From Meryl Nass:
You asked me for the evidence that children who are currently exempted from vaccinations due to a medical exemption, such as previous treatment for cancer, bone marrow transplant, immune deficiency, or an autoimmune or rheumatologic disease such as systemic lupus erythematosus could, under the new rules, be forced to be vaccinated to attend school. See newest version of CDC recommendations in Table 4-1 and Table 4-2 “Conditions incorrectly perceived as contraindications or precautions to vaccination (i.e., vaccines may be given under these conditions)” of ACIP General Best Guidance for Immunization: Contraindications and Precautions
Children with immunodeficiencies (unless severe), autoimmune and rheumatologic diseases are now recommended for vaccinations. Most medical waivers are to be considered temporary. For children who have had severe reactions to previous vaccines (such as a seizure or ‘collapse or shock-like state’ after DTaP vaccination), they must now receive additional doses of the vaccines to which they reacted, because these adverse reactions were insufficiently severe. (See 2nd item in Table 4-2.) Children with autoimmune and rheumatologic diseases are supposed to receive vaccines, as are immune deficient children, unless their deficiency is rated severe.
While S2359 language is not specific about the medical criteria for exemptions, CDC guidelines for exemptions to vaccination are rapidly evolving and narrowing. Most Vaccine Information Statements (VIS’s) that are required to be given to parents before vaccinating their children, were changed on Aug 15, 2019 and October 30, 2019 and are still listed as “interim”. I sent you scans of the the ‘before’ and ‘after’ VIS’s for Polio vaccine with my testimony; I also gave you the URL for all the VIS statements in my testimony. It provides the dates and information on every revision to the VIS documents.)
(h) The department may add additional elements to the exemption application forms described in subsections (f) and (g).
(j) The department shall have the exclusive authority to approve or deny exemption applications…For medical exemption applications, the department shall approve all validly and accurately completed medical exemption applications; provided, however, that a generally accepted contraindication is the medical condition justifying the exemption. If another medical condition or set of conditions is provided as justification for the exemption, the department may approve or deny the exemption application based on a review by an expert licensed provider of the stated justification, or request more information about the participant’s medical history in order to make its determination.
1. Note that an “expert licensed provider” (a nurse practitioner or PA, perhaps, whose scope of practice requires them to follow guidelines) being paid by the state, and who is not the child’s medical provider, probably won’t have discretion regarding exemptions and will likely use the CDC guidelines.
2. Look at how few “generally accepted contraindications” CDC allows. See the language below in Chapter 4 of CDC’s recommendations to health care providers regarding medical exemptions, particularly Table 4-2:
Contraindications and Precautions https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/contraindications.pdf#page=5
Major changes to the best practice guidance in this section include 1) enhancement of the definition of a “precaution” to include any condition that might confuse diagnostic accuracy and 2) recommendation to vaccinate during a hospitalization if a patient is not acutely moderately or severely ill.
Contraindications (conditions in a recipient that increases the risk for a serious adverse reaction) and precautions to vaccination are conditions under which vaccines should not be administered. Because the majority of contraindications and precautions are temporary, vaccinations often can be administered later when the condition leading to a contraindication or precaution no longer exists. A vaccine should not be administered when a contraindication is present; for example, MMR vaccine should not be administered to severely immunocompromised persons (1). However, certain conditions are commonly misperceived as contraindications (i.e., are not valid reasons to defer vaccination).
Severely immunocompromised persons generally should not receive live vaccines (3). Because of the theoretical risk to the fetus, women known to be pregnant generally should not receive live, attenuated virus vaccines (4). Persons who experienced encephalopathy within 7 days after administration of a previous dose of pertussis-containing vaccine not attributable to another identifiable cause should not receive additional doses of a vaccine that contains pertussis (4,5). Severe Combined Immunodeficiency (SCID) disease and a history of intussusception are both contraindications to the receipt of rotavirus vaccines (6)…
Hospitalization should be used as an opportunity to provide recommended vaccinations.
For patients who are deemed moderately or severely ill throughout the hospitalization, vaccination should occur at the earliest opportunity (i.e., during immediate post-hospitalization follow-up care, including home or office visits) when patients’ clinical symptoms have improved. A personal or family history of seizures is a precaution for MMRV vaccination; this is because a recent study found an increased risk for febrile seizures in children 12-23 months who receive MMRV compared with MMR and varicella vaccine (36)…
Clinicians or other health-care providers might misperceive certain conditions or circumstances as valid contraindications or precautions to vaccination when they actually do not preclude vaccination (2) (Table 4-2). These misperceptions result in missed opportunities to administer recommended vaccines (37).
1. The proposed policy for exemptions can be restricted or changed at any time and is likely to follow CDC guidance.
2. The Department will supersede all treating physicians in the granting of medical exemptions.
3. Most contraindications and precautions are now deemed temporary. So, for example, a child with a bone marrow transplant receives intense immune-destroying treatment immediately before and after the procedure, but subsequently, after a period of months, usually requires less immunosuppression. Probably then vaccinations will be advised.
4. Children are to vaccinated during hospitalizations. This has been the case for adults with flu and pneumococcal vaccines for about 10 years. The process involves a “standing order” signed by one physician in the hospital. Then, children can be vaccinated by nurses IN THE ABSENCE OF AN ORDER FROM THE TREATING PHYSICIAN, AND USUALLY WITHOUT THE PHYSICIAN BEING AWARE OR APPROVING.
5. Severely immunocompromised persons can now received “killed” vaccines.
6. Just one example: For DTaP (children receive 5 doses by age 5) even when seizures have occurred after a prior dose, when the child has a chronic seizure disorder or has a severe neurologic condition — these are no longer considered contraindications to vaccinations, as long as the neurologic condition has ‘stabilized’. See 4-2 chart listing contraindications:
7. “Severely immunocompromised persons generally should not receive live vaccines”. This suggests that unless severely immunocompromised, immune compromised children can receive all vaccines. It further implies that severely immunocompromised children can receive all “killed” vaccines, avoiding only those that are live. This will surprise parents of these children.
8. Pregnant women may receive all “killed” vaccines except polio, which include influenza and TdaP, despite the fact that these vaccines have never been approved by FDA for use in pregnancy, and there is reasonable evidence that they are not safe.
9. Most immune compromised children do not receive a diagnosis until after they have had multiple infectious disease episodes; by this time they will already have received the bulk of their required vaccinations. This is why treating physician discretion is so important in determining fitness for vaccination in “sickly” babies and young children who have not gotten their diagnosis yet.
10. IMO this is not a problem that can be solved by altering the language in the Massachusetts bills. Even if wide medical exemption criteria are specifically allowed this year, there is nothing to stop a narrowing of medical exemptions in future. That is exactly what happened in California. Broad medical exemptions were retained in 2015’s vaccine mandate bill. They were significantly narrowed in 2019.