Monday, August 20, 2012

Did the Meningitis Law Go Too Far?

By Jason Terk, MD

Mandatory vaccination of college-bound students has caused a lot of debate in the past decade, and now it’s heating up again. Here’s why.

Vaccine Policy and Meningitis Law
Historically, Texas has provided public funding so the uninsured and others who cannot afford vaccines can be vaccinated. The Centers for Disease Control & Prevention’s Advisory Committee on Immunization Practices (ACIP) issues recommendations for FDA-approved vaccines based on three main considerations: efficacy, safety, and cost-effectiveness. It is on this third concern that the meningococcal vaccine differs from most other recommended vaccines, and at the center of the current debate is the cost and availability of the vaccine. Cases of meningococcal disease are actually quite rare, and the vaccine to prevent the disease is quite expensive. But the disease is serious and can cause infection of the lining around the brain or severe bloodstream infections. These illnesses can spread from person to person. Because the disease is so deadly and because it is rarely detected before disastrous consequences occur, we as a society have decided that it is worth the cost to prevent this disease.

In 2009, Texas legislators passed a law that required all incoming college freshmen living in college dormitories to be vaccinated for meningococcal disease. That law was expanded in 2011 to include all incoming students under age 30.

Current Controversy
Texas vaccine policy for meningococcal disease is a bit different from other vaccine-preventable disease policies. Although Texas public health policy on vaccination traditionally has aligned closely with national recommendations, the expanded law passed in 2011 went further than current national recommendations. In addition, the law impacted a population that does not often seek vaccines and contributed to much confusion and frustration for institutions of higher learning. This, along with changing federal and state policy regarding vaccine funding, has created challenges in implementing the law.

For many college students, the new vaccine mandate is logistically and financially troublesome. First, students required under the new law to get the meningococcal vaccine increased significantly – affecting thousands of students who never had to be vaccinated for the disease before. Second, there was little consideration given to how many students would need the vaccine. Student clinics often do not carry the vaccine, and many physicians do not keep costly vaccines in stock, especially in sufficient quantities needed for this mandate. Third, the vaccine costs more than $100 per dose. The new law also does not provide for financial assistance for students who cannot afford the vaccine. Finally, colleges and universities were unprepared to handle the impact of the new law.

At the beginning of January 2012, some students found they could not enroll for classes because they either could not access or afford the vaccine. Colleges and universities faced the possibility of losing millions of dollars in tuition revenue for students whose enrollments were in jeopardy. And all of that might have been worth the trouble if the public health infrastructure supporting the law was robust. But in this case, the tragedy of Texas A&M student Nicolis Williams’ death (the story that moved hearts and secured votes in the legislature in 2011) was not emblematic of the entire population that came to be covered under the law.

Unintended Consequence: Texas’ Vaccination Exemption Process Weakened
The Texas Higher Education Coordinating Board (THECB) in charge of implementing rules of the new law in Texas colleges tried to alleviate concerns. However, neither THECB nor its staff has a history of dealing with public health issues generally or vaccines specifically. THECB implemented rules to allow students to get a fast and easy vaccination exemption. The form is downloadable from the THECB website, and college and university registrar’s desks can hand it out. This is a huge departure from other school-required vaccines. To get a personal-belief exemption for other vaccines, an individual must request a form from the Texas Department of State Health Services then have it notarized.

Public Health Consequences and Next Steps
In 2013, we need to work with state leaders to make sure the meningococcal vaccine law provides a meaningful public health benefit. The two questions that need to be addressed: 1) Should the law encompass all incoming students or just those most at risk? and (2) What can we do to help uninsured students afford the vaccination?

Vaccination of young adults is changing. The Texas meningitis law provides an opportunity to continue to educate students and parents about a deadly but preventable disease. We must move forward to make improvements to the law and ensure our public health policies are effectively and efficiently protecting the health of all Texans.

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