Traveling to New York to speak with state legislators about an infection preventionist (IP) recertification issue, government affairs staff of the Association for Professionals in Infection Control and Epidemiology (APIC) noticed something unusual.

“We were going to different offices meeting with legislators about our recertification campaign, and the phones were ringing from the beginning of the day to the end,” says Richard Capperell, APIC associate director of public affairs. “It turns out there was a bill that repealed vaccine exemptions on the floor at the time, and all the phone calls were coming in from the antivaccine community.”

This was firsthand evidence that the antivaccine movement in the United States is becoming more resourceful, media savvy, and somewhat relentless. While speaking at a recent APIC webinar, Capperell described various proposed state laws that would undermine or delay vaccine requirements. “Fortunately, New York continued to go with the scientific community on this, but it is important for us to know that the antivaccine community is very active and organized,” he said. “So when we are dealing with these issues, we have to be able to present our evidence and get our folks on the phone as well.”

Antivaccine sentiments are largely responsible for the 2019 U.S. total of 1,250 measles cases as of Oct. 3.1 That is the greatest number since 1992 and comes two decades after measles was declared eradicated in the United States due to routine administration of the highly effective measles, mumps, rubella (MMR) vaccine. Vaccine avoidance based on misinformation - including the thoroughly rebuked falsehood linking autism to the MMR shot2 - threatens herd immunity and vulnerable populations that cannot be immunized effectively.

This effort is not limited to the MMR vaccine, as the antivaccine movement is lobbying state legislatures to widen exemptions against childhood school immunizations and other mandates. As IPs, APIC has taken on this fight as defenders of science, rallying their members to speak up against state laws that would undermine immunization.

The first antivaccine movements began with Edward Jenner’s invention of the first vaccine for smallpox in the late 18th century. Although subsequent iterations of that vaccine would rid the world of the scourge of smallpox eventually, Jenner was burned in effigy nearly a century later at an 1885 rally of antivaccine groups in England. Today, the problem is global, as the World Health Organization (WHO) lists “vaccine hesitancy” as one of the top 10 threats to public health in 2019.

“[T]he reluctance or refusal to vaccinate despite the availability of vaccines - threatens to reverse progress,” the WHO stated in its “Ten threats to global health in 2019.”3 “Vaccination is one of the most cost-effective ways of avoiding disease - it currently prevents 2-3 million deaths a year.”

Almost Half of Public Doubts Vaccine Safety

In the United States, a recent poll4 found that 45% of respondents have doubts about the safety of vaccines, says Lisa Tomlinson, MA, CEA, vice president of government affairs and practice guidance at APIC.

“Fear-based beliefs are hard to change, especially when those beliefs relate to children,” she said at the webinar. The primary reasons for these doubts included “past secrets/wrongdoing” by the pharmaceutical industry and the government. Also cited were social media interactions and content, information from medical “experts,” and advice from family and friends. Somewhat surprisingly, given that the majority of states have exemptions for some version of religious or philosophical beliefs, only 4% of those doubting vaccine safety cited religious beliefs as the reason.

“There are about 45 states that have some kind of religious or personal belief exemption in addition to a medical exemption,” Capperell says. “Overall, we saw about 200 [state] bills dealing with vaccines this [legislative] cycle, and we expect to see just as many next year.”

That is due in part to antivaccine activists lobbying state legislators, some of whom sympathize with the cause and/or see an opportunity for political gain. The ongoing vaccine fight at the state level includes proposed laws to provide broader exemptions for school immunizations, and legislation and delay tactics to spread out or undermine the childhood immunization schedule, he says.

In response, APIC has issued a call to action document5 and is offering to help state and local APIC chapters fight antivaccine laws. IPs have an “ethical responsibility” to promote evidence-based vaccine policies, APIC notes. “We are concerned [that] the increase in the rapid spread of misinformation related to vaccination, especially via social media, has led to unwarranted concerns about childhood vaccination, parental refusal to vaccinate children,” APIC states.

APIC’s comprehensive review of state legislation over the last year shows that “contrary to current scientific evidence, policies that delay vaccination, or spread unwarranted fears about vaccination have increased in state legislatures.” The document states that “innumerable studies have shown that vaccines are one of the safest and most cost-effective ways to prevent infection and prevent the spread of disease.”

APIC is concerned with efforts that try to place the burden on schools and healthcare facilities to justify vaccination or spurious “informed consent” bills that would require providers to overstate the risk of vaccine contraindications.

“As such, we will speak out against these policies and call on our members to contact their legislators to oppose such legislation,” the association said in a statement.5

The U.S. measles outbreaks have led to some pushback from vaccine advocates, as there now are five states that allow only medical exemptions to childhood vaccinations: California, Maine, Mississippi, New York, and West Virginia. “New York and Maine are the newest additions to this list this year,” Capperell says. “Every year in West Virginia and Mississippi, we are seeing legislation to put the exemptions back on the books. The antivaccine movement is quite vocal in their opposition to vaccine requirements and unfortunately, they are very effective at getting their folks active when the time comes.”

In addition, Washington state has repealed personal or religious exemptions, but only for the MMR vaccine. “Most of the legislation we are looking at is regarding requirements for school and childcare facilities,” he says. “These do not include just MMR, but an entire spectrum of vaccines, including meningitis and HPV.”

Bill Breakdowns

State legislation in 2019 has taken a variety of forms, and Capperell broke down the primary laws and proposed bills in a series of multicolored U.S. maps that underscored the flurry of activity around vaccine issues.

For example, some states are trying to expand or restrict employer-mandated vaccinations, which have been most controversial in policies requiring annual flu shots for healthcare workers.

“This has long been a top priority for APIC,” Capperell says. “We have talked a lot about this regarding healthcare facilities. Most bills opposing employer mandates target influenza vaccines.”

In a related development, eight states have introduced some type of legislation that would prohibit employers from requiring employees receive certain vaccines: Oregon, Montana, Oklahoma, Minnesota, Iowa, Mississippi, Ohio, and Maine.

“One concern is that some of the Midwestern states were actually targeting all vaccines - not just influenza,” he says. “[These proposed bills say] for any vaccine, an employer would not be allowed to require vaccination of the employee. That is a little bit of a scary trend we saw.”

On the plus side, Texas, Colorado, Arkansas, New York, and New Jersey were considering legislation that would expand healthcare worker vaccine requirements. Some states want to join the five that have removed all but medical exemptions to for childhood vaccinations.

“But we also saw some states introducing laws either strengthening current exemptions or trying to find new avenues to exemptions a little more lenient,” he says. With most states already allowing some sort of nonmedical exemption, there are efforts to make applying for an exemption easier.

“There is another trend we are seeing as well, making the ability to apply for an exemption easier,” Capperell says. “A [proposed Texas] bill made it so all you had to do is go to an online portal and request an exemption. It kinds of depends on the state. Some states require a notary public or a school nurse to get a health exemption; some kind of additional barrier - not an online portal. So, this was an alarming thing in both New York and Texas, where we not only see additional exemptions being added, but the ease of getting exemptions being included [in bills] as well.”

Uninformed Consent?

Several states are working on variations of bills that would require healthcare providers or school officials to provide information on vaccines. The legislation has many different variations, and targets both healthcare facilities and schools. These bills may require a school system to send literature to students reminding of exemptions.

“Parents may receive a letter saying you can [decline vaccination] of your child for religious purposes,” Capperell says. “The purpose of this legislation is essentially to give parents an ‘out’ to vaccine requirements.”

Other versions of “informed consent” bills for healthcare facilities require that they highlight the rare but real risk of having an allergic reaction to a vaccine. Some of this proposed legislation requires an explanation of the National Vaccine Injury Compensation Program. This federal program was set up in 1988, after lawsuits against vaccine manufacturers and healthcare providers threatened to cause shortages and undermine national immunization rates.

Such bills essentially emphasize risk over benefit of an established public health measure. For example, informed consent bills may include highlighting vaccine ingredients, emphasizing potential harm rather than the protective aspects of immunization.

“Generally speaking, these bills really kind of exploit the risk of vaccines vs. the actual benefits of being cost-effective, extremely efficacious, and saving hundreds of thousands of lives every year,” Capperell says. “The burden is actually put on some healthcare providers because this information can be required to be given days, maybe a week, before a vaccination.”

APIC is not opposed to providing all relevant information to patients, but the proposed laws on informed consent are skewed to build a negative narrative, he says.

“You have an information overload of four or five pieces of information given to you, in addition to being explicitly told about the vaccine injury fund,” he says.

At least 12 states have discussed or are considering some version of these informed consent bills.

Another concern are bills questioning the scientific integrity of vaccine development, with some legislatures introducing bills that would all but ban vaccines unless they were subject to placebo-controlled trials to prove their safety. Some of these bills focus only on vaccine ingredients, primarily the preservative thimerosal, while others target vaccines in general. Proposed bills in Maine, Washington, and Texas would require vaccines to be studied vs. a placebo group to prove that the ingredients do not cause autism, cancer, and infertility.

“It would effectively ban any vaccine at this moment,” Capperell says. “This was quite alarming for us. We haven’t seen this bill in too many places yet. Our concern is that it might appear other places.”

That concern stems in part from having Washington and Texas - two states at the opposite ends of the political spectrum on most issues - taking such a radical stand against vaccines. “It is not very often you see Texas and Washington have the same exact bill introduced, but they did in this case,” he says.

In times of high political polarization, one overall observation about the state vaccine bills and issues is that many are nonpartisan. “The support for vaccines can be a very nonpartisan issue,” he says. “On the other side of that, the antivaccine movement can be very nonpartisan.”

Timing of Childhood Vaccinations

In a legislative strategy that APIC sees primarily as a vaccine delay tactic, some states are pushing bills that would allow blood titer tests to check for existing immunity in lieu of vaccination.

“Our questions are not about the effectiveness of titer tests – they work, and they have their place,” Capperell says. “When we looked at this titer stuff, we were really concerned that it was kind of a delay tactic and less [of] an actual attempt to look at natural immunity.”

Such legislation is being pushed by parents and antivaccine groups who claim the recommended childhood immunization schedule of shots causes harm by requiring too many shots over a condensed period of time.

“This legislation uses these [titer tests] as a delay tactic to receiving a vaccine on the recommended schedule,” Capperell says. “[The APIC] Public Policy Committee expressed concerns that if the titer test shows no evidence of immunity, how do you get the patients back for vaccination?”

The inaccurate attacks on the childhood vaccination schedule have been subjected to considerable pushback, including a 2017 letter6 to President Trump signed by a host of prominent medical groups and associations that thoroughly rejected the claim.

“Claims that vaccines are unsafe when administered according to expert recommendations have been disproven by a robust body of medical literature, including a thorough review by the National Academy of Medicine,” the letter states. “Delaying vaccines only leaves our nation’s citizens at risk of disease, particularly children. As a nation, we should redouble our efforts to make needed investments in patient and family education about the importance of vaccines in order to increase the rate of vaccination among all populations.”

In other bills, a highly publicized case last year of a child seeking vaccinations after being denied shots by parents received some legislative attention. However, bills empowering vaccination of minors against parental wishes gained little traction.

Finally, so-called vaccine “anti-discrimination” bills have come up in some states. These laws would require healthcare clinicians to provide care regardless of the patients’ vaccination status. None of these have passed, but they may stem from reported cases in pediatric offices that may decline or limit ongoing routine care to families who refuse to have their children vaccinated.

REFERENCES

  1. Centers for Disease Control and Prevention. Measles cases and outbreaks. Available at: https://bit.ly/2iMFK71. Accessed Nov. 7, 2019.
  2. Hviid A, Hansen JV, Frisch M, et al. Measles, mumps, rubella vaccination and autism: A nationwide cohort study. Ann Intern Med 2019;170:513-520.
  3. World Health Organization. Ten threats to global health in 2019. Available at: https://bit.ly/2Np3Xyg. Accessed Nov. 8, 2019.
  4. American Osteopathic Association. 45% of American adults doubt vaccine safety, according to survey. June 24, 2019. Available at: https://bit.ly/2K4q4rL. Accessed Nov. 8, 2019.
  5. Lavin MA, Smathers S, Dickey L, et al. APIC Public Policy Committee. Public policy position statement: State vaccine policies. Sept. 2019. Available at: https://bit.ly/2NnTXFk. Accessed Nov. 8, 2019.
  6. American Academy of Pediatrics, et al. Group vaccine safety letter to President Trump. Feb 7, 2017. Available at: https://bit.ly/2NJ0B80. Accessed Nov. 8, 2019.