Friday, April 20, 2012

Letters to Appropriations Committee

Individually-addressed letters to members of the Appropriations Committee

Clicking on the links below will take you to Google Docs, which will allow you to download and edit each letter.  Each letter has further instructions.

You may also send several letters to each Assemblymember, emphasizing different elements in each letter.
Additional Paragraphs for Your Use (in process)

You can download these paragraphs or copy-paste from the links and add them to your letter, if you wish.

Wednesday, April 18, 2012

California's AB 2109: Will Vaccine-Refusing Families Have A Hard Time Finding Health Care?

Here's Dr. Bob Sears on the issue:
However, what gravely concerns me is that some doctors will refuse to sign this form. I know how doctors think. Many doctors strongly believe that vaccines should be mandatory, and that parents should not have the right to decline vaccines. Some doctors are willing to provide care to unvaccinated kids, despite this difference in philosophy. But now the power over this decision will be put directly into doctors' hands. He or she can simply refuse to sign the form. Doctors who oppose vaccine freedom of choice have been frustrated for years over this issue. Finally, they will have the power to impose their beliefs on their patients. Patients will be forced to find another doctor to sign the form, submit to vaccines, or get kicked out of public school.
Several things to notice: he's sure that only doctors can sign the form (wrong: Physician Assistants and Nurse Practioners with appropriate qualifications can sign); and notice that he doesn't quantify anything, or use any facts.  It's just "I know how doctors think" and the threat of "being kicked out of public school".

It's important to know how many vaccine providers there are (pediatricians, family practice MDs, and the county health departments' low-cost or free vaccine clinics) and how many of those would "fire" or discharge vaccine-refusing families.

The survey of physicians reported at the 2011 meeting of Infectious Diseases Society of America showed enormous regional variation in practice responses to vaccine refusal.  The survey didn't cover California or the West at all.

Let's look at some real doctors.

Heidi Roman MD is a mother and a pediatrician who practices in California.  She recently wrote Why I Won't Fire Vaccine-Hesitant Families, giving three sound reasons
....the particular issue of families who are hesitant about vaccinating their children is something all child health providers have come across. I won’t dismiss patients/families for this reason.
Wendy Sue Swanson MD practices in Washington state, but has written (and made videos) about vaccine issues.  In Pediatricians Who Refuse Families Who Don't Immunize, she wrote
I will always keep my practice open to vaccine-hesitant families. However, the waiting room risk (unimmunized kids & risk to vulnerable populations–ie infants, those too young for vaccines, and immunocompromised children) is a good one and the only compelling reason to close to patients who refuse immunizations in my opinion.
But it’s not a good enough reason for me to send families away who have questions and hesitations about the AAP/CDC schedule. All children deserve a pediatrician versed in immunization benefit/risk & deserve an expert in conversation w their parents to foster insight & understanding. Frankly, if waiting room risk is the concern, there are ways to create separate waiting rooms for kids “up to date” and kids who are not.
Roy Benaroch, MD at The Pediatric Insider develops a typology of vaccine-refusing parents, and  concludes: own philosophy that it’s not the kids fault they’re not vaccinated; and with patience and continuous discussions, I can usually get even the most stubbornly misinformed parents to vaccinate. So finally, with a lot of extra work, the kids get protected. That’s my goal.
Linda Shaw MD practices in a low-income area, and has very, very few vaccine-hesitant or vaccine-refusing families.  Given the constraints of her practice,
Our practice group has decided that caring for vaccine-refusing patients is too much of a liability risk. We will alter vaccine schedules if the parents request it, but they are informed that they may have additional out-of-pocket costs. Patients who adamantly refuse to consider immunization for their children are asked to find another provider to see them. (We will also discharge from the practice patients who chronically "no show" for appointments.)
I think that even if AB 2109 passes, the California Medical Association or the two Public Health Associations (North and South) should sponsor research into the facts on vaccine refusal and hesitancy in California.

Dr. Bob Sears: What Was His Role in the 2009 San Diego Measles Outbreak?

I am keeping a list of reactions (pro and con) to the California Assembly Bill 2109 (AB 2109), which would make Personal Belief Exemptions (PBE) to required school entry vaccinations  slightly -- very slightly-- more difficult to obtain.

But there's a side issue.  One of the opponents to the legislation, Dr. Bob Sears, has been caught in ... a fib?  a misunderstanding?

I decided not to add those posts to the list, because the Dr. Bob question isn't really about AB 2109, but about the veracity of a physician who has done more to raise false fears of vaccines.  (If you think that's an exaggeration, why don't you read The Problem With Dr. Bob's Alternative Vaccine Schedule (full text at Pediatrics or  Download Offit_Problems_Dr_Bob_Alterna_Schedule (PDF))
What Dr. Bob claimed:


"I was not involved in that [the San Diego measles outbreak] at all."
But he was.
December 29, 2008, in the Orange County Register:
As it turns out, the boy who spread measles is a patient of Dr. Bob Sears, pictured at left, a member of the famous San Clemente pediatrician family and author of “The Vaccine Book.” 
"NOR have I ever spoken with Seth [Mnookin]"
But he has.
A number of people stepped up to confront Dr. Bob, both in commentsat the Huffington Post and later on other blogs.
And here is Dr. Bob's rather ranty response to Lilady's repeated questioning.

Updated 3/28/2012 There is some confusion.  From news reports in 2008:
The measles-in-the-doctor's-waiting-room transmission:
Eight of the measles cases originated from the Cooperative Charter School, while another four stemmed from the Children's Clinic in La Jolla, according to county health officials.
And this news report from February 16 2008 at SignOn San Diego

The measles outbreak is San Diego County's first since 1991. It began when a 7-year-old patient returned from Switzerland on Jan. 15 with what would later be confirmed as measles. He or she infected two siblings and at least four classmates. The 8-year-old patient identified yesterday is a classmate of the 7-year-old.

On Jan. 25, the 7-year-old's parents took the youngster to the Children's Clinic of La Jolla. The child may have coughed and sneezed in the office, thus infecting four other children.

California: Immunizations Required for Daycare and School Entry AB 2109

Currently in California, it is cheaper and easier to get an exemption from vaccine requirements for school entry than it is to actually comply with the requirements.
Now Assemblymember Richard Pan (D 5th District), a pediatrician, is planning to change that.  He has introduced AB 2109. (As of March 24, the bill is still in the Assembly Health Committee.) The change in the law is pretty mild: parents wishing an exemption have to talk to a licensed health care provider and have a form signed (just as they do if they are vaccine-compliant).
But I've heard read wild talk of what is required, so I thought I'd post a handy guide:
Immunizations Required for Daycare Attendance :

Immunizations Required for k-12 Attendance 

Read why the US vaccinates against Hepatitis B in childhood.  I live in a part of the United States where Asians and Pacific Islanders (API) make up a significant portion of the population.  The Stanford Asian Liver Center writes:
Why should Asian and Pacific Islanders care about Hepatitis B?
Despite the fact that only 0.2-0.5% of the U.S. population has chronic hepatitis B infection, this is still 1.25 million people, over half of whom are Asian and Pacific Islander (API) Americans. Depending on their country of origin, 5-15% of API immigrants have chronic hepatitis B. In some Pacific Rim countries, as many as 10-20% of the population are chronically infected.

Vaccine Exemptions in California: How Many Exemptions, and How Much Will They Cost? re AB 2109

Bob Sears is a vaccine-rejecting physician.  In a post claiming California Bill AB2109 Threatens Vaccine Freedom of Choice, Sears claimed:
At a time when we are trying to decrease health care spending, this bill will add millions of dollars of extra health care visits for families every year.
I haven't seen anyone quantify the numbers of exemptions and the costs yet.  The bill would become effective as of the beginning of the 2013-2014 school year.  As of the 2010-2011 school year (the last year rates were published) over the whole state, an average of 2.28% of incoming kindergarteners' parents had a Personal Belief Exemption

There are at least two times that families have to provide proof of immunization or an approved exemption, at the beginning of kindergarten (required vaccines) and at the beginning of 7th grade (TdaP-- whooping cough booster)

According to California state records: at
566,137 live births in 2007 (estimate for incoming kindergarteners in fall of 2013)
529,245 live births in 2002 (estimate for incoming 7th graders in fall 2013)
566,137* 0.0228 = 12,680 (with rounding)
529,245** 0.0228 =12,067 (with rounding)
Let's say AB 2109 passes, and let's just round up to 25,000 students whose parents are refusing vaccines who require a signed form from an MD, DO, Physician's Assistant or Nurse Practioner (yes, the latter two can provide the education and sign the form.   "Millions of dollars" -- well, that would be at least $2 million.  Therefore:
25,000 * X = 2,000,000
X= $80.00
I'm trying to find out what the largest HMO in California, Kaiser Permanente, charges for a drop-in vaccine clinic visit, without success so far.

My own provider, Palo Alto Medical Foundation, offers a host of classes on various parenting topics.  The baby-safety basics class is two hours and costs $40.00. So I believe that the cost to vaccine-refusing parents of complying with the provisions in AB 2109 would be far less than $80.00.

The decision not to vaccinate has dollar costs also.  The 2008 San Diego measles outbreak (which originated with an intentionally unvaccinated child who was a patient of Bob Sears) was quantified:
The importation resulted in 839 exposed persons, 11 additional cases (all in unvaccinated children), and the hospitalization of an infant too young to be vaccinated. Two-dose vaccination coverage of 95%, absence of vaccine failure, and a vigorous outbreak response halted spread beyond the third generation, at a net public-sector cost of $10376 per case. Although 75% of the cases were of persons who were intentionally unvaccinated, 48 children too young to be vaccinated were quarantined, at an average family cost of $775 per child.
 That's a healthy chunk of change for a family, $775.

Roundup For And Against California's Immunization Exemption Bill, AB 2109

This list will be updated silently
 Currently in California, it is cheaper and easier to get an exemption from vaccine requirements for school entry than it is to actually comply with the immunization requirements. 
Now Assemblymember Richard Pan (D 5th District), also a physician, is planning to change that.  He has introduced AB 2109, which adds the requirement that parents speak with a licensed health professional.  The bill passed the Assembly Health Committee on April 17, 2012.
Blog posts and newspaper reports on AB 2109--In favor
Blog posts and newspaper reports on AB 2109--Oppposed

Evidence-Based Resources

California's AB 2109, Strengthening School-Entry Vaccination Requirements, A Mild Change

Currently in California, it is cheaper and easier to get an exemption from vaccine requirements for school entry than it is to actually comply with the requirements. 
Now Assemblymember Richard Pan (D 5th District), also a physician, is planning to change that.  He has introduced AB 2109. (As of March 24, the bill is still in the Assembly Health Committee.) The change in the law is pretty mild.  Vincent Iannelli MD summarizes the change:
Instead of simply signing a personal belief vaccine exemption form on their own, parents will be required to have a written statement signed by a [licensed] health practitioner that says the parent was given information about the benefits and risks of immunizations and the risks of certain vaccine-preventable diseases.
The provisions of AB 2109 are much milder than the recommendations from the The Pediatric Infectious Diseases Society ( Download Pediatric_infectious_disease_soc_vaccine_exemptions).  I've excerpted part of the Position Statement below, and added emphasis
Position Statement Regarding Personal Belief Exemption from Immunization Mandates from The Pediatric Infectious Diseases Society March 2011
It is recognized that in some states, failure to pass personal belief exemption legislation or regulation could result in public backlash that will erode support for immunization mandates. If legislation or regulation is being considered in this situation, it should contain the following provisions, which are intended to minimize use of exemptions as the “path of least resistance” for children who are behind on immunizations (whereby it would be easier to obtain an exemption than to catch-up the child’s immunizations):
  • The personal belief against immunization must be sincere and firmly held.
  • Before a child is granted an exemption, the parents or guardians must receive state-approved counseling that delineates the personal and public health importance of immunization, the scientific basis for safety of vaccines, and the consequences of exemption for their child as well as other children in the community who are vulnerable to disease and cannot otherwise be protected.
  • Before a child is granted an exemption, the parents or guardians must sign a statement that delineates the basis, strength, and duration of their belief; their understanding of the risks that refusal to immunize has on their child’s health and the health of others (including the potential for serious illness or death); and their acknowledgement that they are making the decision not to vaccinate on behalf of their child.
  • Parents and guardians who claim exemptions should be required to revisit the decision annually with a state-approved counselor and should be required to sign a statement each year to renew the exemption.
  • Children should be barred from school attendance and other group activities if there is an outbreak of a disease that is preventable by a vaccination from which they have been exempted. Parents and guardians who claim exemptions for their children should acknowledge in writing their understanding that this will occur.
  • States that adopt provisions for personal belief exemptions should track exemption rates and periodically reassess the impact that exemptions may have on disease rates.
Despite the relative mildness of AB 2109, both in-state and out-of-state anti-vaccine activists are opposing the bill.

Current status of the bill:

  • Passed the Health Committee 
  • Next: Appropriations Committee (not yet scheduled)