Pa. health chief targets vaccination rate

In February, the country was stunned by a measles outbreak in California that highlighted how many adults and children were not immunized.

Since then, the Pennsylvania Department of Health has redoubled efforts to improve the state's immunization rates.

Now, as another school year is about to begin, Physician General Rachel Levine is pushing to end Pennsylvania's eight-month grace period, which is far longer than that of most other states. It has meant that kids can be in kindergarten almost an entire academic year without getting required immunizations.

It also has meant that Pennsylvania comes out on the short end of the statistical stick in some vaccine reports; measuring at the beginning of the school year puts the state second to last in the nation among kids entering kindergarten. But in other vaccine surveys, the state ranks above average.

About 91 percent of Pennsylvania kindergartners last year started school fully vaccinated; the goal is to achieve 95 percent coverage. At that level, so many kids are protected that disease outbreaks are prevented, Levine said, a concept known as herd immunity.

"Vaccinations are one of the most effective health tools to prevent sickness and death," said Levine, whose department has launched a "Don't Wait. Vaccinate" campaign. "It's an example of how medical science can improve public health."

Cutting the grace period will require either legislative action or regulatory change, which she said would take at least a year.

"So there will be plenty of time to vaccinate so kids won't be excluded from school. We don't want to exclude anyone."

The "Don't Wait. Vaccinate" campaign, however, doesn't touch on a more politically volatile issue, the religious and philosophical exemptions that some parents claim to avoid vaccinating their children. Levine said 1.7 percent of Pennsylvania children fell under such exemptions. Far fewer - an additional 0.3 of a percent - have medical exemptions.

Levine is going after the grace period, she said, because her calculations indicate that the move will help Pennsylvania communities achieve herd-immunity status.

Other experts aren't so sure that will do the job, given that it is so easy to get a religious or philosophical exemption.

"I think eliminating the grace period is a very minor suggestion," said Tony Yang, associate professor of health administration and policy at George Mason University in Virginia. The author of a recent article on vaccine exemptions in the Journal of the American Medical Association, Yang said in an interview that Pennsylvania's eight-month period was unusually long.

"While the grace period should be eliminated or reduced, increasing the burden to get a religious or philosophical exemption would have a much bigger effect on preventing outbreaks."

Forty-seven states have some form of grace period, although most are 30 days or less.

New Jersey offers a 12-month provisional period for students to complete their vaccination schedule, but it requires at least one dose of all vaccines to start kindergarten, and health records are checked every 30 days for compliance. Pennsylvania students have the full eight-month grace period to get vaccines that require only a single dose, and health records are supposed to be checked every 60 days.

New Jersey generally outranks Pennsylvania on reports of vaccine rates, though both states usually rate above average nationally.

During 2013-14, about 15 percent of kindergarten students in Pennsylvania took advantage of the provisional period. In 2014-15, that figure fell to about 10 percent, with 13,980 kids enrolled provisionally. At the same time, vaccine rates for incoming kindergartners went from 86.4 percent to 91.7 percent.

"There is medical assistance that pays for immunizations, private insurers that cover vaccines, and CHIP," Levine said, referring to the government-funded Children's Health Insurance Program.

"And there is plenty of vaccine available for immunizations," she added.

Sue Kressly, president of the Pennsylvania chapter of the American Academy of Pediatrics, said there was no medical reason to justify delaying vaccinations.

"Eliminating the waiting period will assure kids are protected individually and will enter a protected environment where kids who are vulnerable are not at risk because of a lack of herd immunity," she said. Both the AAP and the Pennsylvania Medical Society support the push to cut the grace period.

"Clearly, there are people who don't like the government or school district telling them what to do," said Kressly, a pediatrician in Warrington. "But mandated immunization exists, and without the waiting period, it will be done in a time frame that makes more sense - at the start of the school year."

Under state code, all that parents have to do is object "in writing to the immunization on religious grounds or on the basis of a strong moral or ethical conviction similar to a religious belief."

Why not follow the lead of states like California that are eliminating all but medical exemptions?

"Exemptions are not why we're not at 95 percent herd immunity," said Levine, who blames the grace period.

But a new study from the journal Health Affairs found that state-level vaccination-exemption laws do affect immunization rates and the incidence of preventable diseases. Vaccine policies in Pennsylvania and New Jersey were rated "somewhat effective" in reducing the incidence of pertussis, for example, when compared with other states.

Raising the bar on receiving a religious or philosophical exemption could prevent outbreaks, said Paul Offit, vaccine expert and chief of the division of infectious diseases at Children's Hospital of Philadelphia.

He noted that from 1990 to 1991, more than 1,400 people living in Philadelphia were infected with measles and that nine children died. Two fundamentalist Christian churches whose members did not believe in vaccination fueled the outbreak.

In his recent JAMA article, George Mason's Yang said that all states should follow California, West Virginia, and Mississippi and eliminate all but medical exemptions, writing: "The state's interest in protecting children is a higher priority than the freedom of some."

Two bills introduced in the Pennsylvania General Assembly this year by Rep. Becky Corbin (R., Chester) and Sen. Daylin Leach (D., Delaware) would eliminate the philosophical exemption.

One of the biggest concerns for parents who object to vaccines is a false belief that the MMR vaccine is connected with autism, Levine noted. She stressed that the 1998 study that made the autism claim has been thoroughly debunked as "fraudulent, with the doctor disbarred from the British medical society for using falsified data."

"Since that time," she said, "large epidemiological studies show no connection between the MMR vaccine and autism whatsoever."

Several celebrities who disagree with the medical evidence on vaccines are misinformed, said Levine.

"All of my children had all the immunizations according to the schedule" without ill effects, she said.

As for ending the provisional period, Levine said, "There are no slam dunks in public health. We'll need to explain the issue clearly and really well so people will understand. We expect we will get our point across."

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