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					 Threats and Challenges to
Childhood Health: Vaccines


      Daniel Salmon, PhD, MPH
 College of Medicine, University of Florida
Institute for Vaccine Safety, Johns Hopkins
  Comparison of Maximum and Current Reported
   Morbidity, Vaccine-Preventable Diseases and
     Vaccine Adverse Events, United States
        Disease                 Pre-vaccine Era*              2005             % change

Smallpox                           48,164                       0                100%
Diphtheria                         175,885                      0                100%
Measles                            503,282                     66                >99%
Mumps                              152,209                    314                >99%
Pertussis                          147,271                   25,616                83%
Polio (paralytic)                    16,316                     1                 >99%
Rubella                             47,745                     11                >99%
Cong. Rubella Synd.                    823                      1                 >99%
Tetanus                              1,314                     27                  98%
H.Influenzae type b and             20,000                    226                  99%
Unknown ( < 5 yrs)

Total                              1,064,854                   26,262               -98%




                  * Estimated because no national reporting existed in the prevaccine era
  Comparison of Maximum and Current Reported
   Morbidity, Vaccine-Preventable Diseases and
     Vaccine Adverse Events, United States
        Disease                 Pre-vaccine Era*              2005             % change

Smallpox                           48,164                       0                100%
Diphtheria                         175,885                      0                100%
Measles                            503,282                     66                >99%
Mumps                              152,209                    314                >99%
Pertussis                          147,271                   25,616                83%
Polio (paralytic)                    16,316                     1                 >99%
Rubella                             47,745                     11                >99%
Cong. Rubella Synd.                    823                      1                 >99%
Tetanus                              1,314                     27                  98%
H.Influenzae type b and             20,000                    226                  99%
Unknown ( < 5 yrs)

Total                              1,064,854                   26,262               -98%


Vaccine Adverse Events                  0                      15,472                +++

                  * Estimated because no national reporting existed in the prevaccine era
Evolution of Immunization Program and
     Prominence of Vaccine Safety
                1               2          3              4              5
            Prevaccine    Increasing    Loss of     Resumption of    Eradication
                           Coverage    Confidence    Confidence

                                                                    Vaccinations
                      Disease                                       Stopped

                                                                    ? Feasible
                                                                    In era of BT
Incidence        Vaccine                       Outbreak
                Coverage
                           Adverse
                           Events
                                                      Eradication


                    Maturity
                                                                      Chen, CDC
Undervaccinated Preschool Children

• Black
• Younger mothers who are not married and
  no college degree
• Household income near poverty
• Live in city



                        Smith et al, Pediatrics, 2004.
    Unvaccinated Preschool Children
           Zero Dose Kids
•   White
•   Mother who is married and college degree
•   Family annual income >$75,000
•   Parent expressed concern about vaccine
    safety



                           Smith et al, Pediatrics, 2004.
          School Immunization
          Requirements in US
• All State Laws (not Federal)
• Wide Variability in Implementation
  –   Antigens required
  –   Process for adding antigens or making changes
  –   Applicable Populations
  –   Who provides documentation
Exemptions to School Immunization Laws




TYPE OF EXEMPTION(S) ALLOWED

    Philosophic, Religious &
      Medical (20)

    Religious & Medical (29)

    Medical only (2)             updated March 2005
                               www.vaccinesafety.edu
State Implementation of Exemptions
• Wide variability

• Easy process = High rates




                              Rota et al. AJPH, 2000
       Easy Exemption Process
      Associated with High Rates
                                   Exemption Rate
Administrative      Low                  Medium                     High
  Difficulty      (<0.5%)             (0.5% - 1.0%)               (>1.0%)
                 RI, OK, MO, HI,                                  WA, ID, WI,
    Easy         PA
                                       AK, AZ, VT, CA, MD
                                                                  MI, OR


                 ND, CT, IL, NC,
   Medium        AL, NY, OH, KS,               MA                 UT, SD, CO
                 NJ, LA

                 WY, NH, MT, VA,
                                    IA, DE, CS, ME, NM, TX, NV,
    Hard         IN, AR, MN, KY,
                                    FL, NE
                 GA, TN

                                                         Rota et al AJPH, 2000.
State Implementation of Exemptions
• Wide variability

• Easy process = High rates

• Little contact between parents and health personnel

• Majority of states (67%) never deny exemptions

• States rely on schools to implement exemptions




                                            Rota et al. AJPH, 2000.
Relative Risk of Measles and Pertussis in
      Exemptors from School Laws

                       Measles        Pertussis

  CO (1987-98)1         22               5.9

  U.S. (1985-1992)2     35


                             1= Feikin et al. JAMA. 2000.
                             2 = Salmon et al, JAMA. 1999.
 School Exemption Rates in Counties
     With and Without Pertussis
        Outbreaks: Colorado

Counties with outbreaks        4.7%

Counties without outbreaks     1.3%

                             p = .001


                             Feikin et al, JAMA. 2000..
                                  Mean State Percent and Inter-Quartile
                                 Ranges of Non-Medical Exemptions by
                                     Exemption Type, 1991-2004
                                          Religious                                                                Personal Belief/Philosophical
                 4.0%                                                                                              4.0%



                 3.0%                                                                                              3.0%
Exemption Rate




                                                                                                  Exemption Rate
                 2.0%                                                                                              2.0%



                 1.0%
                                                                                                                   1.0%



                 0.0%
                                                                                                                   0.0%
                     1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
                                                                                                                       1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004


                                                                                                                                                 Omer et al., JAMA, 2006
                           Mean State Percent and Inter-Quartile Ranges
                            of Non-Medical Exemptions by Exemption
                                        Ease, 1991-2004
                                         Difficult                                                                                  Medium                                                                                                  Easy
                                                                                                                                                                                                                5.0%
                 5.0%                                                                                            5.0%
                                                                                                                                                                                                                4.0%
                 4.0%                                                                                            4.0%




                                                                                                                                                                                               Exemption Rate
Exemption Rate




                                                                                                Exemption Rate




                                                                                                                                                                                                                3.0%
                 3.0%                                                                                            3.0%

                                                                                                                                                                                                                2.0%
                 2.0%                                                                                            2.0%

                                                                                                                                                                                                                1.0%
                 1.0%                                                                                            1.0%

                 0.0%                                                                                                                                                                                           0.0%
                                                                                                                 0.0%
                                                                                                                                                                                                                   1990 1991 1992 19931994 1995 1996 1997 1998 1999 20002001 2002 2003 2004
                    1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 20002001 2002 2003 2004                       1990 1991 1992 1993 1994 1995 1996 19971998 1999 2000 2001 2002 20032004



                                                                                                                                                                                               Omer et al., JAMA, 2006
  Associations between State Exemption
Policies and Pertussis Incidence, 1986-2004
                                                    Unadjusted IRR                          Adjusted IRR
                                                      (95% CI)                               (95% CI)
Type of exemption
Only Religious Exemption                                Reference                              Reference
Personal Belief Exemption                           2.06 (1.77-2.40)                      1.48 (1.03-2.13)


Exemption ease
Difficult                                               Reference                              Reference
Medium                                              1.27 (1.06-1.51)                      1.35 (0.96-1.91)
Easy                                                1.90 (1.60-2.28)                      1.53 (1.10-2.14)
   Adjusting for allowing parental signature for school immunization forms, proportion inside urbanized area, income
   (11 categories), and education (7 categories)
                                                                                         Omer et al, JAMA, 2006
    Within State Variations in
    Implementing Exemptions
• Survey 1,000 schools in 4 states (CO, MA,
  MO and WA)
• School Implementation Procedures
• School personnel KABs




                              Salmon et al, Pediatrics, 2004
                   Association Between School Policies
              and Likelihood of Child Having an Exemption
                                                                          LESS LIKELY TO                   NO           MORE LIKELY TO
  RESPONDENTS' REPORT OF SCHOOL POLICY                                  CLAIM EXCEMPTION                 EFFECT        CLAIM EXCEMPTION
                                                                                                                      1.64
                  School permits philosophical exemptions                                                      1.13


                                                                             .50
                 Instructions for completing immunization
             requirement mailed to parents pre-enrollment1                     .53                                           State Does Not Authorize
                                                                                                                             Philosophical Exemptions
                                                                                                                             (MA & MO)
                                                                                      .68
               Increased administrative difficulty2 to claim                                                                 State Authorizes
                                                                                                   .88                       Philosophical Exemptions
                                              an exemption                                                                   (CO & WA)

                                                                                            .85
               If school permits philosophical exemptions,
                                 letter required from parent                                      .78


                                                                                      .70

           School has authority to deny exemption request                                                      1.08


                                                                                                               1.10

                                       Exemption ever denied                                                          1.63


                                                                                                         .96
                School has written policy to inform parents
                                                                                              .84
                                   of the exemption option

1 – MO only for black bar - Question not asked in MA              .25         .5                           1                     2                      4
2 – Administrative difficulty construct ranges from 0-4, based           Odds Ratio and 95% Confidence Interval
   on (1) requirements for annual renewal; (2) letter from
   parent for religious exemption; (3) signature from religious              Adjusted for type of school, whether respondent
   leader, school or physician; and (4) informing parents                          was trained as nurse and the state
   requesting exemption of risks of not vaccinating
School Personnel KABs Associated with
     Children Having Exemption
• Training of school personnel
• Perceived Susceptibility and Severity of Disease
• Perceived Safety and Efficacy of Vaccination
• Who Benefits from Vaccination (Individual and
  Community)
• Vaccine Misconceptions
    – Children get more immunizations than are good for
      them
    – Concerned immune system weakened by too many
      vaccines
• Confidence in local and state health departments
• Use of alternative medicine        Salmon et al, AJPH, 2004.
              WA State Counties’ School Entry Exemption Rates
                                 2005-2006
                                                               Whatcom
                          San Juan                                   7.5%
                             15.2%
                                                                                             Okanogan                                 Pend
                                                                    Skagit                     8.2%               Ferry       Stevens Oreille
                                                                     7.7%
                                     Island                                                                       14.3%        12.2%   12%
                                     11.1%
          Clallam
            6.1%                                               Snohomish
                                                                      6.3%
                                                                                  Chelan
             Jefferson                                                                2.3%
                 19.4%                                                                        Douglas                                  Spokane
                                         Kitsap                                                 1%                  Lincoln               6.8%
                                            6.4%               King                                                  7.1%
                                                                5.1%
              Grays        Mason
                             5.8%
              Harbor                                                                             Grant
                   4.8%
                                                                                 Kittitas         3.7%
                                                         Pierce                       2.8%                        Adams                Whitman
                                  Thurston                   3.9%                                                   1.2%                 3.1%
                                       7%

                 Pacific                      Lewis
                   9.7%                        3%                                                        Franklin                      Garfield
                                                                                 Yakima                    1.3%
                                                                                                                              Columbia
                                                                                      1%
         Wahkiakum                      Cowlitz                                                 Benton                            4%             Asotin
                                                                                                  3.2%
                                                                                                                  Walla Walla                     1.9%
               4.5%                         2.6%        Skamania                                                      2.7%
                                                              8.5%

                                              Clark                          Klickitat
                                                                               3.9%
                                              5.4%                                                          Statewide Total: 5.1%

     <2.0%                                  2.0-2.9%                         3.0-3.9%                 4.0-4.9%                     >5.0%
WA State Dept. of Health – School Status Reports 2005-2006
Why Do Parents Claim Exemptions?

• Survey of the parents of 800 Exemptions
  and 1600 Vaccinated children
  – 4 states (CO, MA, MO & WA)
  – Recruited from over 100 public and private
    elementary schools
  – Matched by state, school, & grade



               Salmon et al. Archives of Ped and Adolescent Med. 2005.
Reasons Parents State for Not Vaccinating
  Reason for Not Vaccinating 1                 Freq.   %
  1. Vaccine might cause harm                   190    69

  2. Vaccines might overload immune system      136    49

  3. My child not at risk for the disease(s)    103    37

  4. Disease(s) not dangerous                    58    21



             1 Not Mutually Exclusive
Reasons Parents State for Not Vaccinating
                       [CONTINUED]
  Reason for Not Vaccinating 1                           Freq.       %

  5. Vaccine might not work                                  36      13

  6. Ethical or moral issues 2                               25       9

  7. Contrary to religious beliefs                           25       9




             1 Not Mutually Exclusive
             2 Includes use of aborted cell lines, fetal tissue and blood, animal
               testing, opposed to requirements, and restatement of above issues
         Parents Who Report a
Moderate or Great Deal of Benefit When a
       Child Is Fully Vaccinated

                                                     % Non-Med Exempt
          100
                                                     % Vaccinated
          75
Percent




          50
                p<0.01     p<0.01     p=0.01     p=0.21     p=0.94
          25

           0
                Child    Community Vac Co.s     Doctors     Gov't

                   Who Benefits when Child is Fully Vaccinated
          Parents Perceptions by Child's
               Vaccination Status
                                                   % Non-Med Exempt
                                                   % Vaccinated
  100

      75
Percent




      50

      25
               p<0.01   p<0.01   p<0.01   p<0.01    p<0.01     p<0.01
          0
                Low     Low      Low     Low        Low        Low
              Disease Disease Vaccine Vaccine      Trust in   Trust in
              Suscept Severity Efficacy Safety      HCP        Govt
       Adjusted Odds Ratios of
Child Having Non-Medical Exemption
 Associated with Parental Perceptions
Perception                    OR      CI
             Susceptibility   4.1   2.8-6.0
Disease
             Severity         2.2   1.5-3.2
             Efficacy         2.0   1.3-3.0
Vaccine
             Safety           3.8   2.5-5.6
             HC Providers     0.7   0.5-1.1
Trust
             Government       1.9   1.3-2.8
    Non-Medical Exemptions
       and Legal Issues
• States are not required to offer non-
  medical exemptions
• If states offer non-medical exemptions
  – Can create administrative requirements
  – May not be able to focus on nature of
    religion
                     Arkansas
• State Permits Religious Exemption (7/02)
  – "immunization conflicts with the religious tenets and
    practices of a recognized church or religious denomination
    of which the parent . . . is an adherent or member."
  – Must provide copy of religious doctrine and details of
    religious organization
• Parent requests exemption for Hepatitis B
• State rejects exemption request
• Parent files lawsuit – goes to US District
  Court
            US District Court
• Three Prong Lemon Test
  – Legislature must have secular purpose
  – Primary effect must not advance nor
    inhibit religion
  – Must not result in excessive entanglement
    of government with religion



                            Lemon v. Kurtzman, 403 U.S. 602
        US District Court Ruling
• Fails 2nd and 3rd Prong of Lemon Test,
  Clearly runs afoul of:
  – Establishment and Free Exercise Clauses of the 1st
    Amendment
  – Equal Protection Clause of the 14th Amendment
• Eliminated Religious Exemption
• Severed from School Requirement and
  Medical Exemption
• Judge suggests legislative relief

                                 McCarthy v. Boozman, 01-2266
            Model Legislation for
           Non-Medical Exemption
• Parent
     – Furnish signed, personal statement explaining reasons
       for exemption request
     – Documentation from licensed physician or DOH that
       parent has received individual educational counseling
• State weighs strength of parent conviction with
  risks of granting exemption:
     – Vaccination Rates
     – Community vulnerability to disease outbreaks
     – Prevalence of VPDs


                                            Salmon et al, AJPH 2005
        Model Legislation for
       Non-Medical Exemption
                  (cont)
• State may reject exemption request
  based on this balance
• Appeals process for exemptions that
  have been declined
• If exemption granted, must be annually
  renewed

                             Salmon, Sapsin, Teret, Halsey
  Arkansas Non-Medical Exemption
• DOH rejects authority to deny
  exemption request
• Includes assessment of impact of
  change in law
  Impact of Philosophical Exemption
             in Arkansas
Exemption
            2001-02   2002-03 2003-04 2004-2005
Type
Medical      110       139       64            62

Religious    419       512       297          362

Phil.         0         0        403          721

Total        529       651       764          1145


                              Thompson et al, AJPM, 2007
GRAVETTE               PEA RIDGE PEA RIDGE                                                             BRUNO-PYATT BRUNO-PYATT                                                                 MAMMOTH SPRING                                                                                PIGGOTT
                                                                                       OMAHA
                                              EUREKA
                                              SPRINGS     Carroll                                   LEAD HILL BRUNO-                        Baxter                                                       WILLIFORD
                                                                                                                                                                                                                  RANDOLPH COUNTY
                                                                                                                                                                                                                                               MAYNARD                    Clay
                                                                         GREEN                                                                                          VIOLA
                                                                                                                PYATT                      MOUNTAIN HOME                                 SALEM
DECATUR      BENTONVILLE                                                 FOREST
                                                          BERRYVILLE
                               ROGERS                                                      Boone                            FLIPPIN
                                                                                                                                                                                                                              Randolph               BIGGERS-REYNO
                                                                                                                                                                                                                                                                         CORNING       RECTOR
                                                                                                 BERGMAN                                                                                              HIGHLAND
                Benton                                                                                                                   COTTER                                   Fulton
   GENTRY
                                                                                                                Marion                                                                                                                                        DELAPLAINE  MARMADUKE
                                                                                                                                                                                     IZARD                      WILLIFORD             POCAHONTAS                 GREENE COUNTY
 SILOAM                 SPRINGDALE                                                    HARRISON
                                                                                                      HARRISON             YELLVILLE-
                                                                                                                            SUMMIT
                                                                                                                                                                                                   Sharp                SLOAN-HENDRIX                                TECH
 SPRINGS                                     HUNTSVILLE
                                                                            ALPENA                VALLEY
                                                                                                               BRUNO-PYATT
                                                                                                                                                   NORFORK     CALICO ROCK         Izard                                                      WALNUT RIDGE
                                                                                                                                                                                                                                                                                  Greene
                                                                                                  SPRINGS                                                                                                                           BLACK                        PARAGOULD
           FARMINGTON                                                                                                                                                                              EVENING                          ROCK
                                                                                                                                        BRUNO-PYATT                                                 SHADE                   LYNN
                    FAYETTEVILLE                                KINGSTON                         WESTERN                                                                    MELBOURNE
                                                                                                                ST JOE
                                                                                                                  .                                                                                          RIVER VALLEY
                                                                                 JASPER           GROVE                                          STONE                                                                                       HOXIE             GREENE COUNTY TECH
           PRAIRIE
           GROVE
                                             Madison                                                                                            COUNTY                                 MOUNT                             Lawrence                                                      BUFFALO ISLAND
                                                                                                                                                                                                                                                                                                      GOSNELL          ARMOREL
                      GREENLAND                                                                                                 MARSHALL                                              PLEASANT                                                                                            CENTRAL
   LINCOLN                      ELKINS                                                                                                                                                              CAVE CITY                  WALNUT RIDGE       WESTSIDE         Craighead
                                                                                                   MOUNT                                            STONE                                                                                                        BROOKLAND
                                                                                                                                                                                                                                                CONSOLIDATED
                WEST FORK                                                                          JUDEA           Searcy                          COUNTY
                                                                                                                                                                                             Independence                           SWIFTON            JONESBORO                                  MANILA
                                                                                                                                                                                                                                                                                                               BLYTHEVILLE

   Washington                                          .
                                                     ST PAUL                 Newton                                                   LESLIE                      MOUNTAIN VIEW          CUSHMAN       CORD-
                                                                                                                                                                                                               CHARLOTTE                                             NETTLETON
                               WEST FORK
                  WINSLOW                                                             DEER
                                                                                                              WITTS
                                                                                                             SPRINGS
                                                                                                                                                                        Stone            BATESVILLE      SULPHUR                                                                     RIVERSIDE
    CEDARVILLE                                                                                                                                    RURAL SPECIAL
                                                                                                                                                                                                          ROCK                                         VALLEY VIEW          BAY                  Mississippi
                     MOUNTAINBURG                                                                                                                                                                                                                                       TRUMANN                         OSCEOLA
                                        Franklin               OARK                                                    ALREAD
                                                                                                                                                   SHIRLEY                       CONCORD           SOUTHSIDE                       JACKSON
                                                                                                                                                                                                                                                     Poinsett                        EAST POINSETT
     Crawford                   OZARK                                                                                                   CLINTON
                                                                                                                                                              Cleburne                                        NEWARK                                                                             SO. MISS. COUNTY
                                  PLEASANT                                    LAMAR                   HECTOR               Van Buren                           WEST SIDE
                                                                                                                                                                                               MIDLAND                  Jackson
              ALMA                  VIEW
                                              OZARK     Johnson                           DOVER
                                                                                                                                                                                                                                               WEINER        HARRISBURG      MARKEDREE
                                                              CLARKSVILLE                                                                                                                         BRADFORD
                            MULBERRY                                                                                   SCOTLAND                                          HEBER WILBURN                                                                                               EAST POINSETT
                                                      WESTSIDE
                                                 ALTUS                                                Pope                                                              SPRINGS
                                                                                                                                                                                      WHITE COUNTY
                                                                                                                                                                                                                               NEWPORT
             VAN BUREN                                                                                             WONDERVIEW               SOUTH SIDE        QUITMAN                   CENTRAL                                                       CROSS COUNTY                          TURRELL
                                                DENNING                                                                                                                    PANGBURN
      FORT                                                                               RUSSELLVILLE                             NEMO
                                                                                                                                  VISTA                                                                                                                                            EARLE          MARION
      SMITH                                                  SCRANTON                                                                       GUY-PERKINS                                                              AUGUSTA
                  LAVACA          COUNTY LINE                                                                                                                                                            BALD KNOB                                             Cross
                     CHARLESTON                                                                                                                                         ROSE BUD
                                                                                                                                                                                             White                                                   WYNNE
                                                                                                                                                                                                                                                                                      CRAWFORDSVILLE
              GREENWOOD                                                                                  ATKINS                                                                                                                    MCCRORY
                                                             PARIS                                                                                                                       SEARCY
      HACKETT                                 MAGAZINE                                          POTTSVILLE              Conway            GREENBRIER
                                                                                                                                                              MT. VERNON/                                                                                                PARKIN   Crittenden
             Sebastian                                                            DARDANELLE                                                Faulkner
                                                                                                                                                                 ENOLA                MCRAE
                                                                                                                                                                                                    RIVERVIEW           Woodruff
                                BOONEVILLE                                                                         SO. CONWAY
                                                                                                                                                             VILONIA                                                    COTTON PLANT
                                                                                                                                                                                                                                                             St. Francis                   WEST MEMPHIS
      HARTFORD                                         WESTERN YELL                                                                                                      BEEBE
                                         Logan                              Yell                            PERRY-CASA                    CONWAY
                MANSFIELD                                                                OLA     PERRY-CASA          EAST END                                                                                                                                FORREST CITY
                                                       DANVILLE                                                                       MAYFLOWER                                                       DES ARC
                                                                            PLAINVIEW-                      Perry                                                           CABOT                                                    PALESTINE/WHEATLEY
                                                                                                                                                                                                                                                                                  HUGHES
                                                                              ROVER
                           WALDRON                                                                                                                                                                        Prairie
                                                                                               PERRYVILLE                                    PULASKI COUNTY SPECIAL                                                         BRINKLEY
                                                                                                                                                                                                                                                         LEE COUNTY
                                                      FOURCHE VALLEY                                           PARON            Pulaski                                                               HAZEN
                                                                                                                                                   N. LITTLE ROCK               LONOKE                        DEVALLS
                           Scott                                                      JESSIEVILLE
                                                                                                                                                                                                               BLUFF
                                                                                                                                                                                                                         CLARENDON CLARENDON
                                                             ODEN
                                                                                                                   Saline                       LITTLE ROCK                Lonoke CARLISLE                      HAZEN
                                                                                                                                                                                                                                                             Lee
                 ACORN                        ODEN
                                                                                                        FOUNTAIN LAKE
                                                                                                                                      BRYANT                                                                                Monroe                           BARTON-
                                                                             MOUNTAIN PINE                                                                                                                                                                    LEXA
                                                             MOUNT IDA                                                                                                                                                         HOLLY GROVE
                                                                                                   CUTTER-MORNING     BENTON                                                                                                                                           HELENA/
                                                                                                                                                                                                                                                MARVELL                W.HELENA
                                                                                                                                                                                ENGLAND
     HATFIELD
                               MENA
                                             Montgomery                        Garland            HOT
                                                                                                        STAR        HARMONY
                                                                                                                     GROVE               BAUXITE                                                    HAZEN
                                                                                                                                                                                                            STUTTGART
                                                                                                SPRINGS MAGNET COVE
                                                                                                                                                                                                                                                             LAKE VIEW

      VAN COVE
                          Polk                                              LAKE HAMILTON                                                                               Jefferson
                                                                                                                                                                WHITE HALL
                                                                                                                                                                                              HUMPHREY

                                                  CADDO HILLS                                   LAKESIDE                GLEN ROSE
                                                                                                                           POYEN            SHERIDAN                        ALTHEIMER UNIFIED                        Arkansas                        Phillips
                           UMPIRE                    KIRBY
                                                                                  BISMARCK       Hot Spring
                                                                                                                                                              DOLLARWAY
     WICKES                                                                                                                                                                                                                 DEWITT
                                                                                                      OUACHITA MALVERN                                                  DOLLARWAY                                                              ELAINE
                               DIERKS
                                                          Pike           CENTERPOINT
                                                                                                                                           Grant                                 PINE BLUFF
     DEQUEEN                                                                         Clark
                                                                                                                                                                                                                        GILLETT
                               Howard MURFREESBORO                                              ARKADELPHIA
                                                                                                                            CARTHAGE                          WATSON CHAPEL
                                                                                                                                                                                                  GRADY
                                                                                                                                                                                                            GOULD
      Sevier                      NASHVILLE
                                                                 DELIGHT                                                                          Cleveland
                 LOCKESBURG                                                                                                                 CARTHAGE
           HORATIO
                                                                                                                SPARKMAN
                                                                                                                               Dallas                          RISON                 STAR CITY
                                                                                                                                                                                                              DUMAS

                                MINERAL                                                      GURDON                               FORDYCE                                                                                   DELTA SPECIAL
                                                         BLEVINS                                                                                                   WOODLAWN
                                SPRINGS
                                                                                                                                                       KINGSLAND
                                                                                                                                                                                  Lincoln                      Desha
                                                                               PRESCOTT
                                                                    EMMET                                                       BEARDEN
                     ASHDOWN                            HOPE
                                        SARATOGA                                                               HARMONY                                                                                         MCGEHEE
  FOREMAN                                                                                           CAMDEN      GROVE                                                                    MONTICELLO
              Little River                    Hempstead                                             FAIRVIEW
                                                                                                                                                                WARREN                                                        ARKANSAS
                                                                               NEVADA                                                                                                                                           CITY
                                                                                                                                Calhoun
                                                     SPRING HILL            Nevada                 Ouachita                                                                                                          DERMOTT
                                  TEXARKANA                                                                                                                                           DREW CENTRAL


                                                                                       MCNEIL
                                                                                                 STEPHENS
                                                                                                                                      HAMPTON
                                                                                                                                                             Bradley                     Drew                                                                                       Exemptions per 1000
                                                          LAFAYETTE                                                SMACKOVER                                                                                              LAKESIDE
                                         GENOA
                                                           COUNTY            WALDO              MOUNT HOLLY                                                   HERMITAGE
                                        CENTRAL
                                                                                                                            NORPHLET                                               FOUNTAIN HILL
                                                                                                                                                                                                                         Chicot                                                                        0
                                Miller                                               MAGNOLIA
                                                                                                           MOUNT                        UNION
                                                                                                                                                                                                  HAMBURG
                                                                                                           HOLLY
                                          FOUKE
                                                                      TAYLOR
                                                                                  WALKER
                                                                                                                       EL DORADO
                                                                                                              PARKERS CHAPEL                          STRONG             CROSSETT                                                                                                                      >0    to     <=5
                                                      BRADLEY                            WALKER
                                                                                     EMERSON                                                                  HUTTIG                                                     EUDORA
                                BRIGHT
                                 STAR             Lafayette                 Columbia                       JUNCTION CITY     Union                                                            Ashley                                                                                                   >5    to     <=10
                                                                                                                                                                                                                                                                                                       >10 to <=15

                       Source: Arkansas Center for Health Improvement, the Department                                                                                                                                                                                                                  >15
                       of Education, Arkansas Department of Health and the                                                                                                                            0       5 10           20         30
                       Census 2002 TIGER Lines Files.                                                                                                                                                                                         Miles



                                                                                                                                                                                                                    Thompson et al, AJPM, 2007
   Impact of Philosophical Exemption
              in Arkansas
Exemptions        2001-02   2002-03 2003-04 2004-2005

Total               529      651       764          1145
% Increase from
Previous Year                23%      17%           50%
Absolute
Increase from                122       113          381
Previous Year



                Absolute or % Increase?
                                   Thompson et al, AJPM, 2007
        Association of Immunization
         Managers (AIM) Position
•   Must be used sparingly, approached
    cautiously, and considered only after an
    appropriate vaccine implementation period
    –   Funding for vaccine
    –   Physician/provider and public support
    –   Stable and adequate vaccine supply
    –   Adequate data to assure vaccine safety
    –   Significant uptake in the recommended
        population to reduce the compliance burden on
        the school/child care system
   Association of Immunization
  Managers (AIM) Position – cont.
• Inappropriate application of mandates risks loss of
  support for immunization programs
• Must be pursued through existing state processes.
  Legislators, advocates, consumer groups,
  manufacturers, and others interested in pursuing
  school and child care immunization requirements
  should first contact the state health agency
  immunization program.
   Association of Immunization
  Managers (AIM) Position – cont.
• Measures to add or alter exemptions to laws
  must be carefully coordinated with state
  immunization policy and goals. Opening
  existing laws for this purpose risks having
  an effective mandate weakened, altered in
  an undesirable way, or even revoked
  entirely.
    Human Papillomavirus (HPV)
• Most common STI
• 100+ genotypes
• Often asymptomatic and transient
• Can lead to cervical, vaginal, vulvar, anal
  and penile cancer and genital warts
• Vaccine highly efficacious against 4 strains
  causing 70% of cervical cancer and 90% of
  warts
    Compulsory HPV Vaccine
• Texas
  – All 6th grade girls in 2008
  – Passed by Governor Order
     • No public comment
  – Overturned by legislature
Compulsory HPV Vaccine in Other
            States
• 24 States and DC have laws pending
• Virginia passed HPV vaccine mandated
  – Exemption for HPV vaccine expanded
  – Exemption not changed for other vaccines
  – May cause slippery slope
 Threats and Challenges to
Childhood Health: Vaccines


      Daniel Salmon, PhD, MPH
 College of Medicine, University of Florida
Institute for Vaccine Safety, Johns Hopkins

				
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