National and state efforts to raise vaccination rates and prevent outbreaks of preventable diseases are ramping up. Measles and whooping cough, once thought to be eradicated in the state, have come back with a force in California.
A measles outbreak that originated in California has spread to half a dozen other states, health officials said. As of Feb. 16, there were 119 confirmed cases of measles in the state, including half a dozen children under age one. Last year California had the largest outbreak of whooping cough in the past 70 years, with one infant death and more than 10,000 cases reported statewide.
Immunization rates are down in California, and lawmakers in the state are considering a bill to eliminate the personal belief exemption — a form parents can sign to opt their children out of vaccines.
Meanwhile, the national spotlight has turned toward vaccinations, as many states and the federal government consider modifications of vaccine law in the wake of the measles outbreak. In Congress, Sen. Barbara Boxer (D-Calif.) and Rep. Anna Eshoo (D-Calif.) introduced the Head Start on Vaccinations Act, which would require children to be vaccinated before enrolling in Head Start and Early Head Start programs across the country.
Media coverage of vaccinations and disease outbreaks has elicited a raft of controversial statements from an array of public figures, including liberal talk-show host Bill Maher, libertarian Sen. Rand Paul (R-Ky.) and conservative New Jersey Gov. Chris Christie (R).
It’s more attention than vaccines usually get.
“Vaccines are like traffic laws,” said state Sen. Richard Pan (D-Sacramento), co-author of the California bill proposing to eliminate the personal belief exemption. “It’s public safety. The government has traffic laws, and everyone abides by the traffic laws. We don’t let everyone drive around willy-nilly.”
“Herd immunity” — the percentage of people in a population who need to be inoculated to ensure the safety of the entire population — is at the heart of Pan’s comparison to traffic laws.
For vaccines to be effective for a large population, a high percentage of the people must be immunized. For instance, the recommendation for herd immunity in measles is 92% to 95%.
When people decline vaccinations, they are counting on the disease being rare enough that it won’t spread rapidly through the population. That’s sometimes referred to as “hiding in the herd.” When the percentage of immunized people drops too low, disease — particularly a highly contagious disease like measles or whooping cough — can spread quickly through a population.
According to health officials, compromised herd immunity puts two classes of children at particular health risk, besides the unvaccinated children themselves:
- Immuno-compromised children can’t get some vaccines because of their medical conditions. There are an estimated 250,000 of them in California. So if communicable diseases spread, they are at risk of catching them — and in a vulnerable state of health if they do catch something; and
- Infants can’t get most vaccines right away, so if there’s an outbreak, they are vulnerable. Whooping cough, for one, can be lethal to infants.
California’s History With Vaccine Exemptions
California requires some vaccinations as a condition for entering kindergarten. In 1961, the state established its “personal belief” exemption in vaccine requirements for schools. That exemption has been used much more recently — the number of exemptions in California tripled between 2000 and 2014.
In 2012, Pan authored AB 2109, which required anyone getting an exemption to first consult with a medical provider about the risks of it. Brown approved the bill, but added this caveat for implementation by the Department of Public Health in his signing message:
“Additionally, I will direct the department to allow for a separate religious exemption on the form. In this way, people whose religious beliefs preclude vaccinations will not be required to seek a health care practitioner’s signature.”
That loophole may come back to haunt the current effort to eliminate the personal exemption altogether.
Brown’s signing message rankles Sen. Ben Allen (D-Santa Monica), who said the discussion over whether the religious exemption stays or goes in the new bill still needs to be made.
“Religious exemption is a murky legal concept because of the way it was created,” Allen said. “There’s no mainstream religion that does not allow vaccinations. There may be some individual leaders within religions who have expressed concerns. But even the Christian Scientists have said they’re not against vaccinations. It’s pretty hard to find a religion that has a problem with this.”
The two U.S. senators from California — Boxer and Dianne Feinstein (D) — have urged California health officials to remove all exemptions, including the religious clause, from vaccination regulations.
“That discussion still needs to play itself out,” Allen said. “I wouldn’t make an assumption about that one, one way or the other.”
Vaccinations for Kids Ages Two and Younger
Another bill on immunizations may be making its way to the California Legislature, as well.
Kelly Hardy, senior managing director of health policy at Children Now, said her organization is working on a bill to address under-immunization of preschool children.
“What we’re working on is a bill that addresses two-year immunization rates,” Hardy said, referring to immunization rates for children ages two and younger.
“The Department of Health Care Services has identified that as something they want to improve,” Hardy said. DHCS specifically identified improvements in childhood immunization rates as a priority in its draft 2014 Quality Strategy report, she said.
Independent of the political maneuvering around vaccination legislation, California health officials are looking at a low rate of vaccinations for children under age two.
As for other avenues to improve the under-immunization of younger children, one obvious factor is active participation by health plans, particularly those involved in Medi-Cal managed care, since those most at-risk for immunization lapses are minority children from low-income families, or those in rural or underserved urban areas.
“I think some health plans are really working to reach the under-immunized and the unimmunized,” Hardy said, “and we should really be encouraging that. It’s a win-win. Plans avoid costly preventable diseases and families live healthier lives.”
Hardy said legislation is needed now to enable better immunization numbers for infants and young kids.
“We can’t leave it to kindergarten, that’s too late,” Hardy said. “That’s a good sort of marker, but we need to be more proactive in immunizing before that. We’re seeing a resurgence in preventable diseases that can really hurt [younger] kids. Having some checks in place before kindergarten seems smart to me.”
Hardy said the bill could emerge over the next few weeks.
Public Good and Private Freedom
Elimination of the personal belief exemption has been framed as a public health issue, but Allen — the bill’s co-author — said he appreciates the personal freedom side of the argument, as well.
“We value freedom, I value freedom,” Allen said. “But lives are at risk here. I have a lot of young moms in my district who worry about going to the market with their young baby. That’s a freedom issue, too.”
When the government bans smoking in crowded bars, it’s an impingement on freedom — for the public good, he said.
“Yes, it’s an interesting and complicated mix of rights,” Allen said. “There’s a public interest associated with sensible policies. And the current [vaccination] situation is impinging on other people’s freedom now.
“A lot of folks need to weigh in on this,” Allen said. “So stay tuned.”
The first stop for the Pan/Allen immunization bill, which lacks a bill number, will be the Senate Committee on Health. No hearing date has yet been set, and bill text is not yet available online.