Vaccinations — wink, wink?


Since Edward Jenner’s development 200 years ago of a vaccine to counter smallpox, we have come to understand that protecting communities from the needless tragedy of most contagious disease epidemics is simple, clinically reliable, and cost-effective, and has eliminated the spread of virulent, infectious diseases. Modern practices rely on effective vaccines, efficient distribution, and herd immunity, which can drastically reduce or eliminate the spread of disease, and so serves to protect the small part of the population which can’t be protected through immunization.

In order for all this to work, though, scheduled vaccinations need to be maintained throughout the community. It’s not a selective, à la carte decision. Without very high rates of immunization compliance, the system breaks down, and a certain percentage of community members, generally the medically compromised — some children, the frail elderly, and all those without proper immunization — are placed at grave risk. Once contagious disease begins to spread, the resulting epidemics occur quickly and are difficult to stem.

Strategies for successfully containing infectious disease epidemics, which combine basic and population sciences, are surely among the glories of Eastern and Western enlightenment. One can imagine that in most instances, in most parts of the world, people feel hugely relieved when vaccination programs become available, as some of us can remember when polio vaccinations became available. The images etched in our brains of lines of children and adults say it all. Apparently, though, that’s not completely true on Martha’s Vineyard, where the system of community immunization is breaking down.

We get a look at Massachusetts compliance statistics each year about this time when the state’s Department of Health publishes its statistical compilations. Dukes County has by far the highest rates of exemption and incomplete innoculations among children entering kindergarten in the state (8.2 percent, versus a respectable statewide rate of 1.4 percent).

While the rates vary by school across the Island, all Island schools have exemption rates of at least three times the statewide average. Even at the regional high school, where exemptions decline, reflecting the effect of children catching up after a delayed immunization schedule, the rate is still, at 4 percent, well above state averages. There was a modest improvement two years ago, coinciding with a publicity blitz after a major measles scare, but the figures remain unacceptably high.

The frontline management of this important component of our public health compliance process, and the sources of information here on the Vineyard, are the schools — school nurses, and ultimately the superintendent’s office, enforcing state requirements. The school nurses know their students, and communicate regularly with Island physicians and families. And they understand that without near-universal rates of immunization, the system breaks down.

Working with standards written into state law, though, school officials don’t appear to have the tools they need to improve performance. Every enrolled student is accounted for in one of three categories: nonexempt and up to date, in partial compliance, or exempt on either medical or religious grounds (Massachusetts doesn’t allow so-called philosophical exemptions). Every state provides for medical exemptions, for children with cancer or other conditions who could be clinically compromised by vaccinations. These exemptions require physician certification, and are relatively rare, accounting for 0.5 percent of the Island’s total 8.2 percent exemption rate.

The remaining exemptions on the Vineyard — 7.7 percent of the 8.2 percent total — fall into the category of religious exemptions. Since few if any organized religions oppose, or at least unambiguously oppose, vaccinations, it’s not immediately clear where the number of religious exemptions on the Vineyard might come from. For the purposes of public health strategy it doesn’t really matter, though, since all that’s needed to claim a religious exemption is a signed affidavit from parents or guardians stating that vaccinations “violate their sincere religious beliefs.”

There is no test beyond the affidavit, which suggests that the religious exemption may reflect sincere belief, but it is rarely or never about religion. With no provision for philosophical exemption and an exceedingly low bar for religious exemption, it’s clear that these exemptions certainly take advantage of the porous language in the state law.

We shouldn’t expect school nurses and administrators to go where state legislators and public health officials won’t: challenging the viability of clearly personal and idiosyncratic objections, however sincere, in the face of extremely serious community-wide risks. As Matt D’Andrea, school superintendent, told The Times’ Cameron Machell for her story “Vaccination rates on Martha’s Vineyard fall far behind state averages”( “As a school administrator, you want to do what’s best for the students, and you want to keep them safe, and sometimes it’s a fine line that you walk.”

That’s true, and it’s what we would hope for on behalf of individual Island children. But it leaves the public health mission without protection, and that’s not acceptable. The state has promulgated these regulations for good reason but apparently — wink, wink — takes a pass on accepting the political headache of disappointing some parents or interest groups, by writing essentially meaningless and unenforceable rules. Since there’s no provision for philosophical exemptions, nor should there be, Massachusetts should join California, Mississippi, and West Virginia, and eliminate religious exemptions altogether.