Edgar K. Marcuse, MD, MPH, FPIDS
Douglas J. Opel, MD, MPH, FAAP
Douglas Diekema, MD, MPH, FAAP
Editor’s note: WCAAP is working closely with the Washington State Department of Health to develop implementation guidelines for HB 1638. We will e-mail this guidance to all WCAAP members and post it on our website once it is complete – likely late May or early June. We are grateful to the authors of this article for sharing their expertise as we consider the implications of this new law.
Once Governor Inslee signs HB1638, it will become law on July 28, 2019: parents will no longer be able to claim a personal or philosophical exemption to the requirement for MMR immunization for all students attending childcare or K-12. What will you do when you encounter a parent whose child has no medical contraindication or even precaution to receiving MMR but adamantly refuses MMR vaccine for child? Perhaps the parent is fearful of potential adverse consequences, such as autism or because a sibling experienced a devastating adverse event in temporal association with receiving an MMR and suffered long-term sequelae.
What is important to remember is that there are few valid medical contraindications to MMR immunization. A parent who is fearful of potential adverse consequences is not one of them. Nor is having a sibling who experienced a devastating adverse event in temporal association with receiving MMR. We also need to acknowledge that the parent may be genuinely terrified and doing what they believe is best for their child. It can be difficult to proceed to administer MMR over the parent’s strong objection. It can be tempting for this reason to find a way to rationalize signing a medical exemption. Or perhaps to encourage the parent to simply claim a religious exemption. What will you do?
The Washington State Exemption form currently says “a health care practitioner may grant a medical exemption to a vaccine antigen required by rule of the state board of health only if in his or her medical judgment, the vaccine antigen is not advisable for the child….Guidance for medical exemptions for vaccination can be obtained from the contraindications, indications, and precautions described in the vaccine manufacturer’s package insert and by the most recent recommendations of the Advisory Committee on Immunization Practices (ACIP).” It will be revised to read “a health care practitioner may grant a medical exemption to a vaccine antigen required by rule of the state board of health only if in his or her judgment…,” which aligns with the language in medical exemptions in statute: https://apps.leg.wa.gov/RCW/default.aspx?cite=28A.210.090, removing the word “medical” prior to “judgment.”
ACIP contraindications and precautions to MMR are a severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component; pregnancy, known severe immunodeficiency (e.g., from hematologic and solid tumors, receipt of chemotherapy, congenital immunodeficiency, long-term immunosuppressive therapy or patients with HIV infection who are severely immunocompromised) and family history of altered immunocompetence. Precautions include recent (≤11 months) receipt of antibody-containing blood product (specific interval depends on product); history of thrombocytopenia or thrombocytopenic purpura; need for tuberculin skin testing or interferon-gamma release assay testing and moderate or severe acute illness with or without fever. Note once again that a family history of an adverse event in temporal association with an immunization is not listed.
What to do? We believe the prudent physician will respectfully explain (1) the child has no medical contraindication to receiving MMR; (2) state that it is in the child’s best interest to receive the vaccine, (3) note that the parent sincerely believes they are acting in what they perceive as the best interest of their child and therefore you will not administer the vaccine over the parent’s objection, and (4) neither will you attest that the child has a valid reason for a medical exemption. Be empathetic. Try to engender trust. Be a partner with the parent. Yet, ultimately, acknowledge to the parent that failing to immunize their child against MMR will result in the child being out of compliance with the law.
The parent and public health officials must then deal with the consequences of the parent’s actions. This is appropriate as it is the civil authority, not physicians, that must balance individual freedom of choice and protection of the public health. The public health authority may then determine what if any degree of coercion is warranted to get the child incompliance with state law or exclude the child from school or child care. Physicians must maintain their professional integrity and attest to only for valid for medical exemptions despite their compassion for the parent’s distress and its consequences for their child.