Taking Another Shot



Lawmakers Prepare Push for Reporting School Campus Vaccination Data

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Tex Med. 2017;113(3):24-30.

By Joey Berlin
Associate Editor

The data are already out there. Texas schools collect and keep the stats, and they can help parents minimize a vulnerable child's chance of contracting a life-threatening disease.

But when the state publishes the data it collects from schools on student vaccinations, coverage and exemption numbers for entire school districts are as specific as it gets. Concerned parents hoping to find out which school campuses have the best or worst immunization coverage are out of luck.

To Corpus Christi pediatrician Daniel Vijjeswarapu, MD, and other physicians passionate about protecting vulnerable patients, that's not good enough. 

"As a physician and an advocate for my patients, and as a parent, I need to strengthen a parent's right to make an informed decision about the child's risk of contracting any vaccine-preventable disease," said Dr. Vijjeswarapu, a member of the physician advisory panel for the Texas Medical Association's Be Wise — ImmunizeSM initiative. "Providing [stats on] campus-level exemptions, it's important. We have not only a moral but also an ethical obligation."

In Texas and around the nation, significant numbers of parents still choose nonmedical exemptions from vaccination. That choice opens up a risk for children who are unvaccinated for medical reasons, whose parents must be extra careful about where they go to school.

In the 2015 legislative session, TMA supported a bill that would have mandated campus-level vaccine exemption reporting by the Texas Department of State Health Services (DSHS). That bill only made it through one chamber of the Texas Legislature, but lawmakers and TMA were planning to try again this session to give parents the information they need without compromising the privacy of children who take exemptions.

Physicians hold hope that this year's dramatic national increase in cases of mumps, including an outbreak in Texas, might give medicine-friendly lawmakers further opportunity to drive home the importance of vaccinating.

"Protection from vaccine-preventable infectious diseases comes not just from our personal immunity; it's the immunity of what we have personally along with the immunity of everybody else, which creates the concept of herd immunity," said Fort Worth-area pediatrician Jason Terk, MD, a member of TMA's Council on Legislation and of the Be Wise — Immunize Advisory Panel. "And when that herd immunity is degraded to a certain level, then the opportunity for outbreak occurs. I think that should resonate for people who make decisions about vaccinations based upon good science. There are people who are not operating on that level, though." 

The Right to Know

For some children, refraining from vaccinations is a choice their parents make. For others, it's a necessity. That's a distinction that Rep. J.D. Sheffield, DO (R-Gatesville), says many people don't make when looking at the issue of immunizations and reporting data on exemptions. 

"There are kids in our public schoolrooms today who have [an] immunocompromised state or chronic conditions that make it harder for them to fight off infections and/or recover from infections," Dr. Sheffield said in January, just before the beginning of this year's session. "That's something most people have not thought of unless that's one of their children, or they know a child [in] that condition."

DSHS culls its annual immunization report from a survey the department currently mails to about 1,240 independent school districts and 890 private schools. The report displays district-wide immunization coverage levels for students entering kindergarten and for seventh-graders. Those annual reports, and coverage maps displaying district-level immunization data, are available on the DSHS website

Dr. Terk says parents of children who are vulnerable to disease have an interest in knowing which schools would pose the greatest risk.

"If your child is going to a school where 8 percent of the students have signed personal-belief exemptions, that would potentially raise a greater concern than if you were going to a school where 2 percent had signed personal-belief exemptions," he said.

At press time, a bill had not been filed representing another try at campus-level vaccine reporting, but TMA was working with Representative Sheffield and Sen. Kel Seliger (R-Amarillo) to file and support such a measure. Two years ago, Representative Sheffield and others gave it a try, backing House Bill 2474 to mandate the availability of each campus' required annual immunization report on the DSHS website. Upon request, under the bill, a student's parent or guardian could have obtained from the school: 

  • Immunization rates at the campus disaggregated by type of vaccine;
  • De-identified exemption information;
  • The number of students provisionally enrolled pending immunization documentation;
  • The number of students claiming reasons-of-conscience exemptions;
  • The number of students claiming exemptions for a medical reason; and
  • The number of students whose vaccinations aren't current. 

The bill ultimately passed 98-40 in the House but stalled after referral to the Senate Committee on Health and Human Services.

"You had to have people with an open mind to understand it," Representative Sheffield said. "And for some people who are on the opposite side on this issue, anything that could've been seen as promoting vaccines is something they'll be against. There [were] some incorrect assumptions and knowledge about this bill."

Comments on the House floor during debate over HB 2474 revealed the thinking driving lawmakers who opposed more localized exemption reporting. For example, Rep. Bill Zedler (R-Arlington) invoked "peer pressure" as a motivation for the bill and referenced a potential bullying "witch hunt" resulting from nonmedical exemptions.

"The State of Texas will not force you to get a vaccine, but you know what? Peer pressure will," Representative Zedler said on the House floor. "The fact of the matter is, if your child is bullied into this, then guess what? That is a way to get people to get vaccinated beyond their real desires. So the fact of the matter is … now don't get me wrong, when these people came before our committee, yes, they came to us with a guise that this was going to give information to parents. We now know the truth, right here."

Rep. Jonathan Stickland, who also voted against HB 2474, referenced privacy and personal liberty and referred to immunization records as "private health care data that some of us feel we shouldn't be reporting at all and that the government shouldn't have anything to do with this."

Mesquite pediatrician Lisa Swanson, MD, chair of TMA's Committee on Child and Adolescent Health, says offering campus-level statistics is a "no-brainer."

"It's revenue-neutral. It isn't going to cost anybody anything," she said. "The information's out there because the school nurses actually collect this data, so any given school nurse actually knows this information; they just can't release it. The data's there; it just needs to be made public. To me, it's an easy thing to do, and … I think the parents at the school have a right to know the vaccination rate."

Senator Seliger says the concerns people have about vaccinations come "from the very best of places, from a parent's concern about those children." He says he's a strong advocate of privacy.

"But because those records will be heavily redacted, nobody's going to know anything about the Smith kid or the Jones kid or something; they are simply going to have the statistical information that may be of concern to them," he said.

Battling the Misinformation

Although DSHS data consistently show the vast majority of students it accounts for have up-to-date immunization coverage, the numbers also show overall conscientious exemptions are on the rise.

The department's annual immunization report shows immunization coverage levels for six vaccinations:  

  • Diphtheria, tetanus and pertussis (DTaP);
  • Heptatitis A;
  • Hepatitis B;
  • Measles, mumps, rubella (MMR), two doses;
  • Polio; and
  • Varicella, two doses. 

The 2015–16 report showed both kindergarteners and seventh-graders were well-covered, with the coverage rate for each vaccine at 96.9 percent or higher for kindergarten and 96.1 percent or higher for grade 7. The highest percentage of conscientious exemptions for any of the vaccinations at the kindergarten level was just 1.21 percent. For grade 7, exemption percentages for all vaccinations were at 0.80 percent or less across the board. However, the report noted there were 44,716 students reported as having a conscientious exemption from kindergarten through grade 12, representing 0.84 percent of students at schools in the survey. That was an increase of more than 3,700 conscientious exemptions since the 2014–15 survey, which showed 0.79 percent of students had taken conscientious exemptions. (See "Exemptions on the Rise," and "The Exemption Leaders.")

The increase may be attributable in part to the persistence of the anti-vaccine community. Nearly 20 years after publication of British physician Andrew Wakefield's now-discredited study, which found a possible link between the MMR vaccine and autism, skepticism over the safety of vaccines still persists. (See "Bad Science," March 2011 Texas Medicine, pages 27–32.)

For those who never found reason to pay attention to the issue before, the internet is a minefield of dubious science and pseudoscience. Dr. Swanson says she deals with the effects of anti-vaccination hysteria when she counsels new parents or parents who steadfastly refuse to immunize their children.

"When you're a new mother, you're a first-time mother, you've never paid attention to this issue before. It just doesn't matter how much I've been dealing with it for how many years; you're a new mom, and this is the first time you've come across this," she said. "And when someone starts giving out this information and you try to look it up, there's just so much misinformation on the internet, and you can't [account for] timing. You have a lot of stuff about autism, although the autism connection has been 100-percent disproven. You can't tell when articles and things were put out or when people wrote things. So for a new mom, it's very confusing."

At least once a month, Dr. Swanson says, she'll have to reassure a new mom about the safety of vaccines. One who recently asked Dr. Swanson about the safety of immunizations "has a sister-in-law who lives in another state that's an anti-vaccinator, and she just inundates her with stuff on her emails and on Facebook,  so the mom was really nervous about it," Dr. Swanson said. "It's 30 to 45 minutes of my time to try to talk to this mother and explain how important this [vaccination] is and how safe they [vaccines] are."

Austin family physician Erica Swegler, MD, a member of the Be Wise panel, says she tells patients the autism issue has been settled, but other reports of supposed dangers, such as the presence of aluminum adjuvants in vaccines, still make some apprehensive. The U.S. Centers for Disease Control and Prevention (CDC) says aluminum salts "have been used safely in vaccines for more than 70 years," and only some vaccines contain adjuvants. 

"But for some people, it becomes a belief system, a very strong belief system, and so it's very hard to alter that," Dr. Swegler said. "And now that the autism issue has been put to rest, they're talking about other trace elements in there that they can point to, so now they're saying, 'Well, what about the aluminum adjuvants?' or this or that. When push comes to shove, they will tell you that they just don't believe in them. It's hard to sway people from a belief system with the science."

Dr. Swegler says the physician's job is to make sure vaccine skeptics at least hear the results of the science so they can't hide behind a lack of knowledge. She equates it to treating smokers, who always hear from her that she can help them quit and that quitting is the best thing they can do for themselves.

"I don't stop mentioning it," she said of immunization. "I don't stop putting it out there, and so even if they refused last year, when they come in this year, I'm going to offer it to them again. Sometimes circumstances change. Sometimes in the interim, they've had a family member with an illness who was immune-suppressed, and they understand better what the implications would be."

Some physicians and practices have ultimately put their foot down. A few years ago, Dr. Vijjeswarapu says he thought about the decisions the parents of some of his patients were making, and he made a decision of his own. If he was seeing patients whose parents, for whatever reason, had decided not to vaccinate their children, he was putting other children in his waiting room at risk of contracting a preventable disease. Mindful of what he calls an "obligation to protect the youngest," Dr. Vijjeswarapu began a new approach with vaccine-averse parents.

"I gave them a visit to talk to them about vaccines and discuss the importance, and I take my 30 minutes, just a free visit," Dr. Vijjeswarapu said. "And I [tell them], 'If you decide to give vaccinations, I'll take care of you. If not, find the other doctors in town.'"

That approach has worked well for Dr. Vijjeswarapu, who says he's never had to go further with a parent than one of those talks.

In 2015, Austin Regional Clinic (ARC) took similar steps and announced it would no longer accept new pediatric patients whose parents or guardians wouldn't allow vaccinations, and parents of any existing patients unwilling to commit to a vaccination schedule would need to seek medical care elsewhere. (See "Shooting for Safety," September 2015 Texas Medicine, pages 22-30.)

Elizabeth Knapp, co-chief of pediatrics at ARC, says patients generally received the new policy well, and it has "made the conversation more about the safety of our whole practice."

"I think that we've had some families that have left ARC, but I've had in my own practice many, many families who have chosen to actually become vaccinated fully because of our policy," she said.

The Johnson County Outbreak

An outbreak of a vaccine-preventable disease can serve as an impetus for change. It did for ARC, which shifted to its vaccine requirement policy in part because of a well-publicized measles outbreak that started at Disneyland in December 2014. CDC eventually credited that outbreak with more than 120 cases of the disease. Lone Star State physicians say they believe or hope an outbreak of the mumps that started in Johnson County late last year might give lawmakers some added fuel for more granular immunization data.

CDC says two doses of the MMR vaccine are about 88 percent effective at preventing mumps, while one dose is about 78 percent effective. But several outbreaks of mumps brought cases of the disease to levels not seen in the United States in 10 years. By Dec. 31, 2016, CDC had accounted for more than 5,300 cases of mumps nationwide, more than three times as many as CDC recorded the previous year and the most since 2006. Texas was one of eight states that had reported more than 100 cases.

As of Jan. 31, the Johnson County mumps outbreak included 88 confirmed cases, 70 probable cases, and three suspected cases, said Elvin Adams, MD, Johnson County's health authority. Local officials believed they had traced the outbreak to students from the town of Keene who had visited family in Arkansas, where officials were dealing with another outbreak.

Dr. Adams said about 95 percent of the Johnson County mumps cases thus far were people who had received two doses of the mumps vaccine. Noting the 88-percent protection rate for two MMR doses still leaves 12 percent of people susceptible to mumps, Dr. Adams also said it was important to examine what percentage of students and adults exposed to mumps in Johnson County didn't get the disease.

"Here, the number is very close to 95 percent again, which is a little bit high because we might have expected that only 88 percent of the classroom would be protected," he said.

That success rate shows the MMR shot "is a highly effective vaccine, and the fact that a significant number of the students who got mumps in fact had two doses of vaccine shouldn't detract from the fact that it is a very effective vaccine," Dr. Adams said. 

Dr. Swanson says the mumps outbreak is "a good learning experience because it isn't one of the deadly diseases."

Another Legislative Push

If Texas did begin reporting immunization data at the campus level, it wouldn't be the first state to do so. Minnesota, California, and Washington, among others, already do it. But another legislative effort to do it in Texas will require backers to deal with passionate views among the public and nuance that Representative Sheffield says serves as a complication.

"The different sides on this issue are very well-entrenched, so there's almost a knee-jerk reaction when you start to talk about this that there won't be any compromise or attempt to see the other point of view here," Representative Sheffield said. "And that ties into the difficulty with this bill: It takes some time to explain the issues. It is not a bill that lends itself easily to be explained in headlines."

Dr. Adams says it's appropriate to make immunization statistics available to parents "maybe only in total numbers." He says taking the size of a school district into account would be appropriate in determining what level of data to report.

Dr. Swanson says district-level data may mislead parents about the risk a child is facing.

"If one school in a large district had a 50-percent immunization rate and all the other schools had a 95-percent immunization rate, the district might look like it's in the upper 80s, so you might not realize you have this one school within the district [with a low rate]," she said.

Dr. Terk says by supporting the availability of more information he's not suggesting privacy and personal liberty aren't important values. But he says there's a need to strike a balance between upholding principles of public health and personal liberty.

"We need to learn from what's happening now," Dr. Terk said, "so that we can prevent similar things from happening in the future and prevent needless suffering and potential death."

Joey Berlin can be reached by phone at (800) 880-1300, ext. 1393, or (512) 370-1393; by fax at (512) 370-1629; or by email.

Be Wise ― Immunize is a joint initiative led by TMA physicians, medical students, and the TMA Alliance. It is funded by the TMA Foundation thanks to major gifts from H-E-B and TMF Health Quality Institute, along with generous contributions from physicians and their families.

All articles in Texas Medicine that mention Texas Medical Association's stance on state legislation are defined as "legislative advertising," according to Texas Govt. Code Ann. §305.027. That law requires disclosure of the name and address of the person who contracts with the printer to publish the legislative advertising in Texas Medicine: Louis J. Goodman, PhD, Executive Vice President, TMA, 401 W. 15th St., Austin, TX 78701.

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