In 2015, California Governor Jerry Brown signed SB277 into law, which eliminated all personal belief exemptions, but still allowed valid medical exemptions, for vaccinations before children enter school. It was considered a public health triumph. Despite a multitude of lawsuits, the law has stood, while impressively increasing the vaccination rate in the state.
California state Sen. Richard J. Pan, M.D., M.P.H., FAAP, led a hard-fought legislative battle against vaccine opponents to pass the law. He had to put up with racist attacks and public confrontations during and after the battle to pass SB277.
Despite the public health importance of mandatory vaccines for children entering school, some California families are utilizing false or questionable medical claims to jump through loopholes to not vaccinate their children. I have been advocating, along with many others, that California needs to close these loopholes, possibly by having public health experts review all medical exemptions before school children are allowed to enter school. This isn’t to force vaccinations on children, but to protect all children from dangerous, sometimes deadly, vaccine-preventable diseases.
In a new study by Salini Mohanty et al., published in Pediatrics, the authors examined the experiences of public health officials and immunization staffs that addressed requests for medical exemptions under SB277.
SB277 medical exemptions – results
The authors conducted 34 interviews with public health officers and immunization staff that represented 35 of the 61 local health authorities in California. The authors uncovered four general themes from these interviews
- The roles of stakeholders – physicians are responsible for medical exemptions, but schools do not have the capabilities to review those exemptions.
- Reviewing medical exemptions – the school districts and local public health jurisdictions were given no responsibility or authority under SB277 to evaluate the medical exemptions.
- Medical exemptions that were perceived as problematic – some of the exemptions were signed by physicians who charged as much as $150-300. And other exemptions were signed off by physicians who were not pediatricians and were not responsible for the child’s health. Moreover, some medical exemptions listed a family history of allergies and autoimmune diseases as contraindications for immunization, despite their not being valid reasons for the medical exemption. In fact, since SB277 took effect, the Medical Board of California has received over 50 complaints about inappropriate medical exemptions, but most were closed without a violation being found or deemed to have insufficient evidence to pursue them. Of course, Dr. Robert Sears, a noted anti-vaccine pediatrician, was cited and placed on probation by the Board. Anti-vaccine groups have even published lists of physicians who are willing to give out medical exemptions for free or a price.
- Frustrations and concern over medical exemptions. They were annoyed by the lack of authority for local health departments, concerns regarding the burden on school staff to review these medical exemptions, frustration with the physicians who are signing off on the problematic medical exemptions, and concern about the increase in medical exemptions since the implementation of SB277.
The authors also found that SB277 put an undue burden on school staff to review these medical exemptions. Because of a shortage of school nurses in public schools across the state, secretaries, registrars, and other staff, who are probably not qualified to determine the validity of medical exemptions are forced to review them.
Moreover, if they deny a medical exemption, that student would be excluded from attending school. But this goes against the policy which sets school funding based on average daily attendance, so these individuals have to way good health policy with educational funding.
Despite all of these issues, the authors found that the vaccination rates for kindergarten children rose from 93% to 95%. Unfortunately, they also found that medical exemptions increased a spectacular 250% from 0.2% to 0.7%.
California medical exemptions – summary
Dr. Pan and Dorit Rubinstein Reiss, L.L.B., Ph.D. (who frequently writes articles on this website), wrote an associated commentary, also published in the same issue of Pediatrics. They stated that disciplining physicians requires cooperation from patients who received these problematic medical exemptions. That’s probably not going to happen, given that anti-vaccine parents are asking for them, so they won’t want to get their physicians into trouble.
The authors called for public health officials across the country to have more authority and responsibility to review and track all exemptions, including medical exemptions. They wrote:
Mandating vaccination for school is an effective strategy to prevent outbreaks. This protection is undermined when unscrupulous physicians monetize their license and abuse the authority delegated to them from the state by granting unwarranted MEs (medical exemptions). Public health officers need the information to identify these physicians and the authority to withdraw their ability to grant MEs and to invalidate unwarranted MEs to protect children and public health.
SB277 made no major changes to California law regarding granting MEs, a power that lies solely in the discretion of any physician licensed by the Medical Board of California or the Osteopathic Medical Board of California. Mohanty et al interviewed California health officers after the passage of SB277 regarding their role in and observations of granting MEs. Health officers expressed frustration with their lack of authority to limit unprofessional behavior by physicians granting large numbers of unwarranted MEs and thus putting students at risk. A local health officer who tracked MEs faced a failed lawsuit and personal attacks by antivaccine extremists. Health officers also felt it is was unfair for school staff to review MEs.
Vaccines are one of the greatest public health successes in history. Mandating vaccination for school is an effective strategy to prevent outbreaks. This protection is undermined when unscrupulous physicians monetize their license and abuse the authority delegated to them from the state by granting unwarranted MEs. Public health officers need the information to identify these physicians and the authority to withdraw their ability to grant MEs and to invalidate unwarranted MEs to protect children and public health. Pediatricians can partner with public health advocates and proscience parents to pass laws that empower public health officers to protect our children and community. Every child needs community immunity.
Pan RJ, Reiss DR. Vaccine Medical Exemptions Are a Delegated Public Health Authority.