Marcia Frellick

September 21, 2017

CHICAGO — Although experts agree that vaccination rates in schools need to improve, they disagree on the best way to make this happen, highlighting the sensitive issues that currently surround vaccinations.

On one side of the debate are physicians like California State Senator Richard Pan, MD, a pediatrician in Sacramento, who sponsored Bill SB 277, passed in 2015, that removed nonmedical exemptions to school vaccinations in the state of California.

The law led to an increase in vaccination rates not seen in more than 15 years, Dr Pan reported here at American Academy of Pediatrics (AAP) 2017 National Conference and Exhibition.

Only two other states — Mississippi and West Virginia — have restricted exemptions to the vaccination requirement for public school enrollment to medical only.

The AAP recently joined organizations such as the American Medical Association and the American College of Physicians in calling for the elimination of nonmedical exemptions (Pediatrics. 2017;139:e20164248).

However, this position is not without its detractors, as was evident by reactions to Dr Pan's appearance at the meeting. Protesters with signs mentioning him by name chanted outside the conference, and he was escorted to and from the session by police.

Extreme measures — such as laws — might embolden the antivaccine factions, said Aviva Katz, MD, associate professor of surgery at the University of Pittsburgh School of Medicine and director of the consortium ethics program at the University of Pittsburgh.

Alternatives might better respect the autonomy of families while at the same time protecting the public, she added.

Protect the Public

Dr Pan argued that a law is necessary to attain herd immunity levels, which require at least 90% of the population to be immunized (or 95% for highly contagious diseases, such as measles and pertussis).

Parents who do not vaccinate their children can choose other education options, including independent study or home schooling, he pointed out. All children have the right to be educated, but that includes those in the community of the unvaccinated child, he added.

"What about the other children in the school? Don't they have a right to an education, to be safe at school? Some have medical exemptions and can't get vaccinations. What about their rights?" he asked the audience.

Requests for exemption had been on the rise in California, and having a law helps clarify the message and redefines the social norm around vaccines, he explained.

"There's an active group of people, and many of them profit from this, pushing false messages about vaccines," he said.

The medical community needs to improve education for parents, he acknowledged, but "it helps when the law is on your side."

As an analogy to nonmedical exemptions, Dr Pan pointed out that "we require people to put their kids in car seats. Is that because we want to put parents in jail who won't put their children in a car seat? No, but we want to remind them that is the thing you should be doing."

Try Other Measures Before Law

One alternative, suggested Dr Katz, could be publishing public data on vaccination rates, similar to the way data on test scores are published so people can make choices about where to live.

"When I look for a home, I know the SAT scores in that region. Why shouldn't I know the vaccination rates?" she asked.

In addition, evidence has shown that financial penalties can wield considerable influence, she reported. They could help nudge people who are on the fence about the issue.

Education on vaccinations should also start earlier, so pediatricians can reach out to their colleagues in obstetrics to start the conversations during pregnancy.

And it should be harder to get a nonmedical exemption than to get a vaccination. "This isn't supposed to be an exception of convenience," she explained.

Policymakers should evaluate the effect of these and other strategies designed to raise vaccination numbers.

"Having nonmedical exemptions may help lessen the perception of coercion and interference with parental decision-making and build trust in the system," Dr Katz said.

"Obviously, the advantage of legislation is that it does increase vaccination rates. That's pretty undeniable," said session moderator Doug Diekema, MD, director of education at the Treuman Katz Center for Pediatric Bioethics at Seattle Children's Hospital.

However, "the biggest concern about using a fairly coercive approach like that — where you eliminate any option other than the medical option — is that you do embolden opponents to vaccination," he pointed out.

"Legislation is a political process and politicians are swayed by pressure, so the loud voice sometimes is the voice that wins," he told Medscape Medical News.

Dr Pan, Dr Katz, and Dr Diekema have disclosed no relevant financial relationships.

American Academy of Pediatrics (AAP) 2017 National Conference and Exhibition. Presented September 17, 2017.

Follow Medscape Pediatrics on Twitter @MedscapePeds and Marcia Frellick @mfrellick


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