Laws, Choice and Pertussis

[imgbelt img=Inst+Vax+Safety+map.gif]Reports are coming in from all over rural America about increases in the number of whooping cough cases. No wonder. States like Vermont are allowing parents to exempt their children from vaccination.

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reported that while all 50 states have legislation requiring certain vaccines for students, and all such laws allow exemptions to the recommended vaccine schedules when medically indicated, only 20 states (Vermont among them) permitted “philosophical exemptions for those who object to immunizations because of a personal, moral, or other beliefs.”

[imgcontainer left] [img:6a00d8341c630a53ef0133efe0a38d970b-300wi.jpeg] With vaccination, the nation cut back the number of whooping cough cases to near zero. But then vaccination rates went down and the number of pertussis cases increased.

A legislative strategy might reasonably be viewed as one tool in the effort to increase U.S. vaccine coverage rates. In the state of Washington, where a whooping cough epidemic was declared on April 3, 2012, a law tightening the rules for opting out was passed in 2011, and many are watching to see whether that requirement impacts the state’s vaccine exemption rates.

The Vermont bill passed the Senate easily, and that’s when the fun began. 

State health officials and health care providers were passionate in their advocacy for vaccination. After all, vaccination was included by the Centers for Disease Control and Prevention (CDC) in its list of the Ten Great Public Health Achievements of the 20th century. In publishing this list, the CDC referenced the impact of vaccination on the eradication of smallpox; elimination of poliomyelitis in the Americas; and control of measles, rubella, tetanus, diphtheria, Haemophilus influenzae type b, and other infectious diseases in the United States and other parts of the world.

But nothing like an element of personal choice to galvanize the opposition (and negate science): enter the Vermont Coalition for Vaccine Choice, whose motto is “Vaccination Choice is a Human Right.” 

After days of heated testimony as the bill made its way through multiple committees, and in a classic last-minute scramble of legislative sausage making, Act 157 emerged with the philosophical (and religious) exemptions intact. As long as parents/guardians annually provide a signed statement to the child’s school, they would be allowed to exempt their children from immunization. 

Parents would be required to certify their religious beliefs or philosophical convictions opposed to immunization. And they would have to show that they had read and understood educational material provided by the health department. (This included information about the increased risks to both those who are unvaccinated and to those who may be unable to receive vaccinations because of medical conditions of vaccine preventable diseases, such as whooping cough and measles.)

New York Times blog (“Whooping Cough: A Stealthy Illness”), even individuals who have been fully vaccinated against pertussis (given in combination with diphtheria and tetanus vaccines, known as DTaP or Tdap) are not completely protected against disease. Research is beginning to show that immunity from the vaccine may not be as long lasting as originally thought. 

But experts do agree that pertussis vaccine remains the single most effective approach to illness prevention. Moreover, vaccinated children who get whooping cough tend to have milder illness. 

Because very young infants are among the groups at greatest risk for life-threatening disease, and are too young to be protected by vaccines that they can only begin to receive at two months of age, their protection depends on immunizing the people around them. 

Thus, the CDC now recommends a pertussis-containing booster shot for teens and adults who have not had one, and this recommendation is being given special emphasis for pregnant women and anyone who has routine contact with infants — siblings, grandparents and other relatives, babysitters, and health and child care providers.

Parents want to do what’s best for their children, and this motivation in part results in opposition to recommended immunization schedules, mistrust of vaccine science, and suspicion toward the pharmaceutical industry and government involvement in health policy. 

Clinicians and public health officials must continue to find ways to participate in respectful conversations and provide credible information in response to questions about vaccine safety. Inevitably in this particular dialogue, it comes down to whether we allow parents to opt out of vaccinating their children based on their own risk evaluation, thus diminishing the benefit to community and jeopardizing the health of others—especially the medically vulnerable and the very young. 

Meanwhile, Vermont is rewriting its immunization regulations to reflect the state’s recent legislation. How all of this will “sugar off” remains to be seen — perhaps not until the results are in from this year’s school nurse data collection, about the time the sap is beginning to boil. 

If the current disease trend is any indication, there will still be plenty of coughing in the classroom by the time that happens.

Dr. Wendy Mahoney is a Vermont physician.

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