunization uptake in certain areas, such as at Waldorf Schools.

Many vaccines require at least 90% coverage in order to establish decent herd immunity. It's higher for some (like MMR to prevent the exceedingly contagious measles), but 90% immunization uptake is pretty good. If immunization rates fall below that level, then it becomes more likely that an infectious disease will be able to establish a hold in the community, with enough individuals not protected that it can circulate. When you have individuals who, for medical reasons, cannot be vaccinated and are at a higher risk of complications from the diseases, establishing community immunity is very important. Those individuals rely on everyone else having immunity so that they do not suffer serious harm. People who opt out of vaccination, therefore, are putting their own ideologies above the health and well-being of their fellow human beings.

In Conclusion

We have two bills that have been introduced in Vermont by a medical doctor/legislator. His goal is to improve public health and reduce the risk of infection and serious injury to the people of his state. It is an admirable goal, but he and his co-sponsors do have their work cut out for them. According to one news report, the Governor, Peter Shumlin (you can contact the governor's office here), said he will not support legislation designed to deal with a pertussis outbreak. So there's the threat of a veto, should the bills actually get passed. But there is a risk even sooner: the bills might not make it out of committee. Representative Mike Fisher, chairman of the House Committee on Health Care, is not keen on dealing with immunization issues again:
We addressed vaccinations last year, and I think we should give that law time to play out before coming back to it...I don’t think we’re interested in taking it up at this time.
This probably stems from the brouhaha raised by anti-vaccination activists last year. Rather than tackle an important issue, it seems he'd rather just avoid the headache of dealing with the loud voices of a vocal minority who, admittedly, are exceedingly passionate about their activism. That, I think, is something that has been lacking among the pro-health side of things: passionate voices willing to speak out. With that in mind, if you are a resident of Vermont, consider contacting your representatives and the members of the Committee on Health Care:
Fisher of Lincoln, Chair
Copeland-Hanzas of Bradford, Vice Chair
Poirier of Barre City, Ranking Member
Dakin of Chester, Clerk
Gage of Rutland City
Mitchell of Fairfax
Morrissey of Bennington
Pearson of Burlington
Spengler of Colchester
Till of Jericho
Woodward of Johnson
Click here to find contact information for your representatives. As they say, it takes a village. Make your voice heard.

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