issue brief CHILDHOOD IMMUNIZATIONS Mississippi’s Mandatory School Immunization Law PUBLISHED NOVEMBER 2014 Mississippi law mandates that all children attending school must be vaccinated against certain diseases. All states have similar laws but vary in the number and type of exemptions allowed. This Issue Brief summarizes the scientific literature on the safety and efficacy of childhood immunizations, outlines the legal environment for Mississippi’s policies, and examines policy issues related to exemptions. Safety and Efficacy of Childhood Immunizations NUMBER OF CASES IN MISSISSIPPI Vaccines have prevented an estimated 103 million cases of childhood diseases YEARS MEASLES MUMPS since 1924, and nearly 26 million cases in the past decade alone. In the U.S., the 1915-25 163,977 46,702 widespread adoption of immunization practices has been credited with reducing the 1926-35 138,483 46,828 burden of disease. The Centers for Disease Control and Prevention (CDC) reports 1936-45 124,069 74,533 that deaths by smallpox and polio were eliminated over the course of the last century, 1946-55 36,454 9177 and deaths by the other seven vaccine-preventable diseases for which childhood 1956-65 22,231 5,431 immunization is recommended have been drastically reduced as well. In Mississippi, 1966-75 4,550 2,926 similar trends have been detected for vaccine-preventable diseases after the 1976-85 455 310 widespread implementation of immunization programs (See Figure 1). 1986-95 114 * FIGURE 1. INCIDENCE OF SELECTED VACCINE-PREVENTABLE DISEASES, MISSISSIPPI (1915-2013) 1996-05 0 61 2006-13 0 8 180 Measles YEARS POLIO PERTUSSIS 160 Mumps* NUMBER OF CASES (IN THOUSANDS) 1915-25 769 104,057 Pertussis (Whooping Cough)* 140 Polio* 1926-35 395 109,876 1936-45 1,089 91,868 120 1946-55 3,725 9,734 100 1956-65 490 1,475 1966-75 0 231 80 1976-85 0 99 60 1986-95 * * 40 1996-05 0 151 2006-13 0 769 20 * Data not available 0 995 005 013 925 935 945 955 965 975 985 VACCINE INJURY REPORTING & COMPENSATION In recognition that adverse events do occur, 6-1 6-1 6-2 6-2 5-1 6-1 6-1 6-1 6-1 6-1 Congress enacted the National Childhood 197 198 199 200 191 192 193 194 195 196 Vaccine Injury Act (NCVIA) of 1986 which required the establishment of the Vaccine Adverse BY TEN YEAR INCREMENTS Event Reporting System (VAERS) to ensure that * Data not available from 1985-1995 vaccine safety is monitored and established the Source: Mississippi State Department of Health, Office of Epidemiology. (2014). See Sidebar: “Number of Cases in Mississippi” for detailed data. Vaccine Injury Compensation Program (VICP) to compensate individuals for injury caused A recent comprehensive review of 67 different studies on the safety of vaccines by vaccines. As of January 2011, the VICP had examined adverse events associated with childhood immunizations and concluded awarded compensation of more than $2.1 billion that these events were extremely rare and absolute risk was low. to more than 2,500 families and individuals. 1 of 4 Center for Mississippi Health Policy � Issue Brief: Childhood Immunizations­— Mississippi’s Mandatory School Immunization Law � NOVEMBER 2014 State Mandates and Exemptions HERD IMMUNITY Laws and ordinances requiring vaccination date back to 1827. Measles outbreaks Prevention of vaccine-preventable diseases in a population relies on the development in the 1960s and 1970s prompted those states without school vaccination laws of a minimum level of shared immunity in the to enact them. By 1980, all states had mandatory school immunization laws. community, commonly referred to as “herd immunity.” Mandatory vaccination policies are intended to protect a community from disease The concept is based on the fact that no vaccine is 100 percent effective at preventing disease, and by ensuring a sufficient level of immunity necessary to disrupt the transmission of that some vaccines cannot be given to people with the disease, a concept known as “herd immunity” (see sidebar). conditions that affect their immune systems (e.g. measles vaccine is contraindicated in children Exemptions from vaccine requirements vary by state. All states allow medical with poor immunity due to cancer). Herd immunity is established if enough members of a community exemptions, with different degrees of administrative requirements. Nineteen states are vaccinated so as to protect those members who allow philosophical exemptions. All states but two (Mississippi and West Virginia) either failed to develop immunity from a vaccination or were unable to be vaccinated due to age or medical allow religious exemptions. condition. Herd immunity also prevents sustained transmission, rapidly causing outbreaks to subside. Mandatory Immunization in Mississippi HERD IMMUNITY THRESHOLDS FOR Mississippi law (§41-23-37) requires that a child be vaccinated against those SELECTED VACCINE-PREVENTABLE DISEASES diseases specified by the state health officer before attending school, unless the child has a certificate of exemption for medical reasons. The law applies to children DISEASE THRESHOLD attending public and private schools, with the exception of a home school program DIPHTHERIA 85% as defined in state law. The immunization requirements defined by the state health officer are based on the recommendations of the national Advisory Committee on MEASLES 83-94% Immunization Practices (ACIP). State law further requires that schools certify to the State Department of Health that all children enrolled are in compliance with MUMPS 75-86% immunization requirements. PERTUSSIS 92-94% The Mississippi State Department of Health (MSDH) recommends, but does not POLIO 80-86% require, that vaccinations be given at intervals advised by the ACIP schedule. RUBELLA 83-85% Parents and caregivers may work with their health care provider to schedule immunizations as they wish, as long as the child is immunized prior to school entry. SMALLPOX 80-85% Children who are home-schooled and not attending a licensed child care center Source: Centers for Disease Control. Slide presentation: are not required to be immunized. History and epidemiology of global smallpox eradication. Retrieved 10/14/14 from: www.bt.cdc.gov/agent/smallpox/ Mississippi law allows exemptions only for medical reasons. The state health training/overview/pdf/eradicationhistory.pdf officer has ultimate authority to judge if an exemption “will not cause undue risk to the community.” In 2012, MSDH adopted a policy to accept any medical exemption VACCINE-PREVENTABLE DISEASES for any medical reason if the request was submitted by a Mississippi licensed TARGETED BY IMMUNIZATIONS REQUIRED FOR SCHOOL ENTRY IN MISSISSIPPI (2014-15): primary care physician. All such requests have been granted following verification • Diphtheria of proper submission. This process requires a letter to be submitted to MSDH from • Tetanus a primary care physician licensed by the state of MS that lists a medical reason for • “Whooping cough” (acellular pertussis) • Polio the exemption and a list of vaccines to be exempted, along with the duration of the • Hepatitis B exemption. The number of exemptions granted in the state for the past three years • Measles • Mumps were as follows: 106 (2011-2012), 109 (2012-2013), and 121 (2013-2014). • Rubella • Chicken pox (varicella) Impact of Exemptions ADDITIONAL DISEASES TARGETED BY One of the central tensions in the debate over mandatory immunization policy IMMUNIZATIONS REQUIRED FOR ENROLLMENT IN A LICENSED CHILD CARE FACILITY (2014-15): arises when the public health benefit of immunizing children conflicts with the • Meningitis desire of parents who want more control over their child’s medical care. These • Pneumonia parents argue that the absence of a philosophical exemption does not allow parents the choice to opt out of a requirement which they believe may put their child at risk for injury. 2 of 4 Center for Mississippi Health Policy � Issue Brief: Childhood Immunizations­— Mississippi’s Mandatory School Immunization Law � NOVEMBER 2014 The number of requests for nonmedical exemptions from immunization requirements has been increasing nationwide, leading to concern in the public health community of greater risk for disease outbreaks. A 2012 study comparing types of exemptions showed that states that allowed philosophical exemptions experienced nonmedical exemption rates two and a Communities with low immunization rates have half times higher than rates of nonmedical exemption experienced a resurgence of vaccine-preventable in states that allowed only religious exemptions. A diseases across the world. relationship has also been established between the ease of obtaining an exemption and the increase of disease risk in a community. Communities with low immunization rates have experienced resurgence of vaccine-preventable diseases across the world. An analysis of bills introduced in state legislatures between 2009 to 2012 related to personal belief exemptions showed that all proposals to expand exemptions failed, and the majority of legislation to restrict exemptions passed. MISSISSIPPI SUPREME COURT DECISION, BROWN V. STONE (1979) a landmark ruling on childhood immunization requirements The precedent for Mississippi’s The Court’s strong stance upholding the law is summarized by their recognition of the current school immunization law, evidence in support of the efficacy of immunization: which allows for only “The fundamental and paramount purpose of the Mississippi Legislature in the medical exemptions, can be found enactment of...Mississippi Code Annotated section 41-23-37 was to afford protection in Brown v. Stone, a 1979 state for school children against crippling and deadly diseases by immunization. That Supreme Court case in which this can be done effectively and safely has been incontrovertibly demonstrated over a the Court ruled that the religious period of a good many years and is a matter of common knowledge of which this court exemption in Mississippi statute was takes judicial notice.” unconstitutional. The Court concluded that this purpose served an “overriding and compelling public interest” The Court reasoned that a religious and further stated: exemption would violate the “The protection of the great body of school children attending the public schools in Fourteenth Amendment since it Mississippi against the horrors of crippling and death resulting from poliomyelitis or would “require the great body of smallpox or from one of the other diseases against which means of immunizations are school children to be vaccinated and known and have long been practiced successfully, demand that children who have not at the same time expose them to been immunized should be excluded from the school community until immunization the hazard of associating in school has been accomplished...To the extent that it may conflict with the religious beliefs with children exempted under the religious exemption who had not been of a parent, however sincerely entertained, the interests of the school children must immunized.” prevail. [The law] is a reasonable and constitutional exercise of the police power of the state insofar as it provides for the immunization of children before they are to be Because these same points would permitted to enter school.” apply to a philosophical exemption, it is likely that a challenge based on Continuing this logic, the Court concluded: personal beliefs would be viewed by “Therefore, we hold that the provision providing an exemption from the operation the courts similarly. of the statute because of religious belief is in violation of the Fourteenth Amendment to the United States Constitution and therefore is void.” 3 of 4 Center for Mississippi Health Policy � Issue Brief: Childhood Immunizations­— Mississippi’s Mandatory School Immunization Law � NOVEMBER 2014 Summary All states have mandatory child immunization laws requiring vaccination against selected diseases before school entry. Mandatory school immunization laws are based on the concept that a sufficient proportion of children must be immunized in order to protect persons who either failed to develop immunity from a vaccination or were unable to be vaccinated due to age or medical condition. All states allow medical exemptions from this mandate, all but two allow religious exemptions, and nineteen allow philosophical exemptions. Because Mississippi’s Supreme Court ruled in 1979 that a religious exemption was unconstitutional, Mississippi only allows medical exemptions. Approximately one hundred medical exemptions are granted annually by the Mississippi State Department of Health. There is a direct relationship between the ease of obtaining an exemption and the risk of resurgence in vaccine-preventable diseases. The nationwide trend in state legislative actions since 2009 has been to restrict exemptions. Vaccinations are generally delivered according to a schedule recommended by the national Advisory Committee on Immunization Practices. The actual schedule followed, however, is at the discretion of the parents and their child’s health care provider, as long as the child is immunized prior to school entry. References For a full list of references and other resources, please visit: www.mshealthpolicy.com/immunization-law Plaza Building, Suite 700 120 N. Congress Street Jackson, MS 39201 Phone 601.709.2133 Fax 601.709.2134 www.mshealthpolicy.com 4 of 4 Center for Mississippi Health Policy � Issue Brief: Childhood Immunizations­— Mississippi’s Mandatory School Immunization Law � NOVEMBER 2014