Support New Jersey Vaccination Reform for an Informed Decision in Vaccines

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We are medical students at New Jersey Medical School. Our state congress is currently discussing two bills on vaccine reform in NJ. These bills are NOT a vaccine mandate. They represent an open dialogue between concerned parents and their doctors. As the next generation of physicians, we see it as our responsibility to foster healthy conversations about the importance of vaccines. Making sure your own child is vaccinated goes a long way, but if more of us are vaccinated, we can protect the most vulnerable members of our families, including babies, the elderly, and those who are too sick to be vaccinated. Make sure that your community is protected -- sign the petition, and call your district representatives and senators. Let them know that you’re ready to talk, because we’ll be here to listen.

Read the proposals here: House Bill A3818 / Senate Bill S2173

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Vaccine Exemption Reform

Introduction

 In light of the recent national measles outbreak from January 4th to April 2nd, 2015 that affected 159 people from 18 different states(1), members and students of the One and The Same (OATS) Foundation have found compelling reason to address the status of vaccines exemptions in the state of New Jersey. The particular growth of vaccination exemptions at the state-level due to nonmedical reasons (2), rooted in philosophical and religious disputes, have been a particular cause for concern.  We believe that in order to promote a safe, and healthy environment for the next generation of Americans, we must take proactive measures to reduce potential epidemiological and public health risks. Therefore we urge the state of New Jersey to reform current vaccine exemption laws to increase child immunization rates by adopting our proposed bill. We hope to address key aspects of the conversation by finding: correlations between New Jersey and California prior to the 2015 outbreak; benefits of increased vaccination coverage such as that found in West Virginia and Mississippi; any prominent religious incompatibilities with vaccines; global comparison of immunization; individual reasons to commit to the greater spread of immunization; course of events in American history when concern for greater public health was of greater importance than that of general apprehension; and finally additional reasons as to why our proposed bill pacifies ideologies seated in both sides of the debate on this particular issue.

California and New Jersey Immunization Statistics

The primary cause for proactive steps towards greater immunization stems from the parallels in immunization rates between California and New Jersey. It is well documented that the origin of the 2015 measles outbreak was traced back to California(3), therefore any correlations in immunization rates should be monitored with caution. Data concerning the immunization rate of both states was pulled from their respective health department databases, the California Department of Public Health, and the New Jersey Department of Health -- both sets of data had a roughly equivalent sample size (around 500,000 children in public and private schools) 486,634 and 524,202 for California and New Jersey respectively. Precipitating the measles outbreak, from the year 2013 to 2014, California had an immunization rate of 89.4%(4), with almost thirteen thousand (2.67%) of these students exempt from vaccines due to personal beliefs. Strikingly, similar statistics can be found in New Jersey today. From 2014 - 2015, the immunization rate in New Jersey is at 88.5%(5), slightly lower than that of California preceding the outbreak. Furthermore, the statistics of unimmunized students entering school for reasons other than medical exemptions is far greater than that of California’s, with nineteen thousand children who have either a religious exemption(1.7%-- 9,115) or provisional status (1.9%--10,218). An even more startling trend is found in New Jersey from 2013-2014 (95.3% immunization rate) to 2014-2015 (88.5% immunization rate), as the rate of immunization dropped a staggering 6.8%[1]. As shown by the data, it is obvious that New Jersey is susceptible to the possibility of an outbreak, and with sites of attraction that draw masses of tourists and residents alike, measures should be taken to proactively inhibit a potential outbreak.

West Virginia and Mississippi Vaccine Requirements

There is precedent for similar vaccination laws in the Unites States. Mississippi introduced legislation in 2005 through Miss Code Ann. 41-23-37; West Virginia did the same in 2007 through W. Va. Code 16-3-4. In both states, it is now declared unlawful to attend any public or private schools without first being vaccinated against those diseases specified by the state health officer. The only certificate of exemption accepted by the state can be offered by a licensed physician for medical  reasons. (6) Since enacting the law, Mississippi has improved its rate of vaccinations to 99.99 percent and the last outbreak of measles in Mississippi was reported in 1992. Even to this day, as shown by Figure x, Mississippi's total cases of vaccine preventable diseases continues to decline. West Virginia, by comparison, has improved its vaccination rates to 97 percent and similarly, as shown in Figure y continues to have less cases of vaccine preventable diseases in recent years. (7) Rates of disease fluctuate year by year, with small outliers coming about every few years. Although the data point for West Virginia in 2012 may show a smaller case rate than 2013-2014, the graph still shows a steady decline in vaccine preventable disease rates from the 2011-2014 time period. Please note that the 2011-2015 time period were selected for the graphs due to their consistency in reporting and clarity in the data. Before this time, inadequate reporting and different methods of data collecting render much of the data incomplete. Despite West Virginia's much lower population than Mississippi (1.85 million to 3 million respectively), Mississippi has less rates of vaccine preventable disease. Herd immunity is a gradual process, which is supported by the data shown by Figures x and Figure y shows a steady, yet slow, decline in case rate. It is therefore imperative to enact legislation to increase vaccination rates in New Jersey as soon as possible. These legislations have proven to be constitutional and continue to stand firm against the small, but vocal, anti vaccination groups that exist in both states. In the 2011 case, Workman v. Mingo Board of Education, a parent tried to sue the Mingo County Board of Education alleging that the denial of a psychiatric medical exemption violated her First Amendment rights to freedom of religion. The US 4th Circuit Court of Appeals ruled that the West Virginia Department of Health were entitled to deny enrollment to students who had not received proper vaccinations and had the authority to add vaccines or change the vaccine schedule. Therefore, not only have the precedents set by West Virginia and Mississippi proven that stricter vaccination rules lead to a lower rates of vaccine preventable diseases, it has also shown that the public health necessity makes such laws constitutional.

Immigration Vaccination Requirements

To gain entrance into this country, U.S Citizenship and Immigration Services requires that anyone applying for an international visa abroad or seeking to become a permanent resident must be vaccinated against all of the following: Measles, Mumps, Rubella, Polio, Tetanus and Diphtheria Toxoids, Pertussis, Haemophilus Influenzae Type B, Hepatitis B, and any other vaccine recommended by the Advisory Committee for Immunization Practices(11). While one Mayo Clinic study published in 2002 found that in Rochester, Minnesota, U.S citizens, Somali, and Hispanic immigrant children were all equally likely to have been vaccinated against MMR (8), the government continues to hold immigrant populations to a higher standard when gaining entrance to this country. Immigrants must have proof that they have received a full vaccination schedule, otherwise they receive the vaccines again. In 2014, thousands of Central American children escaping violence in their home countries were detained in San Antonio and vaccinated, sometimes with adult doses (9), with every vaccine required by the USCIS regardless of whether they had been vaccinated before. And, in actuality, these children were very likely to have been vaccinated before considering El Salvador and Guatemala have higher measles vaccination rates than the United States itself (10). This is just one measure that the U.S government takes in order to protect the health of its citizens(12). Foreign nationals are expected to respect the health and safety of United States citizens, but the very citizens of this country are not currently held accountable to do the same(13). By requiring vaccination against these high profile viruses for entrance to school, we can help to eliminate them from the face of this nation and better protect the health of its citizens.

Global Comparison of diseases and immunization

A testament to the effectiveness of vaccines can be seen in the diseases that plague the world today, yet have been eradicated or eliminated in the United States of America for several years to decades. Eradication of a disease is defined as the ‘complete annihilation of a disease due to methodical efforts,’ (14). One such disease is Poliomyelitis known commonly as Polio. In the late 1940’s to the early 1950’s Polio crippled an average of more than 35,000 people in the United States every year. In 1955 through research funded by what is presently known as the March of Dimes Foundation and communities raising funds, Jonas Salk’s vaccine against Polio was “safe, effective, and potent.” By 1963 Albert Sabin’s oral vaccine also prevented three strains of Polio. Through massive national Salk and Sabin vaccination programs and surveillance efforts Polio was eradicated in the U.S by 1979. Mass vaccination campaigns and surveillance efforts have been proven effective in other parts of the world as well.

In 2014 the World Health Organization certified India, a country home to nearly half the global polio cases and considered one of the most difficult places to eradicate the disease, polio-free after going three years without a case of Polio. Their success is due to an extensive surveillance network and almost 2.3 million vaccine administrators. They targeted the most underserved areas and worked on not just immunizing efforts, but efforts to counter misunderstandings about vaccines as well. Currently there are only two countries in the world that have the ability to transmit Polio, Pakistan, and Afghanistan. Through a combination of vaccine and immunization efforts, global partnerships, and the global mandate to eradicate polio cases of endemic polio have decreased from 650 cases in 2011 to just 250 cases reported in 2012. (15).

Most recently Rubella has been declared eliminated in the Americas after vaccination campaigns across both North and South America. “Elimination is the process of stopping the spread of a disease in a country or continent or other restricted area…also possible to stop people from contracting a disease while the microorganism remains alive in nature,” (16). In 2003 the Pan American Health Organization formally declared that it would be working towards the elimination of Rubella in the Americas. The main effort in the elimination of Rubella has been an annual vaccination week in which as many as sixty million people may be vaccinated. While the disease has been eliminated in the Americas it continues to affect regions in Europe, including Eastern Europe, Russia, and Central Asia. Rubella is also a perfect example of how such diseases don’t just exist in underdeveloped countries. One of the most recent outbreaks of Rubella was in 2013 in Japan, in which there were approximately 15,000 cases. (17). A perfect example of diseases once to thought to be eliminated in the United States is Measles.

Measles was eliminated in the United States in 2000 according to the CDC. In 2014, California experienced an outbreak of measles that first appeared in Disneyland and Disney California Adventure Park which ultimately went on to infect approximately 131 people. Approximately 159 cases in the Canadian Province of Quebec could be traced back to Disneyland. It is believed the outbreak is due to a visitor who caught the virus overseas and visited Disneyland while still contagious, however there were cases reported where the exposure source was unknown. (2015, Fernandez)  Since then cases of Measles and outbreaks have spread across the country to approximately fourteen states. (2015, Vicens) While diseases such as Polio and Rubella have been eradicated and eliminated, there is always the threat that they could reemerge, as Measles has. The only way to continue the to ensure that diseases stay eradicated or eliminated is keeping up with regular immunization and vaccination efforts.

Vaccines and Religion

As the United States grows, different religions and cultures become more integrated into our nation. New Jersey has prided itself on its diversity of different cultures and religions. Vaccination has not been an issue for the vast majority of religions that exist in New Jersey. More than 99.5% of the population in New Jersey claim to follow religions that allow vaccinations. These religions include Christianity, Islam, Judaism, Hinduism, and Buddhism. In making a bill to curb religious exemptions, the breakdown of which religions actually are against vaccination is important.

The few religions that are historically adamantly against vaccination are the members of the Christian Science Church and faith healing affiliates, members of the Dutch Reformed Church, and members of the Jehovah’s Witness Church. Christian Scientists believe that disease is not real and everything can be healed with prayer. Members of the Christian Science Church do not reject all forms of healthcare. They are supporters and users of dentists, optometrists, physicians for broken bones, and vaccination when required by law.  However, they believe faith healing is more effective. (20)  In instances where there would be a difference of opinion between Christian Science parents and medical authorities, the Church's policy is to strongly encourage parents to cooperate with those authorities. The Church urges the reporting of communicable diseases, conforming with vaccination laws. (21) They believe in faith healing over medical care, as does the Church of the First Born, Endtime Ministries, Faith Assembly, Faith Tabernacle, and First Century Gospel Church, but they make up a very small part of the Christian population of the world. Based on statistics, it is difficult to know how much of the .5% of the Christian population are members of the faith healing churches. However, Faith healers such as Christian Scientists allow for vaccination as long as it's a law so officially, their objection to vaccination laws would be more philosophical in nature.  Members of the Dutch Reformed Church were against vaccines for the adverse effects of vaccines when vaccines first became prominent in our society but since then, their reluctance for vaccination has evolved into formal belief that vaccines interfere with the relationship with God. (19) Members of the Dutch Reformed Church also make up the .5% of other Christian faiths in the state of New Jersey. Members of the Jehovah’s Witnesses refuse transfusions of whole blood as well as  the use of certain blood components, such as red blood cells, plasma, and other components. Their refusal of such treatment is due to their belief that it is violation of the law of their god. During the 1920’s through 40’s, the church was opposed to vaccination because they believed that it fell under the violation of blood treatments. However, by the early 1950’s, the church took a neutral stance about vaccinations until the 1990’s when began to acknowledge the clinical value of vaccinations. (19)

Based on the fact that vaccines are propagated in mammalian cells, religions that forbid the consumption of animals would be reluctant to get vaccination. People in these religions have generally agreed that the religious law against consumption of meat is meant for oral consumption.(19) The followers of these three religions are for vaccination with the exception of Muslim Fundamentalists that reside in countries like Afghanistan and Iraq. They believe that Westerners are trying to sterilize their children and not cure them of polio. Unfortunately, if members of the populous decide to immigrant to this country, they could potentially bring polio to the unvaccinated children of this country. Jews make up 6% of the population, Hindus make up 2% of the population of New Jersey, and Muslims make up 1% of the population of New Jersey. (18) 

The Christian religions that have no reservations against vaccination include: Roman Catholicism, Eastern Orthodox and Oriental Orthodox Churches, Amish, Anglican, Baptist, the Church of Jesus Christ of Latter-day Saints, Congregational, Episcopalian, Lutheran, Methodist, Pentecostal, Presbyterian, and Seventh-Day Adventist Church. Catholics and other mainline and evangelical religions make up 73% of the composition in New Jersey. Unaffiliated members of the population make up 14% of the population. Buddhists make up 1% of the population, Mormons make up <.5 % as do Jehovah's Witnesses. Other faiths make up 1%, other world religions make up <.5%, other Christian religions make up <.5%, Other Christian religions which could include Dutch Reformed member and Christian Scientists among other small sects of Christianity.(18) 

Reasons to take a stand

Vaccines are an efficient and cost-effective way to prevent communicable diseases. Through history, scientific advancements, beginning from Jenner’s smallpox vaccine, have validated the use of vaccines. Vaccines develop one’s immunity against deadly diseases and prevent outbreaks, bettering the health of the entire community. If 90-95% of a population is vaccinated, then herd immunity is accomplished, where the entire population is protected from the disease because there are no potential chains of transmission. Herd immunity protects more vulnerable individuals from contracting disease, such as those who are newly-born or are medically exempt from vaccinations. According to the 2014-2015 data, the vaccination rate in NJ is only 88.5% (22), which is less than the necessary rate to achieve herd immunity. This puts the NJ population at risk for contracting communicable diseases, which can be prevented through higher vaccination rates. Not only do vaccinations save lives, but they also save hundreds of dollars in medical expenses. The cost of a vaccine is much lower than the cost of medical treatments for the disease. From CDC’s cost-benefit analysis (23), the cost of a vaccine ranges from $8-29, based on public/private purchase. However, the cost of just one outpatient/hospital visit for that same disease ranges from around $83-$50,500. Excluding any additional doctor’s visits and medication, one already saves at least 90.4% of medical expenses from a vaccination. Vaccines are a low-cost and effective way to protect oneself and the entire community from deadly diseases. Medical expenses saved from treating these preventable diseases can be used to fund other medical needs and overall better the state’s economy.

 Although vaccines are effective to decrease communicable disease rates, over time immunity developed from these vaccines weaken. Therefore, booster shots are important and necessary to maintain herd immunity and prevent communicable diseases(24). In 2011, they examined the cells of a patient who had contracted measles. They found that although he had been vaccinated, the response his cells generated seemed like as if he hadn’t been vaccinated before. Because many years had passed since the vaccination, the immunity had decreased, causing his cells to react as if this virus was new.(25) Therefore, increasing vaccination rates and ensuring booster shots are all crucial in improving the health and economy of NJ. 

Population health security at-large

The boundaries between public health and personal liberties have always been hard to define. Yet this is not a battle between the right to choose vs government mandate as so much as it is a question of basic public health benefit for all. In 1905 the landmark ruling of the US Supreme Court in Jacobson v. Massachusetts established a precedent, affirming the right of the people, through their elected representatives, to enact “health laws of every description to protect the common good(26).” Today more than 100 years later we face the same recurring issue very much of the same nature. However, it is important to realize there are much more recent examples that reinforce the notion of government regulations working for the people for the general well-being of society instead of just purely limiting personal choice (27). For example, although freedom of speech is comprehensively protected by the 1st amendment, it is still illegal in many cases to falsely yell “fire” in public areas (28). This stipulation has been put in place to deter against disruptors who can cause mass panic. Another example is how recently smoking has been banned in some public housing areas (29). This restriction has been introduced to protect the public from the dangers of secondhand smoke while similarly curbing personal choice (30). Therefore, mandating vaccinations will not be any more intrusive to personal liberties than many other regulations for the sake of public health.

Improvements from previous proposal

While senate bill 1047 did take action towards stricter guidelines in childhood immunization standards, the bill did address concerns from both arguments on the discussion of Immunization. We believe that parents are resigned to have a choice in discussions regarding the health of their children. However, we also believe that the discussion of immunization is one that concerns a public health approach rather than an individual approach. With that, the OATS Foundation proposal addresses the dichotomies present in both schools of thoughts and believes that parents who do not wish to vaccinate their children should visit a physician about what risks they are foregoing in the process. An ample discussion would lead to a more informed parent, one who is aware of what actions to take in situations when a child may be exhibiting symptoms found in diseases that can be prevented by vaccines. Overall, the major goal of this proposal is to take a proactive step towards awareness in vaccine information, and prevention from potential outbreaks.

 

[1] Staggering differences in immunization can possibly be linked to improved surveillance tools, alternate community wide assessment results, or other such possibilities
 
 

 Read more about vaccines:

https://www.nytimes.com/2018/01/16/upshot/measles-vaccination-california-students.html

 

https://www.nytimes.com/2016/12/12/well/family/why-doctors-still-worry-about-measles.htmlhttps://www.nytimes.com/2015/02/08/opinion/sunday/nicholas-kristof-the-dangers-of-vaccine-denial.html 



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