County-by-county analysis of vaccine nonmedical exemptions reveals hotspots

[Mr. Bill]

PLOS Medicine, 6/12/18: The state of the antivaccine movement in the United States: A focused examination of nonmedical exemptions in states and counties

... many families choose to opt out their children from vaccinations required for school entry by obtaining nonmedical exemptions (NMEs) based on religious or philosophical beliefs. In 2016, 18 states permitted NMEs due to philosophical beliefs. A detailed analysis of NMEs within each of the 18 states reveals that several counties, including those with large metropolitan areas, are at high risk for vaccine-preventable pediatric infection epidemics. ...

NME data were collected from all 18 states currently permitting philosophical-belief NMEs (Arkansas [AR], Arizona [AZ], Colorado [CO], Idaho [ID], Louisiana [LA], Maine [ME], Michigan [MI], Minnesota [MN], Missouri [MO], North Dakota [ND], Ohio [OH], Oklahoma [OK], Oregon [OR], Pennsylvania [PA], Texas [TX], Utah [UT], Washington [WA], and Wisconsin [WI]). ... VT, CA, MS, and WV were excluded from our analysis because they no longer have NMEs in their respective states. ... The state NME rate is represented by the number of entering kindergarteners with a documented NME out of the total kindergarten enrollments in the state. ...

From our analysis, 12 of the 18 states permitting religious and philosophical-belief NMEs demonstrated an overall upward trend of enrolling kindergarteners with NMEs since 2009: AR, AZ, ID, ME, MN, MO, ND, OH, OK, OR, TX, and UT. ...

Beyond the statewide data, many county-level NME rates were publicly available from state health departments for the school year 2016 to 2017. ...of the 14 states that were analyzed, ID had an abundance of counties with the highest NME rates: Camas (26.67%), Bonner (19.65%), Valley (18.18%), Custer (17.14%), Idaho (16.06%), Boise (15.63%), Kootenai (14.91%), and Boundary (14.61%). WI’s Bayfield County was ranked 6th in overall NME percent (15.70%), and UT’s Morgan County (14.55%) was ranked 10th. ...

Furthermore, we examined total numbers of kindergarteners with NMEs per county to identify focal areas with large numbers of potentially vulnerable pediatric populations. ... They include Phoenix, AZ (Maricopa County); Salt Lake City, UT and Provo, UT (Salt Lake and Utah Counties, respectively); Seattle, WA and Spokane, WA (King and Spokane Counties, respectively); Portland, OR (Multnomah County); Troy, MI, Warren, MI, and Detroit, MI (Oakland, Macomb, and Wayne Counties, respectively); Houston, TX, Fort Worth, TX, Plano, TX, and Austin, TX (Harris, Tarrant, Collin, and Travis Counties, respectively); Pittsburgh, PA (Allegheny County); and Kansas City, MO (Jackson County). The high numbers of NMEs in these densely populated urban centers suggest that outbreaks of vaccine-preventable diseases could either originate from or spread rapidly throughout these populations of unimmunized, unprotected children. The fact that the largest count of vaccine-exempt pediatric populations originate in large cities with busy international airports may further contribute to this risk. ...

...a child with an NME from the measles, mumps, and rubella (MMR) vaccine is 35 times more likely to contract measles than is a vaccinated child. Moreover, a child without the diphtheria, tetanus, and acellular pertussis (DTaP) vaccine is 3 times more likely to contract pertussis than is a vaccinated child. NMEs weaken herd immunity that protects the population at large, particularly children who are unable to get vaccinated for medical reasons. The target vaccination coverage rate to achieve the ideal herd immunity is 90% to 95%, depending on the infectious agent. ...

Heat map of county-level nonmedical exemption rates

[Hurricane]

I don't question the need for, and value of vaccines. The question is, what else is in those shots?

[AvenueQ]

I believe the county I used to live in CO (Jefferson) at one point had the highest national vaccine exemption rate...though it could also have been Boulder county, which was only one county over. Jefferson county has a population of ~400,000, with most of the surrounding counties being similar in size.

I'm a little relieved that Nevada doesn't have this exemption.

[FreeLancer]

California no longer allows NME, but there's enough sleazy/shady/crackpot docs willing to trade medical exemptions for cold hard cash to keep the state's overall exemption rate high. 

[David in MN]

Bad data. I hate to be a broken clock on this stuff but the data assumes that a state that doesn't have the exemption has full immunization. Poppycock. Then they have the guile to use a sliding scale where the highest bracket is 5-30%. Seems a little arbitrary to me and not at all how something should be reported. One would suppose we top out at a 30% county but they fail to report which county it is.

Also, the data only presents "non-medical vaccine exemptions". We are left wanting for total non-vaccinated numbers (which I presume are much higher). We would need data on medical exemptions, unvaccinated immigrants, older people who didn't get the full modern course, etc. For all we know from this data NMEs aren't even the leading cause those not vaccinated.

Feels like scientifically inaccurate fear mongering.

[mountainmoma]

Another very real problem with reporting about vaccination exemptions is that they report all or nothing, and you file an exemption all or nothing. I have done this, if, for example, you decide not to vaccinate the new HPV vaccine, but did vaccinate for MMR, DTP and polio, you would have to file an exemption, and the school would just report the child as "exempt" . Many exempt filers actually have a least some vaccines.

The vaccines required in a given school district may be very different than in another state, it is even possible that parent A complying with requirements in their district and parent B who has not complied have actually chosent to give the exact same vaccines, but that school district B has a few on teh required list that are optional in district A , an both families have decided to avoid that one ! The point is, you dont know much from the map.


Then, the news likes to "report" in the most controversial way possible, and does not even mention the limitations to the data

[mountainmoma]

This is a very politically charged topic, having alot to do with parental rights to choose medical treatment for their children.

And, you can see the divisiveness potential from the comments here. " My opinion is right, and any other ways of looking at this topic is crazy, " that is the message I see on this topic.

[David in MN]

And the data captures those who took the exemption in order to get the shots at 2 years of age rather than 6 months.

Digging through the actual data (I'm a nerd) it's a little worrisome that it got a title about "the state of antivaccine..." because I'm dubious of studies with a conclusion built into the title.

They did do the courtesy of publishing some actual data (rare in medicine these days) and they actually did try to correlate NMEs to kindergarten cases of measles, mumps, and rubella (presuming there would be a link) and reported Spearman correlation of rho=.03. I presume they used Spearman because R squared would have been 0 and even rho=.03 is about as non-linear a response as one could get. They reported it as meaningful, though, which I suppose is a method of reporting unsubstantiated conclusions to an uninformed audience.

The sad (unreported to those who don't speak statistics) truth is that this study offers no actual conclusion and instead of leading with the correlation of NMEs to disease which didn't pan out they fell back on a poorly designed scaremongering "heat map" that offers almost no valuable information and whose methodology could be picked apart by a well informed 5th grader.

Someday math will win out. But not soon.

[surfivor]

And the data captures those who took the exemption in order to get the shots at 2 years of age rather than 6 months.

 Gee, someone questioned medical advice and thought they would use their own judgement after doing some research, can't do that can we

[Mr. Bill]

...the data assumes that a state that doesn't have the exemption has full immunization. ...

That, I do not see.  They merely limited their study to states with the exemption -- hence all the white areas on the map.

I don't much care about their statistical stuff -- it's the locations with lots of unvaccinated kids that interest me.  I'm looking at this as a prepping issue.  If you (or your family members) are susceptible to infection by these diseases (because you can't be safely vaccinated, or because you chose not to get vaccinated, or because you have an immune system problem), it's worth considering whether you really want to live in places like Camas County ID or Maricopa County AZ if you can avoid it.

[David in MN]

I don't much care about their statistical stuff -- it's the locations with lots of unvaccinated kids that interest me.  I'm looking at this as a prepping issue.  If you (or your family members) are susceptible to infection by these diseases (because you can't be safely vaccinated, or because you chose not to get vaccinated, or because you have an immune system problem), it's worth considering whether you really want to live in places like Camas County ID or Maricopa County AZ if you can avoid it.

Again, using the studies own data, the correlation of NMEs to measles, mumps, and rubella is not statistically significant. In other words, NMEs don't drive infections (at least in the parameters of the study). This study suggests that in keeping your kids safe from some diseases NMEs are not a good indicator.

Beyond this, there are multitudes of other possible avenues for disease other than NMEs. I would think living in proximity to a port or busy airport would carry increased risk.

Bottom line, even if you were trying to use this data to make a decision the study itself refutes its value and there are very likely more significant variables.

That, I do not see.  They merely limited their study to states with the exemption -- hence all the white areas on the map.

Yes, they chose to color the states with no data white, But the scale of "danger" goes from pale pink to reddish. This gives the casual viewer the belief that the white states are (on the scale) below .1%. They should have been colored gray and indicated that there is no data in the key. These are sort of red flags to anyone with a statistical background that the results are being massaged to influence the viewer.

[surfivor]

Yea, I don’t know why I get the impression that all the cutting-edge research on vaccine effectiveness is mostly hundreds of years old. We are just told that vaccines work and it matters not what kind of vaccine it is whether smallpox, polio, or whatever they may invent. They just throw them all into the same boat along with flu vaccines. Any thinking person should see a problem there. I also hear claims that vaccines are not really tested for safety

[Mr. Bill]

Chickenpox outbreak in Asheville NC:

11/17/18: School with major chickenpox outbreak has high vaccination exemption rate

...As of Friday, 36 students at Asheville Waldorf School had contracted the varicella virus, known to most as chickenpox. The school has one of the highest vaccination religious exemption rates in the state. ...

...the outbreak at Asheville Waldorf should cause concern, said Dr. Jennifer Mullendore of Buncombe County Department of Health and Human Services.

According to the Centers for Disease Control and Prevention, chickenpox is particularly dangerous to infants, pregnant women those with compromised immune systems, such as people who are HIV positive or coming out of cancer treatment.

"People don't think it's a serious disease, and for the majority of people it's not. But it's not that way for everybody," Mullendore said. Two to three out of every 1,000 children infected with chickenpox required care in a hospital, she said. ...

Those recommendations have by and large have gone unheeded by the parents of Asheville Waldorf's 152 students — 110 of whom have not received the chickenpox vaccine, which was made available in the United States in 1995. ...

American Journal of Public Health, 9/12/18: Weaponized Health Communication: Twitter Bots and Russian Trolls Amplify the Vaccine Debate

...Russian trolls and sophisticated Twitter bots post content about vaccination at significantly higher rates than does the average user. Content from these sources gives equal attention to pro- and antivaccination arguments. This is consistent with a strategy of promoting discord across a range of controversial topics—a known tactic employed by Russian troll accounts. ...

Unlike troll accounts, content polluters (i.e., disseminators of malware, unsolicited commercial content, and other disruptive material that typically violates Twitter’s terms of service) post antivaccine messages 75% more often than does the average nonbot Twitter user. This suggests that vaccine opponents may disseminate messages using bot networks that are primarily designed for marketing. By contrast, spambots, which can be easily recognized as nonhuman, are less likely to promote an antivaccine agenda than are nonbots. ...

Several accounts could not be positively identified as either bots or humans because of intermediate or unavailable Botometer scores. These accounts, together constituting 93% of our random sample from the vaccine stream, tweeted content that was both more polarized and more opposed to vaccination than is that of the average nonbot account. Although the provenance of their tweets is unclear, we speculate that these accounts may possess a higher proportion of trolls or cyborgs—accounts nominally controlled by human users that are, on occasion, taken over by bots or otherwise exhibit bot-like or malicious behavior. ...

Finally, trolls—exhibiting malicious behaviors yet operated by humans—are also likely to fall within this middle range. This suggests that proportionally more antivaccine tweets may be generated by accounts using a somewhat sophisticated semiautomated approach to avoid detection. This creates the false impression of grassroots debate regarding vaccine efficacy—a technique known as “astroturfing”...

[cmxterra]

This..

Ignorance of the science of vaccines is not an argument against them. 

Chickenpox outbreak in Asheville NC:

11/17/18: School with major chickenpox outbreak has high vaccination exemption rate


American Journal of Public Health, 9/12/18: Weaponized Health Communication: Twitter Bots and Russian Trolls Amplify the Vaccine Debate

[Mr. Bill]

When I was a kid in the 1960s, nobody had chickenpox vaccinations, but the virus was always floating around at low levels, and I assume the constant exposure (i.e. natural vaccination) gave us a little bit of immunity.  It would spread around our school now and then, and I caught it eventually.  But we never had a situation like this one in Asheville, where one-third of the unvaccinated students (so far) have come down with the disease at the same time.