Tag: precautions

Standing Orders for Vaccination

Have you heard about standing orders for vaccination?

Anti-vax folks have become overt in how they are now all about conspiracy theories.
Anti-vax folks have become overt in how they are now all about conspiracy theories.

Guess what?

Standing orders does not mean “covert vaccination without consent.”

Standing Orders for Vaccination

For one thing, there is nothing covert about them.

In addition to the Take a Stand! website, the Immunization Action Coalition has hosted workshops all over the United States on using standing orders to increase vaccination rates.

And they aren’t about vaccinating people without their consent.

So what are standing orders for vaccination?

“Standing orders are written protocols approved by a physician or other authorized practitioner that allow qualified health care professionals (who are eligible to do so under state law, such as registered nurses or pharmacists) to assess the need for and administer vaccine to patients meeting certain criteria, such as age or underlying medical condition.”

10 Steps to Implementing Standing Orders for Immunization in Your Practice Setting

Again, that doesn’t mean you can skip getting informed consent before giving vaccines.

“Having standing orders in place streamlines your practice workflow by eliminating the need to obtain an individual physician’s order to vaccinate each patient.”

10 Steps to Implementing Standing Orders for Immunization in Your Practice Setting

All standing orders do is eliminate the need for doctors and other health care providers to assess and write orders for vaccines on each and every patient they see.

Instead, standing orders help delegate that part of the vaccination process to other qualified health care professionals to help make sure that “immunizations are available at all visits, sick or well, regular hours, or weekend clinics.”

Everything else is essentially the same.

Even with standing orders, you still have to get informed consent before giving a vaccine.
Even with standing orders, you still have to get informed consent before giving a vaccine.

The health care provider giving the vaccine still has to:

So what’s the benefit of standing orders?

It removes some of the barriers to getting vaccines, such as needing a well child checkup or physical exam, allowing for vaccination-only appointments.

“The Community Preventive Services Task Force (CPSTF) recommends standing orders for vaccinations—when used alone or when combined with additional interventions—to increase vaccination rates among adults and children from different populations or settings.”

Vaccination Programs: Standing Orders

Standing orders also help make sure that you keep kids on schedule or get them caught up as health care providers automatically check their vaccination status at each and every visit to the office, even during sick visits.

For example, if you child comes in for an appointment in October with a mild ear infection or because they have a wart, a standing order for a flu vaccine can help make sure you child is vaccinated and protected before flu season starts.

Standing orders do not override laws requiring informed consent.
Standing orders do not override laws requiring informed consent and there is no single form that would give consent to all medical procedures.

It should be obvious that standing orders simply lead to fewer missed opportunities to be vaccinated and protected.

Not surprisingly, their source and evidence for forced vaccination is simply another anti-vaccine website...
Not surprisingly, their source and evidence for forced vaccination is simply another anti-vaccine website…

There is nothing covert about them.

“Consent is a communications process, not a form. The process provides an opportunity for the patient to understand the benefits, risks and alternatives to the treatment he or she is about to undergo, and for the physician to explain these in detail. Forms are used to document the process.”

Consents Policy

Not even in the way anti-vax are using them to try and scare you away from vaccinating and protecting your kids.

More on Standing Orders for Vaccination

Will SB276 Revoke Legitimate Medical Exemptions?

Bob Sears has already said that SB276 will eliminate medical exemptions and stop doctors from writing medical exemptions.

ITP after MMR is not a reason to get a medical exemption for all vaccines…

What is he saying now?

Will SB276 Revoke Legitimate Medical Exemptions?

Bob Sears is saying that SB276 will revoke legitimate medical exemptions from children who have had “seizures, nerve injuries, and severe allergic reactions after vaccines.”

He also says that they “will be forced to continue just to stay in school.”

To be clear, neither SB276 nor any other vaccine law in the United States forces anyone to get vaccinated.

Yes Bob Sears, what do you mean forced to stay in school?
Yes Bob Sears, what do you mean forced to stay in school?

Although implying forced vaccination is a common anti-vaccine tactic, even his own followers called him out on it…

What else can you see from reading the comments to Bob’s post?

Some medical exemptions might be revoked under SB276, but it isn’t because they are legitimate.

ITP would not be a reason to get a medical exemption to all vaccines.
ITP would not be a reason to get a medical exemption to ALL VACCINES.

A rash that turned in ‘purple blobs’ after the MMR vaccine sounds like it could be ITP, which is actually a table injury.

Since the ACIP lists that as a precaution to getting another dose of MMR, you would almost certainly get a medical exemption, but not to all vaccines!

While scary for parents, ITP typically goes away on its own without treatment in about two weeks to six months.

Anyway, SB276 doesn’t revoke legitimate medical exemptions.

If you actually read SB276, as amended, what it does do is trigger a review by medical professionals to “identify those medical exemption forms that do not meet applicable CDC, ACIP, or AAP criteria for appropriate medical exemptions” if:

  • a school’s immunization rate drops below 95%
  • a doctor writes five or more medical exemptions in a single year (although that doesn’t sound like a lot, keep in mind that true medical exemptions are not very common, so the average doctor who is only writing medical exemptions for their own patients likely won’t write that many each year)
  • a school doesn’t report it’s immunization rates

And once reviewed, inappropriate medical exemptions can be revoked, although that process can be appealed by a parent who thinks that their child does indeed have a legitimate medical exemption.

Keep in mind that just because a doctor writes more than 5 exemptions in a single year, that doesn’t mean that they will automatically be revoked. That simply triggers a review. Even if the doctor writes 10 or 20, if they are legitimate exemptions, then they will be allowed.

Again, SB276 doesn’t revoke legitimate medical exemptions.

Why does Bob Sears think that it does?

Maybe because many of things that Bob Sears considers to be legitimate medical exemptions actually aren’t, which is why he is already under investigation, even before SB276 is enacted…

More on Legitimate Medical Exemptions

What Is Standard of Care?

Anti-vaccine folks who are talking about “standard of care” when deciding who gets a medical exemption for vaccines obviously don’t really understand what it means.

Why are these advocating against keeping kids protected against life-threatening vaccine-preventable diseases?
Why are these advocating against keeping kids protected against life-threatening vaccine-preventable diseases?

Maybe that’s why they put standard of care in quotes in the above infographic against SB276, a new vaccine bill in California that will eliminate fake vaccine exemptions.

What Is Standard of Care?

When we talk about standard of care in medicine, it is important to understand that it is a legal term, with a legal definition:

“That which a minimally competent physician in the same field would do under similar circumstances”

Moffett et al on The Standard of Care: Legal History and Definitions: the Bad and Good News

Does this mean that the minimally competent physicians can choose whatever criteria they want to write fake medical exemptions for vaccines?

Of course not!

“Treatment that is accepted by medical experts as a proper treatment for a certain type of disease and that is widely used by healthcare professionals. Also called best practice, standard medical care, and standard therapy.”

NCI Dictionary of Cancer Terms

Just because a few doctors do something a certain way, that doesn’t make it the proper way for it to be done.

These are among the common conditions that the AAP says should NOT delay vaccination and which are often mistakenly thought to qualify someone for a medical exemption.
These are among the common conditions that the AAP says should NOT delay vaccination and which are often mistakenly thought to qualify someone for a medical exemption.

And that’s why a doctor making up their own rules for what counts as a vaccine medical exemption, especially when it goes against published guidelines and advice, isn’t standard of care.

More on Standard of Care

Does the CDC Determine Medical Exemptions for Vaccines?

California’s new vaccine law has some folks arguing about medical exemptions again.

Yes, the CDC does not determine medical exemptions for vaccines. That's not news.
Yes, the CDC does not determine medical exemptions for vaccines. That’s not news.

Some want very broad guidelines and are confused about how doctors determine who should get a medical exemption.

Does the CDC Determine Medical Exemptions for Vaccines?

Bob Sears even thinks he has a bombshell revelation that clears everything up.

An email from the CDC!

You can be sure that the "medical provider's prerogative" does not include any reason they think up, even those that have no evidence to back them up.
You can be sure that the “medical provider’s prerogative” does not include any reason they think up, even those that have no evidence to back them up.

The thing is, no one has ever said that ACIP contraindications and precautions to vaccination are the one and only factor that should determine whether or not a child should get a medical exemption.

“If a child has a medical exemption to immunization, a physician licensed to practice medicine in New York State must certify that the immunization is detrimental to the child’s health. The medical exemption should specify which immunization is detrimental to the child’s health, provide information as to why the immunization is contraindicated based on current accepted medical practice, and specify the length of time the immunization is medically contraindicated, if known.”

Dear Colleague letter regarding guidelines for use of immunization exemptions

So no one should really be surprised by an email that says the CDC does not determine medical exemptions.

What Qualifies as a Vaccine Medical Exemption?

What are the other big factors, in addition to ACIP contraindications and precautions?

“A medical exemption is allowed when a child has a medical condition that prevents them from receiving a vaccine.”

What is an Exemption and What Does it Mean?

Medical exemptions for vaccines should be based on AAP and ACIP guidelines, current accepted medical practice, and evidence based medicine.

“Medical exemptions are intended to prevent adverse events in children who are at increased risk of adverse events because of underlying conditions. Many of these underlying conditions also place children at increased risk of complications from infectious diseases. Children with valid medical exemptions need to be protected from exposure to vaccine-preventable diseases by insuring high coverage rates among the rest of the population. Granting medical exemptions for invalid medical contraindications may promote unfounded vaccine safety concerns. Although states may wish to allow parents who make decisions based on poor science or perceptions to withhold vaccines from their children, these exemptions should be distinguished from valid medical exemptions.”

Salmon et al on Keeping the M in Medical Exemptions: Protecting Our Most Vulnerable Children

For example, in addition to kids who may have had a severe allergic reaction to a vaccine, there are often children with immune system problems or who have a moderate or severe illness who can’t get one or more vaccines, at least temporarily.

These are among the common conditions that the AAP says should NOT delay vaccination and which are often mistakenly thought to qualify someone for a medical exemption.
These are among the common conditions that the AAP says should NOT delay vaccination and which are often mistakenly thought to qualify someone for a medical exemption.

Medical exemptions for vaccines should not be based on anecdotes or simply because a vaccine-friendly doctor has scared a parent away from vaccinating and protecting their kids.

There are very few family history issues that would make a child have to skip or delay getting a vaccine.
There are very few family history issues that would make a child have to skip or delay getting a vaccine.

They should rarely be done based on family history of reactions or what some people think are vaccine reactions.

This is what a fake medical exemption will get you - a life-threatening disease.
The child’s medical exemption was for “cytotoxic allergies secondary to immunization,” without any evidence that it was necessary. In addition to a fake medical exemption, he got tetanus.

In general, they should rarely be given, as the AAP states in their policy statement, Medical Versus Nonmedical Immunization Exemptions for Child Care and School Attendance, “only a very small proportion of children have medical conditions prohibiting specific immunizations…”

That’s why rates of medical exemptions should be low.

“Between the 2009-2010 and 2016-2017 school years, the national median prevalence of medical exemptions has remained constant, between 0.2% to 0.3%, with state-level ranges showing little heterogeneity over time, never exceeding the range of 0.1% to 1.6% over this period.”

Bednarczyk et al on Current landscape of nonmedical vaccination exemptions in the United States: impact of policy changes

And why you shouldn’t have schools with high rates of medical exemptions or doctors writing a lot of medical exemptions.

More on Vaccine Medical Exemption Guidelines