Shot wave

Three years after California stopped allowing families to easily opt out of childhood vaccines, the number of kids getting medical waivers has tripled—the result, critics say, of some doctors loosely issuing exemptions to help families get around the law.

The decrease has left some counties, including Nevada and Plumas, below the recommended vaccination rate required for “community immunity” against dangerous diseases such as measles and whooping cough. Butte County is on the cusp.

And the number of medical exemptions will continue to rise unless the state clamps down, warns a study in the journal of the American Academy of Pediatrics. The authors interviewed local public health officers across the state, some of whom complained of doctors charging fees in exchange for writing exemptions.

This winter—as an outbreak of measles strikes several states that allow parents to opt out of vaccinating their children because of personal or philosophical objections—California is one of three states (along with Mississippi and West Virginia) that allow only medical exemptions. Since the law was enacted, California’s vaccination rate has risen more than 2 percent. It’s now just over 95 percent, above the 94 percent rate the state health department says should be sufficient to protect those who can’t be vaccinated, but regional pockets of the population remain at risk.

Nevada County has the lowest vaccination rate, 81.7 percent, and the highest exemption rate, 7.7 percent, among kindergarteners, according to statistics from the California Department of Public Health. Trinity, with 84.5 percent vaccinated, has the second-highest exemption rate, 7 percent, followed by Plumas’ 4.7 percent exempted (with 91.2 percent vaccinated). Butte has a 94.5 percent vaccination rate and just 1 percent exempt.

State public health data show medical exemptions among kindergartners rose to now represent 0.7 percent statewide in the last school year, from 0.2 percent two years earlier—an uptick largely in private schools, where more than 1 in 50 students now have a medical waiver from the vaccination law. All told, 4,111 California kindergarteners had permanent medical exemptions from vaccination in the last school year, out of more than a half-million kindergarteners enrolled.

Legislators and health experts are debating what to do next. One proposal would be modeled on an existing state requirement that any veterinarian seeking to exempt a sick dog from rabies vaccination must obtain approval from a health official.

“We delegated that authority to licensed physicians, and the problem is we have physicians abusing that authority,” said Democratic state Sen. Richard Pan, a Sacramento-area pediatrician who authored the state’s controversial ban on personal waivers after a measles outbreak originating at Disneyland infected 136 people in December 2014. “I think we need the health departments to basically say when someone is abusing that authority—and to withdraw that authority and invalidate exemptions that were fraudulent.”

Pan has yet to propose a legislative remedy, saying he is working with the state health department and the California Medical Board on how to deal with physicians who may be in violation.

The California Medical Association, a doctors’ organization that supported eliminating the personal exemption, is again working with Pan. The organization supports “having standards in place to make sure the medical exemption system is not being abused,” said association spokesman Anthony York.

But critics say any new rules would amount to overkill by lawmakers, who had promised to leave medical exemptions to the discretion of doctors.

“The state is inserting itself in between the patient-doctor relationship,” said Rebecca Estepp, an advocate who campaigned against jettisoning the personal waiver and calls the increase in medical waivers “nothing.”

She attributes most of the rise to the fact that many parents whose children qualified for a medical exemption used to just sign a personal exemption card because it was easier.

The U.S. Centers for Disease Control and Prevention, or CDC, urges vaccinations for the vast majority of children, saying they are generally safe and that the benefits of protection against potentially fatal diseases—such as measles—are worth the risk.

The CDC acknowledges that vaccines can cause side effects. Federal guidelines advise avoiding or delaying certain vaccines for children with certain health conditions, including compromised immune systems, and those with a personal or family history of seizures. California law also allows family medical history to be taken into account.

The study in Pediatrics reported that most California county and city health officers and immunization staff reported few or no problems with medical exemptions. But other staffers did report problems, noting that some doctors were listing questionable conditions such as a family history of allergies, or charging fees in exchange for writing exemptions, or charging families for medical tests to establish family history and exemptions signed by doctors who do not usually treat children.

One local health officer, the study noted, cited the example of a physician charging families to watch a video before issuing a three-month exemption at a cost of $300. Parents then would be required to return for a fresh exemption at additional cost.

This year’s measles outbreak, which started predominantly among unvaccinated children, spread widely from a southwest Washington county bordering Portland. By the CN&R’s deadline, it had reached 10 states, including California, and surpassed 100 cases—though the Butte County Public Health Department reported no measles within its jurisdiction. According to the CDC, the vaccine for measles is 97 percent effective with two doses and 93 percent effective with one dose.

Still, lawmakers may be reluctant to invite a sequel to the turbulent Capitol fight four years ago over vaccinations exemptions; instead they may urge state regulators to more aggressively crack down on dubious medical exemptions. If a new law is proposed, Estepp said, legislators should expect to see vocal parents and advocates who oppose tighter vaccine regulation flood their offices like they did last time.