Who knew? Tightening up requirements for waivers for school vaccine requirements increases vaccine uptake! (Part two)

Well, it's finally done.

The grants that have been taking up so much of my time are finally with the grants office and, hopefully, won't have too many errors flagged as they go through the validation process. So it's time to get back into that blogging thing again, even though I'm admittedly tired. So I'll start out slow. No Orac-ian epics today, just another rather satisfying bit of news mirroring a previous post that I did last week about how making it more difficult to obtain personal belief exemptions to school vaccine requirements works. In states where PBEs are difficult to obtain or not permitted vaccine uptake rates are high or higher.

I saw this gratifying outcome in my very own state, where as of January 1, 2015, the Michigan Department of Community Health issued a new rule that required parents seeking PBEs for their children to go to the local health department office and be educated by a local health worker about vaccines and the diseases they are intended to prevent, after which they would be required to sign the universal state form that includes an explicit statement of acknowledgement that parents understand they may be putting their own children and others at risk by refusing the shots. Initial data from 2015 suggest that this tightening of vaccine waiver rules has had an effect. Vaccine waiver rates fell from 4.6% in 2014 to 2.8% in 2015. Of course, Michigan being Michigan, there are wingnuts in our legislature who want to reverse that in the name of "freedom." Or should I say, "Freedumb!"?

California is another experiment in what happens when vaccine exemptions are made more difficult to receive, but a more extreme example. Like Michigan, California had a problem with areas where vaccine exemption rates were high and, as a consequence, were prone to outbreaks of vaccine-preventable diseases. About a year ago, there was an outbreak that got worldwide news attention centered at—where else?—Disneyland that finally spurred lawmakers to act. Introduced by Sens. Richard Pan and Ben Allen, passed by the California legislature after much controversy (and no shortage of rhetoric likening it to Nazi genocide of the Jews), and signed into law by Governor Jerry Brown in July, basically eliminates nonmedical exemptions to school vaccine mandates as of the 2016-2017 school year.

Already, it seems to be working. At least, initial numbers suggest this is the case:

California's new, more stringent law on childhood vaccinations, SB 277, doesn't fully kick in until July 1. But it started protecting the public months ago when parents heard from schools and doctors that they would no longer be able to claim a "personal belief exemption" from immunizations if they wanted to enroll their children.

The proof is in the numbers. The percentage of fully vaccinated kindergartners entering the state's schools in 2015-2016 was the highest in a decade: 92.9%, up from 90.4% last year. State health officials say the measles outbreak at Disneyland a year ago might have scared a few parents off the vaccination fence, but SB 277, combined with another bill from 2012 that required parents to talk to a pediatrician before obtaining an exemption, had more to do with it.

The law from 2012 referred to in this article is California AB 2109, a law upon which the Michigan Department of Community Medicine based its rule change on. Michigan actually improved upon it. The California law allowed parents to receive counseling from any physician and some other health care professionals, like nurse practitioners. The Michigan rule, in contrast, requires that parents receive their counseling from the health department. Thus, in California, parents seeking PBEs were free to seek out woo-friendly and anti-vaccine friendly physicians for their "counseling," while in Michigan parents seeking PBEs receive the same standardized information from a script and must sign a statement explicitly acknowledging that they are potentially endangering their children.

What these numbers suggest is that a significant part of the problem with unvaccinated children comes not from parents who are truly antivaccine (although certainly they are a major problem) but from sheer human nature. In California, for instance, it was much easier just to sign a vaccine waiver than to have one's children fully vaccinated or to sign the waiver with a promise to finish vaccinating:

The vaccination rebound validates the suspicion that the falling rates were caused in part by procrastination, not politics. Schools encouraged an increase in partially immunized students by allowing parents to sign a form promising they would finish the vaccinations, but the promise wasn't well enforced. This year, the percentage of such enrollees dropped by the same amount the overall immunization rate increased.

When one option is much easier than another, even though it's the wrong option, there will always be some who will choose the easier option. It's human nature. Rules like the one now enforced in Michigan seek to make the effort required to obtain vaccine waivers closer to the level of effort required to have one's children vaccinated, and it's working. It appears to be working in California as well. However, what will be far more interesting is to see the effect of SB 277 next year, after the law has fully kicked in and only medical exemptions are required. Already antivaccine pediatricians like Dr. Bob Sears are preparing for an influx of business to sell medical exemptions, but it's likely that the effects of this will be small. Fortunately, there aren't many pediatricians like Sears.

None of this should come as a surprise. As far back as 2006, I was discussing research that showed that ease of obtaining vaccine exemptions correlated—of course!—with increased vaccine exemption rates, which correlated with higher incidences of pertussis. Basically pertussis was returning in states with lax vaccine laws. Experience since then has validated that observation. More recently, a systematic review of studies of state vaccine exemption laws and vaccine exemption rates concluded that vaccine exemption rates have been increasing and tend to occur in clusters. It also concluded that easier state-level exemption procedures are correlated with increased exemption rates and increase the risk of vaccine-preventable diseases.

None of what is happening in Michigan and California is a surprise. Unfortunately, in today's political climate the widespread adoption of SB 277-like bans on nonmedical exemptions to school vaccine mandates is highly unlikely. This is particularly true since right wing "freedom" warriors have conflated personal freedom with "health freedom" and the freedom to refuse vaccines, even leading Presidential candidates like Donald Trump, Rand Paul (who has suspended his campaign), and Ben Carson to pander to this view. Actually, neither Trump nor Paul are pandering. They appear to really believe antivaccine views. "Freedom" and "parental rights" have become antivaccine dog whistles.

In an ideal world, PBEs would not be permitted. That's not likely to happen any time soon in the current political climate. (Witness the nastiness that happened in California as SB 277 moved towards passage.) However, the Michigan experience suggests that a smart "middle way" requiring parents to visit the health department for a counseling session and to sign a form explicitly acknowledging that they are endangering their children might do almost as much good.

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Did you mix up Trump and Carson? I would've guess that Carson is the one who's not pandering and actually has antivaccine views (cf. his alternative medicine cancer cure), while Trump is the one who is pandering.

After all, it's very easy to tell when Trump is pandering: he opens his mouth and words come out.

By Yerushalmi (not verified) on 04 Feb 2016 #permalink

Whenever someone uses the term "freedumb" I am reminded of the Metallica song "Eye of The Beholder". A song which has lyris that very well fits in with a myriad of topics often discussed on this blog.

\m/ O_o \m/


Damn the inability to edit your comments...

Did you mix up Trump and Carson?

Nope. You obviously didn't click on the link, or you wouldn't ask that question. Trump has been spewing antivaccine nonsense for at least a decade now.

#4 - I had no idea. Then again, I should've known Trump was anti-vaxx. I guess the biggest advantage of being Trump is that you spew soooo much b.s that each individual turd of b.s all blend together with each-other until you end up with just a flood of it and it is nigh-impossible to point your finger at each and every turd!

Trump may have longstanding spewings of anti vaccine nonsense but that doesn't mean he isn't (or wasn't) pandering. That character flaw may be his defining trait. It also wouldn't surprise me that he's internalized it and made it more real.

I have posted comments on various FB treads where this was discussed. Mostly the same old retread arguments against vaccines but a new one dissing California as a state doomed to failure.

It would be very encouraging if increased non-medical vaccine exemptions are due more to parents taking the path of least resistance rather than being brain-washed by AVers into fearing vaccines.

By Chris Hickie (not verified) on 04 Feb 2016 #permalink

@ Chris Hickie:

I'm curious:
what are the vaccinations rates in the places where you've worked recently?
Do they compare to those islands of disease promotion (tm) which Orac has often described ( such as those in parts of California, north and south, or northern Michigan).

-btw- Dara B is currently cranking up the anti-vax nonsense
( AoA) about NY- she may even take out her passport and abscond for less vaccinated climes. Or suchlike.

By Denice Walter (not verified) on 04 Feb 2016 #permalink

The Crusade Against Multiple Regression Analysis

And correlations often misleading. I really have hard time deciding what to believe anymore. But truth data or evidence should be able to stand scrutiny from multiple angles like a math result. Math reasoning seems only way to produce result that can be tested by many different solutions.

In addition to AB2109 and all the publicity about SB277, California -- the Department of Public Health also decided to put some teeth into enforcing existing law (predating AB2109), by threatening schools who had too many "conditional entrant" kindergarteners.

The kindergarten vaccination rate rose to 92.9 percent, an increase of 2.5 percent from the previous year, and a rise that the state agency attributed to a 2.5 percent drop in “conditionally admitted” kindergartners who have completed some but not all of their vaccinations.

The story went on:

Conditional admission is narrowly defined by the California Department of Public Health to cover students who are not currently due to receive a vaccination but have not yet completed their vaccination series. The category is widely misused and 90 percent of students in a recent sample who were conditionally admitted to school did not meet the criteria, the department said.

Among the interventions, which included strategies developed by the Alameda County Public Health Department, was to inform schools that 2015-16 financial and compliance audits will “scrutinize reimbursements for attendance at schools with higher rates of conditional entrance,” the California Department of Public Health said. That intervention and others prompted Alameda County to report the largest increase – 7.3 percent – in the rate of fully immunized students of any county in the state and a corresponding 7.2 percent reduction in the rate of conditionally admitted students.

Personal belief exemptions, which allow parents not to vaccinate their children based on a personal opposition to vaccines, and medical exemptions remained about the same between 2015-16 and 2014-15. Personal belief exemption rates declined to 2.38 percent in 2015-16 from 2.54 percent the year before. Medical exemption rates were .17 percent in 2015-16 compared to .19 percent the year before.

Read the whole thing at:


I work with several folks who work on vaccine uptake and refusal. Data does show that PBEs are often the option of convenience. This shows most often when parents are enrolling children. When they are told that the child is missing a required vac, they are given the option of PBE on the spot. Convenience. Once it is harder to get the PBE due to a mandatory counseling session or doctor's appointment, it becomes easier to get the shot which can be a simple nurse or health department visit.

It would be very encouraging if increased non-medical vaccine exemptions are due more to parents taking the path of least resistance rather than being brain-washed by AVers into fearing vaccines.

The true believers in the evils of vaccinations are the more dangerous types but I am having a hard time with the convenience types too. They really prioritize the children's health lower than their schedule? That irks me in some ways more in that this type of thinking wouldn't just be limited to vaccines.

Full disclosure. I don't have children. Even though my friends say I would have made a good parent, that was a conscious choice knowing that I didn't want the responsibility and a self-awareness of just how self-centered I really am.

By Not a Troll (not verified) on 04 Feb 2016 #permalink

Regardless of my issues, I am glad that they worked out a law that increased the vaccination rate of the children of the too busy parents.

By Not a Troll (not verified) on 04 Feb 2016 #permalink

Oh, there are definitely parents who would put convenience ahead of their kids' health. I tend to believe people aren't inherently evil, so to give them the benefit of the doubt, I tend to believe most of them are not *intentionally* putting convenience ahead of their kids' health. It's more that people really suck at accurate risk analysis, and vaccination (a process which for many people costs money and definitely takes time and involves making the kid angry and screaming) protects against remote risks that may not seem very real or immediate to the parent. They need to get an appointment ot get the kid vaccinated at some point, but first there's that grocery run to take care of or we won't have any milk left, and the car needs gas, and oh hey, did you hear the latest rumor about Star Wars? Yeah, it's really intriguing, and . . . well, then it's four hours later, the clinic has closed, and they have to try and remember to make the appointment tomorrow.

Flash forward three months, it's time to register the kids for school, but they still haven't gotten around to making that appointment. Whoops.... Well, for now let's just sign the exemption waiver, and we'll try to get done sometime this month. Or next month. Or the month after that.....

And of course even I have to admit that some parents really do behave in an evil way towards their kids. They genuinely don't give a damn. These are the parents who never turn up for conferences, never help their kids with their homework, are late on signing permission slips (or never sign them at all), and quite happily send their kids to school sick because that gets them out of their hair for a bit. Of course those parents will pick the waiver if it's presented in this form. It's easier than their previous strategy, which was to just lie about the kids' vaccine status.

By Calli Arcale (not verified) on 04 Feb 2016 #permalink

The true believers in the evils of vaccinations are the more dangerous types but I am having a hard time with the convenience types too. They really prioritize the children’s health lower than their schedule? That irks me in some ways more in that this type of thinking wouldn’t just be limited to vaccines.

Few parents would make that decision if that was their perspective on it. Parents make schedule vs. children's welfare decisions every day* that have far more likely impact on the child, and the vast majority of the time they do so overwhelmingly balanced towards the children's well being.**

It's more that parents have a lot of stuff they have to get done in a short amount of time when they get kids ready for school, and dropping a bombshell that they need to all of a sudden make an unexpected doctor's visit can add a lot of stress to a parent's life. It can be easy to sign a paper thinking that you'll do it later, especially because the marginal risk to the children's health seems imperceptible to the average parent. But then by the time "later" comes, the parent has forgotten all about vaccinations because of the hustle and bustle of other school requirements.

Besides, the socially acceptable balance of "schedule" and "health" doesn't always tilt towards "health." A parent could certainly shave some risk off by never transporting their children in an automobile. But then again, walking places is dangerous, too, so best to never let the children leave the house. This choice would certainly inconvenience the family's schedule. I don't think anyone reasonable would say that it was a good trade-off to make, even if you could ameliorate the mental health risks from being a shut-in.

* Although such decisions become quickly habitualized.
** So you have good evidence that parents in general make good decisions about their children's welfare.

By justthestats (not verified) on 04 Feb 2016 #permalink

Dara B is currently cranking up the anti-vax nonsense
( AoA) about NY- she may even take out her passport and abscond for less vaccinated climes.

Yah, I was seeing that line years ago at MDC. Somehow, these people never seem to reach the point of figuring out that other countries might not, y'know, want them.

But sweet Jesus, that was the most painfully dumb thing I've seen at AoA in ages. It's written at the level of a not very bright 15-year-old.

@ Narad:

I don't know, I think Dara has plenty of company at AoA in that department.
And -btw- is that a nice thing to say about 15 year olds?

See also @ Kim Stagliano to see what I mean.

By Denice Walter (not verified) on 04 Feb 2016 #permalink

In other vaccine news, the fringe crank-group-with-a-respectable-sounding-name “The American College of Pediatricians”....

As fond as I am of the my hypothesis that the real antivaccine issue with HPV is potentially losing a generation of recruits, I see that these guys are indeed all about teh secks.

the fringe crank-group-with-a-respectable-sounding-name “The American College of Pediatricians” dropped this turd in the punch bowl:

It has recently come to the attention of the College that one of the recommended vaccines could possibly be associated with the very rare but serious condition of premature ovarian failure (POF)

It only recently came to their attention? Citing Shoenfeld's crank paper from 2013? These mooks are not the sharpest hammer in the sack.

Our host was rather insolent about the paper at the time:

By herr doktor bimler (not verified) on 04 Feb 2016 #permalink

Somehow, these people never seem to reach the point of figuring out that other countries might not, y’know, want them.

If people had worried about the preferences of the occupants of other countries before relocating there en masse, US history would be entirely different.
Border controls are all about keeping people from other countries out of the US, not vice versa.

By herr doktor bimler (not verified) on 04 Feb 2016 #permalink

Border controls are all about keeping people from other countries out of the US, not vice versa.

I assure you that permanent resettlement ain't particularly easy in countries that are not the U.S., or at least those that I suspect Dara B. would put on her short list as part of the petulant fantasy.

U.S. border controls are indeed all about keeping people from other countries out of the U.S. and not vice versa. As they should be. If they were all about keeping people from the U.S. out of other countries, i.e. confined to the U.S., they wouldn't be any different from the Berlin Wall, would they?

Um. There are other sovereign nations, you know. Some of us issue these things called visas when US citizens want to visit. Some of us also subscribe to the tenets of the International Court of Justice - which is why Dick Cheney isn't likely to visit us again any time soon.

#24 - Sweet, I gotta get me some of that as I've always wanted Atomic Breath!

Narad @25, she could maybe try moving to Mozambique. One of its northern provinces would give her a very natural-living, vaccine-free population around her. Food is 100% sans pesticides or fertilizers, water is very natural indeed (only natural pollutants), and there's hardly any Westernized doctors or pharmacies within easy reach. It should be just the thing she's looking for.

@rhwombat, "Some of us issue these things called visas when US citizens want to visit."

That was kind of my point. Your border controls are intended to keep U.S. citizens -- or other undesireables -- out of your countries. It isn't, or at least shouldn't be, the function of our border controls to keep us out of your countries, because to do that, our border controls would have to keep us in this country. And I am one of those who believes that one token of a free country is that you can leave if you want to. Whether any other country will let you enter is up to that other country.

Those waivers should also serve as evidence that allows the state to charge the parents with crimes up to and including involuntary manslaughter. If their kid gets sick and dies because they refused vaccination, it's manslaughter. If their kid gets sick and goes on to infect another person who dies then its manslaughter. If their kid is harmed then it's child endangerment. It really should be that simple. The only exemptions should be those children who cannot be immunized for medical reasons.