Immunizations for School Children
Dan Onion, MD, MPH
Mt. Vernon/Vienna Health Officer
I was puzzled last week by this political poster at the corner of Castle Island Rd and Rte 27: “Reject Big Pharma”? And what’s “1”? I suspected a referendum question and was aware that the new school vaccination law had been put on hold until a veto referendum could be held, and I wasn’t sure when or if “1” was it. I hadn’t heard of any other referendums, so I went hunting on the internet and by gory it is about that school vaccine referendum indeed! The vote on the recall is to be held state-wide on March 3rd. This is an important public health issue, so I think it appropriate for me, who, as town health officer, is charged with Vienna’s and Mt Vernon’s populations’ health, to write about it.
The medical background.
Infectious disease epidemics occur when disease germs are passed from person to person easily (hence “communicable”) and threaten people’s health and lives. The following immunizations are currently required for children to attend public school in Maine. All but tetanus are communicable, which means they are caught from those around us, who are already infected and spreading the disease:
•Measles (rubeola), a potentially fatal disease in young and/or sickly children, especially in developing countries where it has a 2-10% mortality; in rare cases it can cause an encephalopathy (brain inflammation) 20 years later in adults who had cases as children. Maine had its first measles case in 20 years in 2018, and a 2nd last year. Right now, there are measles epidemics spreading across the country with nearly 1250 cases reported nationally last year, the most since 1994. The closest cases are in Massachusetts; last year New York state had the most in the US. That recrudescence of measles nearby probably played an important role in pushing the Maine legislation (LD 798) allowing vaccination exemptions only for medical reasons through this past year. Vaccines were developed and have been widely available since the 1960s.
•German measles (rubella) doesn’t bother the children infected much, causing only mild rash and fever, but it does cause serious birth defects in the unborn fetus if pregnant mothers are not immune already. The last case in Maine was in 2008. Vaccines were developed and available in the 1960s.
•Chicken pox (varicella) makes infected people, usually children, very sick with bad fever and rash which can get secondarily infected with staph and strep germs; in teens and adults it can cause bad lung scarring. In 2018 there were 252 Maine cases, and 72 in 2019. Vaccines were developed and available in the 1990s.
•Mumps, still relatively rare since widespread vaccination has been achieved, at least for now. It causes fever and salivary gland swelling, occasionally a viral meningitis, but in teens and adults can cause testicular inflammation and damage, pneumonia, joint damage and even pancreatitis. There were 5 Maine cases of mumps in 2019. Vaccines developed and available in the 1960s.
•Polio has been nearly completely eradicated in the world with the exception of some pockets in India and the far East. However, a traveler from those regions could cause an outbreak. Unlike the others, it is spread not by respiratory droplets but by the “fecal-oral” route. Public swimming pools or dirty hands used to be the most common source before the vaccines became available in the 1950s
•Whooping cough (pertussis) is tolerated fairly well by anybody over age 2 or 3, although it may cause persistent cough (“cough of a 100 days”), which continues spreading it. The big danger is mortality in young children, especially newborns up to 6-9-months, who are too young to vaccinate but run out of their mother’s immunity (given them via the placenta before birth or through breast milk), or whose mothers have no immunity to give because they weren’t vaccinated themselves. Half of children under 3 months with whooping cough require hospitalization and some die every year in the US, none in Maine yet that I know of. In 2018 there were 446 Maine cases, and 327 in 2019. Vaccines were developed and available in the 1940s.
•Diphtheria is pretty rare now after 80 years of effective vaccinations, beginning in the 1940s, but a few pockets of persistent disease exist in homeless populations which pose a continuous epidemic threat
•Meningococcal meningitis, a bad, disabling, often fatal disease, occurs in epidemics, often when young adults are crowded together, as with army recruits or college students. Maine had 4 cases last year. Vaccines available since 1950s, but the combination of all 4 common meningococcal types in one vaccine became available only in 2005.
•Tetanus (lock jaw), caused by germs in dirt, does not cause epidemics. Usually a fatal disease in the un-immunized. Just last year tetanus nearly killed an unimmunized farm boy in Oregon. But it has been quite rare since vaccinations began during WWII and shortly thereafter in schools.
Currently Maine law requires all public and private schools to assure that all students have had the following immunizations, with some students exempted for medical reasons, like other diseases which could worsen because of the shots (see below)
•Required for kindergarten entry:
-5 DTaP (diphtheria, tetanus, acellular pertussis [whooping cough])
-4 MMR (measles, mumps, rubella [German measles])
-1 Varicella (chickenpox) or reliable history of having had the disease
•Required for 7th grade entry:
- 1 Tdap
- 1 Meningococcal conjugate (MCV4)
•Required for 12 grade entry:
-2 Meningococcal conjugate vaccinations; only 1 dose, if 1st given after 16th birthday
The politics of it all
“Community immunity” is an important aspect of successful vaccination strategies, as is clear in population studies of epidemics in highly vs less highly immunized communities. These studies have demonstrated fewer and less extensive epidemics once vaccination rates achieve 94-96% levels, presumably because there are no longer enough unimmunized people to sustain ongoing cycles of infections. Preventing disease in 95% of individuals has the spin off benefit of decreasing disease likelihoods in the remaining unimmunized 5% once the 95% rate is achieved. That has allowed a few, <5%, not to be vaccinated for religious or medical reasons ever since these laws were established beginning in the 1940s. Back then the shots were only for diphtheria, tetanus, and whooping cough. Gradually 6 more have been added to the list, all of which have reduced greatly the incidence of these diseases. In addition, several other vaccines are now available and recommended for children for diseases that don’t cause epidemics. Examples are the pneumococcal and Hemophilus vaccines against germs that live in our respiratory tract and cause significant injury and death in children and adults from overwhelming respiratory tract infections. The same is true for hepatitis, and perhaps Rotovirus now. About 20 years ago in Maine, a third exemption option was legally added for parental “philosophical” reasons. That exempted number has grown to about 5% alone, which now, on top of the medical and religious exemptions, has put Maine over the critical 5-6% number (see bar graph below). This increase in exemptions, combined with the growing whooping cough epidemic in Maine, large national measles epidemics in the past few years, and the difficulty with defining justifiable religious exemptions have led to the new Maine law in April 2019 to eliminate all exemptions except medical ones.
Different states have different approaches to these exemptions (see map below). Many have or are contemplating greater exemption restrictions.
National data for 2018 not yet available
Things have changed a lot since “the good old days.” Twenty years ago, I began seeing whooping cough cases for the first time in my professional life, right here in Kennebec County. Children now get many more vaccinations, and because of that, many fewer serious illnesses. A good thing, since we have many fewer children around. When I started practice in Maine in 1972, the state had 25,000 births per year. Smaller family size has cut that number to around 12,500 now. Many other medical risks have been reduced over these decades. Child car seats and safer cars have dramatically reduced traumatic injury and death for adults and children. Medical advances save many more children and adults. All these improved survivals have allowed more and more people to reach their old age, a “squaring off of the survival curve”, as epidemiologists call it when the survival curves look more and more like a rectangle than a right triangle (compare 1900 with 1997 in the graph). A big part of this “squaring off” is due to improved immunizations against childhood diseases, eliminating that awful 20% mortality in the first 5 years of life one sees on the 1900 graph line.
So, the existential question is: do individual parental rights to reject immunization of their own children trump effective immunization for the whole community, when the consequence is that these individual choices are bringing back old days-type epidemics. There is understandable parental reluctance about more and more childhood immunizations, and their not wanting those vaccinations to be a requirement for a public education. The referendum #1 sign gives no explanation of these complicated issues; its only plea, to “reject big pharma”, is particularly puzzling. Pro and con donations certainly don't look like “big pharma” is in the game, about $65,000 for the con and $350,000 for the yes vote on #1 on December 31. Plus, virtually all these childhood vaccines are provided free to children through State and Federal mass purchases. The Federal Center for Disease Control works closely with the vaccine manufacturers to assure high quality and improve and supply vaccines quickly when changes are needed. As Dianne Clay of Litchfield recently said in the Kennebec Journal, ”….we pay outrageous prices for many important medications. However, the drugs that are putting a strain on the family budget are not vaccinations for our children. No one should be advocating for us to stop using these medications that have kept us safe all these years. These signs are misleading.”
I think we need more, not less or misleading, information, to understand the issues. I am impressed that the combined medical and religious exemptions policy did keep the exempt number under 5% for a long time. It is the “philosophical” exemptions that have risen intolerably high. I have learned that the legislators heard no objections from organized religion representatives in their public hearings. So, lacking a third option to eliminate only the “philosophical” one, I will vote for trying out the new law and vote No on Referendum question #1 on March 3 to protect all our children.
It has been a long road from the days of many serious common diseases, to the present where immunizations offer significant protections, but only imperfectly, unless all participate. If we are to live, work, and play together, we cannot allow immunization opt-outs, any more than we can allow driving on the wrong side of the road. Parents falsely hoping to protect their own children by avoiding vaccinating them appropriately, jeopardize their health and that of all our children.