Think Tank

Should California Strengthen School Immunization Rules?

Two statistics are on the rise in California:

  • The number of California kindergarteners who have not been vaccinated against childhood illnesses has increased by 16% over the past year, according to data from the state Department of Public Health.
  • Communicable diseases including measles and whooping cough are increasing in California. So far, 56 cases of measles — the largest outbreak since 2000 — have been reported this year. Last year, 2,300 cases of pertussis — also known as whooping cough — were reported in California.

Under a new state law that took effect Jan. 1 this year, parents are required to consult with a health care provider — physician, school nurse or naturopath — before they decide their child should forego one or more of the standard vaccinations most children receive before starting school.

Before the new law — AB 2109 by Richard Pan (D-Sacramento) — parents could opt out with a signature on the child’s immunization card.

It’s too early to tell how the new law might affect the two trends above, but some health advocates say the new regulations don’t go far enough. Some suggest children should not be allowed to attend school without vaccinations.

We asked legislators, stakeholders and experts how California lawmakers and policy makers should respond.

We got responses from:

Vaccine-Preventable Diseases Must Be Prevented

In medical school, my professor told us that we would likely never see a case of measles or polio, but we needed to learn about them for board exams. After all, universal immunization eradicated smallpox, and measles and polio would be next. But only a few years later, measles became a reality when I saw measles in an outbreak that killed six unvaccinated children.

However, I remained optimistic that with the advent of vaccines that prevented meningitis and cancer, we could still protect more children.

Today, my past optimism has been replaced by concern that too many parents do not understand the dangers of vaccine-preventable diseases. Instead, many parents hesitate to vaccinate their children because of misinformed fears regarding vaccine safety. This past year, the number of California kindergarteners not receiving recommended vaccinations rose 15%. Some even claim children should catch these infections “naturally,” not understanding that prior to accepted use of these vaccines, one in five children with measles were hospitalized and 450 children a year died, that 9,000 children a year died of pertussis, etc.

But we do not have to look back decades to find death from vaccine-preventable diseases. With falling vaccination rates, preventable diseases have returned to California. In 2010, more than 9,000 cases of pertussis resulted in 809 hospitalizations and 10 infant deaths, cases clustered in communities with low vaccination rates, and with another sharp increase in pertussis in 2013. Measles, declared eradicated in 2000 in the U.S., sharply increased with 58 cases already this year in California compared to a low of four cases for an entire year.

AB 2109, implemented this year, requires parents to consult a licensed health care professional before opting out their child from required immunizations. This law is modeled on a law in Washington state, which reduced school vaccine exemptions. Keeping vaccination rates high enough to prevent outbreaks is essential to protect people who cannot be vaccinated such as infants and people with poor immunity, such as chemotherapy patients. Monitoring the impact of AB 2109 on school immunization rates will be important. Public disclosure of vaccine exemption rates at each school can empower parents and community members concerned with disease outbreaks. In addition, the Affordable Care Act eliminated copayments for vaccines to reduce cost barriers for parents to get immunizations. However, if outbreaks continue to increase with low immunization rates, additional steps need to be considered to protect our communities. 

We should not wait for children to die of vaccine-preventable disease to act.

School Nurses Encourage Vaccinations

School nurses share the concern of public health officials regarding the recent increase in the number of California kindergarteners who have not been immunized against vaccine-preventable diseases and the recent outbreaks of measles and pertussis. Despite the increased capacity in our society to prevent infectious disease with new vaccines and the expansion of childhood, adolescent and adult immunization schedules, viruses and bacteria that cause vaccine‐preventable disease and death still exist and pose a risk for unvaccinated people.

Additionally, vaccine‐preventable diseases have a costly impact on Californians, resulting in lost work time for parents, additional doctor’s visits, hospitalizations, and premature deaths. To optimally prevent disease, disability, and death from vaccine preventable illnesses, the vaccine delivery system must target children, adolescents and adults.

The California School Nurses Organization believes that vaccines are responsible for the control and elimination of many infectious diseases that were once common in the United States. CSNO also believes that vaccination against childhood diseases is one of the greatest public health achievements of the last half century. Immunizations are a key to primary prevention of disease from infancy through adulthood.

A primary role of the school nurse is the prevention and control of infectious disease. A key component of school‐based infectious disease programming includes the promotion of vaccination. The school nurse, by virtue of his/her professional knowledge and experience, practices in an ideal setting to educate families regarding the indicators, contraindications, side effects, and timeliness of initial and booster doses of vaccines. The school nurse is in a critical position to create awareness and influence action related to mandated and recommended immunizations in the school community.

To realize the full benefit of immunizations, parents must recognize that vaccines are a safe and effective way to help the body defend against vaccine‐preventable diseases. School nurses, like other health care providers, are in a position to maintain and share current knowledge and recommendations regarding vaccines with parents.

In regard to the new law, California Health and Safety Code 120365, which CSNO supports, school nurses, as the primary health professional in the school setting, have a responsibility to listen to and to try to understand a parent’s concerns about vaccination and to take them into consideration when responding with accurate immunization information and reassuring parents on these specific issues. The goal is to encourage vaccination by providing parents with accurate and reputable vaccine information with which to make an informed decision.

All Children Should Be Vaccinated

Most vaccines protect us in two ways. They provide individual protection to the vaccinated person and each vaccinated person who is protected (immune) contributes to the immunity of the population as a whole. This is called “herd” immunity. Since 2000, measles herd immunity has been so good in the United States that the measles virus no longer circulates. The recently reported cases of measles in the United States have been the result of importations from other countries with limited secondary transmission to non-immune Americans.

The vaccine contrarian Bob Sears recently asked what the big deal is about seven cases (“not 700” cases) of measles in Orange County. In addition to the fact that measles can be quite severe and is vaccine-preventable, there is a bigger public health problem. Specifically, public health staff in each state must identify and check all the contacts of each case in an attempt to prevent additional cases of disease. Since the number of contacts is often sizable, this is an extremely time consuming and costly process. In California this year, there have been 56 cases of measles. For each case, there may be hundreds of exposed persons who need to be investigated by public health; one case this year in Orange County had over 1,000 contacts.  Depending on their immune status and overall health, exposed persons may need to receive preventive immunization or immune globulin after exposure.

As it turns out, a significant number of exposed persons have medical conditions which have precluded them from immunization or otherwise make them at an increased risk for severe and fatal measles. For example, an exposed child who is being treated for leukemia will need to be treated prophylactically with intravenous immune globulin that will cost thousands of dollars. Other exposed persons will need to be vaccinated immediately or given intramuscular immune globulin. This all takes considerable time and is expensive. Furthermore, decisions about which exposed persons are at risk of severe measles infection and need IVIG often require consultation with medical specialists, and decisions need to be made in hours not days, because these interventions are only effective if done in a timely way.

It is concerning that there have been so many imported measles cases and so much secondary transmission of measles in the United States in 2014. Increasing numbers of unimmunized children may decrease herd immunity below protective levels. If this happens, measles could again begin to circulate in the United States. As the number of measles cases increases, the risk that there will be cases that result in death or brain damage also increases. Lifesaving treatments, such as bone marrow transplantation, that weren’t available in the pre-vaccine era, have increased the number of immunocompromised people in the population, but even previously healthy persons can develop complications from measles infection. In addition, the costs to public health departments of tracing measles contacts and seeing that they get appropriate prophylaxis runs into many thousands of dollars.

In 2014, a new law on exemptions from California school and childcare immunization requirements became effective in California. The intent of this law was to ensure that parents wishing to exempt their children from required immunizations received information about the benefits and risks of immunizations and the risks of vaccine-preventable diseases from a health care practitioner prior to obtaining an exemption. Under the previous law, parents needed only to sign a form to exempt their child from the requirements. However, when Governor Brown signed the bill into law he required that there be a religious exemption, which was not in the previous law. Parents who use this provision do not need to receive information from a health care provider, which essentially negated the intent of the law. In addition, naturopathic doctors were added to the list of health care practitioners who could provide information to parents. (This is like having the fox guard the chicken coop).

Yes, Bob Sears, measles is a big deal in 2014.  Parents, doctors, and other health care personnel should ensure that all children without medical contraindications receive two doses of MMR (measles, mumps, and rubella) vaccine.

Policymakers Have Duty to Protect

The 2010 pertussis epidemic, which resulted in more than 9,400 cases and 10 infant deaths along with the current outbreak of measles in California (56 cases as of April 20), highlights the significant risk presented when “herd” or community immunity is compromised. Requiring vaccinations for children enrolled in childcare facilities and schools has been a major contributor to the success of state and national immunization programs and the resultant decreases in devastating and preventable diseases.

In response to a dramatic increase in personal belief exemptions from required immunizations, AB 2109 was signed into law on September 30, 2012 and went into effect January 2014. This law requires a parent or guardian seeking a personal belief exemption from school-required immunizations to first obtain a document signed by a licensed health care practitioner that verifies that the practitioner has informed the parent or guardian of the benefits and risks of immunization, as well as the health risks of the diseases that an unvaccinated child could contract.

The law preserves a parent’s option to exempt a child from immunizations but also requires education and information to ensure that such a decision is an informed one and that parents are aware of the individual and public health risks of not immunizing their children.

In his signing of AB 2109, Gov. Brown directed the Department of Public Health to “allow for a separate religious exemption on the form.” The California Immunization Coalition strongly objects to this addition because the personal belief exemption currently in statute already satisfies and includes those seeking exemption based on religious beliefs. We understand that the governor has concerns about protecting the First Amendment rights of parents who believe their religion does not allow them to seek medical treatment from health care practitioners. However, this new law does not require that parents vaccinate or treat their children, but that everyone receive accurate information.

The governor’s stated concern for protecting the religious beliefs of families is a misunderstanding of public health and the law. There is no known religion that prohibits a parent from seeking health information for their child.

As a coalition of public health professionals and immunization advocates we are dedicated to ensuring that everyone in the community is protected from vaccine preventable diseases. California lawmakers, policymakers and public health leaders also have the duty to ensure this happens by utilizing evidence base research and credible sources for making public health decisions.