Research Published about Vaccine Exemption Policies

It’s no secret that many states including Arizona are struggling to maintain enough vaccination coverage to achieve “herd immunity”.  Herd immunity simply means that you have enough vaccination coverage to protect the entire community – including people that for medical reasons can’t be vaccinated and folks who’ve been vaccinated but still may be susceptible (because vaccines aren’t 100% effective).

Requiring kids in public school to be vaccinated is one of the most important public policy tools to ensure herd immunity.  Arizona does that through statutes labeled ARS-872 & ARS-873 – which require kids to be vaccinated if they attend public school (unless they have an exemption). In Arizona, there are medical, religious, and “personal” exemptions. The problem over the last few years is that more and more parents are exercising the personal exemption option.

Arizona’s immunizations rates continue to decline: 1) immunization rates have decreased across all age groups from 2012 to 2017; 2) personal exemption rates continue to be highest in charter schools, followed by private and public schools in 2017; and 3) overall personal exemption rates increased in the last year- going from 3.9% to 4.3% for pre-school; 4.9% to 5.4% for Kindergarten and 5.1% to 5.4% among 6th graders.

Of course- when looking toward interventions to stem the tide it’s important to look to the scientific literature to see what’s going on in other states.  A very informative article about personal vaccine exemptions was published recently entitled The state of the antivaccine movement in the US: A focused examination of nonmedical exemptions in states and counties.

The researchers conducted a detailed analysis of personal exemptions within each of the 18 states that allow nonmedical exemptions to their school vaccine requirements. Here’s a map of which states allow non-medical school exemptions.

The researchers found that several counties, especially those with large metropolitan areas, are at high risk for vaccine-preventable pediatric infection epidemics.  Since 2009, personal exemptions have risen in 12 of the 18 states that currently allow philosophical-belief exemptions.  On average, states that allow non-medical exemptions have 2.5 times higher exemption rates.

The also dove into the data and found that there is a direct correlation between higher personal exemption rates and lower vaccination rates.  That might be intuitive- but it’s important because it shows that personal exemption rates for school requirements is a good measure of real immunization rates.

The discussion portion of the article discusses the efficacy of interventions in various states, and basically found that more aggressive approaches – like eliminating personal exemptions entirely- are more effective at long term improvements in vaccination rates than softer approaches.

Definitely worth a read.

AZ Develops Pain & Addiction Curriculum for Clinicians

It’s no secret that getting a public health handle on the opioid crisis will take a multi-pronged effort for an extended period.  Part of the solution was the policy development, passage and implementation of the Arizona Opioid Epidemic Act.  Other elements include developing and implementing new Opioid Prescribing Guidelines and developing new regulations for pain management clinics.

Another huge element is changing the culture of pain and addiction care.  ADHS has completed a Arizona Pain and Addiction Curriculum that approaches pain and addiction in a new way – as complex, interrelated, public-health issues. 

The curriculum was jointly developed by Deans and Curriculum Representatives from every MD, DO, NP, PA, ND, DMD and DPM program in Arizona.  The program stresses not only the new evidence base of pain and addiction care.

Resources for programs consist of both a Pain and Addiction Curriculum and a Pain and Addiction Faculty Guide.  Because it was created and facilitated by public health, it’s accessible online at any time, to the appreciation of other teaching programs across the country.

Kudos to ADHS and the dozens of stakeholders for this novel work and especially AzPHA member Lisa Villarroel MD.  Work on this scale hasn’t been done before in the US – so kudos to our Arizona teaching programs for being so open and collaborative. This is another example of the stakeholder driven innovative work being done right here in Arizona that’s likely to be adopted as a best practice in other states.

Tucson Voters Lead the Way

Last week Tucson voters approved Proposition 407 approving $225M in Bonds for improving the outdoor built environment.  The funds will be used over the coming years for playgrounds, sports fields, pools, splash pads, recreation centers, pedestrian pathways, bike pathways, and pedestrian & bike safety infrastructure. 

The plan includes 25 new splash pads, 22 new playgrounds and 17 shade structures installed at city parks in the next several years.  Tucson will be reopening 2 city pools that have been closed and will make renovations the 22 other public pools.  Improvements are also planned for sports fields, 28 new walking paths in parks, 26 new ramadas, 19 new restrooms and an amphitheater.

Safety and mobility projects will connect people to parks, schools, shopping and transportation. New sidewalks, enhanced major street crossings, off-street biking and walking paths and residential street traffic calming are also slated in the plan which will provide more than 210 km of enhancements across Tucson.

The improvements won’t happen overnight though.  The $225M in improvements is spread over 9 years.  You can learn more about the proposed Parks and Connections projects using Tucson’s Interactive Story Map.

Congrats to the voters of Tucson for investing in their built environment and creating more opportunities for folks to enjoy the outdoors and get some exercise!

Public Health Ballot Measures Approved in Other States

Here’s a summary of what voters approved in other states that link to public health policy.  There are a few surprises in here- at least things that I found surprising.

Idaho, Nebraska, and Utah voted to expand their Medicaid programs (up to 138% of the federal poverty level).  Idaho’s Proposition 2 was approved by 61% of voters and Nebraska’s passed with 53% approval (called Initiative 427 to expand Medicaid). Interestingly, neither of those states established a funding mechanism.  

Utah’s Proposition 3 was approved by 54% of voters and funds the expansion with a 0.15% increase to the state’s sales tax. There are now 14 states  left that haven’t expanded Medicaid.  With gubernatorial party changes in Wisconsin & Kansas perhaps those states may be next.

Proposals related to marijuana were on the ballot in five states. Utah voters approved a medical marijuana initiative (Proposition 2) by a 53-47 percent margin. Interestingly, it will be a strictly “edibles” based program (prohibits the medical marijuana). 

Missouri voters approved Amendment 2 (with 66% of the vote) that gives the Missouri Department of Health & Senior Services oversight of the state’s new medical marijuana program. 

Michigan approved a measure to allowing adults to use marijuana for non-medical purposes and a retail sale program.  Proposal 18-1 directs Michigan’s Department of Licensing and Regulatory Affairs to oversee the commercial production and retail sale of marijuana. 

Wisconsin Medicaid Work Requirement Approved

CMS approved Wisconsin’s Medicaid work requirement waiver, making them the 5th state to have their work requirement waiver approved.  Wisconsin is the 1st state to receive approval for work requirements since a federal court ruled them unconstitutional in Kentucky.

Medicaid members between the ages of 19 and 49 will be required to work, volunteer, be in school or in a job training program for at least 80 hours a month. Recipients who don’t comply after 48 months will lose their eligibility.  The state is also allowed to charge premiums for what is normally free and to raise those premiums for people with riskier health behaviors like smoking.

Of the four other states CMS has given the greenlight to, only Arkansas has implemented work requirements. Indiana and New Hampshire will start enforcing them in January, and Kentucky’s have been sent back to CMS for review.

Arizona’s Work Requirement Request

A 2015 AZ law requires AHCCCS to annually ask the CMS for permission to require work (or work training) and income reporting for “able bodied adults” and a 5-year lifetime limit on AHCCCS eligibility. 

Late last year AHCCCS submitted their annual official waiver request including a requirement to become employed, actively seek employment, attend school, or partake in Employment Support and Development activities (with exceptions) and a requirement to bi-annually verify compliance with the requirements and any changes in family income.  CMS hasn’t yet ruled on the AZ request.

HB 2228 requires AHCCCS to exempt of tribal members from the work requirements but CMS has suggested that they won’t be approving waiver requests that exempt tribal members because they believe exempting them could raise civil rights issues.  

For now it’s status quo.

MMJ Edibles Case Appealed to State Supreme Court

Back in 2013 a medical marijuana patient (who had a valid ADHS Medical Marijuana Card) was arrested for possession of a small amount of hashing (a preparation of marijuana) in Yavapai County.   Even though he had a valid card, he was convicted by a jury of a class 6 felony and spent nearly a year in jail. 

Mr. Jones continued to appeal his conviction (State v. Jones).  Over the Summer, the AZ Court of Appeals in the case upheld the conviction, maintaining that the hashish that he possessed did not meet the definition of mixtures or preparations of marijuana as defined in the Arizona Medical Marijuana Act.  An appeal to the Arizona Supreme Court was filed this week.  

If Mr. Jones’ appeal is successful, Arizona’s medical marijuana program will stand as is.  If it is unsuccessful, it’s reasonable to expect ADHS to completely overhaul their medical marijuana regulations and to impose a completely new regulatory scheme that would exclude extracts, resins, and edibles. Dispensaries and patients would no longer have access to these mixtures and preparations of the Cannabis plant, and dispensaries would be required to discard the instruments and equipment needed under the current regulatory scheme and overhaul their business models to one that focuses exclusively on marijuana flowers.

I filed a Declaration in the case on behalf of Mr. Jones (CR-18-0370-PR).  My Brief basically argues that hashish and other mixtures or preparations of marijuana are indeed covered under the voter approved statutory language and the regulations that we developed at the ADHS while I was Director.  I filed the Amicus as the former ADHS Director, not in my capacity as the Executive Director of AzPHA.  Here’s more background about the core issue.

The Arizona Medical Marijuana Act provides qualified patients and dispensaries a number of legal protections under the voter approved  Act.  The Arizona Medical Marijuana Act definition of “Marijuana” in A.R.S. § 36-2801(8) differs from the Arizona Criminal Code’s definition of “Marijuana” in A.R.S. § 13-3401(19). In addition, the Arizona Medical Marijuana Act makes a distinction between “Marijuana” and “Usable Marijuana” A.R.S. § 36-2801(8) and (15).

I expect to see the Arizona Supreme Court to accept the case because this is an important matter of public policy.  More to come.

The People Speak. Will Public Health Policy Follow?

By now all of you know the results of the federal and state election results so I won’t recap them here – except to link the results to the prospects for public health policy.

The results in the US House of Representatives suggest that it’s unlikely there will be another effort to repeal the Affordable Care Act.  That doesn’t mean that the ACA is no longer in jeopardy. There’s still an outstanding lawsuit challenging the mandate for health insurance plans to cover preexisting conditions as well as other provisions in the ACA (AZ is on the list of states challenging the law). The US Justice Department will presumably continue to decline to defend the ACA in court.

The fact that the US House will be controlled by the Dems means that there will be an opportunity for additional oversight of the decisions that the federal agencies are making with respect to public heath and health care (e.g. CMS, EPA, DHS, USDA etc.).  That oversight authority can be used to ensure that the administrative decisions made by the federal agencies are consistent with their statutory authority.

There will be no party changes in the executive branch here in Arizona and we will continue to have the same governor and presumably the same agency heads. The makeup of the state legislature looks like it will shift a little- but party control won’t change. The Senate will likely remain 17-13.  In the House it looks like the new split will be a razor thin 31-29. 

Many of the bills that we supported last year passed with bipartisan support- and it remains important to look toward public health policies that are founded with evidence and for us to continue to frame the issues in a way that builds bipartisan support for sound public health policy.

New Federal Opioid Intervention Becomes Law

A couple weeks ago congress passed and the president signed the Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act. Much like Arizona’s Arizona Opioid Epidemic Act – approval of the bill was bipartisan, with a House vote of 393-8 and 98-1 in the Senate.

The final bill creates, expands and reauthorizes programs and policies across several federal agencies, and focuses on prevention, treatment and recovery. The text of the Act is extremely long, but you can view a high level summary on this landing page.

Some of the provisions are in line with recommendations in the 2017 ADHS Opioid Response Report like calling for changing an old federal regulation that prohibited Medicaid from covering patients with substance abuse disorders who were getting treatment in a mental health facility with more than 16 beds. The effect of the former law limited the number of beds available for low-income patients suffering from addiction- so hopefully the network of treatment facilities will expand as a result of this change in the law. The new federal law allows for 30 days of residential treatment coverage.

The new law allows nurse practitioners and physician assistants to prescribe buprenorphine, which is an anti-addiction medication that requires a special license and extra training.  For the next 5 years, it will also allow nurse anesthetists, nurse midwives and clinical nurse specialists to prescribe buprenorphine.  Right now, only about 5% of doctors are licensed to prescribe it.  It’ll take time for the inventory of prescribers to increase because of the training that’s required- but over time this provision will help network capacity especially in rural areas.

The Act also creates a grant program for comprehensive recovery centers that include housing and job training, as well as mental and physical health care. It will also increase access to medication-assisted treatment.

Some aspects of that law that relate to Medicaid include:

  • Temporarily requires coverage of medication-assisted treatment under Medicaid;

  • Prohibiting the termination of Medicaid eligibility for juveniles who are inmates of public institutions;

  • Requiring CMS to establish a demonstration project to increase provider treatment capacity for substance-use disorders;

  • Requiring state Medicaid programs to establish drug management programs and drug-review and utilization requirements for at-risk members; and

  • Extending enhanced federal matching rate for expenditures regarding substance-use disorder health-home services under Medicaid.

Interestingly, the bill includes a provision to help stop the flow of black-market opioids into the country by mail, especially synthetic fentanyl and its analogs.  The US Postal Service will need to provide the name and address of the sender and the contents of at least 70% percent of all international packages, and 100% of packages from China.

All international shipments will need to have the name and address of the sender by the end of 2020.  The Postal Service was also given the authority to block or destroy shipments for which the information isn’t provided.

The Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act is long and comprehensive so I can’t cover everything….  But the bottom line is that public health policy – both here in AZ and now nationally is beginning to address the epidemic.

More States Implementing School-based Nutrition & Physical Activity Policies

Obesity remains a complex health issue in the United States. Several factors—including behavioral, environmental, and genetic—interact and contribute to increasing obesity rates. Approximately 19% of children and adolescents aged 2-19 years old are obese and face a greater risk of developing chronic and other conditions like diabetes, heart disease, cancer, high blood pressure, asthma, and sleep apnea. By 2012, the estimated annual cost of obesity in the United States was $147 billion, in addition to other social and emotional costs.

The causes of childhood obesity include unavailability of healthy food options, easy access to unhealthy foods, lack of physical activity, as well as policy and environmental factors that do not support healthy lifestyles. Schools play a significant role in diet and activity through the foods and drinks offered and the opportunities for physical activity provided.

Recognizing the unique position of schools, states have enacted and proposed legislation to prevent and reduce childhood obesity by: (1) ensuring that nutritious food and beverages are available at schools, and (2) establishing physical activity and education standards at schools. Below is an overview of current laws and recent state and territorial legislative activities to increase the availability of healthy foods and opportunities for physical activity in schools.

School Nutrition Legislation

Children and adolescents consume much of the food they need each day while at school. Children may receive meals from federal programs like the National School Lunch Program and the School Breakfast Program, or they may purchase competitive food and drinks (i.e., food that’s purchased from school-based vending machines, snack bars, or concessions outside of the school’s food service program). Many states have adopted policies to make competitive foods healthier, set limits on food for rewards, and impose restrictions on food and beverage marketing in schools.

A Colorado statute prohibits public schools from making available any food or beverage that contains any amount of industrially produced trans-fat on school grounds. In Kentucky, each school must limit access to retail fast foods in cafeterias to no more than one day each week. Laws in New Jersey prohibit the sale of foods of minimal nutritional value, all food and beverage items listing sugar as the first ingredient, and all forms of candy on school property during the school day.

In 2017, California’s governor approved a bill limiting the advertisement of food and beverages during the school day in schools, school districts, or charter schools participating in federal lunch and breakfast programs. California also prohibited participation in corporate incentive programs that reward children with food and beverages that do not comply with nutrition standards. New Hampshire proposed similar legislation prohibiting the advertisement of any food or beverage that does not meet the minimum nutrition standards as set forth by the school district, as well as participation in a corporate incentive program that rewards children with food and beverages.

Recognizing that many schools lack the necessary equipment to support the storage, preparation, and service of minimally processed and whole foods, the Washington State legislature introduced a bill that would establish a competitive equipment assistance grant program for public schools to improve the quality of food service meals that meet federal dietary guidelines and increase the consumption of whole foods. In 2017, Puerto Rico proposed a bill requiring that vending machines located in public schools only contain products of high nutritional value according to the standards imposed by the federal government.

Physical Activity Legislation

According to CDC, children and adolescents should have one hour or more of physical activity every day. State policymakers often target physical activity and education curriculums in K-12 schools to combat the childhood obesity epidemic. Promising trends include: improving physical education curricula, integrating physical activity into the school day and maximizing recess opportunities, as well as enhancing physical activity opportunities in school-based after-school programs.

Many states have statutes in place or have proposed legislation imposing physical activity and education requirements in schools. Last legislative session, Arizona approved a new law mandating that public schools include recess in their curriculum. Other states have gone further. 

Iowa, Louisiana, North Carolina, and Texas require 30 minutes of physical activity each school day. Arkansas requires 90 minutes of physical activity each week for grades K-6. South Carolina sets a minimum standard of 150 minutes per week for grades K-5. Colorado requires 600 minutes of physical activity each month for full-time elementary students.  Tennessee amended its statute to require a minimum of 130 minutes of physical activity per full school week for elementary school students and a minimum of 90 minutes for middle and high school students.

Educating Parents to Improve Vaccination Rates

It’s no secret that many states including Arizona are struggling to maintain enough vaccination coverage to achieve “herd immunity”.  Herd immunity simply means that you have enough vaccination coverage to protect the entire community – including people that for medical reasons can’t be vaccinated and folks who’ve been vaccinated but still may be susceptible (because vaccines aren’t 100% effective). Generally, herd immunity happens when a community has a vaccination rate above 95%.

A couple of months ago the ADHS released their latest school reporting data on vaccine exemption rates (medical, personal and religious).  Here’s a 2-page summary of some of the results.  This year’s report covers the 2017-2018 school year. The data show that:

  • Immunization rates have decreased across all age groups from 2012 to 2017;

  • Personal exemption rates continue to be highest in charter schools, followed by private and public schools in 2017; and 

  • Overall personal exemption rates increased in the last year- going from 3.9% to 4.3% for pre-school; 4.9% to 5.4% for Kindergarten and 5.1% to 5.4% among 6th graders.

Requiring kids in public school to be vaccinated is one of the most important public policy tools to ensure herd immunity.  Arizona does that through statutes labeled ARS-872 & ARS-873 – which require kids to be vaccinated if they attend public school (unless they have an exemption). In Arizona, there are medical, religious, and “personal” exemptions. The problem over the last few years is that more and more parents are exercising the personal exemption option.

According to our current statute, parents can get a personal exemption if they “… sign a statement to the school administrator stating that (they) have received information about immunizations provided by the ADHS and understand the risks…” (as defined in R9-6-701-708). Despite numerous interventions to improve immunization rates among AZ school children- we continue to lose ground. In several parts of the state and among certain demographic groups (high income zip codes and some charter schools for example) we’ve lost herd immunity- which means we’re at real risk for outbreaks.

Arizona’s public health system has been doing some creative work to improve our immunization rates. One of my favorites is an innovative on-line immunization education course that’s designed to serve as part of a potential new personal exemption process. The Maricopa County Department of Public Health worked with a University of Arizona medical student and the ADHS Immunizations Program to design and conduct the test pilot program. The new education course was piloted at 16 schools in Maricopa County (8 elementary, 5 middle or junior high and 3 high schools) last school year.  The pilot objectives were to:

  • Learn how to best implement the immunization education module developed by ADHS in Maricopa County schools;

  • Get feedback from school staff regarding the use of the module to ensure a smooth rollout in the future; and

  • Identify whether parents learned new information about vaccine preventable diseases and vaccines using a brief anonymous pre-and post-knowledge assessment survey.

The pilot was small & wasn’t designed as a formal study and therefore wasn’t able to draw any conclusions about the effectiveness of the modules- but it’s a promising intervention that has a good chance of helping improve immunization rates.

There’s a lot of interest among a host of public health stakeholders in continuing to pursue this educational (informed consent) process as part of the personal exemption process.  I’m optimistic that executive branch decision-makers will recognize the value that a more robust parent education policy can have in improving rates and that AZ will continue to develop and implement this innovative intervention.

Part of what makes me optimistic are comments that the Governor recently made during an interview with the Arizona Republic in which (about 25 minutes into the interview) he states that “This is a public-health issue, I’m a big believer in freedom and choice on a lot of issues, but… if your kid’s going to be in the public-school system in Arizona, they’re going to be vaccinated.”

The bottom line is that despite our work to date, vaccination rates continue to decline and are below the herd immunity threshold in some parts of the state and among some demographic groups.  Additional interventions are clearly needed.  Perhaps the education modules will help.  But it may be that the only real solution is to look to other states that have eliminated the personal exemption.  California provides a promising case study.