Who’s Your Herd?

I’m not an epidemiologist. This morning, I had decided I was going to write a post about how I am not an epidemiologist, but that was before I saw this WIRED opinion piece, in which Sarah Fallon makes the point, essentially, that herd immunity is high enough in California and people can’t sue vaccine manufacturers (not true), so California doesn’t need a new vaccine law.

So that this post doesn’t come back to bite me at some point, let me also be clear that I am not in California, and I have no idea what kind of law California needs. No one in Minnesota is seeking to end all non-medical exemptions as they are in California, so the debate in California is not personal for me. (Very few of you will see what I just did there.) But many Californians whom I respect say that now is the time to end the personal belief exemption in California, and I trust them.

I’m also not a lawyer, so I will simply link to the estimable Dorit Reiss’ post about the fallacies of “we can’t sue vaccine makers so evil evil something” here.

Back to the meat of the post. I do try to avoid writing about scientific matters too often because I am not a scientist and because manner scientists are already doing the wonderful work of writing about vaccines. However, a few sentences in the aforementioned WIRED piece irked me:

Remember, vaccination rates have not suddenly plummeted. They are, and remain, high. And we remain at the upper end of the 83 to 94 percent “herd immunity” threshold that keeps measles at bay. To know how many kids in California are vaccinated against what diseases, we need to use the data-crunching tools and reporting methods that are available to us to count all the vaccines that have actually been administered. And I think we would be happy with what we found.

I do not have to be an epidemiologist or a scientist to understand that the description above is not how herd immunity works. Measles does not spread in a statewide manner, blanketing all of California with contagion or not based on the statewide vaccination rates. Measles is spread from in person, in a room or an elevator. Make no mistake, measles is crazy contagious. A measles outbreak in Minnesota illustrates this perfectly:

Lynfield said the virus can spread through the air, as it did in 1991 when 16 people at a Special Olympics event at the Metrodome were infected. A track and field athlete from Argentina was the original case in that outbreak. Interestingly, two of the infected people were sitting in the upper deck of the Dome — more than 30 meters above the athletes.

We definitely should be concerned about those large-view herd immunity issues. If California had an immunization rate of 60%, we would all be concerned.

But for measles or any other vaccine-preventable disease, we need to ask who is our herd? Where are our children most at risk for catching a disease?

A child in preschool or Kindergarten spends a great deal of time playing with toys his or her classmates play with, holding hands with friends, sitting side-by-side in group time. They may only have 15 or 20 classmates, but these children constitute their most important herd because of the amount of time spent with them and the proximity to them.

A college student living in a dorm has a different herd (and different vaccine requirements because of this different herd behavior). Those people sharing a bathroom with a college student or sharing a kitchenette in the floor lounge make up one herd. Classmates in a lab or a lecture hall or a study group are another herd.

If a preschooler is in a classroom with classmates who are all fully immunized, the chance that this child will contract a vaccine-preventable disease are greatly reduced. And if the child we send off to college lives in a dorm and attends classes with people who are all fully vaccinated, they, too, are at greatly reduced risk for catching a vaccine-preventable disease. And this is true whether or not our preschooler or college student in question is vaccinated. That’s the power of herd immunity.

The issue in California is not how many children in the state have parents who are making the choice to contribute to herd immunity. The issue is that too many communities have too many children who are unvaccinated and leaving those community-level herds at-risk. Even a classroom-level herd that has a high vaccine opt-out rate can be at risk if a disease is introduced into that classroom.

Those unvaccinated children who become infected then venture out into the greater community. Is their classroom a fluke, powered by an alpha-mom who has spread anti-vaccine misinformation like a contagion and frightened the classmates out of vaccinating? (See why it is so important not to remain silent during vaccine discussions?) Or is this classroom part of a greater community trend, waiting for disease to take over? Is the community made of tendrils that reach into other communities? How far can an outbreak spread?

“Our state vaccination rates are high enough” is never a cogent argument. Every community deserves protection, and every child in every classroom deserves the safety net of a highly vaccinated herd. I’m not an epidemiologist, but I am a mother with children, and I want them to have the protection of a highly vaccinated classroom. Until anti-vaccine misinformation is vanquished once and for all, we will need better laws to protect our children.

This is a Publicity Tour, Not a Public Service

I have been to a couple of hearings concerning immunization bills, and I have listened to and sent parents to many, many more hearings. I have heard the most passionate, intelligent, and well-respected doctors and nurses try to convey to lawmakers in minutes the complexity of our vaccination program and the importance of high immunization rates. These healthcare professionals who testify on the public health side are from in-state and work directly with the children and parents who are affected by vaccine rates. They are the people who, when bills working to raise rates do not pass or die, must intubate infants with pertussis, admit children to intensive care during measles outbreaks, and put children on ECMO machines when influenza attacks.

In other words, these doctors nurses testifying for tougher vaccine laws do so because they have seen children in their communities suffer, and they want to prevent more suffering. These are not people whose names you would know. They don’t make any money from their appearances in front of legislative committees. Their testimony brings them no further glory.

And then we have those who testify on behalf of the anti-vaccine contingent. Take Robert Kennedy, Jr., for example. In his latest stop, he is going to New York to persuade them not to make the meningitis vaccine mandatory. He claims that the vaccine contains too much mercury. And although he is an environmental lawyer and finds that experience relevant, it is clear he doesn’t understand medicine or public health. His stop might be unremarkable, except that he has also testified in front of legislative bodies in Vermont, Illinois, and Oregon.

Another example of an anti-vaxxer willing to travel to testify against immunizations is Dr. Toni Bark, whom I watched testify in Minnesota (where she was schooled on misusing a local doctor’s research.) She has also testified in Texas and Vermont, and there is talk of her traveling to other states to testify as well.

Part of me takes heart that being anti-vaccine is so rare that the same expert must be flown from place to place to testify. After all, the pro-vaccine forces need only look to their local hospital, university, or health department to find someone who both thoroughly understands the value of vaccines and is passionate enough to give their expert opinion to lawmakers. Apparently anti-vaxxers are not so lucky.

But the other part of me is annoyed. Much of the anti-vaccine belief system is predicated on an assumption that a conspiracy exists to suppress the evils of immunization so that the very many people involved can profit from the near universal usage of vaccines. This conspiracy means that all the doctors, nurses, research scientists, public health officials, and pharmaceutical company employees in the world aren’t in it to save lives. They are in it for cash. Thus the admonition from the anti-vaccine lines to “follow the money.”

Every time I see RFK Jr. or Toni Bark or whomever travel to yet another state legislature, I do follow the money. And I note that Kennedy has a book out–on the topic of thimerosal, of course! He has also been heavily promoting a pseudo-documentary which implicates thimerosal, which has been removed from childhood immunizations, in autism. Meanwhile, Toni Bark has her own horrible pseudo-documentary, starring multiple people with online supplement stores. When I follow the money, I realize that all this fear of vaccines is being used to sell me something. Movies! Books! Supplements!

It comes down to this: public health advocates find local people with expertise to educate lawmakers about bills. Anti-vaccine activists fly in profiteers on publicity tours to promote the very fear that sells their wares. The worst part is that their efforts are sometimes successful.

Don’t Use Your Religious Beliefs to Endanger Your Community

Talking about vaccines as we come off Memorial Day and consider what people have sacrificed in the name of freedom only seems natural. I figure as long as I am mixing patriotism and vaccines together, I might as well add a discussion about God.

People who know me know that I am a religious adherent–the type who even goes to church on Sundays. I believe that people should be allowed to exercise their religious beliefs freely as long as they do not harm others. Most arguments against a religious exemption focus on this last bit: not harming others. Vaccine refusal puts both a child and her community at risk for harm, and ought not be protected by the right to practice religion freely.

People who are religious often feel nervous, however, with the idea of eliminating a religious exemption to school vaccine requirements. Even if they vaccinate their children and want others to do the same, they might worry that giving no exemption on the basis or religious belief will, at some point down the line, be used to limit their free practice of religion. It’s a fair worry, but one that I think is short-sighted.

In fact, the way I see things (as a non-lawyer and a non-scientist), religious exemptions to vaccine requirements weaken religious freedom in the United States. Currently, forty-five states in this country offer a vaccine exemption based on religious beliefs. (I happen to live in one of the states which does not offer an exemption based explicitly on religion, which delights me.)

The way that these religious exemptions are granted differs wildly from state to state. Some states, like Florida, allow unvaccinated students to attend if parents fill out a form that indicates that vaccines are somehow against their religious beliefs. Such a cavalier use of religious beliefs is a threat to anyone who holds any religious belief because religion is not a blank check to opt out of community responsibilities. Can you imagine if you were pulled over for speeding, and you told the officer that as a Lutheran, you sincerely believe that limiting speed is something the state should not impose on you?

If the religiously affiliated play the religious beliefs card too often, we would deserve to have our freedoms closely scrutinized. After all, why should a Methodist be able to send her unvaccinated child to school when an Atheist cannot? (And Agnostics should be able to speed if Lutherans can!)

In the case of religious exemptions, the scrutiny is fair. Which major religious faiths, as a matter of doctrine, advise their adherents to avoid immunization? People often point to Christian Science as the religious that forbids vaccination, but during a round of compulsory smallpox immunization, the founder of Christian Science, Mary Baker Eddy, advised her followers to follow the laws and submit to vaccination. So supporting a religious exemption is not really about allowing the free practice of religion as much as it is allowing people to believe misinformation about immunization and use their religious beliefs as a defense. When the science so clearly supports immunization, such a cynical use of religious beliefs ought not to be supported by law.

Other states, like New York, make it more difficult to obtain a religious exemption. There, a school has the right to accept or reject a religious exemption. In some cases, courts have been called in to rule on whether or not a religious belief was sincerely held in regard to opting out of immunization requirements. Dina Check was one such mother whose religious exemption was denied by the school because her religious belief was deemed insincere, and the court upheld this decision.

When people claim rights based on religious belief, they also potentially subject themselves as to the sincerity of their belief. This sincerity testing has all sorts of potential ramifications legally, I am sure, but even practically–I am not certain how to test whether or not someone sincerely believes something. And I fear handing over to the courts the power to adjudicate on how sincerely someone believes anything.

If we want religious freedom (or freedom from religion), we need to be careful about which rights we ask for on behalf of our religion. Protecting anti-vaccine parents who want to claim religious beliefs against vaccines is not carefully protecting religious rights. It is protecting the right to opt out of protecting a child and a community against diseases that harm children and other vulnerable people. And there’s nothing particularly religious about that.