Medical exemptions soar in California as SB 277 makes personal belief exemptions unavailable [Respectful Insolence]

Before I get into the topic at hand, I want to explain why there was no post yesterday. Some of you on Facebook might have seen my post about why, but basically, we lost power last night. We’re still without power. In fact, the only reason I can write this is because I’m staying at my parents’ house tonight. No, it wasn’t weather. Rather, basically a nearby substation caught fire. Michigan infrastructure is great, and I really need to get a generator.

It also reminds me how much I wouldn’t mind living in California. For one thing, it’s a beautiful state. Even better, California was willing to do something to protect children that only two other states in the union do. In 2015, California passed SB 277, a law that eliminated nonmedical exemptions to school vaccine mandates. The law was passed in the wake of the Disneyland measles outbreak, which started during the Christmas holidays in 2014 and ultimately spread to several states, Mexico, and Canada, facilitated by unvaccinated children. After that outbreak, California legislators, led by Senators Richard Pan and Ben Allen, the bill’s co-authors, actually did something that required a lot of guts. They passed SB 277, meaning that, as of the 2016-2017 school year, personal believe exemptions (PBEs) to school vaccine mandates are no more in California. Even better, SB 277 works. Percentages of students claiming PBEs plummeted in just the first year.

Unfortunately, all is not perfect with SB 277. For one thing, I predicted that parents, stymied by SB 277 when they try to claim a PBE, would shift to trying to find antivaccine-friendly physicians and other health care professionals allowed to sign letters supporting medical exemptions to school vaccine mandates who were willing to—shall we say?—expand the spectrum of medically indicated reasons not to vaccinate. Indeed, this is the weakest aspect of the law. Any doctor can write a letter supporting a PBE, and a cottage industry of doing just that and selling PBEs has sprung up in the state, with that antivaccine dog whistler “Dr. Bob” Sears leading the way with “how-to” lectures. It was noted before as a reason for concern in otherwise good news about how well SB 277 was working. I am, of course, referring to exactly what I predicted, that parents not wanting to vaccinate would start finding ways to get medical exemptions now that PBEs are no longer available to them.

Basically, the number of children with medical exemptions tripled:

Even with a new law that has boosted kindergarten vaccination rates to record highs, hundreds of schools across California still have so many children lacking full immunization that they pose an increased risk of disease outbreaks, according to a Times analysis of state data.

At nearly 750 schools, 90% or fewer kindergartners had been fully vaccinated last year, the analysis found. Experts say the rate should be at least 95% to prevent the spread of highly contagious diseases such as measles.

California’s tougher inoculation law, known as SB 277, was approved in 2015 after a measles outbreak that originated at Disneyland. The law bars parents from citing religious or personal beliefs to excuse their children from immunizations, but some who already had such exemptions were allowed to keep them.

The rest of the unvaccinated children need a form signed by their doctor saying they had a medical reason not to get their shots.

In the school year that began last fall, the law’s first year, the number of kindergartners in California with medical exemptions tripled, the analysis found.

The result is that, even as the statewide percentage of kindergarteners who had received all their vaccines has increased from 90.2% in the 2013-2014 school year to 95.6% in the 2016-2017 school year, the number of children with medical exemptions has increased from 991 to 2,850 during the same period.

No here’s the thing. As discussed in the article, the percentage of children with legitimate reasons for not being vaccinated shouldn’t be more than 3% at most. These would be children with accepted, evidence-based medical reasons for not tolerating vaccines, such as a gelatin allergy or because they’re immunosuppressed, either due to disease or undergoing chemotherapy. You might ask: So what if less than 3,000 kindergarteners in the state have medical exemptions? If those children were evenly distributed, it might not be such a big deal. However, as we know, families that are vaccine-averse tend to cluster, and that’s what appears to be happening here:

But the Times analysis found that at 58 schools, 10% or more kindergartners had medical exemptions last fall. The rate topped 20% at seven schools.

“That’s just totally wrong,” said Dr. James Cherry, a UCLA research professor and senior editor of the “Textbook of Pediatric Infectious Diseases.” “This idea of 20% having medical exemptions is nonsense, and certain doctors buy into that, but it’s wrong.”

Experts say some parents who are hesitant about vaccines may be asking doctors to vouch that their children have medical reasons to avoid them or get them later than when they’re required by law.

There’s no “may be” about it. If you pay attention to antivaccine groups, websites, Facebook pages, and the like it’s not hard to find that doctors are writing letters supporting medical exemptions based on the flimsiest of reasons. Indeed, a parent sent me an example of Dr. Bob Sears basically providing a letter supporting medical exemptions based on filling out an online form and paying a fee of $180 a child. Meanwhile, there’s been a bit of a gold rush of woo-friendly antivaccine-leaning (or at least -sympathetic) doctors seeking to profit by selling medical exemption letters. Dr. Tara Zandvliet, for example, charges $120 a child for such a letter and advertises reasons that are not evidence-based, such as:

Hyper immune conditions
Including, but not limited to:
Asthma
Allergies to food, bee stings, medicines that include hives/swelling/wheezing (hay fever does not count)
Eczema
Hives

Autoimmune Conditions
Including, but not limited to:
Celiac
Crohn’s
Ulcerative Colitis
Lupus
Sjogrens
Scleroderma
Mixed connective tissue
Hashimoto or Graves thyroid (not regular low thyroid)
Psoriasis
Vitiligo
Vasculitis
Antiphospholipid antibody
Multiple Sclerosis
Rheumatoid arthritis (not old age or overuse arthritis)
Wegeners
Type 1 diabetes (child type)
Eosinophilic esophagitis

Let’s just put it this way. None of the above conditions is a contraindication to vaccination. Indeed, the list of true contraindications to vaccination is brief, and very little of what’s on Dr. Zandvliet’s list is on that list. I suppose I should give Dr. Zandvliet credit for one thing. At the end of the list, it does say that autism, autism spectrum disorder, and behavioral issues are “not sufficient to meet medical exemption requirements.”

The problem, of course, is SB 277’s greatest weakness; it is incredibly broad in the range of reasons physicians may give to justify requesting a medical exemption. Dr. Bob himself bragged about that:

The guidelines for providing medical exemptions are extremely broad in the new California law. Parents, physicians, legal experts, and some legislators fought to have the term “contraindication” removed from the guidelines, and succeeded. This means that is it up to the personal judgement of each physician and patient to work together to determine if a child qualifies for a medical exemption. The California bill declares that an exemption can be granted if “the physical condition of the child is such, or medical circumstances relating to the child are such, that immunization is not considered safe, indicating the specific nature and probable duration of the medical condition or circumstances including, but not limited to, family history, for which the physician does not recommend immunization . . .”

Not surprisingly, the areas where these nonmedical exemption rates are highest are all where most of the woo-friendly doctors are:

Statewide, private and charter schools account for the majority of schools where 90% or fewer kindergartners had received all their shots, the Times analysis found. The analysis included 6,500 schools with 20 or more kindergartners — the state did not provide data on schools with fewer than 20 kindergartners.

A third of the schools with low vaccination rates were in Los Angeles County, followed by San Diego and Orange, the analysis found.

Many school administrators said they did not want to comment on decisions made by parents. Others could not be reached for comment or were out of the office for summer vacation.

The report names the ten schools with the highest percentage of medical exemptions. Not surprisingly, four out of the ten are Waldorf Schools (or, as I like to call them, outbreak centers) and the rest are charter schools or Christian schools. The percentage of medical exemptions among these schools range from 19% to 40(!)% Oh, wait. Sunridge Charter School advertises itself as using a Waldorf curriculum. Make that half the schools at germ central are Waldorf schools. .

It’s good that, overall, even the 2,850 kindergarteners with medical exemptions represent only 0.5% of kindergarteners, but the numbers show that they are clustered in such a way that make outbreaks more likely.

So what can be done? Unfortunately, basically the only check on the issuance of letters by doctors supporting medical exemptions based on dubious reasons is the state medical board. Given how overtaxed most state medical boards, including California’s, is, it’s hard to imagine the Medical Board of California doing much to crack down on the sale of medical exemptions. On the other hand, as I noted last year, the board has actually gone after Dr. Sears for, in part, writing a letter supporting a medical exemption based on medically unsupported reasoning. It’s for something he did in 2014, though, which is before SB 277, and I haven’t heard any updates in the year since I learned of this action. I wonder what’s going on.

Despite this problem, the passage of SB 277 remains a major victory in the struggle to protect children from the ravages of infectious disease. It still remains the single biggest defeat in my memory for the antivaccine movement, which marshaled pretty much everything it had to defeat it and still came up short. Unfortunately, it is not perfect. It’s politics. Compromises had to be made to pass it. It is a beginning, not an end, and part of what needs to be done now is to keep an eye on its implementation.

What really needs to happen is for the culture in California to change. SB 277 might be able to accomplish that in the long term.