California's Vaccine Exemption Policy Yields Frustration, Concern

October 29, 2018

By Marilynn Larkin

NEW YORK (Reuters Health) - California's elimination of nonmedical vaccine exemptions for school entry has led to an increase in "problematic" medical exemptions, researchers say.

"California is the first state in nearly 35 years to eliminate nonmedical vaccine exemptions, so the passage of Senate Bill 277 (in 2015) offers a timely and important landscape to see how a strict vaccine exemption policy is implemented in a large and diverse state," Dr. Salini Mohanty of the University of Pennsylvania School of Nursing told Reuters Health.

"In our study," she said, "health officers reported instances of physicians granting medical exemption requests in exchange for a monetary fee; this is concerning because these examples show that some physicians have taken advantage of the law to provide medical exemptions to vaccine-hesitant parents."

"Other states considering similar vaccine exemption laws should be aware that these are issues they may encounter," she noted.

Dr. Mohanty and colleagues conducted 34 phone interviews in August and September 2017, with 40 health officers and immunization staff from more than half of the local health jurisdictions in California.

As reported online October 29 in Pediatrics, four themes emerged from those interviews with respect to medical exemptions:

(1) the role of stakeholders, including physicians, schools, local and state health departments and the California Medical Board;

(2) review of medical exemptions received by schools, including tracking, legal repercussions for not tracking, and verifying the exemptions;

(3) medical exemptions that were perceived as problematic, including some of the conditions (e.g., family history of allergies or autoimmune disorders) listed as contraindications for immunization, physicians charging "steep" fees for exemptions; and exemptions signed by physicians such as cardiologists, who do not typically treat children;

(4) frustration and concern over medical exemptions, including lack of authority for local health departments; burden on school staff to review the exemptions; and concern about the increase in medical exemptions.

Overall, local health jurisdictions described a narrow role in providing support and technical assistance to schools. Only five jurisdictions actively tracked medical exemptions received by schools, with one jurisdiction facing a lawsuit as a result.

"To date, the California Medical Board has received 60 complaints regarding medical exemptions since the implementation of SB277," the authors state. "A majority of cases have been closed because of no violations being found, insufficient evidence to pursue disciplinary action, or the inability to proceed because of a lack of supporting evidence."

Dr. Mohanty concluded, "Without legal changes to Senate Bill 277 related to medical exemption provisions, like a standardized state-level health department review of medical exemption requests, we might continue to see an increase in medical exemptions in California which could potentially limit the long-term impact of Senate Bill 277 to reduce vaccine-preventable disease outbreaks."

Dr. Richard Pan, state senator representing California's sixth district and coauthor of a related editorial, told Reuters Health that the editorial "highlights our opinion that the granting of medical exemptions is an administrative, public health function that the state has chosen to delegate to physicians."

"We need to acknowledge that the granting of exemptions isn't the practice of medicine - there is no treatment or diagnosis of illness," he said by email.

"Since the state delegates this public health authority to physicians, the state should also be able to revoke the duty - and in fact, they should be able to retroactively revoke previously granted medical exemptions that are based upon abuse of authority," he said.

"West Virginia has chosen not to delegate that authority directly to physicians," he noted. "Instead, their department of public health retains oversight of the entire process. Their medical exemption process actually requires that physicians apply to the department of public health, and then the department decides whether or not to grant the exemption."

"There aren't a lot of physicians granting fraudulent exemptions, but it only takes a few," he said. "(These) physicians are providing exemptions because it is a lucrative business. They are in it for the money, and anti-vaxx groups circulate the names of these doctors."


Pediatrics 2018.

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