State tightens rules for parents seeking to exempt kids from immunizations

Vaccine exemptions now require a doctor's note

OLYMPIA -- State Rep. Barbara Bailey knows the difference a vaccination can make.

As a child, she watched a classmate die of polio. And Bailey survived her own difficult battle with whooping cough.
Those memories are why the Oak Harbor Republican helped pass a new law signed by Gov. Chris Gregoire on Tuesday that requires parents to sit down with a doctor before deciding whether to exempt their children from getting immunized.
"I don't want to see any family or community lose an infant or child from a disease that can be easily avoided if the proper steps are taken," she said. "The whole point of this bill is to help parents be well-informed when they make their decision to immunize or not immunize."

Opponents insist the new law coerces parents into pricey visits with health care professionals where they will be pressured to do something they don't want to do.

"We see this as part of a growing push to get more vaccines into kids and fewer options to parents to not get vaccinated," said Ezra Eickmeyer, who lobbied against the bill on behalf of the National Vaccine Information Center. "This bill looks very challengeable in court."

Today, when parents or guardians enroll their child in a public school they must provide either proof of immunization or a signed certificate indicating why they are not getting vaccinations.
 They can object on medical, religious or philosophical grounds.

In the past decade, the number of exemption certificates submitted has more than doubled statewide with the vast majority being for personal reasons, said Michele Roberts, communications manager for the state's Immunization Program. Washington ranks among the highest of all states in its rate of exemptions among school-age students, she said.

Under the new law, which takes effect July 22, those exemption certificates must be signed by a health care professional such as a pediatrician, licensed naturopath, licensed physician assistant or advanced registered nurse practitioner. This does not apply to those who belong to a church with teachings that preclude a health professional from providing medical treatment to the child.

Supporters say this will ensure parents talk about the pros and cons of immunization with a medical professional before acting. Under the law, they can still choose not to immunize afterward.
"It's a professional opinion they are supposed to get," said Dr. Roger Case, health officer for Island County.

There's concern in the health community about a resurgence of childhood diseases and parents not fully understanding the threat because they've grown up in an era without polio and measles.

Yet earlier this year, there were two cases of measles in southwest Washington, one in an infant and one in a teenager. Both recovered.*
"We've become a little bit complacent forgetting how those diseases can kill children," Bailey said.
Backers also hope this law helps curb the number of exemptions filed by parents because it's easier then trying to dig up immunization records.

"The aim is to distinguish exemptions for conviction versus exemptions for convenience," Roberts said.

Pediatricians and school nurses have lobbied for a version of this bill for the past couple of years. As other states tightened their rules for exemptions, Washington remained one of eight allowing parent signatures on the certificates and one of 20 allowing philosophical as an objection.

"We are definitely in favor of this as it could significantly reduce the number of students who, because of the existing exemption option, do not have needed immunizations," said Jim McNally, who supervises the Everett School District's school nurse program. "This will help in our efforts to reduce the risk of communicable illnesses that can be prevented by appropriate and timely immunizations."

Eickmeyer said the law seeks to solve a problem that doesn't exist. The rate of vaccination of children in Washington against the most serious, life-threatening illnesses is on par with the rest of the nation, he said.

When a parent chooses some but not all vaccinations for their children they get counted as an exemption, pushing that number higher, he contended.

"Vaccination does not guarantee immunization," he said. "What this law is really about is an initial assault to eventually get rid of the philosophical exemption. It is a line in the sand."

Dr. Wendy Sue Swanson, a pediatrician at the Everett Clinic who writes a blog on medical issues, said a safer and informed community is the only goal.

"This is not by any means meant to be heavy handed. It is meant to clarify what a true exemption is," she said, shortly before a 1-year-old patient arrived for a vaccination. "This is really about helping a family make a good decision.

"We are not just affecting our children," she said. "We are affecting the community in which we live."
Jerry Cornfield: 360-352-8623; jcornfield@heraldnet.com
Correction, May 11, 2011: An earlier version of this story stated incorrectly that the measles cases earlier this year were fatal. Post Polio Litaff Association, A.C, only  provides information and is neutral in other countries desitions.

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Erradicación de La poliomielitis

Polio Tricisilla Adaptada

March Of Dimes Polio History

Dr. Bruno




A 41-year-old man developed an acute illness at the age of 9 months during which, following a viral illness with headache, he developed severe weakness and wasting of the limbs of the left side. After several months he began to recover, such that he was able to walk at the age of 2 years and later was able to run, although he was never very good at sports. He had stable function until the age of 18 when he began to notice greater than usual difficulty lifting heavy objects. By the age of 25 he was noticing progressive difficulty walking due to weakness of both legs, and he noticed that the right calf had become larger. The symptoms became more noticeable over the course of the next 10 years and ultimately both upper as well as both lower limbs had become noticeably weaker.

On examination there was wasting of the muscles of upper and lower limbs on the left, and massively hypertrophied gastrocnemius, soleus and tensor fascia late on the right. The calf circumference on the right exceeded that on the left by 10 cm (figure1). The right shoulder girdle, triceps, thenar eminence and small muscles of the hand were wasted and there was winging of both scapulae. The right quadriceps was also wasted. The wasted muscles were also weak but the hypertrophied right ankle plantar flexors had normal power. The tendon reflexes were absent in the lower limbs and present in the upper limbs, although the right triceps was reduced. The remainder of the examination was normal.

Figure 1

The patient's legs, showing massive enlargement of the right calf and wasting on the left


What is that nature of the acute illness in infancy?
What is the nature of the subsequent deterioration?
What investigations should be performed?
What is the differential diagnosis of the cause of the progressive calf hypertrophy?



An acute paralytic illness which follows symptoms of a viral infection with or without signs of meningitis is typical of poliomyelitis. Usually caused by one of the three polio viruses, it may also occur following vaccination and following infections with other enteroviruses.1 Other disorders which would cause a similar syndrome but with upper motor neurone signs would include acute vascular lesions, meningoencephalitis and acute disseminated encephalomyelitis.


A progressive functional deterioration many years after paralytic poliomyelitis is well known, although its pathogenesis is not fully understood.2 It is a diagnosis of exclusion; a careful search for alternative causes, for example, orthopaedic deformities such as osteoarthritis or worsening scoliosis, superimposed neurological disorders such as entrapment neuropathies or coincidental muscle disease or neuropathy, and general medical causes such as respiratory complications and endocrinopathies.3


Investigations revealed normal blood count and erythrocyte sedimentation rate and normal biochemistry apart from a raised creatine kinase at 330 IU/l (normal range 60–120 IU/l), which is commonly seen in cases of ongoing denervation. Electromyography showed evidence of denervation in the right APB and FDI with polyphasic motor units and complex repetitive discharges, no spontaneous activity in the left calf and large polyphasic units in the right calf consistent with chronic partial denervation. Motor and sensory conduction velocities were normal. A lumbar myelogram was normal. Magnetic resonance imaging (MRI) scan of the calves is shown in figure2.

Figure 2

Axial T1 weighted MRI scan (TR 588 ms, TE 15 ms) of the calves, showing gross muscle atrophy and replacement by adipose tissue on the left, and hypertrophy of the muscles on the right, with only minor adipose tissue deposition


The differential diagnosis of the progressive calf hypertrophy is given in the box.

Causes of calf muscle hypertrophy

Chronic partial denervation

  • radiculopathy

  • peripheral neuropathy

  • hereditary motor and sensory neuropathy

  • spinal muscular atrophy

  • following paralytic poliomyelitis

    Neuromyotonia and myokymia

  • Isaac's syndrome

  • generalised myokymia

  • neurotonia

  • continuous muscle fibre activity due to: chronic inflammatory demyelinating polyradiculopathy, Guillain Barre syndrome, myasthenia gravis, thymoma, thyrotoxicosis, thyroiditis

    Muscular dystrophies



  • tumours

  • amyloidosis

  • cysticercosis

    Link here