Washington Measles Emergency: Why Banning Vaccine Exemptions Isn't Enough

"I don't know that the law itself is a mechanism by which we persuade people."

The Washington State measles outbreak has bled into a second month, expanding from a county-level public health concern to a state-wide emergency that has put the state’s anti-vaxxers under a microscope. As measles tears through un-immunized kids — largely a result of parents with religious or philosophical views opposing vaccination — the debate over non-medical exemptions (NMEs) to vaccines has erupted once again.

It’s well-established that nine out of ten unvaccinated people who are exposed to measles will contract the disease. Meanwhile, the measles, mumps, and rubella vaccine (MMR) is nearly 97 percent effective in preventing measles, which is highly contagious and can be fatal for little kids. But in some states, parents who are skeptical of the MMR vaccine because of its disproven link to autism and other health problems can acquire NMEs, which are public health waivers that allow their kids to skip the vaccines but still attend public and private schools.

Nationally, the NME rate is around two percent, but in Washington State, it’s about four percent. In Clark County, ground zero for the measles outbreak, it’s about seven percent. On Monday, in response to the region’s worsening crisis, US Representative Paul Harris from Vancouver proposed a bill to remove NMEs altogether, requiring parents to either vaccinate their kids or receive a medical exemption if they want to enroll their kids in school.

This may seem like the most straightforward and common-sense way to prevent future outbreak emergencies, but public health and sociology experts tell Inverse it’s not that simple.

A new bill in Washington proposed in the wake of the measles outbreak would ban philosophical exemptions to vaccines. 

Public Domain Files/CDC

What Actually Happens When NMEs Are Banned

Right now there are three states that have banned “personal” exemptions to vaccines: California, West Virginia, and Mississippi. California removed them in 2015, in the wake of a measles outbreak at Disneyland the year before. Senate Bill 277 made it illegal to enroll in a public or private school without being fully immunized, even if parents object on philosophical grounds.

There was a reduction in NMEs after they were banned in California, says Alison Buttenheim, Ph.D., who studies the effects of this law in her role as a professor of health policy at the University of Pennsylvania Perelman School of Medicine. As a result, she tells Inverse, the overall vaccination rate in the state increased to 95 percent — an ideal percentage to protect public health. However, legitimate medical exemptions subsequently nearly tripled and still remain high in California, casting suspicions on some physicians. It isn’t enough to simply use legislation to ban NMEs, it seems, because adamant parents will always find a loophole.

Unfortunately, California’s medical exemptions are highly clustered, suggesting certain communities are still at serious risk of outbreaks.

“It’s one thing to say that ‘Washington is at 88 percent coverage and California is at more than 90 percent coverage,’” Buttenheim says. “But if we still end up with districts and communities where that threshold is much lower, then we’re still going to have outbreaks.”

Families that request NMEs tend to cluster together in "hotspots" which make outbreaks even more dangerous. 

PLOS Medicine 

It’s About More Than Just Increasing Vaccination Rates

To properly tackle the problem of anti-vaccination, argues University of Colorado, Denver sociologist Jennifer Reich, Ph.D., public health officials must address the issue at its core: the way that parents feel about vaccinating their kids. Laws banning NMEs might increase the percentage of vaccinated kids, but they leave more important concerns — like the emotional reasons that people refuse vaccination — untouched. And that can leave room for other groups to prey upon parents’ existing insecurities about vaccines.

"I don’t know that the law itself is a mechanism by which we persuade people.

“If your sole goal is to get more people vaccinated, it probably did that pretty well. I don’t know that the law itself is a mechanism by which we persuade people. I think it’s very different to have a conversation that makes it clearer how vaccines are tested, how they’re monitored,” she tells Inverse.

Harris’ bill has already seen opposition from the National Vaccine Information Center, a notorious anti-vaccine group that says the ban has left parents feeling “extremely oppressed,” as the AP reports. The argument that a ban on NMEs is actually an attack on parental rights is dangerous, Buttenheim cautions, because it’s easy for that idea to spread to people who are vaccine hesitant but not yet staunchly opposed to vaccines.

“I think one thing we can say is that eliminating them all together is probably not optimal for all the reasons we’re seeing in California. My hunch is that a lot of parents in California who had never paid attention to the vaccine exemption issue prior to the SB277 heard about it and thought: ‘Wow! That really goes too far. They are really taking away parental rights and parental decisions and excluding these kids from school.’”

The spread of such sentiments can undo years of work in convincing skeptical people that public health organizations have their best interest at heart, says Oakland University bioethicist Mark Navin, Ph.D. If the removal of NMEs is interpreted as a “coercive” policy that limits choice, he says, it may become a political rallying point that is ultimately used or misused for political gain.

"I do not want to contaminate immunization policy discussions with political polarization.

“We need to be really sensitive to that when we’re thinking about policy changes that take away rights that parents used to have, particularly when it comes to non-medical exemptions,” Navin tells Inverse. “President Trump in the campaign said that he was committed to a robust parental right to sent unvaccinated kids to school. I do not want to contaminate immunization policy discussions with political polarization. That scares the heck out of me.”

This has already happened in Italy, where a populist government has targeted anti-vaccine sentiment to further its cause. In September, the government rolled back its vaccine laws, allowing children to attend school as long as parents “attest their children have been vaccinated,” as the New York Times reported.

How to Design the Ideal NME Policy

The ideal policy must improve vaccination rates, preserve parental autonomy, and also encourage those who are on the fence about vaccines to embrace the technology to protect their children. It’s a tricky balance. A common approach among policymakers is to make the process of getting an NME just annoying enough to deter people who are unsure about vaccines — but isn’t so heavy-handed that it makes people feel they have been forced into vaccinating their kids. Buttenheim calls this the “hassle factor.”

The NME policy that’s been in effect since 2015 in Oregon already attempts to impose a hassle factor. Anyone trying to get an NME must first get a vaccine education certificate by watching a series of videos about the benefits of vaccines. When it was first introduced, the number of NMEs dropped, but they have since started to rise again. Perhaps, says Buttenheim, the hassle factor wasn’t high enough.

Oregon's NME rates dropped after a hassle factor was introduced but have started to climb again.

“Why do we expect that to work?” she says. “Is it something like, ‘Oh forget it. I’ll vaccinate my kid. I don’t want to go through this video module thing?’ Probably not, because if you really don’t want to vaccinate your kid, the hurdle of watching an eight-minute or 12-minute video is probably not that high.”

Both Buttenheim and Navin think it might be worth considering financial incentives for vaccination, as recent research has suggested. These laws would hold parents who don’t vaccinate their kids liable for the financial costs that may be incurred by a potential outbreak. The current outbreak in Washington has already cost hundreds of thousands of dollars.

However, financial incentives don’t have to be punitive. There’s also the idea that state health departments or school districts could financially reward school districts for keeping vaccination rates high.

“Schools can do a lot,” Buttenheim says. “I’ve interviewed school nurses, parents, and officials at really different types of schools in California, and the attitude of a school nurse and the policy he or she puts into place to manage kindergarten registration can have a huge effect on whether incoming parents say, ‘Oh, this is something we do or this is something we don’t do.’”

To Reich’s point, however, these policies probably won’t do much in addressing the emotional reasons parents don’t vaccinate their kids. But they may tip the vaccination scales just enough to maintain herd immunity — the idea that if the majority of people are vaccinated, the rest are protected as a result, even if you have a few defectors. The problem in Washington is that the rates of NMEs have skyrocketed into what Buttenheim calls “outbreak territory,” and herd immunity is moot.

A hard-line NME policy won’t solve the anti-vaccination problem overnight. But it may buy public health officials time to think creatively about how people make the decision to avoid vaccines, and how we can sway most people away towards embracing their lifesaving power.

For now, Washington’s bill proposing the removal of NMEs is scheduled for a public hearing on February 8, when the rest of the state weighs in on the best kind of policy to address this tragic outbreak.

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