Personal Belief Exemptions to Required Immunizations: Putting a New Law Into Practice

u Dean A. Blumberg, MD, FAAP –Disclosure »speakers bureau: sanofi pasteur –Discussion: “off label” use of FDA approved vaccines u Catherine Martin –Nothing to disclose

u Parental vaccine safety concerns –Increase in personal belief exemptions (PBEs) –Consequences of PBEs u PBE policies –Exemption policies and exemption rates –Washington experience u AB2109 –Summary –Governor’s signing statement –Implementation u Provider’s role –Resources u Questions Personal Belief Exemptions to Required Immunizations: Putting a New Law Into Practice

Vaccine-Preventable Diseases: Baseline 20th Century & Current Morbidity MMWR 1999;48:245, 2013;62(33)

Vaccine Adverse Event Myths u No credible scientific evidence that vaccines cause: –autism –multiple sclerosis –diabetes –asthma –inflammatory bowel disease –SIDS –overwhelm immune system

Monday, February 17, 2014 New slide

Lee et al NVIC 2010 Permanent Medical Exemptions & Personal Beliefs Exemptions, Kindergarten Students, California

 Refused pertussis vaccination 22.8 times increased risk of pertussis

Invasive H. influenzae Type B Disease MMWR 11/98 47:993, 1999;47:38,77, 2002;51:234 conjugates infants *est.

parent/guardian deferral or refusel

Marin et al Pediatrics 2011;128:214 Varicella Mortality Rates, United States

 Refused varicella vaccination –8.6 times increased risk of varicella

2009 Lee et al NVIC 2010 Kindergarten PBEs by County 2000

Dean, I inserted this next slide as it compares 10 years vs 9 years, - use whichever one you prefer

New slide

Vaccination Policies & Rates of Exemption Omer et al NEJM 2012;367:1170

Vaccination Policies & Rates of Exemption Omer et al NEJM 2012;367:1170

Vaccination Policies & Rates of Exemption Omer et al NEJM 2012;367:1170

July 2011

AB2109 Genesis u Objective –change PBE: Washington State as a model u Coalition –California Immunization Coalition –American Academy of Pediatrics, CA –California Academy of Family Physicians –California Medical Association –Health Officers Association of California

AB2109: Implementation u Effective January 1, 2014 u Parents wanting to exempt their children from one or more required immunizations –must use form u Students affected –newly admitted to CA school (K-12 th ) –advancing to 7 th grade –newly admitted to child care u Form must be signed no sooner than 6 months before admission to school/child care/advancing to 7 th grade

AB2109: Health Care Providers u Provide information –benefits and risks of required immunizations –health risks of specific vaccine-preventable diseases to child and community u Sign form along with parent –only parent signs for religious exemption u Who can sign form –MD, DO, NP, PA, naturopathic doctor, credentialed school nurse

Parental Immunization Refusal u Listen carefully to concerns –encourage questions u Discuss known risks and benefits –risks to unimmunized child u Concerns about specific vaccines –discuss –administer other vaccines u Multiple injection concerns –modify schedule u Revisit discussion in future visits u Document

Vaccine Safety Discussion Strategies u Empathize: acknowledge that there are many conflicting messages in the media u Assess level of scientific evidence desired u Maximize benefits to their child –not a public health discussion –vaccines provide protection –risk of disease for omitted vaccines u Provide appropriate resources

Continued Vaccine Refusal u Challenges –time commitment for discussions »frustration u “Fire” patient from practice/clinic? –acknowledge differences »“it sounds like you and I have different philosophies” –agree to disagree on this subject

MMWR 1999;48:241

AB2109: Summary u Personal belief exemptions rising –linked to increased risk of vaccine-preventable diseases among those exempted and their community u New exemption process in California in 2014 –effect on exemption rate?

Educational Resources

ImmunizeCA.org

Provider Resources for Vaccine Conversations with Parents Updated information to help healthcare professionals talk to parents about: Vaccines Vaccine-preventable diseases Vaccine safety Resources healthcare professionals can give parents

www2.aap.org/immunization/families/families.html American Academy of Pediatrics Childhood Immunization Support Program (CISP)

National Network for Immunization Information

Children’s Hospital of Philadelphia Vaccine Education Center

Immunization Action Coalition (IAC)

February 18, 2014 CDPH Webinar ShotsforSchool.org

Vaccine Safety Concerns: Resources u CDC – u AAP –www2.aap.org/immunization/families/safety.html u NNII – u CHOP – safety u Shots for School –

For more information: Shotsforschool.org