Skirting the needle

As a family practice physician as well as Butte County’s public health officer, Dr. Andy Miller views vaccinations as a significant component of a healthy childhood. He knows a sliver of the parenting population has doubts, skepticism, even staunch opposition—but he sees the benefits of immunization as conclusive.

In speaking with the CN&R last Thursday (Sept. 7), three weeks into the local school year, Miller compared this to another scientific topic on which dubiousness persists despite near unanimity among experts.

“I know that people who don’t agree with vaccines will not like this analogy,” he said by phone, “but it’s very similar to the climate change debate where there are a small percentage of scientists—less than two, in immunizations less than that—who raise questions, and if you want to, you can choose their conclusions and their questions rather than the vast majority[’s].

“Science, the whole purpose of it is to try to understand the world in ways that question our own biases. A scientist is supposed to be someone who is well thought of because of the accuracy of their conclusions rather than the drama that their conclusions create. In both of these fields.”

In his experience—including 14 years at Northern Valley Indian Health before moving to county Public Health last fall—Miller said he’s found a common theme among the objections he’s heard from local parents: distrust. They distrust the data and distrust the sources of data and analysis, including the U.S. Centers for Disease Control and Prevention.

“People worry, not without cause, about the influence of the energy industry on one side [climate change] and the pharmaceutical industry on the other [immunizations],” he continued. “But what I usually try to say is there are people who don’t have financial interest in this, like the CDC; I’ve been to the CDC, and there are few sources I’m going to trust more than those hard-working, underpaid people.”

Miller doesn’t convince everyone. Nor do his colleagues in family medicine and pediatrics, countywide and statewide. Parents still opt-out of immunizations, even though California requires vaccinations for school children with—following implementation of Senate Bill 277—just one exception. Only a medical condition is grounds for an exemption.

That law took affect for the 2016-17 school year. Exemption requests dropped significantly (see chart)—but there’s a wrinkle, a caveat.

Families who oppose mandated immunization for schoolchildren may be seeking medical exemptions to get around the new state law, which requires kindergartners entering public and private schools to be fully vaccinated regardless of families’ personal beliefs, according to a study published Sept. 5 in JAMA, the Journal of the American Medical Association.

Before the 2016-17 school year, parents who opposed vaccination, or anti-vaxxers as they are often called, could enroll their unvaccinated children in school citing the personal belief exemption, based on religious or philosophical convictions, for example.

After a rampant measles outbreak originating at Disneyland in 2014 that resulted in 147 cases reported across seven states, California scrapped the personal belief exemption. The law, which was hotly contested by some parents, left in place waivers for medical reasons.

The increase in medical waivers suggests that anti-vaccine parents may be finding doctors willing to exempt their kids from the mandate, according to the researchers.

The study, which used data from the California Department of Public Health, shows that the number of medical exemptions among kindergartners, though small, tripled to 2,850 in 2016 from the previous year. Meanwhile, the number of exemptions for personal beliefs was about four times lower in 2016 than in the year before. (They did not plunge to zero in part because some pre-kindergartners had exemptions that were grandfathered in under the law.)

The state’s law, however, gives doctors more wiggle room to authorize medical exemptions—for example, for children with a family history of adverse reactions to vaccines.

Paul Delamater, an assistant professor at the University of North Carolina-Chapel Hill and lead author of the JAMA study, said this reason is inconsistent with the recommendation from the American Academy of Pediatrics. The academy states that medical exemptions should be reserved for students who could truly be harmed by vaccination, such as those with a weak immune system because of chemotherapy or a known dangerous reaction to a vaccine ingredient.

Many of the California counties with the biggest increases in medical exemptions since the law took effect are in Northern California, including Shasta, Plumas, Sonoma and Marin. (Butte County’s medical exemptions increased five-fold between 2015-16 and 2016-17, reaching the 1 percent mark, double the state average.)

“The medical exemption increase is concerning,” said Catherine Flores-Martin, executive director of the California Immunization Coalition, a public-private partnership that promotes vaccinations and co-sponsored the state’s vaccine law.

Flores-Martin said health professionals expected a short-term rise in medical exemptions because parents previously may have obtained the easier-to-get personal belief exemptions for children who actually qualified medically. (Miller gave the CN&R a similar explanation.) But the rise in medical exemptions is greater than she had anticipated, and Flores-Martin said some doctors may be inappropriately offering them to parents on a broad basis.

“It would be unusual for a child to be exempted from every vaccine forever, because that’s pretty extreme. You see patterns [of such exemptions] in some of these schools. I don’t think that’s a coincidence.”

As far as Miller knows, no local parent has sought or received a medical exemption from county Public Health. He said he’s confident that those issued by local physicians are legitimate because, among family practitioners and pediatricians, “it’s hard to find someone who’s not a strong proponent of immunization.”

However, an hour’s drive south to the Sacramento area are “clinicians who essentially advertise for permanent medical exemptions,” he said—known to the county medical community and state public health officials. He declined to get more specific, other than to say anti-vaxxers know to find “a clinician who’s either made this decision based on their philosophy or based on their finances, or both.”

Miller remains concerned about gaps in vaccination. He mentioned measles—impetus for Senate Bill 277—as a 2017 example, noting that an outbreak in a heavily anti-vaxx Minnesota community left more people sick (79) than got the disease across the U.S. last year (70).

“We’re victims of our own success; our fear of these diseases has gone away because we’ve done a fairly good job of minimizing them,” he said. “It used to be you didn’t have to convince someone to get the measles vaccine [because] we’d lose 6,000 people a year dying from measles 100 years ago. Now we don’t.”