On March 4, 2018, a 15-year-old boy returned to Silicon Valley from a trip to Europe with a fever, cough, rash and other symptoms of measles. Over the ensuing four weeks, the virus spread to six others, including siblings, classmates and fellow Boy Scouts members.
Santa Clara County public health officials traced hundreds of contacts in 10 California counties and Nevada from those seven local patients, six of whom lacked immunity because of parents who chose not to vaccinate them during childhood. Of the un-inoculated, two—a 7-year-old boy and his 4-year-old brother—were granted identically broad medical exemptions by the same doctor hundreds of miles from home despite having no underlying health issues that would make them ineligible for immunization.
The Centers for Disease Control and Prevention (CDC), which labeled them patients “F” and “G” in a study of the outbreak, pointed to the pair as bellwether of a troubling trend. That is, California’s vaccination rates continue to fall as medical exemptions climb.
A few years ago, in response to a measles outbreak that began in Disneyland, California enacted Senate Bill 277, which banned parents from opting out of legally mandated vaccines based on personal beliefs. The good news: it worked. The rate of families citing personal beliefs to skip vaccines went from 2.4 percent to zero. However, the years since have seen a steady rise in the number of medical exemptions, which are usually granted to children with serious health conditions such as immune system disorders.
Before SB 277 became law in 2016, just about 0.2 percent of students statewide got a permanent medical exemption. Since the personal belief standard was nixed, the physician-granted exemptions have more than tripled to 0.9 percent this past school year, according to new data from the California Department of Public Health.
Last fall, 94.8 percent of California kindergartners received all their shots, a drop from 95.6 percent in the prior school year. That may seem inconsequential, but it brings the state below the 95 percent threshold the CDC considers necessary to prevent outbreaks through herd immunity. The figures also vary wildly by ZIP code, ranging from less than 20 percent in one Los Angeles suburb to 99 percent in Santa Cruz County farm country.
In Santa Clara County, the rate rests at a safe 97.3 percent.
But no community exists in a silo. And the upward trending medical-exemption rates fuel fears that some doctors are contributing to immunity gaps by giving parents a loophole to skirt the state’s strict vaccination standards.
California lawmakers have responded by advancing a bill that would tighten up rules for clinician-granted exemptions. Under SB 276, authored by pediatrician-turned-state Sen. Richard Pan (D-Sacramento), public health officials would deem whether the underlying health condition cited by a doctor in a vaccination exemption meets federal standards.
In a letter endorsing Pan’s proposed law, Santa Clara County Executive Jeff Smith—a trained physician—said unscrupulous doctors pose a threat even to jurisdictions like his own that manage to maintain safe immunity rates.
“Overall vaccination rates sharply increased to more than 95 percent statewide after California implemented your Senate Bill 277 in 2016, which abolished the personal belief exemption in California,” he wrote. “For the 2017-18 school year, 96.7 percent of all kindergarten students in Santa Clara County received their required vaccinations. However, despite this success, some physicians have been able to circumvent the spirit of the law by issuing inappropriate medical exemptions when families are willing to pay, rather than reserving these exemptions for children with true medical contraindications.”
Last year’s outbreak in Santa Clara County was only made worse because of dubious health exemptions, Smith explained.
Widely accepted federal guidelines say such exemptions should be exceedingly rare, reserved for children with documented allergies to vaccine components or whose immune systems are critically compromised. Garden-variety allergies and asthma are no reason to skip the shots, according to the CDC. Per the same agency, neither is autism.
But those are just guidelines, and California law does not require doctors to follow them. So when parents motivated by misguided fears about the safety of vaccines, many doctors will go along with it—for a price.
In response to growing concerns about unvaccinated kids, however, the state recently resolved to investigate schools with “biologically unlikely” rates of medical exemptions. Doctors identified by state health officials as having signed off on questionable exemptions will be referred to the California Medical Board for investigation.
State health authorities estimate that SB 276 would disqualify as much as 40 percent of the 11,500 exemption requests doctors field each year in California. That’s welcome news to public health officials as they grapple with what the CDC calls one of the worst years for U.S. measles cases in a quarter-century.
By April 2019, officials confirmed 40 measles cases in California—four of which traced to Santa Clara County. Nationally, by the same time this year, at least 704 cases had been documented in 22 states, marking the largest number of cases reported since the disease was all but wiped out in 2000.
Smith said the stakes are too high to let Pan’s bill die.
“Without reshaping California’s process to require state-level public health approval of all medical exemptions, like the provisions set forth in SB 276, we risk continuing to see the number of cases and outbreaks rise and leaving individuals who are too young to be vaccinated, or who have a medical condition that prevents them from being vaccinated, vulnerable,” he wrote. “We also risk losing the community immunity we’ve built thus far and which we continue to build that keeps all our residents safe and healthy.”
That should go without saying.
But scientifically baseless controversy over one of the single greatest advancements in modern medicine—one that saved at least 10 million lives from 2010 to 2015, per the World Health Organization—requires experts these days to state the obvious.
“Vaccination protects individuals and their families, and it also protects the entire community, including babies too young to be vaccinated,” Santa Clara County Public Health Officer Dr. Sara Cody wrote in an email to San Jose Inside. “Thankfully there are safe, effective, and widely available vaccines that prevent serious illnesses.”