Vaccine Exemptions: Conference Call with Richard Pan MD and Paul Offit MD --Pt 1

Edited to give credit where credit is due:

The conference call was hosted by Amy Pisani of Every Child by Two.  I was invited to the call by Christine Vara of Shot of Prevention.

This afternoon (July 24, 2012) I had the distinct pleasure of being on a conference call with Richard Pan MD (who is also a California state representative) and with Paul Offit MD, who is perhaps the US's leading advocate for vaccine safety and efficacy.  The call focused on vaccine exemption issues.

What follows is not a word-for-word transcription (that will be posted at Shot of Prevention) but the gist of Dr. Pan's and Dr Offit's comments. Part 1 will focus on Dr. Pan; Part 2 will be Dr. Offit's remarks. Any mistakes or inaccuracies are solely my own.

Dr. Pan spoke on the bill he introduced, AB 2109, which is a very simple bill.  If a parent wishes to  send her child to school without the required vaccines, the parent must document having had a face-to-face conversation about vaccine risks and benefits with a health care provider.  

That's it.  That's all.  It doesn't take away "parent choice" or "force parents into a relationship" or any of the other specious objections the anti-vaccine forces, lead by NVIC and the Canary party, have ginned up.

California's current Personal Belief Exemption law is one of the most lax in the nation. All a parent has to do is to merely sign the back of the school immunization form, attesting that their personal beliefs means their children are exempted from vaccines.

This is the extent of the exemption process.  Click to enlarge:

That's it: one or two parental signatures, depending on the district.

Going back to the conference call: Pan is a pediatrician and made the case that vaccines are the #1 health care advance of the last two centuries.. His experience as a pediatrician led to two insights: (1) Parents are frightened by the misinformation that is more easily available than accurate information, and (2) the value of vaccination is difficult for the current generation of parents to percieve, because they don't have the personal experience of the misery of mumps and measles (for example).  The current generation tends to undervalue the benefit of vaccines.  And for everyone, it's hard to appreciate the value of a negative -- that vaccines prevent infection.

In Pan's experience, most parents who are vaccine refusers do so because they are uncertain about the risks and benefits of vaccines, not because they are hard-core anti-vaccinationists.  The fence-sitters and the hesitant, provided with answers to their questions and fears, nearly often choose to vaccinate.

On the internet, there is a raft of misrepresentation and confusion about vaccine safety and efficacy; it is easier to find misinformation than accurate information. Pan specifically named Jenny McCarthy as a promoter of vaccine misinformation.  Pan felt very strongly that face-to-face conversations between a health-care provider and a family is necessary to dispell the family's fears.  One of the anti-vax talking points is "informed choice".  Pan countered that  the counselling gives parents truly informed choice. 

In his closing remarks after his presentation, Pan spoke of what he has learned from experiencing the fervor of the anti-vaccination movement.  Many of the anti-vaccine folks have been vociferous.   He went on to comment on celebrity opposition to AB 2109, The celebrities didn't do as much research as they might have; they really misrepresented vaccines.  

(Dr Pan is being polite. ToddW at Harpocrates Speaks demolishes the anti-AB 2109 talking points  and demonstrates anti-vax hypocracy about informed consent. Orac at Respectful Insolence has covered AB 2109 rather thoroughly, in Real Informed Consent; Despite the Anti-vax Movement, AB 2109 Moves On;  The Latest Celebrity Antivaccinationist Makes a Fool of Himself; and School Vaccine Mandates: The Nuremburg Code.  One of the speakers against AB 2109 at the Senate Health Committee hearing was Julian Whitaker, MD.  Recently, the noted skeptic Steven Novella MD debated Dr. Whitaker over the safety and efficacy vaccines. Dr. Novella easily refuted each of Dr. Whitaker's tropes and canards. (So much so that some fun was later had.) Later Orac came back with Dr Whitaker Responds.)

Later in the conference call, there was opportunity for questions and answers.  

Russell Saunders MD, who is a pediatrician, commented that he has not had Pan's success with converting the vaccine hesitant. 

Pan responded with three points:  

1. There is evidence that the conversation requirement will make a difference: the data from Washington State, which enacted a similar law last year.  After just one year, vaccine exemption rates dropped from about 6.2% to 4.5%.
2. Fence sitters can be persuaded.  Pan's experience is that the vaccine-hesitant have been highly underestimating vaccine benefits and exaggerating the risks.   For these reasons, a hand-out isn't good enough.  Parents need and deserve a face-to-face conversation with a knowledgable health-care provider, with ample opportunities for parents to ask the questions they may have and to express their fears.
3. Sometimes parents who currently have personal belief exemptions (PBE) aren't actually  vaccine refusers or vaccine hesitant at all.  The PBE is a matter of convenience not conviction.  These kind of parents have experienced some kind of barrier to on-time vaccination, such as not havingtime for vaccine visits, financial difficulty, or other kinds of access barriers.  California's form is so easy, compared to getting the student's shots up to day money etc. access.  You might say these are vaccine refusers   by convenience.

One of the things that has bothered me about AB 2109 is that it doesn't really specify what kind of information needs to be shared with parents.  I asked Dr. Pan why the bill did not specify a curriculum, or if there would be a curriculum developed.

Dr. Pan responded with points I hadn't given enough consideration: that what works best in converting vaccine-hesitant parents to vaccine-accepting parents is a conversation that is unique to each set of parents.  While there will be common questions and fears, the real issue is to develop more trust and communication between the parent and the health care provider.  

(Later, a friend from the California Immunization Coalition suggested that when the bill passes,  the California Department of Public Health would likely develop a list of resources similar to that developed by the State of Washington.  Here's a copy of the Washington exemption form.   Here's a more robust form developed by the Immunization Action Coalition.)

Shannon Rosa asked a question of both Dr. Pan and Dr. Offit, about helping autism parents to understand that vaccines do not cause autism.  Dr. Pan spoke about taking parents' vaccine safety concerns seriously.  When the question of the MMR being causal in autism came up, the question was addressed by serious research, with multiple studies in multiple countries.  When the notion of thimerosal being causal in autism came up, again parents' concerns were taken seriously with multiple large-scale studies.  This huge research investment indicates how seriously the medical establishment takes vaccine safety.

Edited to add: two questions from the Moms Who Vax team, Karen Ernst and Ashley Shelby

 Karen Ernst  asked Dr. Pan about CA AB2109, specifically about the language and how parents were to report that they had had an interaction with a doctor.

Ashley Shelby  asked why naturopaths were included on the list.

The questions arose because Ernst and Shelby, who live in Minnesota, would like to have Minnesota's exemption law be strengthened.  Currently, exemptions only have to be notarized, and even that was threatened this year by an anti-vaccine legislator.

Dr. Pan responded to both questions.  The language was intentionally vague, as  the anti-vaccination activists had both attacked the language of the bill as it stands, and had submitted their own proposed amendments with more specific language.  As to the naturopaths, the bill allows only naturopaths who are practicing under the direction of a licensed MD.

At the end of the call, Dr. Pan brought up another anti-vaccination talking point, the so-called issue of "parental rights" -- in other words, parents' rights to direct their childrens'  medical care.  Pan indicated that vaccine advocates shouldn't let that assertion pass unchallenged. He called for vaccine advocates to vigorously present the opposing view: That parental rights end with the parents' own child.   Parents who refuse vaccination for their children are making choices for other people and their children--those too young to be vaccinated, those who cannot be vaccinated, those who are immune-compromiased.  These people have a right to health that vaccine-refusing parents endanger. 

Next I will post on Dr. Offit's remarks, on how the language we use for describing school vaccine exemptions is inaccurate and misleading.

Edited to add Shannon Rosa's tweet stream

Shannon Rosa @shannonrosa Listening to Amy Pisani, exec director of Every Child By Two, about vaccine exemptions affecting our national public health. #vaxfax

Shannon Rosa @shannonrosa Every Child By Two works with orgs nationwide to ensure our kids are vaccinated against vaccine-preventable disease #vaxfax

Shannon Rosa @shannonrosa Will be hearing from Dr. Richard Pan, pediatrician and state legislature member, on CA AB 2109, on tightening vaccine exemptions. #vaxfax

Shannon Rosa @shannonrosa Dr. Pan speaking now. Been in pediatric practice for over 10 yrs feels vaccinations = 1 of our century's most important pub health advances.

Shannon Rosa @shannonrosa Dr. Pan: Have vaccines been too successful? Parents no longer understand the consequences of vaccine-preventable disease, haven't seen them.

Shannon Rosa @shannonrosa And then there's the Internet and Jenny McCarthy, promoting theories like vaccine- #autism causation that have been widely debunked.

Shannon Rosa @shannonrosa Parents come into his office after being scared by woo, but emphasizing benefits of vaccines is hard because evidence = lack of infection.

Shannon Rosa @shannonrosa When parents have a chance to sit down with a health care professional, they generally make the right decision re #vaxfax.

Shannon Rosa @shannonrosa So AB 2109 says that if you want to send your child to school unvaccinated, you have to have a conversation with a health care prof. 1st.

Shannon Rosa @shannonrosa AB 2109 is about *ensuring* informed choice, so they understand broader effects of not vaccinating. #vaxfax

Shannon Rosa @shannonrosa Vaccination rates are falling below herd immunity rates because of ant-vaccination scare-mongering. AB 2109 aims to counter that

Shannon Rosa @shannonrosa AB 2109 will be on CA Governer's desk but the end of this session, unfortunately celebrity anti-vaccination folks are muddying waters.

Comments

[Alice]

But this is not as simple as you portray. If it were the whole bill would not be necessary. We already know that some of the best doctors risk careers and reputation to tell the truth. You are suggestioning a silent (but loud) use of coercion against the doctors who know more than the usual chapter or two med school taught them (the recent pulling of the Merck cover up article by WSJ is disconcerting...where does one find full disclosure? Not at the government mandated clinical trial site where only 22% of trial data is uploaded....although, Cochrane Collaborative is trying). And your heralding of Mr. Offit left an important fact off his intro....you really need to let readers know about his dog in the race....money....tons of it. Not just on one shot...but the whole tree...he is just a branch...a highly controversial branch.

My daughter was harmed by a negligent doctor at
Cleveland Clinic, and cancer spread from the delay in treatment. He was cited...I did not sue...but what I learned about peer reviews and the so called medicinal "veil" of secrecy, ambition, and money.....left me disillusioned...but much better able to maneuver the "system". Knowing patients are using the Internet the same way doctors use their careers....sometimes it helps mankind...sometimes selfishly....and sometimes with great risk you help others.

Offit an altruistic? Okay....we'll go with that for now:)

[Liz Ditz]

Oh dear. Alice hits some of the anti-vaccine talking points.

Referring to Dr. Offit as "Mr."? Check. Smearing him with the pharma shill brush? Check.

And the obsession with ellipses instead of proper punctuation? Check (although I have no idea why that is so popular with anti-vaxxers, but it is).

Alice's "argument" (if you can call it that) is that (1) she feels her daughter was a victim of malpractice and (2) therefore all doctors are corrupt and malignant.

For accurate information about Dr. Offit's payment stream from the vaccine he spent decades developing, see A Statement from Paul Offit MD.

For a refutation of other common canards against Dr. Offit, see Meryl Dorey: Seven Assertions About Paul Offit: Six are False.

[Alice]

Well...Dear Ditz...you seem to have trouble deciphering the truth of my post. My point was as Dr. Jerome Groopman shares in his book, How Doctors Think....it's that oftentimes the best doctors aren't allowed to think. peer reviews are as messy as BigPharma research where the truth is not utmost...and as your post shows assumptions are utmost over the truth.

In your zeal to promote vaccines you completely missed the point...that being the tainted peer review process...not malpractice (and this is worrisome that you assumed so much without asking for clarification...that's a foundation of true research skills). I love my daughter's doctors....who are able to think...they admit the delay in treatment caused cancer to spread. Award winning researchers who do not immunize. But. Yeah...thanks for your empathy and proving...once again...that some people just believe BigPharma and doctors who make millions over the hidden data and would prefer to beat down concerned moms instead of demanding that all the truth be disclosed.

[Katie Ellis]

Alice, I am sorry to hear about your daughter. It seems as though you have a deep mistrust of medicine, in general, due to your personal experience. However, this does not mean that all doctors and "Big Phamra" employees are money-hungry sociopaths who attempt to hide scientific data and "beat down concerned moms."

It may be easier for you to believe that there is a massive conspiracy involving not only the FDA, AMA, AAP, WHO and CDC, but the majority of medical doctors around the world to promote vaccines and hinder human health...this doesn't make it true.

[Autismum]

Here's a great post about Paul Offit.
http://www.skepticalraptor.com/skepticalraptorblog.php/tag/paul-offit/
While, Alice, I do sympathise with your situation your willingness to simply smear individuals is not acceptable nor is it the action of one thinks rationally or critically. Further, you rudeness to Miss Ditz, who has been nothing but respectful to you (unless you have mistaken pointing out glaring errors in your reasoning as disrespectful) is very poor form.