State Vaccination Exemption Policy Makes A Difference

Mother Jones has just run a very nice analysis of recent years' research on state laws governing non-medical exemption from childhood vaccines. It turns out that if a state makes it very easy for parents to exempt their children from recommended school vaccinations for non-medical reasons, lots of parents will exempt their children. This causes loss of herd immunity, and children die of childhood diseases that haven't been common for decades. And when one state (Washington) tightened up its rules by requiring a doctor's signature for exempting children from vaccination, exemption rates fell by 40%.

Meanwhile, cases of measles are on the rise in California--more than half of them involving children who were intentionally not vaccinated.

Bad News on Vaccinations

This letter to the New England Journal of Medicine reports an increase in the rate of non-medical exemptions from the childhood vaccinations generally required by state law. (Non-medical exemptions are permitted in 48 of the 50 United States.) States that allow "philosophical," as opposed to only "religious," exemptions to mandated childhood vaccinations, had higher rates of exemption, as did states with "easier" opt-out provisions. Easy opt-out states allow parents to opt out of the vaccination requirement by filling out a standardized form supplied by the school; harder opt-out provisions require an original and/or notarized letter from the parent, or a form obtainable only from the state health department.

For whatever reason--but certainly including unscientific vaccine/autism fear-mongering--there has been a dramatic decline in US parents' willingness to vaccinate their children. The result has been the return of deadly childhood diseases including pertussis, whooping cough and measles. Vaccination is among the most effective public health measures. Certainly, states should make it harder for parents to opt out of vaccination programs for non-medical reasons. But rates of opt-out are on the rise even in "difficult" opt-out states, and there is some evidence that when states make it hard to opt out of vaccination for non-medical reasons, parents respond by pressuring doctors to write them bogus "medical" excuses.

The root of the problem seems to be that vaccines are victims of their own success. Most people haven't seen the effects of the awful childhood diseases that vaccines have been so effective at eradicating. But they've heard about vaccine reactions, and have heard all the unsubstantiated--or downright fraudulent--claims about vaccines and autism. How many kids will have to suffer or die with whooping cough or measles or pertussis before the public can be persuaded to trust in some of the most reliable science in all of public health?

Wakefield Sues BMJ Editor for Defamation

Wow. Author of the a now-discredited Lancet article which started a vaccine scare by falsely linking MMR vaccination to autism onset, Andrew Wakefield is suing BMJ's editor, Fiona Godlee, and British investigative journalist Brian Deer, for defamation of his character. The complaint, filed in Travis County, Texas, is here. It focuses fairly narrowly on statements by Godlee and Deer to the effect that Wakefield manipulated or falsified data in the study.

The UK's General Medical Council, after the longest hearing in its history, found Wakefield guilty of serious professional misconduct in connection with the conduct of the research underlying the article, and erased him from its rolls. But they didn't specifically find that he altered data in the study; their main complaint about the article itself was that it mischaracterized the children under study--especially the means by which, and purpose for which, they were recruited. The GMC's findings spoke mainly to other forms of research and clinical misconduct. To review, the GMC found that Wakefield violated the limits of his appointment as an Honorary Consultant in a "breach of trust of patients and employers alike," and mismanaged funds, and failed to disclose "matters which could legitimately give rise to a perception of a conflict of interest," and conducted research on vulnerable children without required ethics review, and concealed that fact, and repeatedly breached "fundamental principles of research medicine," and acted contrary to the clinical interests of 9 of the 12 children mentioned in the article, and violated his duties as a senior author, and failed to correct his mistakes when given the chance, and made "dishonest and irresponsible" statements to the GMC board itself.

Of course, the fact that Wakefield was unprofessional in a bunch of different ways doesn't mean that he was unprofessional in all of the ways that Godlee or Deer have, at one time or another, alleged. It's just possible that one or the other of them has said something factually wrong by accusing Wakefield of some specific kind of scumbaggery that he didn't actually engage in. If so, may the damages found be very, very small.

Because the damage caused by Wakefield hasn't been small. The publicity around his unethical research likely caused children to die of completely preventable childhood diseases, and is certainly still causing misguided parents to fail to vaccinate their children. It is depressing to note that here, the Autism Action Network is already trumpeting Wakefield's suit against Deer and a woman whom they call "Fiona Godley." Their view is that Wakefield and his co-author John Walker-Smith "had their medical licenses suspended for their refusal to recant their hypothesis." They don't mention the actual GMC findings against Wakefield, nor those against Walker-Smith (which you can read here), nor the fact that in 2004, six years before the GMC acted, Walker-Smith and nine of Wakefield's other co-authors specifically retracted the portion of the paper that posited a link of MMR with autism.

Vaccine Exemptions

This AP story gives a lot of interesting detail on the current parental flight from childhood vaccination. In eight of the US states, over 5% of kids don't get the required vaccinations before kindergarten; their parents exercise the right to exempt them from some or all vaccinations, instead. The exemption rate is up in more than half of all states, but highest in Western and Upper Midwestern states.

Part of the trouble is that some states make it quite simple to exempt a child from vaccination--a note from home alleging a personal opposition to immunization does the trick in Colorado, for example. Some kids need to be exempt for medical reasons, of course, and some accommodation must be made for religious opposition to vaccination; but the response to mere personal or philosophical opposition to immunization should be education, at least in the first instance, rather than surrender. Parents who exempt their children are endangering them and other people as well.

Vaccine Trouble

An October study in Pediatrics shows that 13% of parents follow a non-standard vaccination schedule for their children, by refusing particular vaccines, delaying certain vaccines, or (in about 2% of all cases) refusing all vaccines. More disturbing is the fact that many parents who are currently using the recommended schedule are at risk of departing from it in the future: 22% of them disagreed that the expert-recommended schedule they were following was the best one to use, and 28% of them thought delaying vaccination would be safer for their children. This is the legacy, I think, of Andrew Wakefield's fraud and the misguided activism of RFK Jr., Jenny McCarthy, and others. Meanwhile, a paper presented at last week's meeting of the Infectious Disease Society of America showed that younger doctors have less faith in vaccines than older doctors. In a WebMD interview, one of the authors stated that while there was generally strong support among all doctors for vaccination, every increase of five years in year of graduation was associated with a 20% reduced likelihood that the doctor believed that vaccines were very safe, and with a 20% increased likelihood of agreement with the statement that "children get more immunizations than are good for them." Why would younger doctors have less faith in vaccines? This, too, may be partly a legacy of the recent controversies surrounding HPV vaccination, the alleged vaccine/autism link, and so on. But there may also be something else at work: younger doctors have no experience of the devastating effects of childhood diseases. Indeed, many young physicians are more apt to have seen an adverse reaction to a vaccine than a case of polio or whooping cough or rubella. Vaccines, in other words, may partly be victims of their own success.