Threading the Needle

Anti-vaxxers spot a loophole in New Mexico’s immunization law—one the state’s known about for years, but that’s proven hard to close

The New Mexico Department of Health began to sound warnings in March; by then, the scope of the nation’s largest measles outbreak since the 1990s had snapped into focus.

Reports popped up in the state's newspapers and on local television broadcasts. Department officials urged parents to vaccinate their children and warned people who suspected infection to contact the DOH before walking into a clinic.

It seemed like a proactive attempt to head off a potentially serious threat. But a review of data and documents acquired by SFR through a series of public records requests tells a different story. It's one of ignored warning signs, bureaucratic errors and missed opportunities to close a loophole that allows more children to go to school without required vaccinations.

Increasing numbers of New Mexico parents seem to be exploiting the loophole, and the story's epilogue is chilling: The state's children are at greater risk of contracting a preventable illness now than at any point in a generation.

SFR's analysis of state data shows:

– More and more school-age children are being granted exemptions from vaccinations by the state Department of Health. The 4,545 children exempted in 2018 represent a 43% increase since 2014 and nearly 300% since 1999.

– The percentage of vaccine-exempt school-age children increased in 27 of New Mexico's 33 counties between 2014 and 2018. The largest increase was in Sandoval, where it rose 2,050%, from just 16 to 344. Rio Arriba's exempt percentage jumped 1,300%, from four to 56, while Santa Fe's rose 20% and Bernalillo's by 15%.

– Nearly all exemptions are granted based on a sentence or two in which a parent claims, with no required supporting evidence, a "religious belief" that prohibits vaccination. Exemptions based on a physician's letter or a sworn statement from a religious official account for less than 5% of the total.

Moreover, legislative records show New Mexico had a chance in 2015 to tighten the rules governing exemptions. By that time, the state already knew vaccine exemptions were being sought by parents who intended to skirt state law. But pressure from vocal vaccine opponents outside state government and internal fears of exposure—not to pathogens but to lawsuits—cemented the status quo.

Four years later, as the nation is gripped by a 26-state measles outbreak—driven in large part by a revitalized "anti-vaxx" movement—at least one childhood case has been confirmed in New Mexico, which is one of a shrinking number of states that has failed to tighten its rules on who can skip vaccinations in recent years.

Dr. John Beeson, a Santa Fe family medicine physician and chief medical officer at Christus St. Vincent Regional Medical Center, says the medical community is "very concerned" because of how that particular disease can spread.

"Measles is the big topic because measles is the most contagious," he says. "If you have 100 unvaccinated people in a room and one gets measles, then 98 and a half of the others will get it. It's a very high-risk."

BLANKET APPROVAL

New Mexico requires all children who enter daycare or schools—private and public—to prove up-to-date vaccinations for 13 diseases, including measles, pertussis (whooping cough), hepatitis A and B, and varicella (chicken pox).

State law lays out a narrow path to exempt a child from the vaccination requirement: Only medical or religious exemptions are allowed. The former requires a signed letter from a licensed physician stating that a required immunization would endanger a child's life. The latter requires a church official to write a letter stating a parent is a member of a congregation that uses prayer or spiritual means to heal. If no church official is available, the parent must write a statement explaining the religious reasons for exempting a child from vaccination.

In all cases, the parent must fill out the DOH exemption application form, get it notarized and attach the required statements. The exemption application form specifically states: "This form may not be used for exemption from immunization for personal or philosophical reasons. New Mexico law does not allow for such exemption."

The vast majority of parents who are granted exemptions for their kids—94%, according to Health Department data—take the third route, supplying a so-called "written affirmation" rather than a document from a physician or clergy member. SFR reviewed 226 written affirmations, sampled at random from those in DOH files, and found multiple cases in which the department granted approval to parents who described non-religious objections, such as a refusal to vaccinate due to fears that vaccines cause autism.

Such claims circulate widely on social media but have been soundly debunked by medical research. Using them to leave a child unvaccinated contradicts New Mexico law.

"Over the last 50 to 70 years, we've developed very effective vaccines with minimal to zero side effects that have saved the lives of hundreds of thousands of children in the US," Beeson says. "There is no connection whatsoever to autism [from the measles vaccine], but the evidence of what happens to a population where lots of people are not getting vaccines is really significant."

One of the written affirmation forms reviewed by SFR, from a parent of a student at Amy Biehl Community School in Santa Fe, appeared to have been amended to add language that would comply with the rules. In black ink, the parent wrote on the form in 2018, "I do not believe in multi-viral immunizations many ingredients in immunizations are known to cause issues in children." Below that statement—which clearly does not state a religious objection to immunization—is written in blue ink, "because of religious beliefs."

The application was approved.

Santa Fe Public Schools did not respond to repeated requests to speak to the issues raised in this article.

Another application, from a parent of a student at McKinley Middle School in Albuquerque in 2017, read in part, "I prefer not to immunize my son due to horrifying reports. They have lots of chemicals in them that are very harmful for my son. … I prefer the natural way. I give him the best food and the best care," and included seven pages of printouts from an anti-vaxx website.

The application was approved.

In all, seven of the 226 statements reviewed by SFR made no mention of a religious reason for a vaccine exemption—in other words, they were "personal or philosophical statements" of the kind New Mexico's immunization statutes do not allow.

DOH approved them all.

Extend that ratio out to the over 15,600 "religious" exemptions granted since 2014, and it means the Health Department may have incorrectly approved nearly 500 exemptions.

And that number might be understated. While some written affirmations went into detail about a parent's religious objection—such as citing various verses of Scripture—nearly a third of the statements SFR reviewed made minimum effort.

Seventy-four of the 226 statements were entirely or in part a simple restatement of the exemption clause, which is printed on the application form right above the two lines parents are to write on. The clause reads, "I hereby certify through the written affirmation below, or attached affidavit, that my religious beliefs, held either individually or jointly with others, do not permit the administration of vaccine or other immunizing agents."

For example, this written statement by a parent of a student at Stapleton Elementary School in Rio Rancho, which was approved by DOH in 2018, read in its entirety, "my individual beliefs do not permit the administration of vaccine or other immunizing agents." "Vaccine," without an "s", is not a unique typo—52 of the 74 statements that simply parroted the clause did not correctly pluralize "vaccine" in context.

DOH approved them all.

Health Department spokesman David Morgan says that in 2017, rather than requring an attached written affidavit, forms began to contain space to explain the religious basis for an exemption. He claims that if an application like some of those reviewed by SFR came in now, the Health Department would reject it.

The process of changing the form, Morgan tells SFR, "took some time to implement, and now any requests for [this type of exemption] that do not reference religious beliefs as specified in statute are rejected, and any that are questionable are reviewed by the Office of General Counsel."

MISSED OPPORTUNITY

At least one legislative attempt has been made to tighten the rules for opting out of childhood immunizations. It didn't get far.

In 2015, her first year in the Legislature, Rep. Deborah Armstrong, a Bernalillo County Democrat, carried a bill that would have struck the written affirmation exemption from the state's immunization law. It gained seven co-sponsors before Armstrong herself pulled it from consideration, and it hasn't resurfaced since.

Now chair of the House Health and Human Services Committee, Armstrong says she pulled the bill mainly because of concerns that the religious exemption was too narrow. While she had many people express support, she says, she also heard from a vocal group opposed to vaccines—on personal grounds.

"Everything [that group of people] told me is they didn't believe in vaccinations or it was because of autism or their kid had a bad reaction, and so they chose the [written affirmation] exemption," she says, adding that she also heard from people who described opposition that was strongly rooted in religion.

While Armstrong says the law needs to be revisited, she stops short of committing to a legislative solution. But her thinking on the exemption hasn't changed: Any carveout for religion would likely let personal objections slip in.

"I couldn't figure out how to [maintain a religious exemption] without it being abused as it is now," she says. "It's almost impossible to craft a religious exemption that cannot be broadly interpreted as a philosophical exemption."

In fact, legislative documents show that DOH was aware as early as 2012 that some parents were blurring the line between religious and philosophical exemptions. A Health Department-sponsored survey that year found 55% of 729 New Mexico parents who had been granted vaccine exemptions said they did so "for philosophical or personal reasons," not religious ones, according to the fiscal impact report prepared for Armstrong's 2015 bill.

The report also noted a concern from DOH that the bill, as written, could open the state to lawsuits by religious people who weren't part of a recognized denomination.

SHRINKING COMPANY

Yet in allowing a religious exemption of any kind, New Mexico is increasingly out of touch with the rest of the United States.

In recent months, Maine and California joined West Virginia and Mississippi on the list of states that ban all religious exemptions for vaccinations. Similar bills are being considered in New Jersey, New York, Iowa, Vermont and Connecticut. Washington state has eliminated "philosophical" exemptions, bringing the number of states that allow them by law to just 16.

Ground Zero for the current measles outbreak, New York City declared a state of emergency in April, and the health department there mandated that parents in the hard-hit and heavily Orthodox Jewish neighborhood of Williamsburg vaccinate their children. A group of parents filed a lawsuit, claiming the law was coercive and discriminatory, which a judge promptly rejected.

As of early June, 26 states have confirmed measles cases. New Mexico's case emerged in Sierra County, when officials said a 1-year-old had the disease in May.

The number of nationwide infections so far this year has outpaced this point in 1992—the high-water mark since vaccines became widely available.

The disease killed 110,000 people globally in 2017, mostly children under 5, according to the US Centers for Disease Control and Prevention. Before vaccines were common, up to 4 million Americans would contract it annually, and up to 500 would die.

Meanwhile, New Mexico has struggled to immunize its children.

According to a report from the state's Legislative Finance Committee, New Mexico's immunization rate for children aged 19 to 35 months was 68.5% in 2016, putting the state at number 37 nationwide and trailing the US average of 71%. By 2018 the rate had fallen to 62%.

That has consequences. New Mexico was ranked 10th nationwide in cases of potentially fatal pertussis (whooping cough) in 2016. Yet thousands of school-age children were granted exemptions from the pertussis vaccine in that and subsequent years due to a "religious objection."

Beeson, of Christus St. Vincent, says medical professionals are limited in what they can do when a parent who refuses to immunize a child enters a practice. A doctor cannot force a parent to give a kid a shot. It's more about handing out literature and debunking myths—and lobbying, he says.

“Physicians and schools have been encouraging the state to be more rigid in the exemptions, to try to allow fewer of them,” Beeson says. “How much freedom should you have to put others in the population at risk? That’s a very difficult question.”