Does online tool help or hinder vaccination objectives?

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This Wednesday, March 27, 2019 file photo shows a sign explaining the local state of emergency because of a measles outbreak at the Rockland County Health Department in Pomona, N.Y. Some states, including Utah, allow parents to exempt their children from vaccinations. (AP Photo/Seth Wenig)

An online learning module created to educate Utah parents about the importance of vaccinations may have actually made it easier for them to receive non-medical exemptions for their children.

Vaccination opponents claim the module is neither persuasive nor contains completely accurate information, and state health officials have expressed concerns it’s difficult to assess just how many people are actually using the module for its intended purposes.

The learning module on the Utah Department of Health website went into effect July 1, 2018. It was created by Utah H.B. 308, which passed almost unanimously in both the Utah House and Senate a year ago.

The module allows users to print out a completion certificate that can then be used to obtain an exemption from immunizations required for attendance in state public schools.

Utah is one of 18 states that allows personal exemptions and one of 47 that allows religious exemptions. For the 2017-18 school year, 2,606 vaccination exemptions were granted for kindergartners in Utah, of which 2,507, or 96.2%, were for philosophical or personal reasons. Only 80 exemptions, or 0.3%, were granted for medical reasons, according to data from the Centers for Disease Control.

Last year 5.2% of Utah’s kindergartners received an exemption. Only four other states reported higher exemption percentages, including Alaska (6.1%), Arizona (5.3%), Idaho (6.7%), and Oregon (7.5%), according to the CDC. Overall, 93.4% of Utah kindergartners met the two-dose requirement for measles.

According to a study published in 2018 by “PLOS Medicine,” the Salt Lake/Provo metropolitan area is among the 15 most vulnerable regions in the United States for vaccine-preventable diseases because of the state’s higher rate of unimmunized children.

This comes at a time of increasing outbreaks of illnesses that were once thought to be eradicated throughout the U.S. and the world, including in Washington state, where 66 measles cases have been reported since last fall. New York City has a controversial mandatory immunization policy in place that is facing legal challenges. The Associated Press reported this week that 285 measles cases have been identified in New York City since last fall.

The World Health Organization recently listed vaccine hesitancy as one of the top global health threats for 2019.

In Utah, H.B. 308 sponsor Rep. Norman K. Thurston, R-Provo, said the goal of his bill was to create an education module to inform parents, particularly those who oppose vaccinations, about the implications of what could happen if their child does not receive the shots. “It’s a way for them to be informed if they change their mind,” he said.

But according to Rich Lakin, the Utah Department of Health’s immunization program manager, the success of the module depends in part on the need for Utah school districts to make parents aware of its existence and how it can be accessed.

According to Tom Hudachko, communications director for the Utah Department of Health, it is difficult to know exactly how many people have used the new to module to obtain an actual exemption. “Somebody can go onto the immunization module and basically run all the way through it until the certificate (of completion). Unless they actually send it to their school and register it as an exemption, it doesn’t count as an exemption for us.”

Some people completing the online module have used “names like Mickey Mouse or Donald Duck,” he said. “We know that the number of certificates doesn’t coincide with the actual number of exemptions that are taken from the schools.”

Lakin also noted that poor communication between school districts and parents regarding vaccination deadlines also had made it difficult to obtain an accurate assessment of how the module is being used. Some parents, he said, may have turned to the module as a last resort when they realized they had run out of time to get their children immunized before the start of school. Obtaining an exemption prevented their children from missing class.

(AP Photo)
FILE – In this March 27, 2019 file photo, signs advertising free measles vaccines and information about measles are displayed at the Rockland County Health Department, in Pomona, N.Y. U.S. measles cases are continuing to jump, with most of the reported illnesses continuing to be in children. Health officials on Monday, April 8 said 465 measles cases were reported through last week, the second-highest total in 25 years. (AP Photo)

Parent rights vs. public safety

Thurston said he believes the vaccination issue has created a conflict between those who see this as a parental rights issue and those who see this as a matter of public health and safety. He said he hoped his bill would “bridge the gap” between these two perspectives.

In at least five states, lawmakers have or are planning to introduce bills that would eliminate the personal exemption. An effort to eliminate exemptions in Arizona recently failed. Vermont, which already eliminated the personal exemption, is now considering legislation that would eliminate the religious exemption, according to a recent Washington Post report.

Rep. Mitch Greenlick, a Democrat from Oregon’s 33rd district, has a bill in committee that would eliminate the personal exemption for elementary school students. He said he sees this primarily as a major public health concern rather than an issue of parental rights.

Rep. Paul Harris, a Republican who represents Washington’s 17th District, is the leading sponsor of House Bill 1638, that has passed the House and has moved on to the senate. It would remove personal exemptions and that would allow exemptions through declaration of immunity proved through laboratory research.

Unlike their counterparts in the Pacific Northwest and elsewhere, Utah lawmakers have chosen to tackle the vaccination issue through parental education. This discussion began in early 2016 when H.B. 221 was introduced. Sponsored by Rep. Carol Spackman-Moss, D-Holladay, the bill sought to develop and provide an immunization exemption form free of charge, online and at local health departments. In addition, it also mandated the development of an education module.

In video records of the floor debate, Spackman-Moss argued her purpose was to “honor those parents who want to get exemptions, but to make sure that all parents of unimmunized children (receive an education) through an online education module to keep their children safe… All of these children are totally dependent on the decisions and actions of their neighbors.”

Because so many adults and children are not immunized, “this bill is directed at providing them with the information they must have to make them safe in the event of an outbreak,” she said during the floor discussion.

H.B. 221 never became law, but a year later Thurston revived the issue by introducing H.B. 308, which passed, mandating the online education module.

The anti-vaxxers

Ironically, many of the parents who have chosen not to vaccinate their children said they do not identify as “anti-vaxxers.” Many of the parents interviewed for this story said they are not against vaccines in general, but rather they simply believe they are not the best option for their children.

The anti-vaxxers who spoke to The Daily Universe offered several reasons behind their choices, including a fear of government and big pharma conspiracies as well as a preference for more holistic medical approaches. Several indicated they did not find the information provided by the state’s learning module to be sufficiently persuasive.

Lucas and Shara Ramirez from Orem said they have studied both sides of the issue and decided that following the normal vaccination schedule was not best for their children. Lucas Ramirez, a nurse practitioner, said parents know their children best.

“The best plan for vaccination is an individualized one,” he said. The Ramirez’s children are partially vaccinated, because Lucas and Shara decided that would be best for their family.

Anti-vaxxers are often highly critical of pharmaceutical companies being involved in vaccines in order to make a profit.

Jamie Egbert, a St. George mother who has not vaccinated her children, is among those parents concerned with big pharma conspiracies. She said she believes information about vaccines doesn’t educate people about risks.

Lori Barber, the nursing director in the Division of Family and Personal Health of Utah County, said she has received phone calls from parents asking about alleged vaccination conspiracies. “I had people calling me a lot when I was over the immunization clinic, asking me things like, ‘Did the government put microchips in immunizations?'”

Aislynn Tolman-Hill, public information officer for the Utah County Health Department, said there are pockets in Utah County, for example, where people prefer a more holistic route over vaccinations, “sometimes just totally not wanting any vaccinations whatsoever” to choosing some vaccinations and not others or using remedies like essential oils.

Utah nurse practitioner Shauna Chris said she found the state’s online module condescending. “My colleagues and I have completed a document refuting much of what was said in the module with scientific documentation. A lot of what was presented in the module was not properly sourced.”

Herd immunity

Herd immunity, also known as community immunity is defined as the protection of unimmunized individuals — such as babies, the elderly and those with compromising medical conditions — that is created by the overall immunity level in the surrounding community. To obtain community immunity against measles, for example, 90 to 95% of a population must be vaccinated. When vaccination rates drop below this level, vulnerable segments of the population lose their protection.

According to the Utah Department of Health’s online educational module, declining vaccination rates are on the verge of eliminating community immunity in the state. This creates a higher risk for unvaccinated children to contract and spread a disease during an outbreak.

In the Provo School District, for example, data compiled by the district and the state in 2018 indicate that only 86.9% percent of kindergarten students are adequately immunized compared to 91.7% and 87.9% of Nebo and Alpine school district kindergartners respectively. By comparison, Utah County schools reported lower rates than several other state districts: Logan City Schools (98.1%), Davis (92.5%), Canyons (93%), Granite (93.7%), and Weber (93.3%).

Tolman-Hill expressed her concerns about declining immunity levels in the valley. “I would add in the message of caring about their family, friends, neighbors, because it’s not always just about them. It really is important to especially care and think about those that cannot be immunized, specifically infants.”

Reporting: Emily Anderson, Karina Andrew, Livy Andrus, Victoria Bjazevich, Ashley Dean, Sariah Farmer, Juliet Favero, Jillie Denna, Tori Gurr, Sarah Houssian, Elisa Huhem, Ashley Jorgenssen, Wanzhe Li, Lisi Merkley, Rebecca Nissen, Mitchell Price, Sydney Townsend, Hailey Tueller, Nathan Wanlass, Tanner Wilkinson

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