The number of N.C. kindergarteners opting out of required childhood vaccinations on religious grounds more than doubled in the five school years from 2012 to 2016. And both public health officials and anti-vaccine advocates agree that the exemption is being claimed by parents whose true objection to the shots has nothing to do with faith.
“I’ve had parents tell me they use it because there is no way for the state to decline it,” said Sen. Jeff Tarte, a Republican from Mecklenburg County. In 2015, he introduced a bill that would have eliminated the religious exemption for all children except those who are homeschooled. He and his co-sponsors dropped the bill within two weeks because of opposition from those who say the government should not force anyone to be injected with anything.
Tarte has two concerns about the growing use of the religious exemption:
▪ Because North Carolina doesn’t allow exemptions based on personal or philosophical beliefs, some parents who don’t want their children vaccinated essentially have to lie, claiming a religious objection that doesn’t exist.
▪ But the bigger issue, Tarte said, is that the exemption is allowing the number of unvaccinated children in the schools to rise each year, making outbreaks of preventable diseases more likely.
Since late November, Henderson County in Western North Carolina has seen 20 cases of pertussis, or whooping cough, and has identified another 1,000 people who had close contact with one of the patients. The outbreak of the potentially fatal respiratory illness started in the schools, the county said, and most of those who have fallen ill had been immunized, demonstrating that vaccines are not 100 percent effective. Health officials say that without the vaccine, those who get the illness might be sicker longer.
Dr. Wendy Sue Swanson, a pediatrician, mother and spokesperson for the American Academy of Pediatrics, offers some answers about the safety and efficacy of the MMR vaccine.
The anti-vaccine view
Anti-vaccine activists say outbreaks may happen among unvaccinated populations, but they believe the health risks from vaccines are greater than the risks posed by the diseases the shots are designed to prevent.
“Parents are waking up,” said Maren Caldwell, who volunteers with People Advocating Vaccine Education, a Charlotte-based nonprofit. From her home in Johnston County, Caldwell shares information with parents trying to decide whether to have their children injected with the 23 doses of vaccines now required for every kindergarten-age child in the state, plus six more needed for enrollment when the child gets to seventh grade.
If parents choose not to vaccinate, Caldwell tells them North Carolina offers two exemptions: medical and religious. A medical exemption requires a doctor’s certification that a vaccine could harm the child’s health, as in the case of a child with a compromised immune system. Each request for a medical exemption must be approved by the state.
Of 126,000 to more than 130,000 children entering kindergarten across the state each school year from 2012 to 2016, fewer than 180 were medically exempted from getting their shots.
To claim a religious exemption, a parent needs only to write a statement “of the bona fide religious beliefs and opposition to the immunization requirements,” and give it to the child’s school in place of an immunization record, according to state law.
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The statement doesn’t need to be prepared by an attorney, signed by a religious leader or notarized. No form is needed. The statement doesn’t go to the state for review or approval.
Alan Phillips, an Asheville-area lawyer who counsels parents all over the nation on how to exempt their children from vaccine requirements, said that, under the N.C. rules, “You don’t even have to believe in God.”
In 2012, at least 871 children entered kindergarten in North Carolina with religious exemptions to vaccinations. The number rose each of the next four years, and in 2016, at least 2,073 kindergarteners avoided vaccinations under the religious exemption.
If all those children remain in North Carolina schools and still have not been vaccinated, that means at least 6,416 students are now enrolled in kindergarten through fourth grade in the state who have not been immunized for religious reasons. Thousands more are likely still enrolled in higher grades who never got the required shots.
The annual numbers may be slightly higher because not all schools reported the data to the state Department of Health and Human Services, though they are required to do so. Numbers for the 2017-18 academic year are not yet available.
Combined with the children who received medical exemptions, the total number of reported exemptions in academic 2016-2017 – with 88 percent of schools reporting – was 1.8 percent of the statewide kindergarten enrollment, up from 1.1 percent the year before. The national average for exemptions is 2 percent, according to the U.S. Centers for Disease Control and Prevention, which monitors vaccination rates nationwide.
‘Good for society’
Health officials use education campaigns in the hope that more than 95 percent of parents will immunize their children and achieve community protection, sometimes called “herd immunity.” The immunization rate needed to achieve the protection varies by disease, based on how contagious it is. Pertussis and measles spread easily and quickly; polio doesn’t travel quite as fast.
The more contagious a disease is, researchers say, the more people need to be immunized against it to stop it.
“Immunization is something we do that is good for society,” said Dr. David Weber, a professor in the UNC School of Medicine and director of UNC Hospitals’ departments of Hospital Epidemiology and Occupational Health Service. “There is a small risk to it, because nothing in life is completely risk free. But we do it because it benefits all of us.”
Some children, such as those fighting leukemia, HIV, or who have certain heart conditions or recent organ transplants, can’t tolerate vaccines. But if everyone around that child is vaccinated, the chance of the child being exposed to vaccine-preventable diseases is greatly reduced.
“We call it cocooning,” he said.
In the event of an outbreak within a school, state law requires that unvaccinated children stay out for 21 days to prevent the disease from spreading.
The notion of introducing a version of a pathogen into a person’s bloodstream to prompt their immune system to develop antibodies against it dates back to at least 1796. Today, vaccines are used to protect against dozens of diseases. Public health officials say vaccines have saved millions of children from death or disability caused by once-common illnesses. Vaccines are widely supported and are available at low or no cost with insurance or through public health clinics.
Vaccination rules vary by state, and states add or subtract required vaccines as health officials deem prudent. North Carolina requires children to be inoculated against diphtheria, tetanus, pertussis, polio, measles, mumps, rubella, haemophilus influenza type B (Hib), hepatitis B and chicken pox.
‘Diseases are beneficial’
As the list of required vaccines grows, so does objection to the shots.
“I feel like diseases are beneficial in boosting the immune system,” said Lisa Jillani, who founded PAVE in 1996. She thinks the older of her two daughters developed symptoms of autism as a result of vaccines she received as a young child. Jillani didn’t take her daughter for the last shots she was required to have, and she never immunized her second daughter at all.
Jillani says that, as a Christian, she felt guided by God in the decisions she made for her girls, including using the religious exemption to avoid required vaccinations and instructing other parents that they have the same right. She has a template on her group’s website that parents can use to craft their exemption statements.
Jillani acknowledges that some parents claim the religious exemption when their rationale has more to do with concerns over the safety or efficacy of vaccines.
“But I don’t feel like it’s my place or the state’s place to stand by and question their motives,” she said. “I believe we have the constitutional right to make our own health care choices, whether the state says so or not.”
Jillani said she has told parents that if they can’t get a medical exemption and don’t have a bona fide religious objection to vaccines for their children, they need to go to work on getting the N.C. General Assembly to approve a personal or philosophical exemption.
Dr. Kelly Kimple, chief of Women’s and Children’s Health at N.C. DHHS, continues to try to convince people not to seek an exemption, but to learn the dangers of childhood diseases. Parents have become complacent, she said, either because they survived childhood illnesses that are now largely avoided through vaccines, or they have never seen the illnesses and don’t appreciate the harm they can do.
“We want to communicate the danger of the disease without having to live through it,” Kimple said.
The ongoing pertussis outbreak has alerted some people in Henderson County to the risk of that illness, which is considered especially dangerous for infants.
With cases still being confirmed, county spokeswoman Kim Horton said Thursday that the health department has been getting a lot of calls.
“More people are coming in to get the immunization,” Horton said, “and more people are calling to check their records and make sure they’ve had the shot.”
Religious exemptions to N.C.’s kindergarten immunization requirements:
2012-13: 871 religious exemptions out of total kindergarten population of 130,612.
2013-14:1,105 out of 126,084.
2014-15:1,127 out of 129,792.
2015-16:1,240 out of 128,290.
2016-17: 2,073 out of 126,454.
Source: N.C. Department of Health and Human Services
To prevent vaccine-makers from being subjected to lawsuits that might devastate the industry, the United States in the 1980s established the National Vaccine Injury Compensation Program, funded by a surcharge on every vaccine dose sold. The federal Health Resources and Services Administration says that more than 80 percent of the payments awarded by the fund are the result of settlements in which the government has not concluded that a vaccine caused the injury.
Anti-vaccine activists say vaccine injuries are vastly underreported.
Parents who oppose vaccines for children say the risk of death or permanent disability from a childhood illness in the United States is smaller than the risk of injury from the growing list of required vaccines. They are concerned about additives such as thimerosal, formaldehyde and aluminum salts, and about the use of bovine products in vaccines.
Parental pushback against childhood vaccines increased dramatically during the 1990s when case reports suggested a connection between autism and the measles-mumps-rubella vaccine. In 1998, British Medical Journal The Lancet published a study by Dr. Andrew Wakefield suggesting that the triple-vaccine was connected to autism-spectrum disorders.
The Lancet fully retracted the study years later, after the British General Medical Council found Wakefield had been dishonest and unethical in his research. Many studies have been done since that failed to find a connection between vaccines and autism.
While acknowledging some problems throughout U.S. vaccine history, the government maintains that vaccines are safe and continue to improve. According to the Centers for Disease Control and Prevention, the risk of severe allergic reaction from the MMR, hepatitis B, diphtheria, tetanus and pertussis vaccines is 1 or less than 1 out of a million doses. The mainstream medical community overwhelmingly supports childhood vaccines as a way to reduce the risk to the public from avoidable disease.