Authors

Professor of Health Policy and Management, Indiana University Richard M. Fairbanks School of Public Health and Professor of Law, Indiana University Robert H. McKinney School of Law in Indianapolis, IN.
doctor holding clipboard.

Preventing Misuse of COVID-19 Vaccine Medical Exemptions

Ross D. Silverman 10 Comments

By Ross D. Silverman and Gabriel T. Bosslet

As COVID-19 vaccination mandates become increasingly common, we can expect exemption requests (and misuse) to become increasingly widespread, too.

Most entities requiring vaccination mandates or proof of vaccination upon entry may offer limited grounds upon which an individual may request an exemption, usually based upon religious beliefs or medical reasons. Recent history with childhood immunization programs shows less rigorously-structured and -enforced vaccination exemption policies are vulnerable to increased usage, relative to narrower or more stringently-monitored programs. That history also shows there is a possibility some health care licensees may be willing to support individuals seeking to circumvent COVID-19-related requirements through offering questionable medical exemptions.

Entities imposing COVID-19 vaccination mandates, and state health care licensure boards, can take several simple but significant steps to counter misuse of medical exemptions and better protect communities from COVID-19. These safeguards also can decrease the temptation for licensed health professionals to recklessly undermine critical, lawful, evidence-driven public health efforts.

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Masks.

Indiana’s Mask Mandate Debate Raises Public Health Enforcement Questions

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By Ross Silverman

On Wednesday, July 22, 2020, Indiana Governor Eric Holcomb announced an Emergency Order to mandate mask wearing in public places beginning July 27, and indicated that violations of the order could potentially result in criminal penalties. Shortly after, Attorney General Curtis Hill issued an opinion questioning the Governor’s authority to criminalize mask violations under the state’s Emergency Management and Disaster Law (EMDL).

Indiana’s Executive Order, while in line with some 30 other states now imposing mask orders, represents a change of positions for the Governor. Holcomb has been an advocate for mask wearing in both word and deed, but, until now, not a mandate. As he indicated at his press conference, there have been “concerning changes” in the state’s trajectory of new COVID-19 cases, and that “By masking up, we can & will save lives & slow the spread of #COVID19.”

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Corralling the Herd: California Medical Board Acts Against Anti-Vax Doc

Ross D. Silverman 1 Comment

This summer, California’s strict new childhood immunization law, barring all exemptions except those needed for medical purposes, went into effect for public and private schools, preschools, and day cares. This law was passed as a response to the highly-publicized 2014-2015 multi-state measles outbreak that originated at Disneyland, and also in response to the growing number of California communities with large clusters of families exempting their children from vaccine requirements, putting at risk community protection from vaccine-preventable illnesses.

As I’ve written about before, both here and in articles with Tony Yang, there are many different ways to structure childhood vaccination laws. While much of the attention goes to whether or not states offer parents the right to exempt their children based on religious and/or philosophical grounds — see, for example, the recent American Academy of Pediatrics report supporting mandated vaccination for school and daycare attendance —  there are many other implementation-related details in the laws that can increase or decrease the law’s efficacy at maintaining high vaccination coverage rates. For example, some states may require that exemption requests be filed annually (increases efficacy), some states require only that a form be correctly completed (decreases efficacy), some states allow for historically anti-vax practitioners, such as naturopaths, to complete medical exemption forms (decreases efficacy, and creates a new, permanent loophole for gaining exemptions), some states require that medical exemptions be reviewed and approved by a state public health officer (increases efficacy). Read More

IU Fairbanks School of Public Health seeks Center for Health Policy Director

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I’m pleased to share with my Bill of Health colleagues that my home department, the Department of Health Policy and Management at the Indiana University Richard M. Fairbanks School of Public Health in Indianapolis, is seeking a Director for its Center for Health Policy.

The full announcement can be found here.

This is a great opportunity for a senior researcher interested in joining a rapidly growing and dynamic department sitting at the center of a health sciences campus that includes the following collaborators:

  • a leading health informatics and healthcare research organization (the Regenstrief Institute https://www.regenstrief.org/aboutus/);
  • one of the largest medical schools in the country (https://medicine.iu.edu/);
  • a nursing school led by a top patient-centered outcomes researcher (https://news.iupui.edu/releases/2015/04/newhouse-nursing-dean-appointment.shtml);
  • a well-established relationship with a top Health Law and Bioethics program;

as well as strong relationships with a large health care system, a progressive public hospital, and local, state, national, and international NGOs and agencies.

For Vaccines, Public Health Protection Trumps Religious Freedom (Again)

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This week, the Supreme Court appropriately declined to hear an appeal of a 2nd Circuit decision upholding the right of the state to require vaccination as a condition of enrollment in public schools, and to exclude exempted children from attending school during an infectious disease outbreak.

Tony Yang and I wrote in the New England Journal of Medicine about the January 2015 Federal appeals court decision (Phillips v. City of New York). As we wrote at the time:

Under the Constitution, states have police power to protect the public’s health, welfare, and safety. A long-standing use of this authority is to protect communities from risks related to vaccine-preventable illnesses. In addition, when an infectious-disease outbreak occurs, states may use their police power to interrupt further transmission of the disease by restricting the movement of individuals. All states have incorporated this concept of social distancing into their school immunization laws. Schools can prohibit an unvaccinated child, who is more susceptible to acquiring highly infectious vaccine-preventable illness and more likely to become a carrier and vector for it, from coming to school until the danger subsides. Such measures, coupled with ready availability of vaccines, reduce the potential spread of serious disease in a vulnerable and tightly packed community. Read More

Why does Mississippi lead the nation in child immunization?

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By Ross D. Silverman

In the midst of the national discussion of measles and the state laws that foster or inhibit its spread, a curious fact has emerged, as noted recently by my JAMA co-author Tony Yang:

Mississippi, dead last in the nation’s overall health rankings in 2012, 2013, and 2014, leads the nation in childhood vaccination rates, and hasn’t had a measles outbreak in more than two decades.

How did this happen?

Mississippi’s state childhood immunization law does not offer exemptions for religious or personal beliefs, and its medical exemptions may only be issued by pediatricians, family physicians, or internists.

Why doesn’t Mississippi have a religious or a personal belief exemption?

First, states are not obligated to offer one, Read More

Ebola, Ethics, and the WHO Getting to Yes

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Earlier this week, the World Health Organization, responding both to the international outcry over the rapidly rising number of Ebola cases and deaths across sub-Saharan Africa (and critiques of the speed of their action), and the news that western health care workers and ministry had found ways to get access to the untested-in-humans Ebola drug ZMapp, convened a panel of ethicists to offer recommendations on more widespread use of experimental Ebola treatments.

The issues considered by the ethicists included:

1) Whether it is ethical to use unregistered interventions with unknown adverse effects for possible treatment or prophylaxis. If it is, what criteria and conditions need to be satisfied before they can be used?

2) If it is ethical to use these unregistered interventions in the circumstances mentioned above, then what criteria should guide the choice of the intervention and who should receive priority for treatment or prevention?

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