Sei Unno

Associate Editor

Loyola University Chicago School of Law, JD 2019

A measles outbreak that has affected 71 people in Washington and4 people in Oregon has ignited public health discourse over vaccinations. Vaccination rates in the Pacific Northwest are among the lowest in the nation. Both Washington and Oregon allow personal belief exemptions from immunizations for school-age children. The outbreak, which continues to spread, may lead Oregon and Washington to follow California’s example of eliminating personal belief exemptions. Eliminating personal belief exemptions, however, may not be the panacea that lawmakers seek. The rise in medical exemptions for vaccines in California indicates the need for a comprehensive vaccination framework.

The Current Outbreak

Measles was declared eliminated in the United States in 2000. Nearly 20 years later, a measles outbreak is spreading in Washington and Oregon. So far, there are 53 cases in Clark County, Washington and 1 in King County, Washington. In Multnomah County, Oregon, there have been 4 confirmed cases. Exposure locations have included grocery stores, Costcos, Amazon Lockers, museums, and airports. The majority of those affected in Washington are children younger than 10 years old. On January 25, 2019, Washington Governor Jay Inslee declared a state of emergency because of the outbreak.

The Importance of Herd Immunity

Measles is highly contagious and the virus can linger for two hours, even after an infected person has left a room. Complications of measles include ear infections, bronchitis, pneumonia, encephalitis, and pregnancy problems. Herd immunity can help prevent the spread of infectious diseases like measles. The World Health Organization has stated when the number of secondary infections generated by each infective person is less than one, transmission of the disease will stop. For measles, the herd immunity threshold is 93 to 95%.

Vancouver, Washington’s vaccination rate of 66% falls below the minimum 93% that is required to achieve herd immunity. Vaccination rates in Clark County, Washington are 78%, with some schools having rates lower than 40%. According to the CDC, measles can spreadwhen it reaches communities where many people are unvaccinated. So long as these pockets of unvaccinated individuals exist,measles outbreakswill occur.

Legislative Response

In Oregon, State Representative Mitch Greenlick has proposed a bill that would eliminate personal belief exemptions to vaccine requirements. Although not yet finalized, the proposed bill would eliminate all non-medical exemptions for children who are attending schools and some childcare facilities. Greenlick’s work and career has been in public health and he previously served as Chair of the Department of public Health and Preventive Medicine at Oregon Health Sciences University.

Similarly, Washington lawmakers are considering removing personal and philosophical exemptions for immunizations with House Bill 1638 (HB 1638). Hundreds of people who were opposed to the bill lined up to attend the hearing. HB 1638 is sponsored by Republican Representative Paul Harris of Vancouver, an area that has been affected by the outbreak. The bill would allow for proof of disease immunity through laboratory evidence or history of disease to substitute for immunization. Another bill has been introduced in the Senate that would not allow personal or philosophical exemptions for any required school vaccinations.

However, Oregon and Washington lawmakers need to be cognizant of the lessons that can be learned from California Senate Bill 277.

California Senate Bill 277

In 2015, California passed Senate Bill 277 (SB277). SB277 eliminated the personal belief exemption for immunization requirements for school-age children. SB277 was, in part, a response to an outbreak of measles at Disneyland. A study conducted by Salini Mohanty and colleagues revealed the impact of SB277 on the ground. Mohanty et al. found that health officials had received “problematic” medical exemptions for mandatory vaccinations. The exemptions were identified as problematic if the conditions listed as contraindications for immunizations were not medically accurate, medical exemptions sourced from physicians who were charging fees, and the various types of health care providers who were signing medical exemptions. Although some of the participants in the Mohanty study stated concerns about the type of medical conditions used as contraindications for vaccinations, SB277 states that family medical history can be taken into consideration when granting a medical exemption. Some physicians even went as far as advertising medical exemptions for a fee. Additionally, the study found that the health care providers that were signing the medical exemptions were cardiologists, nurse practitioners, or physicians that work at medical cannabis dispensaries.

Another study, conducted by Paul Delamater and colleagues found that counties where personal belief exemptions were prevalent saw an increase in medical exemptions. Delamater and colleagues studied publicly available data from the California Department of Public Health’s annual Kindergarten Immunization Assessment reports. Delamater and colleagues concluded that the increase in medical exemptions questions the clinical benefits of SB277 in the long run. SB277 reveals that compliance with a law does not automatically equate to preserving public health and safety.

What Lawmakers Can Do

Even though eliminating personal belief exemptions for vaccinations have been granted by courts, the content of the law is crucial. It is not enough to simply remove personal and philosophical belief exemptions. Taking cues from the lessons that can be learned from the California law, medical exemptions should only be able to be issued by physicians, preferably pediatricians. Physicians should also not be able to advertise that they will sign a medical exemptions for a fee. The goal of eliminating the personal belief exemption is to ensure that there is herd immunity and the ways in which individuals can use loopholes to obtain medical exemptions for vaccines should be limited.

A well-written law, conscious of previous efforts made by other states, will ensure that compliance translates to public health and safety.