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Under new law, school nurses aim to stop rise in vaccination opt-outs



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In her 33 years as a school nurse, Robyn Ettl has listened, sometimes quietly, sometimes not, to parents in rural Nevada County explain why their children don’t need vaccinations against contagious and potentially fatal diseases, including polio, diphtheria, measles and pertussis.

Now, with nearly a half a million 5-year-olds and soon-to-be-5-year-olds registering for kindergarten in the fall, school nurses like Ettl are more invested than ever in a delicate task: trying to change the minds of parents intent on opting out of school-entrance immunizations.

Under a state law that took effect Jan. 1, parents are required to consult with a health practitioner – doctor, naturopath or credentialed school nurse – before they’re allowed to obtain a personal-belief exemption from their child’s required immunizations. Prior to the legal change, parents could receive an exemption by stopping by the school secretary’s desk and signing the back of their child’s blue immunization card.

Nowhere is the impact of the law, Assembly Bill 2109, more anticipated than in Nevada County, a former gold mining haven in the Sierra foothills where 20 percent of kindergartners have been exempted from the vaccination law – the highest opt-out rate in the state for many years and now a close second to sparsely populated Trinity County.

That exemption rate is driven by huge percentages of vaccination opt-outs at public charter schools in the county, led by Yuba River Charter School in Nevada City. At this Waldorf school, which emphasizes learning through art and movement and eschews technology, 81 percent of kindergarteners in 2013-14 received personal-belief exemptions.

Caleb Buckley, director of the Yuba River Charter School, said many students’ parents steer clear of Western medicine and, by association, its core tenet that immunizations save lives. “I don’t know too many that go to see the local pediatrician group, unless they really have to,” Buckley said.

As Trevor Michael, president of the Nevada County Board of Education, explained, “Our county is rural. People live alternative lifestyles and have alternative beliefs.”

At Grass Valley Unified, Ettl hears parents state that it is better for a child’s immune system to get the disease than the vaccination, and that polio is passé. And even though a research paper alleging a link between vaccinations and autism was retracted, deemed a fraud by the British Medical Journal and its author stripped of his medical license, they say they’re still not sure that a vaccination won’t give their child autism.

“I don’t argue with them,” Ettl said. In the past, when she has refuted their claims, “They get mad and head right to Holly,” she said, referring to Holly Hermansen, superintendent of the Nevada County Office of Education.

At some charter schools in the county, a philosophical opposition to vaccinations has become a defining feature of the culture, said Sharyn Turner, coordinator of school health services at the Nevada County Office of Education.

“All of a sudden it becomes socially unacceptable to be one of the few parents immunizing your child,” Turner said.

Public charter schools lead the state in enrolling the highest percentage of kindergarteners with personal-belief exemptions – 10.1 percent in 2013-14, according to new data from the California Department of Public Health. At private schools, 5.6 percent of kindergarteners received personal-belief exemptions, while 2.3 percent opted out at public schools.

Those high rates are driving an overall increase in personal belief exemptions statewide. The percentage of exempted kindergarteners has more than doubled, from 1.4 percent in 2007 to 3.1 percent in 2013-14, according to the state Department of Public Health. 

And those figures don’t include children attending 12,500 small home schools, defined as enrolling five or fewer students. The California Department of Education does not collect immunization data from those schools.

If roughly 90 percent of a population is fully vaccinated, “herd immunity” helps keep at bay infectious diseases like rubella, which in the pre-vaccination era sparked an epidemic among pregnant women, causing 2,100 newborn deaths and nearly 17,000 infant cases of deafness, blindness or intellectual disability, according to the Centers for Disease Control and Prevention. For children and adults who have not been vaccinated, herd immunity protects them, too, along with newborns too young to be vaccinated, people whose immune systems have been compromised by chemotherapy or other factors, and the elderly.

With longstanding herd immunity comes fading awareness of dire infectious diseases. “There’s no fear,” said Lindsay Dunckel, executive director of First 5 Nevada County, which funds community programs for babies and young children. “These diseases that were once so frightening have disappeared.”

Now some of them are coming back, and the role of unvaccinated people in spreading disease is under scrutiny. In 159 cases of measles across the country last year, 82 percent of those infected were unvaccinated and of those, 79 percent had philosophical objections to vaccinations, according to the CDC.

Schoolnurse-GrassVallNo2March2014JA

Robyn Ettl, Grass Valley Unified school nurse, gives a vision test to second grader Chase Littlejohn at the Grass Valley Charter School. Credit: EdSource Today/Jane Meredith Adams

So far in 2014, the California Department of Public Health has received reports of 51 cases of measles in the state, the largest number since 2000, when measles was declared eliminated in the U.S. In the decade before the introduction of a measles vaccine in 1963, the disease killed about 450 people a year in the U.S., according to the CDC.

Also increasing in California is the number of cases of pertussis, better known as whooping cough. Reported cases in 2013 hit more than 2,300, including an infant who contracted the disease at 4 weeks old and died. During a 2010 California outbreak of pertussis, in which 10 infants died and more than 9,000 cases were reported, children with personal-belief exemptions played a role in transmitting the disease, according to research published in the journal Pediatrics. Communities with high rates of personal-belief exemptions were 2.5 times more likely to also have pertussis clusters, the researchers found.

Eager to drive down exemption rates, Cindy Wilson, director of public health nursing at the Nevada County Public Health Department, interviewed six Nevada County families in 2013 who were opposed to some or all of the required childhood vaccinations. She wanted to suss out what might change their minds.

She found the parents didn’t like the ingredients in vaccines – the additives and preservatives – and that they worried the vaccinations would cause neurological problems in their children, as alleged in the debunked research by Andrew Wakefield. Some said being sick would strengthen their child’s immune system and character.

“Their bottom line was that nothing could change their minds,” Wilson said. “I was looking at what interventions are going to work and the answer was, basically, none.”

Dale Jacobson, a Nevada City chiropractor, and his wife, Diane, who has been active in Waldorf education and breastfeeding advocacy, raised their now-grown children on a diet of organic foods on their 20-acre farm. Jacobson credits his children’s good health to healthy living. At work, he advocates for preventative health measures such as pesticide-free foods, natural childbirth and breastfeeding. Vaccinations aren’t in the equation.

“Four kids, no vaccinations,” Jacobson said.

“We’re pretty much anti most vaccinations,” he said. “The reason is because there is no research, especially on the flu vaccine, that they make any difference. The whole thing is a big business scam.”

At Grass Valley Unified, Ettl met recently with a parent of an incoming kindergartener who was dead-set against immunizations. The meeting was perfunctory: The parent read the vaccination information sheet, and Ettl explained that an unvaccinated child may not attend school for 21 days if an outbreak of whooping cough or measles occurs. Then Ettl and the parent signed the new personal belief exemption form.

Ettl’s hopes, and the hopes of public health officials, rest largely with parents whose opposition to vaccination is not entirely locked in. “‘I’ll ask, ‘Are you against every vaccine or some of them?’” she said.

One mother of a kindergartener recently told Ettl that although her child had received one vaccination, she was now inclined to opt out of the rest. Ettl talked to her about the risk of tetanus, a bacterial infection in soil and dirt that can be contracted through wounds. “We live in a rural place and tetanus is a serious disease,” Ettl recalled telling her. “I said, ‘Why don’t you start with one?’”

The mother left without a personal belief exemption in hand, saying she would think about it.

That’s just what the law is intended to do.

“Some parents are never going to change their mind,” said Catherine Flores Martin, director of the California Immunization Coalition, “but there is a larger number that want to have their vaccine concerns acknowledged and answered.”

Jane Meredith Adams covers student health. Contact her or follow her @JaneAdams. Sign up here for EdHealth, EdSource Today’s free newsletter on student health.

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29 Responses to “Under new law, school nurses aim to stop rise in vaccination opt-outs”

  1. Joanne said

    on April 7, 2014 at 3:35 am

    If a parent refuses to allow a child to have a blood transfusion, even for religious reasons, a court in California will generally step in and require it. And yet we let these narcissistic quacks spread disease in our communities because they’re (let’s be honest) louder and wealthier–the currency of politics.

    The rule should be no vaccine, no school. And if their children die of a preventable disease or pass it on to someone else, the parents should be prosecuted for manslaughter.

    • LindaRosaRN replied

      on April 7, 2014 at 12:39 pm

      Well said, Joanne. West Virginia and Mississippi allow only medical exemptions and those states have enviable high vaccination rates.

      The courts have ruled that children have rights, including the “right to a future” and “equal protection under the law.” Regarding vaccine-preventable childhood diseases, these rights should insure that children are not made martyrs on behalf of their parents’ beliefs.

      With the rise in these diseases and the deaths/disability/expense they bring, this all points to the eventuality that we need to do away with non-medical mandates. Better sooner than later.

      • clarynet replied

        on April 8, 2014 at 10:01 am

        What about those children who are damaged from the vaccines (the martyrs)? They HAD a right to a future and equal protection under the law…oh, wait…no, that’s not right. The PARENT is responsible for any damages that might occur (by giving their consent). Government has made sure that the pharmaceutical industry, docs and nurses are all off the hook. The parent and the child have to pay in monetary loss and physical suffering (if they survive)”for the greater good” of society? Get real! VAERS is a joke…docs won’t report damage for fear of losing their license. Very few stand in the gap for these families.

        I used to be like you and had your beliefs until it happened to my family and my kids were damaged. Funny how life turns the tables on those who think they know it all. It’ll eventually happen to you in your family. Give it time. In the meantime…leave these families alone.

    • MrsFun replied

      on April 8, 2014 at 10:36 am

      It’s not black and white. Vaccines can be harming or even deadly. I’m not willing to let my child be harmed by neurotoxins. I am 40 years old and been vaccinated but the titer shows differently, I am not immune to many diseases even though I have been vaccinated against them multiple times as an adult. This is when my research on vaccines started. What I found is an alarming truth. http://gianelloni.wordpress.com/2014/04/07/dear-parents-you-are-being-lied-to/

      Click the links and do research before throw manslaughter out there.

  2. navigio said

    on April 7, 2014 at 8:54 am

    Schools have deadlines by which vaccinations should be done and reported. If the student misses the deadline yet eventually gets vaccinated anyway,or if the parent is unable to produce a vaccination record at a specific time, the easiest way of dealing with that is to sign the exemption form. It would be interesting to know how many exemption students are actually vaccinated but filled out the form for some other reason.

    • Jane Meredith Adams replied

      on April 7, 2014 at 9:27 am

      That’s an interesting point, Navigio, and some researcher suspect that many exemptions might actually be from “convenience, rather than conviction.” There is a researcher who is looking into that in this coming year, with the goal of obtaining a truly accurate count.

      • Paul Muench replied

        on April 7, 2014 at 12:58 pm

        I used the APP to see how many exemptions there are for my school. About 1 in 10 were exempted. The APP listed three reasons for exemption: belief, conditional, and medical. All of the ex prions were classified as belief. How does this relate to the convenience discussion?

        • Jane Meredith Adams replied

          on April 7, 2014 at 1:27 pm

          It’s listed as a belief exemption if that’s the what parent signed. But, as Navigio noted, some parents may have signed a belief exemption because they didn’t have the vaccination record and they wanted to get their child into school. Those exemptions of “convenience” are expected to go away in 2014-15 because it is now more time-consuming to get the belief exemption, so why not go home and get the missing record, if that’s the case.

          • navigio replied

            on April 8, 2014 at 2:28 pm

            By the way, it’s not only just leaving the record at home, but it can be about misalignment of vaccination scheduling and school reporting requirements.
            The most common situation seems to be the parent didn’t know that a certain vaccination was due until after the fact or with not enough time to get the vaccination done. In the cases where I’ve seen this happen it’s always been after school has been in session for a few weeks.
            Also note that because the school needs either a vaccination record or an opt out document, the school may even ask the parents to sign the opt out document even if the parents are planning to get the kids vaccinated.
            And my goal is not to try to justify all of this, rather to point out that the number of unvaccinated kids may not accurately be represented by the number of opt out documents submitted.

  3. CarolineSF said

    on April 7, 2014 at 9:36 am

    We have to call out Waldorf schools more strongly on this — rather than just mentioning them in passing — because they are centers of vaccination-refusal culture.

    I believe that the reason the press largely lets this slide is because so many of our own friends have kids in Waldorf schools (that applies to me — what about others reading this?). At some point we have to grow a spine, though, when public health is at stake.

    The Waldorf Way: No Tests, No Grades, No Shots?
    Slate
    By KJ Dell’Antonia

    http://www.slate.com/blogs/xx_factor/2011/11/01/who_dares_confront_the_parents_of_the_bay_area_waldorf_school_wi.html

    • sherri replied

      on April 8, 2014 at 11:48 am

      it is not the “Waldorf way” to not have vaccinations. Waldorf in no way tells a parent what to do or not to do with the child’s health. The school just follows the law of the state they are in. This is parent led. The thing is, those opting out are more highly educated as a whole. And more highly educated are also more likely to enroll their kids in a private school. So this is not a “Waldorf way.”

      • Vincent Iannelli, MD, FAAP replied

        on April 9, 2014 at 6:32 am

        “The thing is, those opting out are more highly educated as a whole. And more highly educated are also more likely to enroll their kids in a private school. So this is not a ‘Waldorf way.’”

        Sure. Parents opting out of vaccines and putting their kids at risk of life-threatening vaccine-preventable diseases are more highly educated than 90 to 95% of the people in the world, including over 99% of the highly trained specialists in the field of pediatric infectious disease, immunology, and autism, etc.

        This is about people who think they know better, rejecting logic and science, and putting the rest of us at risk.

      • CarolineSF replied

        on April 9, 2014 at 7:59 am

        Not vaccinating is a major part of the Waldorf culture. Waldorf schools consistently have high rates of personal belief exemptions. Your statement is false, Sherri.

  4. djs said

    on April 7, 2014 at 10:12 am

    Children do not opt out, their parents do. When kids come to school with serious diseases they can pass it to homes with infants and the elderly. I agree, no vaccinations, no public or charter schools. Let them go private. And if a child dies, sounds like premeditated murder to me.

    • CarolineSF replied

      on April 7, 2014 at 11:58 am

      DJS, it also needs to be called out more forcefully. Regarding Waldorf schools, some are charters and many are private (and I know of one non-charter Waldorf public school). Private schools actually have the right to absolutely require vaccinations without exemptions, I know from formerly being on the board of a co-op preschool — anti-vax applicants would squawk that we had no right to not allow exemptions, but yes we did.

      Many of us are looking the other way (because our friends are doing it and it’s awkward to speak up). We really need to man (woman) up.

      The unvaccinated child of one of these parents is not that likely to die — they tend to be privileged and able to afford good medical care. What’s likely is that the child may spread the illness to someone vulnerable, with a compromised immune system or elderly or frail or without good health care — and THAT person will suffer the consequences.

  5. Lily Biro said

    on April 8, 2014 at 8:53 am

    If vaccines work, those who choose to not vaccinate — or to selectively vaccinate — the vaccinated are at no risk. Some of us have seen our children literally change before our eyes during/after a vaccine; my son is one of them. Until you’ve seen it, you have no clue. I won’t inject him again to protect someone else, as ALL parents’ priority is supposed to be their own child. We have peanut-free classrooms because some kids die from peanut exposure, but we want to believe that a vaccine with numerous ingredients is safe for 100% of the world? Pure ignorance. People don’t all not vaccinate due to beliefs, but many to experience that can’t be discounted. Read the insert from the vaccine; it’s eye-opening about the known side-effects, and even if it’s 1-in-10,000, that 1 is someone’s child. That child is not acceptable loss.

  6. Sarah said

    on April 8, 2014 at 8:55 am

    Would just like to point out that “cases” of a disease don’t equal “death” or “injury” from a disease.

    A case of measles can mean someone got a rash and felt crummy for a few days and that was it. It COULD mean there were worse symptoms as well, but there are no reported measles deaths from any of the cases nationwide in 2013. There aren’t even any reports I can find saying there was serious or lasting injury from any of the cases.

    Not trying to say that people shouldn’t be fully informed of the risks of vaccination, the risks of the diseases themselves / risks of not vaccinating, and all that goes along with informed consent. I just wish that articles like these didn’t just focus on “cases” but instead put what that means into perspective.

  7. Robyn Charron said

    on April 8, 2014 at 9:18 am

    Firstly, kindergartner is misspelled.

    Secondly, notice how the unvaxed don’t go to the doctor often? Do you wonder whether that is because they don’t exhibit many random viral infections and don’t suffer from vaccine-induced chronic illness, such as asthma, food allergies, diabetes and epilepsy?

    Thirdly, if you are going to rely on surveillance data to speak about measles in the unvaccinated, then you should likewise use the surveillance data in speaking about pertussis in the unvaccinated rather than a study that used magic math to come to the “2.5 times more likely” number. The fact is that out of 986 children in San Diego with pertussis in 2010, only 69 were unvaccinated.

    Fourthly, Dr. Wakefield losing his medical license had nothing to do with so-called “fraudulent” work on the MMR/bowel disease case series. He lost his license for drawing blood outside of his medical office. The board hearing his case did not declare him to be a fraud; it was a slanderous name called him by the BMJ, who he later sued for saying it.

    Fifthly, tetanus infection is contracted from a puncture wound so deep that it does not bleed, and the object causing that wound had the toxin on it. How on God’s green earth a child at school is going to encounter an animal to bite them so deeply that they do not bleed is beyond my wildest imagination.

    • sullivanthepoop replied

      on April 9, 2014 at 6:13 am

      Unvaccinated children are as likely to have random viral infections as a vaccinated child if the viral infections are not vaccine preventable. Unvaccinated children are as likely to have chronic illness which are not vaccine induced like asthma, food allergies, diabetes and epilepsy.

      Why would we during a measles outbreak take the focus off where it should be and put it onto pertussis? So people can have a false sense of security? I don’t think you understand epidemiology. I got tetanus once, luckily I was only a about 13 months past due for my booster so I still had a good immune reaction. It was not a deep cut, it was a scrape. So, do not give people advice that can kill them because you are ignorant on this subject.

    • Dorit Reiss replied

      on April 9, 2014 at 8:28 pm

      Unvaccinated children do not go to the doctor often because many of their parents do not believe in evidence based medicine. Instead they use unsupported, baseless treatments like homeopathy. There is no evidence of better health outcomes and excellent evidence that vaccines do not cause allergies, asthma, and so forth.

      The evidence is that rates of every vaccine preventable disease – including pertussis – are higher among the unvaccinated. The numbers may be higher among the vaccinated – hardly surprising when most people are vaccinated – but unvaccinated children are, for example, 9-23 times more likely to get pertussis.

      Andrew Wakefield lost his license because he was found guilty of serious ethical violations, including hiding conflicts of interests, lying about obtaining an ethical approval, and performing invasive treatments with no ethics approval. His Research Assistant testified in the Autism Omnibus proceeding that the samples he examined were negative; the paper then said they were positive. Not exactly honest.
      Anyone can sue for anything; Andrew Wakefield had to withdraw his libel suit in England, that has plaintiff-friendly libel laws. The BMJ and Brian Deer’s claim are strongly documented.

      Tetanus can be acquired even if the wound bleeds. All you need is for some of the spores – which are microscopic – to get to an area which is anaerobic, low on oxygen. The spores are in the soil.

      Accuracy. It matters.

  8. clara said

    on April 8, 2014 at 9:26 am

    No way am i stiking horse urine or monkey dna or formaydihide in my tiny baby

  9. Michelle said

    on April 8, 2014 at 12:38 pm

    Dr. Tetyana Obukhanych, PhD (Immunology) explains in the referenced article linked here, that the only true “herd immunity” is that which is gained when large segments of the population acquire permanent immunity by contracting and overcoming diseases. http://www.greenmedinfo.com/blog/herd-immunity-myth-or-reality

    Additionally, the FDA announced recently that fully vaccinated individuals are able to spread pertussis, as well as to contract it themselves:

    FDA News Release Nov. 27, 2013:
    “…acellular pertussis vaccines licensed by the FDA …may not prevent infection from the bacteria that causes whooping cough in those vaccinated or its spread to other people…”

    “The FDA conducted the study in baboons, an animal model that closely reproduces the way whooping cough affects people…Animals that received an acellular pertussis vaccine had the bacteria in their airways for up to six weeks and were able to spread the infection to unvaccinated animals. In contrast, animals that received whole-cell vaccine cleared the bacteria within three weeks.”

    “This research suggests that although individuals immunized with an acellular pertussis vaccine may be protected from disease, they may still become infected with the bacteria without always getting sick and are able to spread infection to others, including young infants who are susceptible to pertussis disease.”

    http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm376937.htm

    Additionally, in the pertussis outbreak of 2012, Anne Schuchat of the CDC stated that exemptors did not appear to be driving the outbreak.

    “We know there are places around the country where there are large numbers of people who aren’t vaccinated. However, we don’t think those exemptors are driving this current wave…we cannot blame this wave on that phenomenon.”
    http://www.cdc.gov/media/releases/2012/t0719_pertussis_epidemic.html

    According to these sources (and many others), the vitriol directed at vaccine exemptors is unwarranted.

    • CarolineSF replied

      on April 9, 2014 at 7:56 am

      So how do vaccine exemptors feel about the fact that all parents used to have to live in terror of diseases that would kill many children — or leave them disabled, such as polio — and no longer do?

      We’ve seen a number of pertussis outbreaks at schools with large populations of vaccine exemptors (Google pertussis and Waldorf), and I’ve never heard of one at a school that DIDN’T have a large population of vaccine exemptors. What’s the response to that?

  10. Gary Ravani said

    on April 8, 2014 at 2:06 pm

    When I read comments about how some “reform” will bring actual knowledge of science and the Common Core will somehow develop critical thinking skills for all, the quick antidote to all that hopeful thinking is to read the comments here. A rumor mill against immunization begun by a defrocked doctor in England coupled to the usual “paranoid style” that runs through American society is dangerous to children. Some epidemic costing many children their health and/or lives is a tough price to pay to coddle the superstitions of some parents. Don’t like immunizations? Fine. Keep your child at home or in the company of children with parents of a like mind. (Fat chance.)

  11. Jeff Smith said

    on April 9, 2014 at 10:36 am

    http://vaxtruth.org/2011/08/vaccine-ingredients/

    OK. Here are the additional ingredients in vaccines – I hope people will review this, and file it where they can find it again. Can you imagine that these ingredients, injected up to 70 times by age 18, beginning in the hours immediately after birth and sometimes given 4-5 vaccines at a single dose (“pentavalent”) or office visit, could have harmful effects on the immune, metabolic and neurological systems of growing children ? Could you imagine that even if there are no immediate serious effects, the cumulative injections of these substances could have QUITE serious effects ? Parents are showing up by the thousand, telling doctors and nurses “this is what happened to my child”. Or maybe they don’t make a connection – and are mystified. Nurses, THINK – and before you buy into this practice, look into the growing body of science that cautions AGAINST it !

  12. Don said

    on April 9, 2014 at 11:45 am

    I used to think the readers here were a particularly informed lot. Then I read this thread and realized how many people, even the educated, allow themselves to wallow in pseudoscience.

  13. Gary Ravani said

    on April 9, 2014 at 1:35 pm

    Partial message from Dr Jennifer Raff, Phd, Genetics:

    Dear parents,

    You are being lied to. The people who claim to be acting in the best interests of your children are putting their health and even lives at risk.

    They say that measles isn’t a deadly disease.
    But It is.

    They say that chickenpox isn’t that big of a deal.
    But It can be.

    They say that the flu isn’t dangerous.
    But It is.

    They say that whooping cough isn’t so bad for kids to get.
    But It is.

    They say that vaccines aren’t that effective at preventing disease.
    But 3 million children’s lives are saved every year by vaccination, and 2 million die every year from vaccine-preventable illnesses.

    They say that “natural infection” is better than vaccination.
    But they’re wrong.

    They say that vaccines haven’t been rigorously tested for safety.
    But vaccines are subjected to a higher level of scrutiny than any other medicine. For example, this study tested the safety and effectiveness of the pneumococcal vaccine in more than 37,868 children.

    They will say that doctors won’t admit there are any side effects to vaccines.
    But the side effects are well known, and except in very rare cases quite mild.

    They say that the MMR vaccine causes autism.
    It doesn’t. (The question of whether vaccines cause autism has been investigated in study after study, and they all show overwhelming evidence that they don’t.)

    They say that thimerosal in vaccines causes autism.
    It doesn’t, and it hasn’t been in most vaccines since 2001 anyway.

    They say that the aluminum in vaccines (an adjuvant, or component of the vaccine designed to enhance the body’s immune response) is harmful to children.
    But children consume more aluminum in natural breast milk than they do in vaccines, and far higher levels of aluminum are needed to cause harm.

    They say that the Vaccine Adverse Events Reporting System (and/or the “vaccine court”) proves that vaccines are harmful.
    It doesn’t.

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