Saturday, February 15, 2014

Forging Potential Harm

In the United States, every school maintains records on the immunization status of its students. Which students are fully vaccinated? Which have medical exemptions? Who get a religious or philosophical exemption for one or more vaccines? In the event of an outbreak of a vaccine preventable disease, these records can be used by the school to figure out which students are at risk and should be kept home until the outbreak is over. Public health officials also benefit from these records, as they can report vaccination rates across the state. This can show which communities may be vulnerable to a disease outbreak and narrow down where investigators need to look for potential index cases or contacts during an outbreak.

I've written before about an instance where parents forged their children's immunization records so they could get into day care. In that instance, the unimmunized children developed chicken pox, creating a small outbreak of the disease that put the other children, as well as two pregnant staff members, at risk of infection. This raised the question of the legal liability to the parents for their actions, handily addressed by The Skeptical Lawyer. No charges were filed in that case, and it's unlikely that any legal actions would have prevailed, according to the Skeptical Lawyer. A couple months after my original post, there was a chicken pox outbreak at a day care center in Alaska's Kenai Peninsula. Just like the earlier case, the parents refused vaccination for their children, ultimately resulting in a small outbreak.

The issues raised by those two events came together recently, again in Alaska's Kenai Peninsula. A nurse at a public school forged parent signatures on four immunization documents, noting in one instance vaccine refusal for religious reasons.

Donna Cotman, 65, was a school nurse at Redoubt Elementary School in Soldotna, Alaska. According to reports, after destroying the immunization record for a student, she created a new document and forged the mother's signature, noting that the student had not received the Hepatitis A and Hepatitis B vaccines, with a religious exemption. The student had, actually, received both vaccines, according to the parents, Aaron and Susan Parker, who also stated that the signature was not Susan's.

After investigating additional student records and finding three more forged documents, the state charged Cotman with four counts of second degree forgery, a Class C felony offense. These charges were dropped in favor of Cotman pleading guilty to second degree tampering of public records, a class A misdemeanor. She was fined $1,500 and ordered to complete 80 hours of community service by August 10 of this year. The judge also sentenced her to one year probation.

It is not clear why the original record was destroyed, but without it, the Parkers' daughter would not have been allowed in school until either an exemption was filed or they submitted proof of her immunization. So it would seem that Cotman was doing them a favor. She stood no personal gain, and no one was hurt. No big deal, right?

Not really. Although no one was harmed by Cotman's actions, at least up to the point the forgeries were discovered, there was potential for harm. The reports don't mention whether or not the other three documents contained incorrect information, so I'll stick to the one for the Parkers' daughter. The most immediate issue is if there were an outbreak of Hep A or Hep B at the school, she could have been forced to stay home until the outbreak was over and she was no longer at risk of infection. She would have missed out on school, and her parents may have been forced to stay home from work to care for her, costing them vacation time or, if they did not have vacation time, lost wages. If they did not stay home, they may have needed to pay for a sitter or someone else to watch over her. However, since she actually was immunized, the Parkers would have had to contest their daughter's exclusion from school. She would ultimately be allowed back in, most likely, but she may still miss one or more days while the issue was resolved.

But there is a wider reaching impact from Cotman's tampering. As I mentioned, states collect immunization information in registries to track vaccine uptake, exemption rates, etc., which is, in turn, reported to the CDC for national statistics. This information can be used for disease surveillance and predicting where outbreaks might occur, effectiveness of vaccination campaigns on local disease rates, tracking adverse reactions, etc. If the information is incorrect, public health efforts may go in the wrong direction, wasting public health professionals' time and taxpayers' money. Cotman's attorney is quoted as saying, "I would guess that 99.9 percent of all school district nurses in the state have done this." While the four documents that Cotman was found to have tampered with may not seem significant when looking at the state as a whole, if, as her attorney suggests, it is a widespread practice, the effect on public health efforts could be quite profound.

I ran the question of what would happen if immunization records were incorrect by my pal EpiRen:
Say we got an outbreak of measles or chickenpox on our hands. If we don't have the correct number of vaccinated/unvaccinated, it could affect if we worry about more cases (if herd immunity will hold up), about a batch of vaccine working or not, and how much vaccine we should get to vaccinate the exposed. If we don't have the correct vaccine record on a kid, we might disqualify them for vaccine when they're not immune, or immunize them again if they're already immune. Those kinds of things.

It happened with a measles outbreak in refugees. They didn't have clear immunization records, so everyone got the vaccine, at great expense to the state. Later it was found out that the adults and some children were immunized as soon as they got to the states, but the records were lost in the shuffle of getting those folks a place to live.

There's always the issue of funding and planning for responses. If it turns out that we don't have the correct number of vaccines in the stockpile because the info was wrong, we'd be in the uncomfortable position of choosing who gets it and who doesn't.
Which brings us to those opposed to vaccination and school vaccine programs. Cotman's actions may give fuel to such outspoken individuals. They can point to this case to (falsely) cast doubt on epidemiological studies that utilize school immunization records as source data, especially in light of her attorney's comment suggesting the practice could be widespread. If a study shows that school immunization programs help reduce the disease burden on a community or the risk of an outbreak, anti-vaccine activists can claim that there isn't any evidence that the vaccines played any role at all, since the source data itself may have been forged. But perhaps the most likely result is using this foolish decision to create doubt, fear and mistrust of public health officials, like school nurses. Of course, all of those things are spurious, but they carry emotional appeal and lend a veneer of plausibility to the claims.

According to Cotman's attorney, though, "The prosecution of this is stupid because it makes it more difficult for the school district to manage kids." But that's a short-sighted view. Although individual instances of document tampering or forgery may not immediately harm others, the more it happens, the greater the risks to individuals and the larger community. When such malfeasance is discovered, the ones responsible ought to be held accountable and appropriately punished. Far from being "stupid", prosecuting the tampering of public records helps to ensure we can trust our public officials and health providers and avoid wasting scarce resources, not to mention taxpayer money.


  1. Why would the children in the daycare agency get sick from the unvaccinated child if they had been vaccinated? Is not that the point of vaccines? Think about it.

    1. @Rabia Shaheed

      Read this link:

      If, after reading that, you still don't know the answer to your question, come back and ask again.

    2. Well, if vaccines aren't always effective like the link says, why are we being forced to get them? Todd, I had to hear every debate you can possibly think of in medical school and I can still tell you confidently that there is no argument you can make to win this debate. If the vaccine isn't effective and all the kids get the vaccine then it still doesn't matter because the vaccine was never effective.

    3. How do you know they are not effective in a certain person until they get the vaccine? Plus, if the child is not protected from a vaccine what other mechanism do you propose to protect that child from measles, diphtheria, pertussis, etc than to make sure others around them are immune?

      If the answer is to not assure herd immunity through community vaccination, then provide the PubMed indexed studies by reputable qualified researchers that you solution to protect that child has merit.

    4. "If the vaccine isn't effective and all the kids get the vaccine then it still doesn't matter because the vaccine was never effective."

      Please provide the PubMed indexed study by reputable qualified researchers that any vaccine required to attend a public school in any of the fifty states of the USA is not at least 50% effective.

    5. "Me": Please read Todd's cited post. Just because something is not 100% effective does not mean it is useless.

      If that were true, seat belts would be useless because they won't protect you if your car hits a bridge abutment at 65 mph or drives off a cliff.

      Vaccines are actually much better than seat belts, because not only do they protect most people most of the time, but they also reduce the chances that an unprotected person (for example, someone who is immune-compromised or allergic to a vaccine component, or someone who is one of the unlucky small percentage for whom the vaccine didn't "take") will get exposed to the disease in the first place. It's as though wearing seat belts made other drivers into better drivers, less likely to crash into you!


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