hill country observerThe independent newspaper of eastern New York, southwestern Vermont and the Berkshires




A clash of parents’ rights, public health

Vermont moves to limit vaccine exemptions, prompting backlash



Contributing writer



Asked about the subject of childhood vaccines, Lauryn Starkie Kreuder became guarded.

Starkie Kreuder and her husband have chosen not to vaccinate their two children. Citing philosophical objections, they obtained a waiver from the state’s vaccine requirements. The waiver allows their older child to attend school without the usual battery of vaccines.

The issue has become a hot topic in Vermont lately as the Legislature has moved to do away with parents’ right to opt out of vaccines on philosophical grounds. Last month, the state Senate voted by a wide margin to do away with philosophical exemptions. If the House approves the measure too, Vermont parents would only be able to obtain vaccine waivers based on religious or medical concerns.

Starkie Kreuder is among dozens of parents from Bennington and Rutland counties who’ve signed an online petition against the proposal. As of late March, the petition had garnered more than 1,300 signatures from around the state and beyond.

But many parents are reluctant to discuss the issue. Before agreeing to be interviewed for this story, Starkie Kreuder conferred with her husband, with whom she runs a popular local café. Later, she said she didn’t want to be photographed. She is well aware of the high emotions surrounding the issue, and like others who’ve chosen not to vaccinate, she’s wary of being stereotyped as an irresponsible parent or a religious zealot.

“I don’t feel fanatical,” she said. “It’s definitely a very complicated issue, and I feel I have to keep thinking about it.”

Public health officials and other advocates of the proposed change say they’re trying to protect children from once-common diseases like measles and whooping cough. Boosting the state’s vaccination rate, they say, would reduce the risk of disease outbreaks. And they warn that parents who opt out of the state’s vaccine requirements could be putting other people’s children at risk.

But parents like Starkie Kreuder say the issue isn’t so simple -- and that they want to preserve the right to make their own decisions about what’s best for their children.

More vaccines, more conflict

As in other states, the list of mandated vaccines has grown over the years in Vermont. By the time they enter kindergarten, children are required to have received multiple doses – 16 shots in all – of vaccines against diphtheria, tetanus, pertussis, polio, measles, mumps, rubella, hepatitis B and chickenpox.

Starkie Kreuder is among the parents who worry about the cumulative effects all those vaccines might have on children’s immune systems.

“I haven’t seen any really good long-term studies of all of these things on the immune system,” she said.

Some parents appear to be using the philosophical exemption to pick and choose -- opting, for example, to have their children vaccinated against polio, measles, mumps and rubella while skipping the vaccines for diseases like hepatitis B and chickenpox that they consider less of a threat.

Some parents who’ve chosen not to vaccinate also espouse an unconventional view of illness -- one that considers diseases like chickenpox, for which the state didn’t require a vaccine until 2008, as a natural and ultimately beneficial part of childhood development, rather than as something to be prevented through vaccines.

But to many doctors, public health officials and legislators, those unconventional views represent a hazard.

The bill to eliminate the philosophical exemption, introduced by state Sen. Kevin Mullin, R-Rutland, passed the Senate on March 1 by a vote of 25-4. A House committee was expected to hold a series of hearings on the proposal in the last few days of March.

Proponents of the bill say too many parents are opting out of vaccines. They point to data from the U.S. Centers for Disease Control that appear to show Vermont’s immunization rate has declined in recent years, which they say could raise the risk of disease outbreaks.

Opponents of the measure, however, say the bill’s supporters are cherry-picking data to support their case. They also contend that removing the philosophical exemption is an infringement on parents’ rights.

Vermont is one of 20 states that allow both philosophical and religious exemptions to vaccines required to attend school. In contrast, New York and Massachusetts allow parents to opt out of vaccine requirements only for religious reasons. Forty-eight states allow religious exemptions, and all allow some exemptions based on medical conditions.

Too easy to opt out?

Under current law, Vermont parents can avoid mandated vaccines simply by signing a form saying they are opposed on philosophical grounds. The state is one of only seven that don’t require parents to visit a doctor to complete the paperwork, said Christine Finley, immunization program director for the Vermont Department of Health.

Finley said the current process might make it too easy for parents who simply don’t want to be bothered with vaccines.

“For some parents, it could be an exemption that’s more convenient,” she said.

Health officials say they have become victims of their own success. As more vaccines have been deployed in recent decades, the effects of many communicable diseases have largely vanished from public view. But a measles outbreak last fall in Quebec shows the danger still lurks, Finley said.

She added that she wishes the public would just trust public health officials about the dangers.

“We’re trying to protect kids from pertussis and polio,” Finley said. “We’re not really evil.”

But the Quebec measles outbreak Finley mentioned, in which more than 750 people were sickened, shows that not every health official is in agreement about what vaccines are necessary and when to administer them.

According to a Canadian Broadcasting Corporation report on the outbreak, Canadian health officials were mystified that 52 of the 98 teenagers who contracted measles in one small town actually had been vaccinated against the disease.

A provincial public health official told CBC News that this might be evidence that the measles vaccine has been given too early to babies, when their mothers’ inherited immune system might neutralize the vaccine. He said it might be better to delay this immunization.

Maintaining ‘herd immunity’

Mullin, the senator from Rutland County, has said he sponsored legislation to do away with the philosophical exemption because he was alarmed by a report showing that Vermont’s immunization rates were falling. He did not respond to several requests to be interviewed for this story.

Data from the U.S. Centers for Disease Control seem to back up Mullin’s claim that fewer Vermont children are getting vaccinated. A link on the Vermont Department of Health Web site shows that the percentage of Vermont kindergartners given three required vaccines dropped on average from 95.6 percent to 91.3 percent in the last five years. Health officials generally say a rate of 90 percent is required to achieve “herd immunity” to once-common diseases like measles, and Vermont has set a goal of achieving a 95 percent childhood vaccination rate by 2020.

Vermont’s current vaccination rate also ranks low nationally, according to the state. A map prepared by the CDC using 2010 data shows Vermont, Washington and Oregon as the only three states where more than 4.1 percent of kindergartners have been granted nonmedical exemptions to vaccines. Washington recently tightened its rules on philosophical exemptions; it now requires parents to visit a pediatrician before being granted a philosophical exemption to vaccines.

By comparison, in New York and Massachusetts, fewer than 2 percent of kindergartners have non-medical exemptions to vaccines.

Amy Pisani, executive director of the vaccination advocacy organization Every Child by Two, argues that vaccination rates must be kept high partly to protect parents who have chosen to vaccinate their children.

Recent outbreaks of pertussis, also known as whooping cough, illustrate that herd immunity is not high enough, she said. The pertussis vaccine typically has a 75 percent success rate in protecting those who receive it, and Pisani argued that some children whose parents have made the effort to get the vaccine are being put at risk unfairly when children who are unvaccinated are allowed to attend school.

“The people who vaccinate have a right to know they aren’t going to get a communicable disease,” Pisani said.

(Every Child by Two, based in Washington, receives funding from vaccine manufacturers, although Pisani said the organization does not push for one vaccine product over another.)

Global society, wider risks

Judy Orton, a Bennington pediatrician, is among those hoping the Legislature will do away with the philosophical exemption. The risk of an outbreak of preventable diseases is too great with the increased mobility of the 21st century, she said.

“We’re a global society, so it’s just a plane trip or a car ride away,” Orton said.

In her office, Orton sometimes displays pictures of the effects of diseases, hoping to sway parents who are wavering on whether to vaccinate. If the philosophical exemption is scrapped, she said, she hopes to have a greater chance to show parents the importance of vaccines.

“We don’t want to halt the conversation,” Orton said.

But some worry the bill will quash conversation about vaccinations and take a medical decision out of parents’ hands.

Julian Jonas, a practitioner at the Center for Homeopathy of Southern Vermont, in Brattleboro, says he has treated many patients who have been injured by vaccines. It’s unacceptable that parents might not get to decide the issue for their own families, he said.

“I think people should have a choice of what to put into the immune systems of their children,” Jonas said.

Parents’ resistance to vaccinating children has sparked probing debates about vaccine safety, said Alan Phillips, a North Carolina lawyer who specializes in vaccine exemption cases. Removing the philosophical exemption might choke off that debate, especially amidst continued pressure from vaccine manufacturers to expand the required number of vaccines, he said.

“I would hate to see that conversation continue to be stuffed under the rug,” Phillips said.

Vaccinations, like all medical treatments, carry a risk of disability or death, but it’s hard to quantify the amount of risk, Phillips said. Public health officials say the benefits far outweigh the risks. But Phillips said many vaccine injuries go unreported because of misdiagnosis or onerous reporting requirements, and without that data, it’s impossible to generalize the safety of vaccines.

“We don’t have the information to calculate whether vaccines are a net benefit,” Phillips said.

Misleading data?

Some Vermonters feel health officials are manipulating data to tip the scales of the debate.

Jennifer Stella, one of the founders of the Vermont Coalition for Vaccine Choice, which started the online petition Starkie Kreuder signed, pointed out that a Vermont Department of Health chart on kindergartner vaccination rates understates the percentage of children complying with vaccine requirements.

The chart shows an overall figure of only 83 percent of Vermont kindergartners receiving all recommended vaccinations, even though the compliance rate for each of the individual vaccines required by Vermont tops 87 percent in every case. The overall rate includes vaccines on a more expansive, CDC-recommended list -- a list with some immunizations, such as those for Hepatitis A and human papillomavirus, or HPV, that are not required in Vermont.

“Are we going to measure ourselves against a wish list?” Stella asked. “It’s a little bit misleading to refer to children as unimmunized just because they didn’t get the hepatitis A shot.”

CDC reporting of vaccinations takes an all-or-nothing approach to vaccines, which can produce alarmingly low rates, Stella said.

Finley confirmed that children who get some vaccines but not others are counted as unimmunized. With the data available, the state can’t determine how many vaccines a child might be missing, she said.

Yet some parents have their children vaccinated against diseases like measles and whooping cough while skipping the vaccines for chicken pox, which they consider less dangerous, and Hepatitis B, which is spread mainly through sex and intravenous drug use.

“Any child missing just one shot was dropped” from the state’s count, Stella said. “We have a question of semantics here.”

Ever since states began adopting vaccine regulations, there has always been an attempt to maintain the notion of informed consent, Stella said. Parents want to be able to weigh the risks of vaccinating against the risks of not vaccinating with the most accurate data possible, but that’s not happening in the current climate in Vermont, she said.

State health officials say more than 300 children in Vermont have avoided vaccines because of philosophical exemptions requested by their parents. A map produced by Department of Health shows the rates of vaccine exemptions at elementary schools around the state; those with the highest exemption rates, involving more than 6 percent of kindergartners, include schools in Bennington, Manchester, Dorset, Middletown Springs, Clarendon, Rutland, Chittenden, Orwell and Sudbury.

But Stella’s group points out that these percentages can be misleading, particularly at small, rural schools that have small numbers of students. At a school with five kindergartners, a single student whose parents opted out of one vaccine would register as a 20 percent non-vaccination rate.

Some school officials also say they’re worried that if the philosophical exemption is eliminated, parents who feel strongly about the issue will withdraw their children from school and home-school them instead, resulting in a loss of education funding for schools.

A middle ground?

Although the debate over the bill has grown heated, with some on both sides lobbing accusations of fraud and conflict of interest, there may still be room for compromise.

Stella said she and many others who oppose the pending bill believe vaccines are a part of the toolbox for public health. Many who signed her group’s petition have decided to vaccinate their children for some diseases, just not all of those required by the state, she said.

Vermont Health Commissioner Dr. Harry Chen, formerly a state representative from Mendon, said in February that he would be open to a compromise that would leave the philosophical exemption intact but instead require parents to speak with pediatricians before obtaining waivers.

Both sides agree that even if the philosophical exemption is stripped from state regulations, the religious exemption would remain. Proponents of the bill say there is no appetite for doing away with the religious waiver, and they know any attempt to do so would end up in court.

Both sides also acknowledge there is little to stop parents who oppose vaccines on philosophical grounds from claiming they object instead for religious reasons.

Finley, the Health Department’s immunization chief, has said that if a parent wanted to sign a form requesting a religious exemption, “nothing would stop you.”

But there still are many unanswered questions about the religious exemption, Jonas said.

“Can you be part of a Buddhist meditation society?” he asked. “Who’s making the determination?”

States often limit how much a physician or school can probe a parent’s religious beliefs, but such challenges do happen. A handful of states have established rules that those applying for religious exemptions must be part of a codified or organized religion, and some states challenge questionable assertions of the exemptions in court.

In 2010, for example, the courts upheld the denial of a vaccine waiver for a New York mother who said she saw God in everything but who wouldn’t define her beliefs more specifically.

Stella said she worries that the Vermont Constitution’s narrow definition of the separation of church and state might make it easy for religious exemptions to be challenged in court.

For some Vermont parents, the end of the exemption would mean a sea change in how they raise their children. If the bill passes, Starkie Kreuder’s child would no longer be able to attend school based on the philosophical exemption. She and her husband would face a choice of trying for a religious exemption, vaccinating or homeschooling.

“I’m not quite sure what would happen,” she said.





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