Colorado's Non-Medical Vaccine Exemption Form Ruffles Anti-Vaccine Feathers

Back to school time. Show your child you care about their health.
Image Source: South Florida Caribbean News

Note: see update at the end of the article.
 
School is nearing (or already upon us) in many states. Parents are out buying notebooks, pens and pencils, folders, and new clothes for their children to make sure they're ready for the first day. It's also the time when many parents need to make sure that their children are up to date on their vaccinations in order to attend school. Naturally, this is also a time that anti-vaccine activists absolutely hate, especially in states where public health officials have taken efforts to ensure parents are better informed about vaccines and the diseases they prevent, as well as making opting out of vaccinations closer to the same burden that exists for those who choose to protect their children from diseases.

One of the latest battlegrounds is Colorado. Anti-vaccine activists and organizations, like the National Vaccine Information Center, are really upset with Colorado. Nothing has changed with regard to the law in that state, though. Non-medical exemptions haven't been removed, like they have in California. Parents aren't required to sit through an educational session on the benefits and risks of vaccines and the diseases they prevent. All that changed is this year's vaccine exemption form and the rules around its use.

Jim Carrey's The Bad Tweet

Did you learn nothing from this movie, Jim?

[Update 7/2/15 at 6:30pm: Jim Carrey has removed the tweets mentioned below and replaced them with text-only tweets. He has not tweeted any apologies.]
 
Oh, Jim Carrey. Not content to be a fool on screen, you decide to (continue) to be a fool on Twitter. After the passage and signing of California's SB277, a new law that removes non-medical exemptions to school immunization requirements, Carrey went on a bit of a rant on Twitter, declaring the law fascist (it's not), playing the Pharma Shill Gambit, the toxin gambit, and, like so many other anti-vaccine activists, declaring he's not anti-vaccine. In short, he's just following the anti-vaccine handbook. But he wasn't content to keep it to just being mildly unhinged. But I'll get to that in a bit.

I first became aware of Carrey's anti-vaccine nonsense back in 2009, when Carrey was with anti-vaccine spokesperson Jenny McCarthy. For a while, Phil Plait, aka the Bad Astronomer, had occasionally written about the anti-vaccine movement. Like clockwork, anti-vaccine activists would show up in the comments spouting the same tired tropes over and over. It prompted me to write up a summary addressing the more common myths around vaccines. It's helped some learn the truth and facts about vaccines and exposed many of the lies told about them.

Apparently Jim Carrey didn't bother reading it, or, if he did, he didn't learn a thing. So what has he done this time around that went beyond merely making a fool of himself and showed that he is an opportunistic and insensitive ass that doesn't really care about those affected by autism?

SB277 Signed! Congratulations, California!

June 30, 2015 - A happy day for California children!

This is just a very brief post to celebrate the triumph of science and public health over the fear and lies of the anti-vaccine movement. On June 30, 2015, Gov. Jerry Brown signed SB277 into law. As I mentioned briefly before, SB277 ensures that only medical exemptions will be allowed for school immunization requirements. California has joined Mississippi and West Virginia as the only three states in the country that put children's health above misguided personal and superstitious beliefs.

In his signing statement (PDF), Gov. Brown noted the importance of vaccines and the science that supports their use:

The science is clear that vaccines dramatically protect children against a number of infectious and dangerous diseases. While it's true that no medical intervention is without risk, the evidence shows that immunization powerfully benefits and protects the community...

...Thus, SB277, while requiring that school children be vaccinated, explicitly provides an exception when a physician believes that circumstances - in the judgement and sound discretion of the physician - so warrant.

My thanks go out to Senators Pan and Allen for shepherding this bill through the California legislature, to all of the senators and assembly members who voted for this bill, the parents and activists who supported their efforts, and Gov. Brown for signing it. You have all done an amazing thing to protect the health of California's most vulnerable population.

SB277 Opposition: The Smokescreen of Parental Choice

Humans love to have choices. From early on in our childhood, we like to be able to choose what we want to do. Play with this toy or that one. Eat this food or that. And we don't like having limitations placed on our choices, especially if it involves doing something we don't want to do. Our parents try to teach us that while we are able to choose, sometimes our choices have strings attached. "You need to finish your vegetables if you want dessert." We're given the power to choose what to do: eat the veggies so we can have dessert, or choose not to eat the veggies and miss out on dessert. We might not like the options, we might wish we could choose the dessert without any other limits on our choice, but we have to deal with the reality. Depending on our maturity, we may throw a tantrum when we don't get what we want, when there is even the most minor constraint on our choices.

By the time most people are adults, they're mature enough to realize that every choice we make has some sort of consequences. They may occur prior to getting what we want, or they might follow it; they may be good consequences, or they may be bad. Then there are those who never seem to reach that maturity. They're stuck in the childish dream of wanting their choices to be free from any limitations, unable to accept that their choices may have consequences or that there may be some manner of prerequisite before they can have their choice fulfilled.

We can see this in action in the anti-vaccine movement, in particular as they fight against a bill in California (SB277).

Stand Up for Parents' Rights to Accurate Information on Vaccines

A few years ago, California's legislature took steps to ensure that parents who wished to opt out of getting their children immunized for school or day care understood what their decision meant. Assembly bill AB 2109 required that before a philosophical exemption could be granted, parents had to get a health care provider to sign the exemption form, indicating that the parent received information on the risks and benefits of vaccination. In order for parents to make an informed choice, they ought to have good, science-based information on which to base that choice. SB 2109 seemed like a bill that should have had unequivocal support from the anti-vaccine, sorry, "pro-vaccine-choice" movement. Instead, they vehemently opposed it, led by the National Vaccine Information Center (NVIC). Despite NVIC's lobbying, AB 2109 passed.

The latest unprecedented outbreak of measles, starting in California and up to 132 cases in that state as of March 6, has led several state legislatures to consider bills that would tighten up school vaccine exemptions and improving parent education regarding immunizations. Naturally, this led to claims that government was trying to remove choice and personal belief. Some of those complaints are against bills aimed at removing non-medical exemptions. And some oppose bills similar to AB 2109, like Minnesota's SF380/HF393.

Is the Government Taking Away People's Beliefs?

Measles has been in the news a lot, lately. And it's not surprising, with the unusual 644 cases in 2014 and 154 (as of Feb. 20)  and counting already in 2015. The outbreaks have not only grabbed the attention of the media, but politicians are starting to take notice, as well. Several state legislatures are either already considering or will be introducing bills aimed at improving tracking of vaccine uptake and improving immunization rates overall. Some of these bills require disclosure of immunization rates for each school. Others go much further and would remove philosophical exemptions from school immunization requirements. These latter bills would bring those states more in line with Mississippi and West Virginia, which only allow for medical exemptions for students' school shots (and also just happen to have some of the lowest rates of vaccine preventable diseases).

To say that those who, either in total or just the mandated school-entry immunizations, are opposed to vaccinations are unhappy would be an understatement. Moves to remove non-medical exemptions from school vaccination requirements are met with arguments about personal freedom, that this is no different than what the Nazis did to the Jews during the Holocaust, or that the government is taking away people's beliefs or rights.

So what's going on? Is the government taking away people's beliefs? Are they infringing on our rights as citizens? And what about the children who are affected by all of this?

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.

Mississippi Parent Group Working to Make It Easier to Get Sick

In the United States, every state has some manner of requirements for immunizations before children are allowed to attend schools or day care. They vary from state to state, with some requiring almost all of the vaccinations on the recommended immunization schedule, while others only require a smaller subset. Each state decides which ones they will require, and which they simply recommend. As with any medical intervention, there may be medical reasons that a person should not receive a vaccine. Usually, this is something like an allergic reaction to a previous immunization or one of the ingredients or because at the time the shot would normally have been given, the patient had an illness which contraindicated the vaccine. In other instances, the child may have a chronic disease or disorder that prevents safe immunization. Because of this, every state allows for medical exemptions to school immunization requirements. Nearly all states allow for a religious exemption, with Mississippi and West Virginia being the odd ones out. A smaller proportion of states allow for a broader sort of exemption: the philosophical (or personal belief) exemption. Like the laws requiring immunization, these exemptions vary by state (a map of which states allow which type of exemptions can be found at the Institute for Vaccine Safety).

As I mentioned, Mississippi and West Virginia are unlike the rest of the country, in that they only allow for medical exemptions from school and day care immunization requirements. However, a recent report in the Clarion Ledger discusses the efforts of one organization to change the law in Mississippi, by trying to pass legislation that would establish a philosophical exemption in that state.

The New California Personal Belief Exemption Form Unveiled

The anti-vaccine movement is a study in contradictions. They want fewer vaccines, but advocate for actions that ensure vaccines that could be taken off the schedule aren't. They want studies done, and even get involved in their design, but then reject them when the studies produce results they don't like. And they clamor for informed consent, but then raise a stink when efforts are made at improving education and helping parents make informed choices.

That was the case last year when, in March 2012, a bill was introduced in California (AB2109) that would require parents who want to opt out of required school immunizations for their children to get information about the "benefits and risks of the immunization and the health risks of the communicable diseases listed in Section 120335 to the person and to the community" from an authorized health care provider (which was rather broadly defined). These efforts at ensuring parents make informed choices were so objectionable, that anti-vaccine pro-informed choice activists vehemently opposed the bill. Yes, in the twisted world of people like NVIC's Barbara Loe Fisher, a doctor largely responsible for a measles outbreak or certain reality-challenged celebrities, a bill that requires parents be informed tramples on parents' rights to be informed. Yeah, I don't get it either, but supposedly it makes sense to them.

At any rate, AB2109 was signed into law by Gov. Jerry Brown on September 30, 2012, but with a catch. As I wrote at the time, Gov. Brown issued a signing statement with it, stating that he would direct the Department of Public Health to allow for religious exemptions to the whole getting informed piece of the legislation, despite the fact that California does not have any religious exemptions to vaccinations. As I noted at the time, there were significant problems with this, both legal and practical.

Well, the California Department of Public Health has announced the new form and made it available here (PDF).

A Pox on Health Reporting

Science and health reporting in the U.S. can be a bit of a mixed bag. Sometimes, reports on these topics are level-headed, presenting accurate information in the proper context. There is often a great deal of nuance involved. More often, though, news outlets do a less than optimal job. They oversimplify. They leave out important details. They get details wrong. They engage in inappropriate emotional appeals to spin the story, often to the detriment of truthful reporting.

You may have heard in the news, recently, of FrankieElizabeth Staiti, a 5-year-old New York kindergartener who has been barred from school because she has not received the varicella vaccine. The reason? Her pediatrician refuses to give the varicella vaccine to any child who has an infant sibling, believing that the varicella vaccine poses too great a risk, since it uses a live, weakened virus. FrankieElizabeth has a 14-week-old sister. Her mother, Elizabeth Wagner, applied for a medical exemption for her daughter, but it was rejected after the Department of Education reviewed it with her and FrankieElizabeth's pediatrician.

That is the basic story. But there are some problems with the way that a lot of outlets are reporting on this.

Poking a Wasp Nest

A couple weeks ago, I wrote about two bills that had been introduced in the Vermont House of Representatives, H.114 and H.138, that would improve public health by tightening up religious and philosophical exemptions in public schools and, in the case of H.114, child care facilities. The first bill was introduced as a result of the pertussis epidemics going around the country, with Vermont being the second-hardest hit in 2012, with 100.4 cases per 100,000 people, roughly 7.5 times the national average of 13.4 cases per 100,000 people. This outbreak was driven by several potential factors: waning immunity in teens (necessitating an additional booster), possible mutations in the bacteria (rendering the vaccine less effective), pockets of low vaccine uptake (e.g, a 13.16% overall opt-out for philosophical reasons among kindergarteners [Excel file] in Vermont private schools in the 2011-2012 school year, and a 9.73% opt-out among middle schoolers), and adults whose immunity had waned (nationally, adults have historically had poor pertussis vaccine uptake). The second bill focuses on keeping herd immunity at necessary levels within public schools, by implementing temporary bans on religious and philosophical exemptions on a vaccine- and school-specific basis when immunization rates fall below 90%.

As I mentioned in my previous post, both bills face an uphill battle. Some legislators, like Rep. Mike Fisher, chair of the House Committee on Health Care, and gubernatorial appointees, like Health Commissioner Harry Chen, seem not to want to deal with the headaches that come part-and-parcel with the topics of immunizations and exemptions. Last year, they got an earful from individuals opposed to vaccines, resulting in the blunting of a bill that took a small step toward improved public health. This year does not look to be much different, as the same people, the Vermont Coalition for Vaccine Choice, are once again rallying their forces to lobby legislators to oppose these bills.

Oregon Looks to Educate, Improve Public Health

A couple weeks ago, I wrote about two bills introduced in Vermont aimed at improving public health through modifications of the state's religious and philosophical exemption laws. One, H.114, would remove non-medical exemptions for the pertussis vaccine, since Vermont had the second highest incidence of pertussis in the entire nation in 2012. The other bill, H.138, would only suspend non-medical exemptions on a vaccine- and school-specific basis if uptake for the vaccine at the school drops below 90%. Once uptakes improve to 90% or more, non-medical exemptions will once more be allowed.

Now it's Oregon's turn to work on boosting public health.

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.

AB2109 Signed! But Gov. Brown Creates Other Concerns

On Thursday, I echoed Orac in his call for people to support California's Gov. Jerry Brown in signing AB2109 into law. This bill would help strengthen California's school vaccination laws by requiring that parents become informed about the risks and benefits of vaccinating prior to getting a personal belief exemption for their children. Anti-vaccine activists vehemently opposed this bill, showing that they are actually against informed consent. They even recruited comedian Rob Schneider as their new Jenny McCarthy, acting as a celebrity spokesperson to champion their nonsense. And based on my twitter exchanges with him, he's swallowed their tripe hook, line and sinker.

I spent the weekend mostly off-line, so I missed a rather big development in all of this. As user "Unknown" commented on my call to arms, Gov. Brown signed the bill! This is fabulous news, but it's tempered with a bit of, well, if not bad news, at least something a little perplexing.

A Call to Arms

Orac, over at Respectful Insolence, has called on those of a scientific bent to take action on two important issues. First off, investigative journalist, Brian Deer, will be speaking at the University of Wisconsin - La Crosse on October 4 and 5. Brian Deer, you may recall, is a U.K. journalist who has harshly criticized pharmaceutical companies and who uncovered the research fraud committed by Andrew Wakefield. The anti-vaccine activists at Age of Autism have encouraged their followers to rally against Mr. Deer and to support a press conference that Andrew Wakefield will be giving on October 4, also at the University of Wisconsin - La Crosse. Here are the details about both:

Brian Deer's Talks

• "An Elaborate Fraud: The MMR Vaccine & Autism"
• Thursday, October 4 at 5:30pm
• Centennial Hall, Room 1309 

• "Stiletto Journalism: Busting the Vaccine Scare"
• Friday, October 5 at 3:30pm
• Centennial Hall, Room 1309

Andrew Wakefield's Press Conference

• Thursday, October 4 at 1:00pm
• Location to be provided - email info@drwakefieldjusticefund.org for more info

The other item that need your support is AB2109, about which I've written before (here and here). As a quick reminder, this bill would require parents who want a philosophical exemption for their children from school immunization requirements to talk with a medical provider about the risks and benefits of vaccination, and the risks of not vaccinating for both themselves and their community. The bill has passed both the California State Senate and Assembly. It is currently on Governor Jerry Brown's desk, waiting to be signed. A vocal contingent of anti-vaccine activists and Tea Partiers are holding a rally to oppose this legislation tomorrow, September 28 from noon to 2pm on the West Steps of the state capitol. If you live nearby, I urge you to attend in counter-protest to voice your support for this bill. I also encourage you to contact Gov. Brown, asking him to sign AB2109.

If you decide to attend any of these events, please remember to remain civil. Do not be goaded by the anti-vaccine activists you are likely to encounter.

Praying, in Vain, for Exemption

In polite conversation, especially with strangers, there are some topics that you should just avoid. Anything related to politics or religion can, unless you really know your audience, produce rather, shall we say, heated disagreements. Okay, let's be real. When politics and religion come up, people can get vehemently argumentative. There tends to be such a strong personal investment in political and religious beliefs that to question the belief is seen as somehow questioning or even denigrating the individual. From personal experience, it's hard to avoid that even when sticking to the facts and avoiding personal opinion. So people tend to steer clear of such conversation topics in order to play nice, keep the peace and avoid jeopardizing friendships.

Vaccines have become a topic similar to politics and religion. Anytime I meet someone new and the subject arises (and even with good friends, on occasion), there's always this sense of trepidation. Has the person I'm talking to read something on the interwebz that they found convincing enough to distrust vaccines? How personally invested are they? If they've been fooled by anti-vaccine propaganda (which, admittedly, can be quite convincing to someone who has not been following things for a while), what arguments will they use to justify their beliefs? The rationalizations will very likely draw politics or religion (or both) into the mix, and given how intertwined are personal identity and political/religious beliefs, sticking solely to facts and reason aren't likely to sway the person. In such cases, fighting fire with fire, so to speak, might work, but it's a risky proposition, especially when using religious arguments.

The problem is that once you start bringing religion into an argument dealing with non-religious policies and topics, you get bad religion and bad policy. Take, for instance, a religiously-based list of anti-vaccine arguments [EDIT 8/12/14: updated link to a cached version of the page, as the original appears to have been taken down] recently forwarded to me.

Mostly Good News from Vermont

Back in March, I wrote about how Vermont was moving toward improved public health by putting forth a bill that, if passed,would eliminate philosophical exemptions from school and daycare immunization requirements, while still leaving religious and medical exemptions intact. After a considerable amount of going back and forth, in committee, out of committee, to the House, back to the Senate and so on, Senate bill S.199 was signed into law on May 16, 2012.

As with all things legal and political, there are positive aspects of the enacted law (PDF) as well as some negatives. The big negative, from my perspective, is that philosophical exemptions are still allowed in Vermont. But not all is doom and gloom. The various revisions the bill underwent added significantly to the school immunization laws, going beyond the simple issue of exemptions.

So, what all has changed?

Quick Legislative Update: Vermont and California

I just wanted to give my readers a quick update on where things stand with vaccine exemption-related legislation in Vermont and California. If you'll recall, Vermont's Senate passed a bill that would remove philosophical exemptions from school immunization requirements (leaving in place religious exemptions). California introduced a bill that would require parents in that state to get a written, signed form from a physician, surgeon, nurse practitioner or physician assistant stating that the health care provider gave the parent information about the risks and benefits of vaccines before a philosophical exemption from school immunization requirements will be granted.

The Vermont bill (S.199) was referred to the state's House of Representatives (H.527), where it is currently in committee. I urge any of my readers in Vermont to contact their representatives and ask them to support this bill.

The California bill (AB 2109) is also currently in committee. As with my Vermont readers, I would ask any of my readers in California to please ask your assembly member to support this bill.

California Assembly Working to Protect Public Health

Efforts to improve public health and revamp vaccination programs seem to be popping up all over the place, lately! First, there were the recommendations from the Alaska State Section on Epidemiology following a chicken pox outbreak at a day care, then there is the bill to eliminate philosophical exemptions from school vaccine requirements in Vermont that has passed that state's Senate and is on its way through the House and will hopefully be signed by the governor.

Actually, even before these two developments, there was last year's step towards improving public health in Washington when they passed a bill (PDF) that would require parents to speak with a physician about the benefits and risks of vaccinations before being granted a philosophical exemption from vaccine requirements.

Well, California has joined the fun.

Vermont Steps Toward Improved Public Health

Vaccination requirements for entry to day care programs and schools tend to be a bit of a touchy subject among those who, for one reason or another, are opposed to immunization. They tend to view such requirements as violations of their personal rights, all the while ignoring the rights of their own children, to say nothing of the rights of the other people around them, to not be infected with diseases that can be quite serious. As I recently wrote, the state of Alaska Section on Epidemiology came out with several recommendations following a chicken pox outbreak at a day care facility, which started after an unimmunized child infected their infant sibling who attended the day care. In my post, I suggested that the recommendations did not quite go far enough, arguing that philosophical or religious exemptions should require speaking to a physician before being granted. Personally, I don't think that there should be exemptions for anything other than legitimate medical reasons, but that's a topic for another post. In the meantime, requiring discussion with a medical professional seems, to me, to be a reasonable compromise for the time being.

The issue of philosophical exemptions came up last summer, as the Massachusetts state legislature considered a proposal to add philosophical exemptions to that state's immunization laws. It's a proposal that pops up just about every year in Massachusetts and is consistently, and, in my opinion, correctly shot down. Well, it looks like the state's neighbor to the north, Vermont, is considering making its laws similar to those of Massachusetts. A bill was recently passed by the Vermont state Senate, in a vote of 25-4, to remove philosophical objections as a reason to forego immunization, leaving only medical and religious exemptions. As the bill goes to the House for consideration, there is, not surprisingly, a vocal few who see the legislation as a Bad Thing^TM.

Take, for example, Charlotte Gilruth, who wrote in to the Barre-Montpelier Times Argus with her opinion in a letter titled "'Herd immunity' is misleading". From the second sentence, her letter is a treasure trove of errors and misinformation. Before I delve into it, go ahead and click on her name above to read her thoughts. See how many mistakes you can find.