STATE ACTION ON IMMUNIZATION POLICY IN 2019

*last updated June 2019

Written by Rita Swan, President Emeritus of CHILD Inc., CHILD USA board member

 

As of May 31, the number of U.S. measles cases in 2019 had already surpassed U.S. annual totals for the past 25 years.  Given the massive costs plus the dangers in these outbreaks, state legislators introduced scores of bills dealing with religious and philosophical exemptions from immunization mandates.

Some bills actually created or expanded these non-medical exemptions, but several states including Alabama, Iowa, New York, Vermont, and Missouri had bills introduced to repeal them.

As of June 15, bills had passed in only three states, Washington, Maine, and New York.  The Immunization Action Coalition reports that some bills remain viable in legislatures still meeting.

Washington had 71 cases of measles in Clark County alone this year. The county health department declared the outbreak over in April, but new cases were confirmed in other counties the next month.  A six-month-old baby, too young to be vaccinated, required hospitalization. The costs of containment have run well over a million dollars.  Nine hundred students missed 30 days of school because of the outbreak.

Many of the Clark County cases were within Slavic and Russian Orthodox immigrants.  Several measles outbreaks in recent years have been mainly within ethnic groups.  [source]. These communities may maintain their native language and distinctive culture and feel threatened by the outside world.  Anti-vaccination outsiders have specifically targeted some of these groups and generated widespread fear of vaccines.  In Washington a Ukrainian member of the tight-knit community promoted rejection of vaccines and thousands accepted her advice.  In the 2004-05 school year 91.4% of Clark County kindergartners were fully immunized.  By the 2017-18 school year only 76.5% of them were.

The outbreak, however, was not confined to the Eastern European immigrant community.  Measles cases were found at 53 Clark County sites, including 16 schools and 13 health care facilities.  The first confirmed case was of a child who had traveled to Ukraine, but the health department could not determine that it was the index case for the outbreak. 

Washington has wrestled with the issue of non-medical exemptions before. In 2011 it enacted a requirement that parents wanting such exemptions must get risk-benefit information about vaccines from a licensed provider unless they were members of a religion opposed to medical care.  At that point 4.8% of Washington schoolchildren had the personal belief/philosophical exemption and 0.2% had a religious exemption.  In the 2017-18 school year, 3.7% of Washington schoolchildren had a personal belief/philosophical exemption from immunizations while 0.4% had a religious exemption.  There has, then, been a decline in the percentage with personal belief/philosophical exemptions and a small increase in the percentage with religious exemptions.  The fact is, however, that the decline has not been enough to prevent several outbreaks of vaccine-preventable disease.

In 2019 with Governor Inslee declaring measles a public health emergency, the Washington House passed HB1638, which prohibited a personal belief exemption for the measles, mumps, and rubella (MMR) vaccine but did not affect the religious exemption.  SB5841 was introduced in the Senate to repeal all personal belief exemptions but did not advance in the process.  

Legislators debated HB1638 for hours.  More than 600 vaccine opponents showed up for one committee hearing.  They claimed the Centers for Disease Control themselves had 1,200 studies on the dangers of the MMR vaccine and had reported deaths of 445 children because of the vaccine. However, the CDC reports in detail that the vaccine is very safe. [source

One witness pointed out that school enrollment in California was declining and worried that perhaps 20,000 Washington children would be pulled out of school because of HB1638.  In fact, California’s small decline in public school enrollment preceded the state’s repeal of non-medical exemptions and could be due to many factors.  A naturopath claimed that adults lose immunity to measles regardless of their immunization status, making it impossible to achieve herd immunity.  Some legislators said Washington did not need to tighten vaccination requirements because the outbreak was “solely” confined to immigrants in an isolated ethnic church community, but that was not true then and the next month measles cases appeared in three more counties.  One legislator called HB1638 an “anti-prevention bill” in preventing parents from protecting their children from the dangers of the MMR vaccine. 

The bill nevertheless passed in April and has been signed into law in Washington.  It remains to be seen whether it will substantially raise vaccination rates or opponents will simply claim a religious exemption for the MMR vaccine.

Maine, in contrast, repealed all non-medical exemptions this year.  A large pertussis outbreak, an imported measles case, and Maine’s low vaccination rates were a catalyst for LD798, which repealed both the religious and philosophical exemptions.

LD798 passed the House by a 19-vote margin but the Senate voted 18-17 to restore the religious exemption.  The bill went back to the House, which refused to accept the Senate’s amendment and sent it back to the Senate.   Senator Jim Dill switched his vote, the Senate voted 18-17 to accept the House bill without a religious exemption, and Governor Mills quickly signed it.  Maine Families for Vaccines and the Maine Medical Association worked long and hard for this excellent outcome. 

With 854 measles cases this year, New York also repealed its religious exemption in the bill A2371/S2994 and never had a secular belief exemption. The outbreaks were mainly in Ultra-Orthodox Hasidic communities where mothers have been targeted for five years by Parents Educating and Advocating for Children’s Health.  PEACH print materials spread fear and claim that vaccinations violate Jewish law though many rabbinical leaders encourage vaccinations on the basis of Jewish law.  [source].

It is hard to find a true religious basis for their opposition to vaccines.  Scholar Samuel Heilman suggested the cause is their fear that mandates by the secular world will weaken their social structures.  [source].

Whatever their motives, their opposition was strident.  They held mass anti-vaccination rallies in their communities. At the capitol, persons dressed in Orthodox garb, many accompanied by children, screamed expletives, jeers, and threats from the galleries until they were dispersed by the police.  [source]

Colorado’s new governor, Jared Polis, opposes vaccine requirements.   Reportedly, State Representative Kyle Mullica wanted to introduce a bill repealing the non-medical exemptions, but Governor Polis ordered the Health Department not to cooperate with Mullica in developing the bill.  Then Mullica introduced a bill that required parents to fill out a form in person each year at the county health department to get a non-medical exemption.

Even this modest bill consumed fourteen hours of floor time before passing the House at 4:00 a.m.  The Senate held four hours of debate time on the bill and then let it die with Polis complaining that the bill imposed a hardship on rural parents.  [source].

Oregon was a strange story in 2019.  The Oregon House passed a bill to repeal all of Oregon’s non-medical exemptions from immunizations.  It reportedly had a good chance of passing the Senate.  But then the Senate Republicans fled the capitol because they did not want to vote on an education bill.  After a week of nothing getting done in the capitol, Oregon Senate Democrats agreed to drop the vaccination and gun safety bills, which Republicans also opposed, and the Senate Republicans then agreed to return and vote on other bills.

In 2013 Oregon mandated that parents obtain risk-benefit information on vaccines before getting an exemption.  Unfortunately, the law allowed parents to obtain this information either by talking to a provider or by clicking through an online education module.  Of the 31,500 non-medical vaccine exemptions submitted last year nearly 30,000 were from parents watching the video and fewer than 2,000 were from parents who talked to a provider.

The education requirement has not enhanced protection for Oregon children. In fact, the percentage of children with non-medical exemptions from immunizations has continued to climb steadily.  It jumped a full percentage point from 6.5% last school year to 7.5% in the current school year, making Oregon the state with the nation’s highest percentage of kindergartners lacking some or all of the mandated immunizations.  [source].

An education requirement also backfired in Illinois.  Before the state enacted a law in 2015 requiring religious objectors to get risk/benefit information, 13,000 Illinois children had a religious exemption.  Today the number has climbed to 19,000.  [source].

New York’s new immunization requirement provides a striking contrast to past government dealings with Ultra-Orthodox practices.  From 2004 to 2017 there were 18 cases of New York City infants contracting herpes from the Ultra-Orthodox ritual of the mohel sucking drops of blood from the penis of male infants during circumcision.  Two died and two suffered brain damage.  [source

As CHILD USA founder Marci Hamilton reports, New York City has been very timid in its response.  In 2012 the New York Health Department required mohels to have parents sign an informed consent form pointing out the dangers of the procedure and that the Health Department advised against it.

Even this modest requirement met with strident opposition from hundreds of rabbis charging that their first amendment rights were being violated.  After a court ruled the requirement unconstitutional for being specific to one faith, the Department simply dropped the requirement in 2015 rather than rewording it.  [source

What is the difference between New York policymakers resisting Ultra-Orthodox opposition in 2019 and capitulating to it in 2015?  Certainly 854 cases of measles impacts many more children and costs the public far more than the 18 infants who contracted herpes.  And much of the argument in legislatures this year has been that unvaccinated carriers raise the risk for everybody else.  CHILD USA, though, maintains that our form of government is supposed to protect the individual.  The community needs protection but so does the individual child, however few may be at risk from a religious practice.  Measles, for example, may be the most infectious virus on the planet, and Washington State focused on limiting exemptions from the measles vaccine to protect the community.  But the children of religious objectors deserve equal protection from the other vaccine-preventable diseases too.  Tetanus is not a contagious disease but it is very painful and can be fatal.  An individual child deserves protection from tetanus even though s/he poses no risk to the community.     

The most protective policy is to offer only medical exemptions from immunizations.  Mississippi has not had a single measles case since 1992.  West Virginia has had only one measles case since 1994 and that was of a two-year-old, who was not required to be immunized.  California repealed non-medical exemptions in 2015, but the new policy is coming in gradually because immunizations are required only for kindergarten and seventh grade.  This year California has had 40 cases of measles, which is a minor fraction of the cases in the Disneyland epidemic that prompted repeal

As of June 2019, five states—Mississippi, West Virginia, California, Maine, and New York—allow only medical exemptions from immunizations.