From the Journals

Counseling parents may curb nonmedical vaccine exemptions

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Clarify medical exemptions to protect communities

Restoring community immunity requires diligence on the part of medical professionals, policymakers, and parents, wrote California state senator Richard J. Pan, MD, MPH, in an accompanying editorial.

Laws requiring that children be vaccinated before starting school are designed to protect the vaccinated children and the community at large, wrote Dr. Pan, but the passage of certain laws resulted in nonmedical exemptions that can reduce the effectiveness of childhood vaccinations on community health. In the past, parents rarely chose nonmedical exemptions because they recognized the dangers of diseases such as polio and measles and acknowledged the safety and effectiveness of the vaccines to protect against them, said Dr. Pan.

“However, some saw the opportunity to exploit these circumstances for personal gain by spreading vaccine misinformation over the Internet and social media to fuel parental anxiety and promote sales of their supplements and books, leading to increased use of nonmedical exemptions,” he said.

In Dr. Pan’s view, community immunity can be restored by creating stricter policies for vaccination and eliminating nonmedical exemptions. He authored a bill in California to abolish these exemptions, and the vaccination rate was 96% among kindergartners in California during the first year the policy was in place.

But antivaccine groups are well organized. One study found that “half of all Twitter posts about vaccines contain antivaccine beliefs.‍ Just this year [2017] in Minnesota, antivaccine groups targeted a community, causing a significant drop in vaccination rates.‍ The resulting measles outbreak exposed more than 8,000 people, sickened 79 (of which 73 were less than 10 years old), and hospitalized 22,” Dr. Pan said.

Pediatricians and other child health advocates must continue to work to address medical exemptions as well and to define the standards for what constitutes a medical exemption, Dr. Pan said. By educating and working with parents, legislators, and other health care professionals, “pediatricians need to build the political will to pass effective vaccine policy,” he said.

Dr. Pan is a California state senator in Sacramento. He had no financial conflicts to disclose. He commented in an editorial accompanying the study by Omer et al. (Pediatrics. 2017 Dec 18;141[1]:e20173449).



Nonmedical vaccine exemptions for children in Washington State decreased by 40% after the implementation of a law requiring parent counseling and a signed form from a medical provider, based on data from a regression analysis of kindergarten students during time periods before and after the law took effect.

“Evaluating the impact of mass implementation of a counseling intervention can therefore provide important insight into population level interventions that focus on interpersonal communication by an authority figure, in this case a health care provider,” Saad B. Omer, PhD, of Emory University in Atlanta, and his colleagues wrote in the journal Pediatrics.

The Washington State Senate Bill 5005 (SB5005), implemented in 2011, requires parents seeking exemptions to file a certificate of exemption (COE) signed by a Washington-licensed health care provider. It documents that the parents have discussed “the benefits and risks of immunizations” with the provider, the researchers wrote.

The researchers examined the effect of the parent counseling and signature requirement on exemption rates by reviewing data on kindergarten students.

Overall, the significant relative decrease of 40% translated to a significant absolute reduction of 2.9% in immunization exemption rates, and vaccine coverage increased or remained the same across all vaccines required for school. The greatest decline in exemption rates occurred in geographic areas with historically high rates before the bill was passed, the researchers said.

Dr. Saad B. Omer

Dr. Saad B. Omer

The findings may not be generalizable to other states, and additional studies will be needed in other states where vaccine laws have changed, Dr. Omer and his associates noted. However, the results suggest that evidence-informed laws can help improve vaccine coverage and reduce the risk of vaccine-preventable disease.

Based on the Washington findings, “states in the United States and jurisdictions in other countries should consider adding parental counseling as a requirement for obtaining exemptions to vaccination requirements,” they concluded.

Dr. Omer had no financial conflicts to disclose. One of the coauthors disclosed ties to vaccine manufacturers, and another’s organization had such ties. The study was supported by the Robert Wood Johnson Foundation.

SOURCE: Omer, SB et al. Pediatrics. 2018;141(1):e20172364.

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