Health

Why Some Children Still Get Questionable Exemptions for Vaccines

California is investigating five physicians for signing off on vaccine medical exemptions. Experts say a lack of clarity in the law allows some parents to get around the rules.

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Experts say vaccine medical exemptions are starting to create a public health problem. Getty Images

Eight children got medical exemptions from vaccines in Marin County in Northern California in 2015.

This year, 81 children from the high-income county north of San Francisco got them.

Similar increases in medical exemptions have caught the attention of regulators elsewhere in the state.

As a result, five California physicians are under investigation for issuing what authorities describe as unwarranted medical exemptions.

The investigations have brought new attention to the increasing use of medical exemptions. That tool has been increasingly relied on by parents who don’t want their kids to be vaccinated against preventable diseases, such as measles.

These exemptions are also beginning to pose a public health risk, health experts said.

In Marin County, which historically has had some of the highest rates of unvaccinated children in the state, that tenfold increase in medical exemptions only amounts to a few dozen children.

But that small number brings a big risk.

“Why do we worry about medical exemptions at all given the high average overall?” Dr. Matthew Willis, Marin County’s public health officer, told Healthline. “Because 95 percent countywide is a misleading way of thinking about it. Not every school has 95 percent.”

“Some of the smaller schools have vaccination rates of less than half or as low as 20 percent, and an increasing percent of those are due to medical exemptions,” he explained.

Some children have reasons for not getting vaccines that most physicians would agree are legitimate.

Those include undergoing chemotherapy, taking drugs that suppress their immune system, being born with an immune deficiency, or having a documented allergy to components of the vaccine.

To protect the children who can’t be vaccinated, it’s important that the children and adults around them are vaccinated, so there’s less chance the unvaccinated child comes into contact with someone with the disease.

“There are kids out there who can’t get vaccines, and those are the ones we want to protect,” said Dr. Sterling Ransone, a family physician in Deltaville, Virginia, and a board member of the American Academy of Family Physicians.

But as the number of kids getting questionable medical exemptions has increased, so has the number of kids who may need bona fide exemptions, said Dr. Kathryn Edwards, a spokeswoman for the American Academy of Pediatrics and a professor of pediatrics at Vanderbilt University’s Division of Pediatric Infectious Diseases.

That’s due to advances that have led to more organ and bone marrow transplants.

“And that’s all the more reason why those that can be vaccinated should,” Edwards said, “to provide a sort of safety net for those who can’t be.”

Knowing whether a certain exemption is legitimate or not — or even, in some cases, which reasons should be considered legitimate — is difficult.

That’s largely due to lax regulations.

Ironically, it appears this spike in medical exemptions arose due to a state law that made other types of exemptions from vaccines much harder to get.

Personal belief exemptions were often used by parents skeptical of the safety of vaccines.

In 2012, Willis said, only 78 percent of children in Marin County schools were fully vaccinated, one of the lowest rates in the state. Almost all of those lacking vaccines were due to personal belief exemptions.

But a law passed in 2015, SB 277, banned the use of personal belief exemptions. But language in the law and a letter from Gov. Jerry Brown accompanying it granted what Willis called “really wide latitude” for medical exemptions, without specific guidance on what were and weren’t valid reasons for an exemption.

After the law’s passage, Willis said his department sought to learn more about what reasons were being given for the medical exemptions, as they’ve become increasingly common.

“But that language prevented us from doing a more thorough investigation of the reasons for the medical exemptions,” Willis said.

Edwards offered one example of a questionable exemption.

She said a friend wrote to her to say a neighbor’s grandson had been granted a medical exemption due to having a certain gene that’s been linked to possibly getting a skin reaction from the smallpox vaccine.

That possible link was revealed by a 2008 study Edwards had worked on. But that was a small study, she said, and its results haven’t been confirmed.

Moreover, the gene in question is relatively common — she said about 25 percent to 30 percent of white people have it.

And, she points out, this study was on the effects of the smallpox vaccine, but it’s being used by parents to avoid vaccines for measles.

“In the decade since that paper, there’s been no evidence it’s been associated with adverse events, but a fairly large number of children were given an exemption,” Edwards said. “We need to make sure people understand that this isn’t a reason to get an exemption.”

Edwards and others say some reforms that would be helpful would be to make it clear why a child is getting an exemption and having a way to review those exemptions.

They also need to be based on “sound medical principles,” she said. That means hard data and a clear medical standard of care.

In California, a new bill is seeking to do that. SB 276 would rein in the use of medical exemptions and make them subject to approval by health departments.

“I think that’s a great idea personally,” said Ransone.

Willis said that would put medical exemptions in line with how most aspects of medicine are done.

“It wouldn’t be more scrutiny than others. It’s just about having it catch up to the way we approach medicine in other areas. … If we had widely different approaches to heart surgery, medical boards would say something,” he said.

In addition to standardizing why and when medical exemptions can be used, public education is key.

Even when personal belief exemptions were still allowed, Marin County saw that 74 percent rate in 2013 increase dramatically.

That was due to increasing awareness of the risks of not getting vaccinated, as well as of vaccines’ safety and efficacy.

“Now we’re at about 94 percent, which is similar to the statewide rates,” Willis said. “We caught up through combination of education and policy.”

But, as he said, that 94 percent can be misleading, and medical exemptions aren’t helping.

“There are kids out there who can’t get vaccines” for legitimate medical reasons, said Ransone. “And those are the ones we want to protect.”


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