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In Perspective: Exemptions and Health

 

F. Edward Yazbak MD, FAAP

 

Abstract

The state of Mississippi where Personal Belief (Philosophic) Vaccine Exemptions are not allowed has the highest pediatric vaccination rates in the Country and so far no measles cases in 2015.    

Sadly, Mississippi also has the highest infant mortality rate (IMR). 

New Mexico where philosophic exemptions are not allowed, has also not reported any measles activity in 2015 unlike adjoining Texas, Colorado and Arizona, where philosophic exemptions are permitted. New Mexico’s IMR is just as alarming as that of Mississippi and has always exceeded that of its three neighboring states.

Blaming young parents claiming philosophic exemptions for the 2015 California measles outbreak seems unfair when vaccinated, partially vaccinated and unvaccinated individuals have been affected and when the disease seems to have become more prevalent among individuals older than 20.

Geography rather than exemptions may be the real cause why the present measles outbreak started in California.

Religious exemptions are likely to become the next evil.   

The CDC has the ability to distinguish between wild and vaccine-strain measles virus by PCR testing. It is likely that this testing has already been done. It is unlikely that the findings will soon be revealed.

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A newspaper report topped with a large Gold Cup surrounded by many #1s and titled "Mississippi: Last In Everything, First In Vaccinations" was published on October 17, 2014. It boasted "No Mumps in Ole Miss."

"The Magnolia state is used to being last on measures of childhood well-being—but it’s beating the rest of the nation when it comes to immunization rates. Be it wealth, health, or education, when it comes to most measures of well-being, there is one state that reliably comes in last place. Mississippi is so used to trailing the pack in these rankings that it was a surprise when the state moved up to #49 in the annual Kids Count report last year. It was the first time in 24 years, since the Annie E. Casey Foundation first issued its survey that Mississippi didn’t sit at the very bottom. (It fell back to last place in 2014.) But there’s one indicator where Mississippi’s children outperform every other state: childhood vaccination rates."                                                               http://www.thedailybeast.com/articles/2014/10/17/mississippi-last-in-everything-first-in-vaccinations.html#

Obviously an infant has to turn one to become a toddler and then a child in order to attain wealth, health, education and most measures of well-being.

Sadly, according to another newspaper account on January 18, 2015; "Mississippi’s infant mortality rate, which had dipped below nine deaths per 1,000 live births for the first time in the last decade, has increased to 9.7 per 1,000 live births, according to the latest data. State Health Officer Dr. Mary Currier told members of the House Appropriations Committee she is once again asking for $1.5 million for an infant mortality initiative....“We feel like we could make a difference,” Currier said of having an infant mortality initiative.”
http://www.clarionledger.com/story/news/2015/01/18/mississippis-infant-mortality-rate-climbs/21976023/

It is only fair to state that Dr. Currier was recently appointed as State Health Officer and that she cannot and should not be blamed for the state's health ills. Her request for serious funding for an urgent infant mortality initiative is laudable and overdue. It should become the state’s #1 priority.

It is equally imperative to assure the Good People of Mississippi that my argument is not with them but with those - including the CDC and previous state health officials– who were more interested in vaccination rates than in addressing Mississippi’s poor indicators of overall Child Health and Well-being.

Maybe it is time for Mississippians to consider the choice between a few cases of measles from time to time and … “HEALTH”.  

Furthermore, parents in the state should know that even with their outstanding and enviable vaccination rates, there were 65 whooping cough reports and 34 reports of Invasive H. Influenzae B disease in 2014, up from 2013. Both illnesses are vaccine-preventable and both are potentially more serious and life threatening than measles or mumps. http://msdh.ms.gov/msdhsite/_static/resources/6144.pdf       

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Wild-type measles viruses are classified into distinct genetic groups, referred to as genotypes. CDC experts are confident that the 2015 “California” measles outbreak was started by a patient with measles genotype B3 mostly identified in the Philippines, where thousands have come down with the disease.

The CDC and the California Department of Public Health (CDPH) have both acknowledged that the early confirmed measles cases of the 2014-2015 outbreak occurred among vaccinated, partially vaccinated and unvaccinated individuals even though blame was only copiously heaped on cases with philosophic exemptions.

By accurate PCR testing, the CDC can distinguish wild from vaccine-type measles. Although it is likely that the CDC has been performing such tests all along, it is not expected that the test results will ever be made public.  

The most recent CDPH Measles Surveillance Update released on February 27, 2015 reveals that the majority of known cases are strain B3 with a small number (3) of D8 and D4 strains. Of the 130 confirmed measles cases in California, 15 (11.5%) were under the age of 1, 18 were 1 to 4 year old, 23 were 5 to 19 and 74 (57%) were older than 20. http://tinyurl.com/novbaxj

The update does not identify how many individuals came from abroad with the infection and how many were native Californians. If those older than age 20 or 57% of all cases were Californians, then it is unfair to accuse informed young parents in the state who are concerned about the number of presently recommended pediatric vaccines. http://www.cdc.gov/vaccines/schedules/downloads/child/0-18yrs-child-combined-schedule.pdf

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It seems that the Good people of Mississippi would have been better served if the state’s regrettable health issues, infant mortality rate (IMR), vaccination status and the absence of measles had not been revealed.

Was it so important to boast about Mississippi’s “#1”vaccination rates if it also meant telling everyone in the other 49 states that more Mississippi babies never reach their first birthday? Besides, it is a fact that many other states have also not reported a single measles case this year even though they had lower pediatric vaccination rates and a number of philosophic and religious exemptions.

It is near certain that Mississippi would have already recorded several measles cases if the state had a huge international airport where non-stop flights from Manila landed frequently, day and night.

It is also likely that even if California’s vaccination rates were identical to those of Mississippi that infected visitors from the Philippines going to visit relatives in Minnesota would have left a trail of statistics by spending a few days near Disneyland before proceeding to the cold weather.

Lastly it would be naïve to think that a parent visiting the United States for the first time  would want or be able to keep a busy child, who is not too sick, in a hotel room when Mickey and the Magic Mountain Ride are around the corner.  

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Another attempt to publicize Mississippi’s outstanding vaccination rates came in an NBC News Report in February that boasted that Mississippi was “leading the fight against the spread of measles”. http://tinyurl.com/nj3atu4

The NBC Atlanta GA reporter who filed the report in Jackson MI, just a mere 381 miles away, must have been reassured that measles cannot and would not cross state lines.

The incidence map attached to the NBC News article reveals confirmed measles cases in WA, OR, CA, AZ, NV, UT, CO, TX, SD, NE , MN and IL. Of those states, Nevada, Nebraska and Illinois do not allow philosophic waivers.

Regardless of their vaccination rates and their vaccination waivers, all of the remaining continental states have not reported measles cases so far this year.

A list of up to date exemptions by state is available. http://vaccines.procon.org/view.resource.php?resourceID=003597.

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There were no measles cases reported in New Mexico in January while adjoining Texas, Colorado and Arizona reported a few.  According to its DOH, "New Mexico’s most recent case of measles was confirmed in December 2014 in a baby who did not receive the first measles vaccination. It was not determined where or how the baby was exposed. The baby was hospitalized and recovered." (It would be safe to guess that unless the baby was out of state for a while, the “exposure” occurred in New Mexico)

The report went on: "Measles is a very contagious respiratory disease caused by a virus. It is so contagious that if one infected person has it, 9 out of 10 exposed people who are not immune will also become infected. It spreads through the air when infected persons cough and sneeze. It can live for up to two hours in an airspace where the infected person was coughing or sneezing, and on surfaces." http://nmhealth.org/news/alert/2014/12/?view=196

According to the Department of Health, New Mexico law allows parents to request vaccination exemptions for their children based on medical need or religious beliefs. The exemptions registered with the Immunization Program at the Department of Health are as follows:

  • 2012 – 2,845 exemptions
  • 2013 – 3,195 exemptions
  • 2014 – 3,335 exemptions

"The New Mexico Department of Health is concerned that the number of vaccine exemptions among school-aged children increased again in 2014. An increase in vaccination exemptions can increase the risk for outbreaks of vaccine-preventable diseases, such as measles...Since measles is still common in many parts of the world and travelers with measles continue to bring the disease into the US, we want all New Mexicans to know that it can spread when it reaches communities where groups of people are unvaccinated”. http://nmhealth.org/news/information/2015/1/?view=217

The population of New Mexico is now over two million yet the NM DOH is warning about the grave danger that those exempted from vaccination (less than 0.2% of the 2 million) pose because they dare have certified medical contraindications or serious religious issues with certain vaccination(s).

This in a state where 1, 000 truckloads of Cold War-era nuclear waste from the grounds of Los Alamos were moved to a salt cavern deep under the Southern New Mexico desert." http://tinyurl.com/l2z4hm2

In 2012, when NM population was 2,092,432, the leading cause of death was cancer (3422 deaths), followed by heart disease (3306 deaths) and accidents (1331 deaths.) http://nmhealth.org/publication/view/data/141/

This is unlike the rest of the country where the leading cause of death is heart disease followed by cancer.

http://www.cdc.gov/nchs/data/databriefs/db168.htm

A 1994 report on Firearms in New Mexico revealed: 

  • That the presence of young children in the home did not appear to improve firearm storage safety
  • That Household firearm ownership did not vary with the presence of young children
  • And that 24% of households stored guns unsafely

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1022524/

More importantly, New Mexico has also been competing with Mississippi for last place on the aforementioned KidsCount in the last three years: 49th in 2012, 50th in 2013 and 49th in 2014 while Mississippi rated 50th, 49th and 50th those years. http://tinyurl.com/l7homqy

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The most recent National Vital Statistics Report (2012) was released in September 2014. It includes international comparisons of infant mortality rates and related factors among 26 selected industrialized countries.

The first graph of the report is truly shocking.

It sadly illustrates how the United States – with the highest per capita health coast in the world, is listed last with an Infant Mortality Rate of 6.1/1,000 live births. Slovakia, New Zealand, Hungary, and Poland and many other nations actually had a lower IMR than the US. http://www.cdc.gov/nchs/data/nvsr/nvsr63/nvsr63_05.pdf

It is certainly strange that certain interests are boasting about the absence of measles cases in Mississippi when the state’s IMR is higher that that of many nations. 

If we do not improve our infant mortality rate soon, many children will not be around to get their 18-month-booster.

 

Summary 

The current outbreak of measles is occurring against a background of impressively good vaccination rates. Using it to restrict the rights of parents to choose whether or not to vaccinate their children carefully and selectively seems dictatorial.

Our vaccination rates are impressively high already and it has become clear that small outbreaks of disease will occur from time to time in populations with near 100% vaccination rates.

There are immensely more pressing health issues to address than trying to maintain near 100% vaccination rates when the risk of disease importation into well vaccinated areas is, as the CDC so frequently warns, JUST A PLANE RIDE AWAY

Pediatricians and other Primary Care Physicians and Allied Professionals should continue to encourage parents to vaccinate their children. 

On the other hand, it seems unfair that in this Great and Free Nation some individuals or groups want to strip parents of their right to decide what is best for their children.

Philosophic exemptions should remain available for the small number of parents who would prefer to use them.

Religious wishes concerning vaccination should also be respected.

Of course, certified medical contraindications to vaccines should be carefully noted.      

With the excellent vaccination rates we now have, it is extremely more important to turn our attention to improving health conditions, education, nutrition and hygiene.

 

F. Edward Yazbak MD, FAAP

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