A Philosophical Debate Sharpens

Michigan, which has some of the nation’s highest nonmedical vaccine exemption rates, adds new rule for parents seeking waivers for kids as other states take more radical steps.

Recent measles and whooping cough outbreaks in the nation have raised public health concern, prompting tighter vaccination rules for children.

Michigan, which is part of a shrinking minority (one of 18 states) that allows philosophical exemptions from vaccines, now has a regulation that adds an extra step for parents who cite philosophical reasons to not immunize their children before entering school.

The rule, which went into effect Jan. 1, requires that parents seeking a nonmedical vaccine exemption — including those for religious reasons — make an appointment with a public health nurse to talk about vaccination.

Officials hope this will result in a higher immunization rate for children entering day care, kindergarten, and seventh grade or transferring to a new school district.

Up until this year, parents seeking a nonmedical exemption only needed to fill out an exemption form — or waiver — and turn it into the school or day care center. As a result, Michigan’s exemption rate has been among the nation’s highest over the last six years. In the 2013-14 school year, for example, the state ranked fourth in the number of nonmedical exemptions taken by kindergartners, with the vast majority for philosophical reasons.

States that don’t allow exemptions for any nonmedical reason have a higher immunization rate. In Mississippi, 99 percent of kindergartners have had their shots. Michigan’s full vaccination rate is in the 70-80 percent range.

“Herd immunity,” the goal of widespread vaccination, breaks down when fewer people choose to get their children immunized or don’t get fully vaccinated. In the wake of measles outbreaks over the past five years, other states have taken more radical steps than Michigan to boost herd immunity.

In May, Vermont ended the philosophical exemption option (but kept the religious one). California, the epicenter of a measles outbreak earlier this year that infected 178 people, ended all nonmedical exemptions for children in school and day care in June. And in Colorado, waivers are now required every year from pre-K through 12th grade rather than just one time. Oregon is grappling with its high exemption rates, but proposed legislation to make it more difficult to get a waiver has stalled in the Senate.

While Michigan isn’t currently considering eliminating the philosophical exemption, folks who oppose coercive vaccination say the new rule is intrusive.

Bloomfield Hills resident Joel Dorfman, a nonpracticing attorney who is active in the group Michigan Opposing Mandatory Vaccines, says the new rule states “you now have to go to the county health department, and you have to be educated on the benefits and risks of not being vaccinated,” he says.

“Nowhere is there education about the risks of being vaccinated.”

The majority of side effects from vaccines that are reported to the federal government’s Vaccine Adverse Event Reporting System is fever. Redness, itching, and swelling at the injection site are also common complaints, as well.

Commerce Township parent Vanessa Lynn, who refers to herself as a “vax choicer,” opposes the regulation because she considers it intrusive and rather pointless.

“This is a punitive law that is designed to sway you away from being able to exercise your right to opt out, to make it as difficult as possible,” says Lynn, who has three children, two of them from her first marriage and a daughter from her second marriage. She did not have the older children vaccinated (but they were vaccinated after the divorce) and her 3-year-old daughter has never been immunized.

Lynn says that her middle daughter suffered from neurological disorder apraxia of speech because of vaccines she received in early childhood and it had a big impact on her life.

People against vaccines have pointed to thimerosal, a mercury-based vaccine preservative that they thought could lead to autism. The ingredient was removed from most childhood vaccines in 2001 (it is still found in some flu vaccines), and studies showed no link between thimerosal and autism. According to the American Academy of Pediatrics, rates of autism went up after the preservative’s removal.

The right to take an exemption based on religious or philosophical beliefs is still in place in Michigan. If the parent elects not to immunize his or her child, the waiver will be signed and certified by the health department.

“We are encouraging a conversation, nothing more than a conversation,” says Bob Swanson, director of immunizations at the Michigan Department of Health and Human Services. “The purpose is to promote education. We know there’s a lot of misinformation on the Internet, so we want to give the facts to parents.”

Public health officials and health care providers say the consequences of spreading the measles can be dire, especially for people whose immune systems have been weakened by chemotherapy or illness, and of course, for those who are not fully vaccinated. And the “cluster effect” — the concentration of people who are not vaccinated or not fully vaccinated — means a much faster spread of measles and whooping cough. “What I fear most are pertussis, measles, haemophilius influenza, meningococcal pneumonia — vaccine-preventable diseases,” says Dr. Basim Asmar, chief of infectious diseases at Children’s Hospital of Michigan in Detroit. “If we keep cutting down on the vaccination rate, (diseases) will come back,” he says.

As of June 26, there were nearly 180 cases of measles reported in 24 states, including Michigan, according to the CDC. In 2014, a record number of cases were reported, with 668 cases in 27 states; the highest number of cases since measles were eliminated in the U.S. in 2000.

Throughout the country, pediatric practices have stopped seeing patients whose parents refuse immunizations (the American Academy of Pediatrics does not endorse the practice). Beverly Hills Pediatrics in Bingham Farms, for example, will no longer take new patients who are not up to date on their vaccines — not only to protect vulnerable patients like infants and children with weakened immune systems, but also to appease parents who won’t bring their children there if they do.

Dr. John Dorsey, one of the practice’s six pediatricians, says the measles outbreaks have created a dilemma for practitioners. Should they turn away well-meaning parents?

“Over the decade we’ve had families who wouldn’t vaccinate, and our point of view was that if we waited long enough they’d come around. We had a nice recovery rate,” he says.

“First, the mumps epidemic resurrected talk about vaccinations. Then the measles epidemic, which criss-crossed the country, brought a different popular voice — people who didn’t want to come into a practice where doctors treated kids who weren’t vaccinated. Now I have the possibility of a youngster who is not immunized coming in with a disease that could be lethal or cause brain damage.”

Measles may lead to complications like pneumonia and encephalitis. A study published in May in the journal Science found that measles in a child may not be fatal, but it breaks down the immune system for 2-3 years after the infection, making it likelier that a child will die of another infectious disease.

A woman died of complications of pneumonia in Washington state in July after being exposed to measles in a health clinic. An autopsy showed she had contracted the disease, although it is unclear whether she had been vaccinated against measles as a child. She was also on immune-suppressing drugs, according to reports.

In Michigan, officials are not considering ending the philosophical exemption, which was written into the public health code in 1978 and provided the basis for the majority of parents and guardians cited in the last two years when getting waivers for their children.

“It is possible for Michigan to go even farther in limiting philosophical exemptions in the future,” says Dr. Matthew Davis, a University of Michigan professor of pediatrics and internal medicine. Davis served as the state’s chief medical executive from 2013-15.

“However, the belief in the public health community in Michigan is there needed to be a stepwise approach to addressing the increasing rate of philosophical exemptions across the state, in order to encourage conversation rather than conflict.”

Ten counties (not in metro Detroit) independently implemented the educational component for waiver exemptions in previous years. They’ve seen a drop in the number of waivers sought. Oakland County, which has a high rate of vaccine exemptions among children – 7.1 percent compared to 4.7 percent for the state (as of March) – implemented the rule in January.

This year, public health nurses have conducted about 450 educational sessions, says Shane Bies, administrator of public health nursing services at the Oakland County Health Division.

The number of minds changed by these sessions is yet to be seen until the waivers are totaled at the start of the academic year, he says.