Citing new measles outbreaks amid a dangerous surge in dubious vaccination exemptions, some state leaders want more power to question doctors’ decisions
By Gary Walker
State Sen. Ben Allen is caught between science and a promise.
Four years ago, Allen and California Senate colleague Dr. Richard Pan led the charge to eliminate personal belief exemptions for common childhood vaccinations. It was a principled but politically risky stand for the former Santa Monica school board member, whose constituents were opting out of the measles vaccine in such great numbers that local kids were actually getting sick.
But now medical exemptions, which are only supposed to be for kids not healthy enough to tolerate vaccines, are quickly on the rise — a symptom of some doctors writing questionable exemptions for parents willing to pay for them, public health officials suspect.
And measles itself is making a comeback this year, with four confirmed cases in Los Angeles County (including exposure risks at UCLA and Cal State L.A.) and a fifth attributed to an international arrival at Los Angeles International Airport earlier this month.
Pan is now campaigning for a new state law that would require all medical exemptions for childhood vaccines to pass a review by the California Department of Public Health, which would also track how many exemptions individual doctors are issuing. The California Medical Association is sponsoring the bill.
Allen, a staunch believer in childhood vaccines, has yet to get on board. On the way to passing the 2015 law eliminating personal belief exemptions, Allen told parents opposed to vaccinations that he wanted doctors to have the final word on exemptions. They aren’t going to let him forget it.
Opponents of childhood vaccinations, many of whom believe vaccines cause harm despite scientific consensus to the contrary, follow the Santa Monica Democrat to just about every public appearance he makes these days. Most tend to be women who live in Allen’s district. Many would call them anti-vaxxers; Allen calls them “very passionate moms who care about their children.”
“My core concern was preserving the right of the doctor to decide whether a child needs an exemption or not when I co-sponsored SB 277 [which banned personal belief exemptions]. I’m concerned that SB 276 will kick the responsibility to [the California Department of] Public Health instead of the doctors,” Allen said in response to questions about Pan’s legislation during the spring general meeting of the Del Rey Residents Association.
“I’m very proud of 277. We’ve been able to significantly increase the vaccine rates in our state since it was passed, and I think that’s great and it was a real victory for public health. But if it’s going to take away the discretion of the doctor, that would be against the public commitments that I made when I co-sponsored SB 277, and I would feel hypocritical if
I went against those commitments,” Allen explained to The Argonaut.
It’s usually parents who get most of the attention in conversations about vaccination rates, but this time it’s doctors who are facing public scrutiny.
A study published by the medical journal Pediatrics in October 2018 found that some medical exemptions came with dubious or unclear justification, such as a “family history of allergies.” The study also found that some doctors, including doctors who don’t normally treat children, were offering medical exemptions in exchange for special fees — some charging as much as $300 to renew temporary exemptions up to four times a year.
The state medical board is investigating dozens of complaints about improper exemptions and put an Orange County doctor on probation for inexplicably waiving a child from all vaccinations. Nonprofit investigative news site Voice of San Diego has reported that a single doctor is responsible for nearly one in three of the 486 medical vaccine exemptions invoked in the San Diego Unified School District.
A blog post to a parenting website identifying “vaccine friendly doctors” lists six in Santa Monica, one in Mar Vista and another in Culver City.
According to a California Department of Public Health immunization assessment, the proportion of kindergarten students receiving all required vaccinations (including measles) climbed from about 90.4% statewide in 2014-15, before SB 277, to 95.6% in 2016-17, after the law took effect. But for the 2017-18 school year, the vaccination rate dropped to 95.1%
As personal belief exemptions disappeared, medical exemptions rose to fill the gap, growing from 0.2% of all kindergarten students in 2014-15 to 0.5% in 2016-17 and 0.7% in 2017-18. That amounts to nearly 4,000 kids with permanent medical excuses last year.
“It is clear that a small number of physicians are monetizing their exemption-granting authority and profiting from the sale of medical exemptions,” Pan said at a press conference for SB 276 in March.
Pan’s new legislation, added California Medical Association President Dr. David Aizuss, “will close a loophole in the current law that has allowed a small handful of rogue doctors to skirt the spirit of the original law and has put millions of Californians at risk.”
Dr. Deborah Lehman, a professor of clinical pediatrics at the David Geffen School of Medicine at UCLA and an expert in communicable diseases, told The Argonaut she supports Department of Public Health oversight for medical exemptions.
“The fact that [medical] exemptions grew out of proportion since the passage of SB 277 points to how these exemptions are being given,” Lehman said. “We’ve seen a significant number of workarounds by physicians who are signing medical exemptions for money. It’s unfortunate because our primary responsibility is to protect patients from disease.”
OVERSIGHT OR OVERREACH?
Dr. Jay Gordon, a prominent Santa Monica pediatrician cited in the “vaccine friendly doctors” list, wrote scores of personal belief exemptions prior to SB 277 and testified against the law at state Senate hearings in 2015. Pan’s new legislative proposal represents “a broken promise,” he said.
“It’s a pretty unethical move by the legislators who are pushing [SB 276]. SB 277 was pretty extreme, but at least there was a commitment to keep decisions about vaccinations in the hands of doctors,” Gordon said.
“There can be a discussion about whether a vaccine is needed or not,” Gordon conceded, “but putting that decision in the hands of a doctor who doesn’t know the child is wrong. This decision should be made with the parents and a doctor who knows the child well.”
Dr. Shannon Kroner, a clinical psychologist who created an online forum called California Against Mandated Vaccines, is one of those who pressed Allen about his position on SB 276 during the Del Rey Residents Association meeting. She said the legislation borders on government intrusion between a doctor and patient.
“I think this will destroy doctor-patient confidentiality. Doctors and parents know what’s best for their children. Some children have suffered vaccine injury, which is a real thing, while being vaccinated,” Kroner said.
Dr. Danelle Fisher, a pediatrician who has practiced for 18 years in Westchester and Playa Vista, said she’s had only three patients in nearly two decades who’ve shown an adverse reaction to vaccines.
She’s one of many local pediatricians who aren’t very excited about the prospect of state officials looking over their shoulders but support Pan’s legislation nonetheless.
“This is a public health issue. We need SB 276 to protect public health because unfortunately we have doctors who are willing to sell exemptions. We need to police ourselves,” Fisher said.
“I have sat at the bedsides of dying children and held the hands of parents who have lost their children to preventable diseases. I find it really abhorrent to see so many children and young adults being put at risk because of a doctor who is selling exemptions or a parent who has read something on the internet and now thinks that vaccines are bad,” added Fisher, who completed her residency at Children’s Hospital Los Angeles.
Lehman, who worked at Cedars Sinai Medical Center before moving to UCLA five years ago, has also seen family tragedies that physicians think could have been avoided.
“I trained in pediatrics in the 1990s and took care of children who were hospitalized and died because of measles. We thought that measles was eradicated here in the United States in 2000, and I didn’t think that we’d ever see it again. I’m surprised and incredibly frustrated,” she lamented.
A NUMBERS GAME
Most people who have been vaccinated probably won’t catch measles. According to Los Angeles County Health Officer Dr. Muntu Davis, “the best way to protect yourself … is to get the measles immunization, with two doses of measles immunization being about 97% effective at preventing measles.”
And while it may not be necessary for every child to be vaccinated against measles, experts say that specific populations with vaccination rates below 90% to 95% — whether the size of a city or an amusement park or a school — are at high risk for fast-moving measles outbreaks. In 2015, for example, 145 people contracted measles at Disneyland from a single carrier.
According to the CDC, measles is so contagious that nine out of 10 unvaccinated people who are close to an infected person will contract the disease, which can live for up to two hours in an airspace where that person coughed or sneezed. Before the measles vaccine became available in 1963, there were as many as 4 million cases in the U.S. each year, resulting in tens of thousands of hospitalizations and hundreds of deaths.
Kroner acknowledges that some unvaccinated children could contract measles, but she said measles is “largely a benign illness — it’s a rash and a fever.”
While most measles patients do make a full recovery, there are sometimes deadly complications with the disease, Lehman counters.
“Between one and two people per 1,000 die of measles, and one in 1,000 can get encephalitis [swelling of the brain]. I wouldn’t call those statistics benign,” she said.
California, meanwhile, is one of three states where personal belief exemptions have been banned in response to perceived overuse. The others are Mississippi and West Virginia.
In the Mountain State vaccination exemptions must be vetted by public health officials, and according to the Los Angeles Times that’s pushed the medical exemption rate in West Virginia to about half of California’s.
‘NOT A MATTER OF PRIVACY’
UCLA constitutional law professor Adam Winkler thinks SB 276, if it becomes law, can withstand potential legal challenges.
“While the right to privacy and body integrity is important, the courts have said that vaccines are different. It’s not a matter of personal privacy, it’s a matter of exposing the community to disease and infections,” he said. “The arguments about body integrity and religious freedom have failed. So I think SB 276 will hold up.”
Gordon said he hopes Allen honors his promise not to put the state between doctors and patients when SB 277 became law four years ago.
“Keeping herd immunity [the idea that high vaccination levels can protect an entire population] is good, but this kind of coercive bill is a bad idea,” Gordon said.
Kroner was happy to hear Allen respond publicly in Del Rey that he feels uncomfortable about potential state interference with doctors’ decisions about patient care.
“I appreciated his response,” she said. “I hope that he honors his word when they have to vote.”
Allen and other state legislators won’t have to vote on the bill until this summer. In the meantime, he’s keeping his options open — particularly if the language of the bill changes on its way to becoming law, which is to be expected in Sacramento.
“A lot can happen to SB 276 before we see its final version,” Allen noted. “If it remains as it is currently, I would have a hard time voting for it. But we’ll see.”
Managing Editor Joe Piasecki contributed to this report.