February 16, 2015
As the multistate measles outbreak is attracting national attention, Oregon might soon switch from being a state with one of the easiest immunization opt-out laws to among the toughest.
Up until 2014, Oregon parents could opt out of their children’s school immunizations simply by signing a form. The rate of parents using the exemption has been growing steadily since 2000, the same year measles was declared eliminated, said Dr. Paul Cieslak, medical director of Oregon Health Authority’s communicable disease and immunizations division.
The latest statistics show that 7 percent of Oregon kindergartners had nonmedical exemptions in the 2013-14 school year, the highest rate in the country.
If the trend were to continue and measles reached an Oregon school or a community with immunization rates below 94 percent, the highly contagious disease would spread faster than public health officials could react, Cieslak said.
The Senate Health Care Committee on Wednesday is scheduled to hear testimony on a bill that would eliminate the option for parents to claim nonmedical exemptions from school shots. The sponsor of Senate Bill 442, Sen. Elizabeth Steiner Hayward, a Portland Democrat and family physician, said she has lost confidence that staunchly anti-vaccine parents will change their minds, making her bill necessary.
In 2013, the Legislature passed a policy requiring parents who intend to claim a nonmedical exemption to demonstrate that they’ve been educated about the risks of denying vaccines through a consultation with a medical provider or videos produced by the Oregon Health Authority.
This school year is the first since that law went into effect in March, and Wednesday would be the first School Exclusion Day, the deadline by which attendees of schools or child care facilities must prove up-to-date vaccination status or claim an exemption.
Steiner Hayward’s original intent was to introduce a “technical fix” into how OHA enforces exemptions, but she plans to propose amendments that would get rid of nonmedical exemptions altogether. Based on anecdotes from school-based health centers and fellow physicians, she said, it’s already clear the new policy isn’t working.
Parents who were set on refusing vaccines weren’t taking the OHA educational videos seriously, multitasking as the videos played and then printing out the certificate to satisfy the requirements for a nonmedical exemption, Steiner Hayward said. Few, if any, were budging on their anti-vaccine stance.
“I’m past the point of being patient about this,” Steiner Hayward said.
If the bill passes, parents will only be able to claim medical exemptions to school shots.
Is Oregon ready?
The question remains whether Oregon is ready for a policy that many will undoubtedly protest as robbing parents of their autonomy.
Dr. Jay Rosenbloom, a Portland pediatrician who helped draft the 2013 legislation to tighten Oregon’s vaccine exemption policy, said he would support eliminating religious and philosophical exemptions — but he isn’t sure it is possible.
He said that the option was brought up in discussions of 2013 Senate Bill 132 but that it would have been impossible to pass. This year, however, the news of the measles outbreak might motivate the Legislature to take a tougher stance.
“I would love to see an elimination of the religious exemption, but the culture in Oregon is such that, with the focus on civil liberties, I’m not sure that that would work for the people of this state,” Rosenbloom said. “So that’s something that the Legislature has to decide.”
California and Washington legislatures are also considering bills that would not allow parents to opt out of vaccines because of personal beliefs. California, more specifically Disneyland, is where the current measles outbreak originated. As of Feb. 11, 125 cases were reported in at least 17 states and Washington, D.C., according to the U.S. Centers for Disease Control and Prevention.
Parents refuse vaccines for a variety of reasons. Some are still concerned that the measles, mumps, rubella, or MMR, vaccine causes autism, a belief that stems from a debunked 1998 research paper by British doctor Andrew Wakefield. Others fear the side effects of vaccines more than the diseases they are meant to protect against. Another common complaint involves thimerosal, a mercury-containing compound that is used as a preservative for many vaccines. Some also distrust pharmaceutical companies that manufacture the vaccines and the doctors who recommend them.
For Mount Angel mom Summer Sheldon, decisions about her three children’s vaccines are made on a case-by-case basis. For example, she refused all of her kids’ infant shots because she wanted to wait until their immune systems were more developed, around age 2. She refused the polio shot because polio was no longer circulating in the United States. They also don’t have the chicken pox vaccine, because she’d rather her kids develop their immunity from natural chicken pox. She’s been delaying the MMR vaccine, but in light of the measles outbreak, she plans to put it at the top of the list.
A key factor in Sheldon’s decision was that she was confident she could control her children’s environment. They are in home school, and all three were breastfed.
“If my baby was in a day care situation, exposed to a lot more people, I would’ve made a different choice,” Sheldon said. “Because I knew we’d be home and breastfeeding, I thought, why take that risk of the vaccine.”
Assessing the risks
Many doctors say the perception of the risk in vaccinating children is overblown. While vaccines aren’t perfect, the risk of complications due to vaccines are miniscule compared to what children encounter every day in their environment, they say.
“They’re exposed to far more challenges to their immune system just eating and breathing than all the vaccines combined,” Rosenbloom said.
A complicating aspect of the debate about immunizations is that they’re a combined medical and public health measure. The vaccines not only protect the person receiving them; they also protect the community at large from the spread of disease.
This herd immunity — maintaining a certain level of immunization in the community to prevent disease outbreaks — is especially important for infants who are too young to be fully immunized, pregnant women and people who have conditions, such as cancer, that suppress their immune systems.
“You’re part of our society,” said Dr. Jim Lace, a Salem pediatrician. “You live here. And you have to be socially responsible. You cannot be selfish. You’re part of the whole society that we live in. You can’t separate yourself. You don’t live on the moon.”
Ultimately, Steiner Hayward said, the fear should be of the disease the vaccines protect against, not the vaccines themselves.
“Look, are vaccines perfect? Of course they aren’t. I don’t know any medical treatment that is,” she said. “There is no vaccine that’s perfect. Either it’s not 100 percent effective — but no medication is 100 percent effective — or it has adverse effects. Every medication has some small percentage. But the rate of adverse effects from the vaccines are dramatically lower — orders of magnitude lower — than the rate of bad effects from any of these diseases.”
Passing SB 442 would put Oregon among the states with the strictest vaccine exemption policies. While many states don’t allow philosophical exemptions, only two states don’t allow either religious or philosophical exemptions: West Virginia and Mississippi, according to the National Conference of State Legislatures.
Mississippi has the highest vaccination rate in the country, at near 100 percent, according to the CDC. But while other states seek to toughen their vaccine policies, Mississippi’s Legislature is considering allowing exemptions for “conscientious beliefs.”
Despite Oregon’s famously high vaccine exemption rate, Steiner Hayward is confident she has the support she needs in the Legislature to rid Oregon of nonmedical exemptions.
She believes she has a majority of the Senate and the House on her side, though there are some lawmakers who want to keep the religious exemption, she said.
In the correspondence she receives about this issue, 10 times as many people are for the change than against it, she said.
“I’ve had more people requesting to co-chief-sponsor this bill than any other bill I’ve done in the Legislature,” she said.
Steiner Hayward expects a packed hearing room Wednesday, and many will speak in support of the bill, she said.
Physicians were cautiously optimistic that Steiner Hayward would be successful.
Even Dr. Caroline King, who has a softer, more sympathetic approach to parents who are vaccine-averse, said Oregon would benefit from a tougher exemption policy. The Kaiser Permanente family physician delayed her first son’s chicken pox vaccine until he was 3.
“For some things, I do feel like we do have to have faith in the system that is looking at us as a herd, as a tribe, a population,” King said. “I feel that we have certain entitlements and sometimes people are exercising a little bit too much personal entitlement and putting the population at risk.”
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If you go
A public hearing for Senate Bill 442, introduced by Sen. Elizabeth Steiner Hayward, D-Portland, is set for 3 p.m. Wednesday in Hearing Room A of the Capitol.