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“How To Handle The Vaccine Skeptics”: Parents Should Face A Higher Burden Before Removing Their Children From The Immunized herd

The alarming number of measles cases — a record 644 last year, and 102 last month, the most since the disease was declared eliminated in the United States in 2000 — has focused scrutiny on parents who refuse vaccinations for their children. There are some who want state and local governments to sue, or even criminally charge, such parents. A bill in California would end all nonmedical exemptions to immunization requirements.

For epidemiologists like me, eliminating exemptions may seem satisfying, but it is not the wisest policy for protecting kids. Instead, we should borrow a concept from behavioral economics, and use administrative rules and procedures to “nudge” parents to immunize their kids, rather than trying to castigate or penalize these parents.

Currently, all states allow medical exemptions, since some children — for example, those getting chemotherapy or who have certain types of immune disorders — cannot safely receive vaccines. All but two states (Mississippi and West Virginia) allow exemptions for religious reasons. Nineteen states allow exemptions based on personal (or “philosophical”) beliefs. Such beliefs are increasingly cited by parents whose misplaced skepticism is not really principled but premised, rather, on false notions like that of a link between autism and the measles vaccine.

So shouldn’t all states follow the example of Mississippi and West Virginia, and ban all nonmedical exemptions? The courts have generally upheld such bans, but the political backlash is great, as history shows. After the smallpox vaccine was made compulsory in England and Wales in 1853, there were years of protests, until a commission exempted those with conscientious objections.

Partly because of intemperate comments by politicians, some Americans continue to view vaccines as an intrusion on their personal liberty rather than as a matter of public health. Between 2009 and 2012, 31 bills aimed at making it easier to obtain exemptions were introduced in various states (including 11 in Mississippi and West Virginia). Vaccination advocates who want to make exemptions harder to obtain will have an uphill fight.

But even states like Arizona and Colorado that allow fairly broad exemptions can tweak their rules to make sure parents are as informed as possible — and to make the exemption process difficult.

They can require parents to write a letter elaborating on the reason their child should be exempt. They can require that the letter be notarized. They can insist that parents read and sign a form that discusses the risks of nonvaccination. Better yet, they should mandate in-person counseling so that the decision not to vaccinate is truly informed.

States can also require that parents obtain an exemption form by specifically requesting one from the state or local health department, rather than downloading it online. They can insist that these parents acknowledge that they will be responsible for keeping the children away from school during outbreaks. Moreover, they should have procedures to review each request for exemption rather than automatically approving them, as many states do now. And they should require parents with exemptions to apply annually for renewal.

States with easy procedures for obtaining exemptions have higher rates of nonmedical exemptions — and, more important, higher rates of vaccine-preventable diseases. In a 2006 study published in The Journal of the American Medical Association, for example, we documented that states with easy procedures for granting nonmedical exemptions had approximately 50 percent higher rates of whooping cough.

In a 2012 study, which my colleagues and I published in The New England Journal of Medicine, nonmedical exemption rates were 2.3 times higher in states with easy administrative policies for granting exemptions (like Connecticut, Missouri and Wisconsin) than in states with difficult policies (like Florida, Minnesota and Texas). Moreover, the annual rate of increase in nonmedical exemptions was about 60 percent higher in states with easy exemption policies compared with states with difficult policies.

These practices will cost taxpayers money. But they will be more effective, in the long run, than condemning vaccine skeptics as ignorant and irresponsible. The goal should be to make the number of parents who decide to seek exemptions — and follow through with it — as small as possible. Given the high costs of controlling disease outbreaks, including the current rise in measles, it might be reasonable to tax parents who seek exemptions to recover some of the cost.

All democratic societies must try to balance the rights and views of a variety of constituencies. Parents of children who are too ill for vaccination should of course be granted an exemption. Everyone else — no matter their belief — should face a high burden before being allowed to remove their children from the immunized herd.

 

By: Saad B. Omer, Associate Professor of Global Health, Epidemiology and Pediatrics at Emory University; Op-Ed Contributor, The New York Times, February 6, 2015

February 7, 2015 Posted by | Measles Outbreak, Public Health, Vaccinations | , , , , , , | Leave a comment

“Scarier Than Ebola”: On Matters Exotic, We’re Rapt; On Matters Quotidian, We’re Cavalier

We Americans do panic really well.

We could use a few pointers on prudence.

Do me a favor. Turn away from the ceaseless media coverage of Ebola in Texas — the interviews with the Dallas nurse’s neighbors, the hand-wringing over her pooch, the instructions on protective medical gear — and answer this: Have you had your flu shot? Are you planning on one?

During the 2013-2014 flu season, according to the Centers for Disease Control and Prevention, only 46 percent of Americans received vaccinations against influenza, even though it kills about 3,000 people in this country in a good year, nearly 50,000 in a bad one.

These are deaths by a familiar assassin. Many of them could have been prevented. So why aren’t we in a lather over that? Why fixate on remote threats that we feel we can’t control when there are immediate ones that we simply don’t bother to?

On matters exotic, we’re rapt. On matters quotidian, which are nonetheless matters of life and death, we’re cavalier. Tens of thousands of Americans die in car crashes annually, and according to a federal analysis from 2012, more than half of them weren’t wearing seatbelts.

Perhaps that didn’t make a difference in many cases. In some, it probably did. But on this front, as on others, we have clear answers about how to minimize risk and we simply proceed to forget or ignore them.

There’s no way to square skin-cancer statistics in the United States — more than 3.5 million cases diagnosed yearly and almost 10,000 deaths — with the number of Americans showing off their tans. They aren’t all getting body paint. They’ve been lectured about sunscreen and shade and hats. But vanity trumps sanity, and melanoma rides its coattails.

I’m not dismissing the horror of Ebola, a full-blown crisis in Africa that should command the whole world’s assistance. And Ebola in the United States certainly warrants concern. We’re still searching for definitive answers about transmission and prevention.

But Americans already have such answers about a host of other, greater perils to our health, and we’d be wiser to reacquaint ourselves with those, and recommit to heeding them, than to worry about our imminent exposure to Ebola.

“People get very fearful and stressed out and have a lot of anxiety about things like Ebola that aren’t a general health risk,” said Jeffrey Duchin, who is the chairman of the public health committee of the Infectious Diseases Society of America. “Just look at causes of death in the United States. Everything is higher than Ebola, and there are things that we can do about many of them.”

Duchin, a physician, moderated a panel of experts who discussed Ebola at the society’s conference last week. These doctors sought to refocus attention on influenza, which lacks novelty but not potency.

In my conversation with him, Duchin also pointed out that between 2.7 and 5.2 million Americans are believed to be infected with the hepatitis C virus. Deaths related to it can range widely, from 17,000 to 80,000 annually, he said. There’s a test for it. There’s effective treatment. But the C.D.C. says that up to 75 percent of the people with the virus don’t know they have it.

Stephen Morse, a professor of epidemiology at Columbia University’s Mailman School of Public Health, told me: “We have a lot of vaccine-preventable diseases and we see more and more people refusing to have their children take vaccines.”

He was referring to outbreaks of measles and pertussis (or whooping cough) in states and cities where parents have hallucinated a connection between immunizations and autism. They cling to this fiction in the face of scientific information to the contrary.

Both The Hollywood Reporter and Time magazine recently published accounts of anti-vaccine madness among supposedly educated, affluent Americans in particular. According to the story in The Hollywood Reporter, by Gary Baum, the parents of 57 percent of the children at a Beverly Hills preschool and of 68 percent at one in Santa Monica had filed personal-belief exemptions from having their kids vaccinated.

Such numbers, Baum wrote, “are in line with immunization rates in developing countries like Chad and South Sudan.”

On CNN on Monday night, a Dallas pediatrician was asked about what she had advised the families she sees. She said that she urged them to have their children “vaccinated against diseases that we can prevent,” and that she also stressed frequent hand-washing. Ebola or no Ebola, it’s a responsible — and frequently disregarded — way to lessen health risks.

So are these: fewer potato chips. Less sugary soda. Safer sex. Tighter restrictions on firearms. More than 30,000 Americans die from gunshots every year. Anyone looking for an epidemic to freak out about can find one right there.

 

By: Frank Bruni, Op-Ed Columnist, The New York Times, October 15, 2014

October 16, 2014 Posted by | Communicable Diseases, Ebola, Public Health | , , , , , , | Leave a comment

   

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