Coalitions Conference Call

Highlight of ACIP Meeting and Non-medical Exemptions to School Mandates

 
REMINDER: Presentations and photos from the 10th National Conference on Immunization and Health Coalitions, May 23-25, 2012, are now online! Access the slides and photos at http://immunizationcoalitions.org/2012-ncihc-conference/.
 
Dr. Kroeger provided a quick overview of the recent ACIP votes on pneumococcal and influenza vaccination.
 
Pneumococcal
At its June meeting, ACIP voted to recommend 1 dose of PCV13 for adults age 19 years and older who are at high risk of invasive pneumococcal disease. This includes adults who are immunosuppressed and those with functional or anatomical asplenia, renal disease, CSF leaks, and cochlear implants.
 
If such patients have never received a pneumococcal vaccine, ACIP recommends administering PCV13 first, followed by PPSV eight weeks later, followed by another PPSV five years later. If such a high-risk patient has already received PPSV, you should wait 1 year before giving PCV13 to avoid interference between the vaccines.
 
Although PCV13 is now licensed for adults age 50 years and older, ACIP did not recommend its routine use in all adults at this time.
 
Influenza
At its June meeting, ACIP voted on the following algorithm for providers to use in determining which children under age 9 years will need 2 doses of influenza vaccine:
 
Has the child ever received influenza vaccine?

• If yes, did the child receive two or more total doses of seasonal vaccine since July 2010? If yes, give one dose.
• If not, or if the information isn’t known, give two doses at least 4 weeks apart.
• If the child has never received influenza vaccine or the information isn’t known, give two doses at least 4 weeks apart.

The reasoning is based on the fact that children younger than 9 years of age need two doses of seasonal vaccine in order to establish immune system priming, and 2 out of the 3 influenza strains included in the 2012-2013 influenza vaccine are different from those of the 2011-2012 vaccine. The one that remains the same is the 2009 pandemic strain, which was available in 2009 as a monovalent vaccine and then was included in the seasonal 2010-2011 and 2011-2012 flu vaccines.
 
As many children receive vaccinations from multiple sources, it can be difficult to track down past doses. The algorithm is purposely simple to encourage vaccination. The published recommendations will include more information for providers who have patient records from before July 2012 who wish to avoid providing an extra dose if not necessary.
 
Much more detail will be included when these recommendations are published in MMWR (date unknown). If you have questions, feel free to email the CDC immunization experts at nipinfo@cdc.gov.
 
 

 
Please see the accompanying slide deck for more detail on all these points.
 
Diane pointed out that non-medical exemptions to school mandated vaccines tend to be clustered in certain states (e.g., Washington, Vermont, Oregon, Alaska, and Utah), as well as certain areas or pockets in states that have low overall rates of exemptions.
 
Nineteen states allow for non-medical/non-religious vaccination exemption but the terminology of the law varies:

• Personal beliefs/personal reasons/convictions (7)
• Philosophical/moral reasons (4)
• Other grounds/objections/written objection (3)
• Conscientiously held beliefs/reasons of conscience (3)
• Philosophical or personal objection (1)
• Strong moral or ethical conviction similar to a religious belief

The Pediatric Infectious Diseases Society released a statement regarding personal belief vaccine exemptions in March of 2011. This resource includes recommended components for states that have or are considering personal belief exemption (PBE) legislation:

• Personal belief must be sincere & firmly held
• Parents/guardians must receive state-approved counseling
• Parents/guardians must sign a statement delineating the basis, strength, and duration of their belief; their understanding of the risks on the child’s health and to others; and their acknowledgment that decision is on behalf of their child
• Parents/guardians should be required to revisit the decision annually with a state-approved counselor, submit a signed statement annually, and acknowledge in writing their awareness that child will be excluded if an outbreak occurs
• State must track PBE rates and evaluate impact on VPDs

A number of states have been dealing with legislation related to PBEs in recent years (see slides 13-18). The process for obtaining legal exemption should be no easier than getting vaccinated, but it often is and changing the law can be difficult. Consider proposing additional administrative procedures within existing exemption(s), but before submitting proposals, build support with immunization partners.
 
You can contact Diane at diane@immunize.org.
 
 

 
Please see the accompanying slide deck for more detail on all these points.
 
Oregon only allows for medical, immunity, and religious vaccination exemptions. From 2000-2012, the religious exemption rate rose steadily; for the 2011-12 school year, 5.8% of kindergarten students claimed a religious exemption.
 
The definition of “religion” is broadly defined. Oregon Revised Statute 433.267allows parents to sign a statement that their child is “being reared as an adherent to a religion* the teachings of which are opposed to such immunization.” *Oregon Administrative Rule 333-050-0010 defines “religion” for the purpose of immunization requirements to be “any system of beliefs, practices or ethical values.”
 
Because of this increasing use of the “religious” exemption, the Oregon Health Authority has been working with partners to determine the best ways to reduce religious exemptions. Options considered:

1. Follow Washington’s lead of requiring a healthcare provider’s signature. This approach would require legislative change.
2. A multi-pronged educational approach: required webinar, online information sessions, interested groups could be certified to provide training, etc. This approach would require legislative change.
3. Require a notarized affidavit. This approach would require legislative change.
4. Change administrative rule to redefine “religion” to not include “any system of beliefs, practices or ethical values.” This approach would require administrative rule change.
5. Require an annual parent signature for a religious exemption to be considered valid; does not require a law change.
6. Encourage schools to search in ALERT IIS for immunization records for students with religious exemptions. Some parents that are using an alternative or delayed schedule do not update school/facility records after vaccine doses have been administered. This would not require a law change, as schools/facilities can already access ALERT IIS.
7. Require parents to obtain a religious exemption form online or at another location, rather than having the form available on the Certificate of Immunization Status at the school/facility. This approach would require legislative change.
8. If the school reported statewide immunization rates for kindergartners drops below 90% for DTaP, MMR or varicella or the children’s facility reported rate for DTaP, MMR, varicella or Hib drops below 90%, the Oregon Health Authority will remove the religious exemption option for the specific vaccine for a specified time period. This approach would require legislative change.

Option 2 is favored by health officers, the Immunization PolicyAdvisory Team, and the Immunization School Law Advisory Committee as a potential legislative change. Option 5 is also favored, but would not require legislative change. The Oregon Pediatric Society is taking the lead and will be working with interested partners to start crafting legislation.
 
You can contact Lorainne at lorraine.duncan@state.or.us.
 
 

 
Please see the accompanying slide deck for more detail on all these points.
 
Vermont is a small, liberal state focused on individual liberties which has had a “philosophical exemption” for vaccination since 1979. Since 2005, the vaccination rates in the states have decreased, at least partially due to philosophical exemptions (and based on NIS data, which has large confidence intervals, so the exact level of decrease not be totally accurate). About 5% of Vermont kindergarten students’ families claim a philosophical exemption to immunization.
 
The Vermont Department of Health and partners initially worked to remove the PBE option entirely. Christine now believes this was a mistake because it worsened the polarity of the sides. Some cautions from her experience:

1. Be aware that any information/data that you make public can be used against you. For example, Vermont was very transparent with the school district data across the state and the anti-vaccine groups studied this carefully to make points (e.g., pointing out that many of the high exemption rate schools were very small and had few students and claiming that the health department was just trying to create a problem).
2. Don’t underestimate the anti-vaccine forces. Be prepared before you start your campaign so it doesn’t seem as if you’re always reactive.
3. Make sure everyone on your coalition/team is on the same page.

Vermont eventually passed compromise legislation. Parents/guardians are now required to sign an exemption form annually and read evidence-based immunization education materials. In addition, school nurses have to report on the vaccination status of the entire student body and report stats on each required vaccine for grades K, 1 and 7.
 
You can contact Christine at christine.finley@state.vt.us.