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Wednesday Oct 14, 2015

Fewer, Not More, Vaccine Exemptions Needed

I am fortunate, compared with many of my peers, when it comes to immunizations. I have the luxury of taking care of patients in a state with a mandatory vaccination policy(www.dhhr.wv.gov).

No religious, conscientious, personal preference, made-up or any other type of exemption is allowed -- only true medical contraindications. In West Virginia, we have mandated vaccination standards for children involved in public education.  

© 2015 David Mitchell/AAFP

A 1-year-old girl receives a vaccination. The AAFP recently adopted a policy against nonmedical vaccine exemptions. 

Until recently, only Mississippi shared my state’s vision for mandated vaccination, but California joined our ranks earlier this year. It likely is one of the few things West Virginia and California have in common.

Children who attend state-licensed daycares in West Virginia must be up-to-date with the vaccine schedule recommended by the AAFP, the American Academy of Pediatrics and the CDC. To enroll in pre-K, children must have received at least the first dose of all recommended vaccines. They then have eight months to obtain the additional doses recommended for their age group.

Children entering West Virginia schools for the first time from kindergarten through high school must show proof of immunization against diphtheria, pertussis, tetanus, polio, measles, mumps, rubella, varicella and hepatitis B unless they have medical exemptions. And all students in seventh and 12th grades -- regardless of whether they have been previously enrolled -- must prove they are up-to-date with tetanus, diphtheria and acellular pertussis (Tdap) and meningococcal vaccinations. Unlike the pre-K policy, there is no allowance for provisional enrollment.

These policies have provided West Virginia with some of the nation's highest immunization rates -- and correspondingly lower vaccine-preventable disease rates. In 2013-14, students entering kindergarten in public schools had coverage rates ranging from 97 percent to 98 percent(www.dhhr.wv.gov) for five recommended vaccines. Medical exemptions were allowed for only 0.1 percent of students.

Yet despite this public health success story, bills were introduced during our last legislative session that would have weakened our vaccine requirements by allowing nonmedical exemptions. I would like to assume that when something good for our state exists, it will stick around, so I was shocked when I heard one of these bills actually had some momentum. Why would we move backward? Why would we start putting our citizens at risk? Why wasn't every physician in the state at the capital in Charleston expressing outrage?

Fortunately, these bills -- which were debated while a measles outbreak was spreading in 24 states(www.cdc.gov) -- did not become law. There were plenty of physicians and other public health-minded people willing to testify in support of mandatory vaccination policies, and we kept our current standards. I fear, however, we will see similar bills introduced in the next legislative session.  

If I had been chosen to testify during the previous session, I would have referenced public health data and general information about the benefits of vaccines. Because of the success of our state's immunization policy, I have never seen a case of measles or mumps, so I can’t give first-hand testimony about infants dying of vaccine-preventable diseases. In the coming legislative session, however, I will be able to provide concrete examples I’ve seen in my adult patients who have acute hepatitis B infection.

West Virginia didn’t start to mandate hepatitis B vaccinations until 2000. Unfortunately, we have the highest rate of acute hepatitis B cases(www.cdc.gov) in the country, a shocking 10.5 per 100,000 persons in 2013, when the national rate was 1.0 per 100,000.

National data show most of the cases are in the 25-50 age group, which is consistent with what I see in my state. I see far too many cases of hepatitis B and C infection in my rural practice. Thankfully, I know I will see a change in this disease pattern in my lifetime because of our vaccination policies. The children I vaccinate today will grow up to be adults without hepatitis B infection.    

I have never had an adult patient refuse the hepatitis B vaccine series. They come see me for vaccination when a friend or relative is diagnosed with hepatitis B infection. I think that is in part due to the groundwork we lay with childhood vaccines. My patients see stories in the news about disease outbreaks happening in other states, and that just doesn't happen here.

The AAFP recently adopted policy that objects to immunization exemptions for any reason other than a documented allergy or medical contraindication. I hope that California adopting a mandatory vaccine policy is just the beginning and soon, that state, Mississippi and West Virginia will be part of a long list of like-minded states.  

We need to be smart about crafting these programs and learning from what already exists. Health Affairs published an article(content.healthaffairs.org) exploring disease patterns that result from state-specific exemption policies. The numbers speak for themselves, but we as family physicians must speak for our communities. No legislative conversation -- or, more importantly, vote -- about vaccination policies should occur without our input. We have to be willing to sacrifice a few hours, or even a day, of patient care to influence policy.

This issue should not be up for debate. Immunizations are a medical necessity.

Kimberly Becher, M.D., practices at a rural federally qualified health center in Clay County, W.Va.

Posted at 03:37PM Oct 14, 2015 by Kimberly Becher, M.D.

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