SB 277 and bogus medical exemptions to vaccine mandates in California

Here in the states, yesterday was a holiday, the 4th of July. This year, because the 4th fell on a Thursday, for many in the country this is the equivalent of a four day weekend, not unlike the Thanksgiving weekend. Given that, I had debated about whether or not to post anything today, but there was a story published this week that I just can’t allow to pass uncommented on, and next week would likely be too late. As longtime readers know, a frequent topic on this blog in 2015 was SB 277, the law passed in California that eliminates nonmedical so-called “personal belief exemptions” (PBEs, or, as I like to call them, “I don’t wanna” exemptions) to school vaccine mandates. After SB 277, nonmedical exemptions were no longer allowed in California. The law was basically fallout from the Disneyland measles outbreak. The outbreak began over the Christmas holidays of 2014 and continued for several months into 2015, ultimately spanning eight states and two additional countries (Canada and Mexico). Because of where it happened and how many states it encompassed, the Disneyland measles outbreak made it politically possible for California legislators to do something that would definitely not have been possible before the outbreak: Pass a law outlawing PBEs. Prior to the outbreak, only two states (Mississippi and West Virginia) allowed only medical exemptions, while the other 48 states allowed some combination of religious or personal belief exemptions. The same thing is happening now with the current massive ongoing measles outbreak, with Maine and New York having passed laws eliminating religious/PBEs.

SB 277 took full effect at the beginning of the 2016-2017 school year, and for a while things went quite well. Early results showed that SB 277 was working swimmingly. The percentage of children not vaccinated plummeted. There was, however, a troubling sign when the study showing the improvement in vaccine uptake was published two years ago. There was a significant uptick in the medical exemption rate. At the time it was speculated that some of the increase in the medical exemption rate was due to parents of children who did have medical conditions for which a medical exemption was legitimately indicated but had just opted out using a PBE because it was so much easier. (At the time, no muss, no fuss, no doctor’s note required.)

On the other hand, as I noted right after SB 277 passed, the biggest flaw in the bill was (and is) that it allows any doctor to write a letter requesting a medical exemption, and the exemption would be granted. It wasn’t long before Dr. Bob Sears led the way teaching parents how to secure medical exemptions for questionable indications. Soon, there was a cottage industry of quacks selling bogus medical exemptions to school vaccine mandates, even online. As a result, Senator Richard Pan, who co-sponsored SB 277 and was the driving force behind getting it passed, introduced SB 276, a law that would mandate a database of medical exemptions, so that the state can keep track of which doctors are issuing the most medical exemptions, and require that requests for medical exemptions to school vaccine mandates be approved by the State Public Health Officer or designee, who could reject exemptions not supported by science. Unfortunately, SB 276 hasn’t been passed yet, and the fake medical exemptions racket is, if anything, more profitable than ever. Indeed, five doctors wrote one third of the medical exemption letters in eight Bay Area school districts.

Still, despite the medical exemption grifters, since SB 277 took effect, vaccine uptake increased, which was the intended effect; that is, until now. Earlier this week, the Los Angeles Times published a story, California vaccination rate drops as doctors grant more exemptions. Is there a link? The news, for once, is not good:

California’s kindergarten vaccination rate dropped again in the most recent school year as more parents sought permission from doctors to not immunize their children, according to new state data. The troubling trend comes amid a national measles outbreak as well as intense debate over whether California should strengthen its school immunization laws.

And, consistent with what we know about the antivaccine movement:

In the school year that ended last month, 4,812 kindergartners had obtained medical exemptions from vaccines, a 70% increase from two years ago, when the vaccination law first took effect, according to data from the California Department of Public Health. The data suggest that large concentrations of medical exemptions are being granted to school children in relatively affluent parts of the state, such as Santa Cruz and Sonoma counties.

The California Department of Public Health even provides a handy-dandy interactive map to show where vaccine uptake rates are the lowest, and its report for the 2018-2019 school year, just finished:

Reported immunization rates remain at high levels but have decreased over the last two years. The proportion of students attending kindergarten in 2018-2019 reported to have received all required vaccines is 94.8%, a 0.3 percentage point decrease from the 2017-2018 school year, a 0.8 percentage point decrease from the 2016-2017 school year, and a 4.6 percentage point increase over five years since 2013-2014. The 2018-2019 rate of 94.8% is the third highest reported for the current set of immunization requirements for kindergarten, which began in the 2001-2002 school year.

The report also noted that the school districts with the most medical exemptions were Los Angeles Unified, Capistrano Unified and San Diego Unified, with the rate of medical exemptions in Capistrano Unified being 10 times higher than that of LA Unified. Another finding was that around 1,500 schools had kindergarten vaccination rates less than 95%, which for measles is the usual estimated rate needed for herd immunity, while medical exemption rates equalled or exceeded 30% in kindergarten at 17 schools. Basically, to sum up, in 2018-19, 0.9% of kindergarten students had medical exemptions, which was up from 0.7% in 2017-2018 and 0.5% in 2016-2017. The data are summarized here:

Yes, it is true that only around 20% of the unvaccinated or undervaccinated is explained by medical exemptions, but this nonetheless matters. Why does it matter? Because these exemptions are not spread evenly. As we’ve known and seen for so long, the vaccine-hesitant and antivaxers cluster, and this results in areas of low vaccine uptake in the middle of a state with generally high vaccine uptake. That’s where the risk of outbreaks is the highest. That’s where outbreaks tend to happen.

And here’s how the schools with low vaccination rates cluster:

As the LA Times notes:

Dr. Monica Asnani, a Miracle Mile pediatrician and member of the advocacy group Vaccinate California, said during her 18-year career, she has written one medical exemption, which was due to a child carrying a neurological disorder. “I’ve asked my colleagues and they have either written none or one or two. Then you see reports of doctors with dozens, which is far outside the norm,” she said. Asnani said that a few years ago, she heard a radio ad from a doctor who was offering patients an exemption if they visited his office and paid $180. When parents come to her seeking vaccine exemptions, she said, she explains that the concern that prompted them to seek a waiver is not a valid medical reason. “So they go and find another doctor who will write one,” she said.

Some of these doctor shoppers are even celebrities, like Jennifer Biel.

Also:

Among kindergartners, schools with high medical exemptions rates tend to be Waldorf schools, which have come under scrutiny in California for their relatively low vaccination rates. Waldorf Schools practice a holistic approach to learning and are based on the philosophy of Austrian thinker Rudolf Steiner, who was critical of many aspects of medicine during his era, the late 19th and early 20th centuries. Hannah Henry said she pulled her three children from a Waldorf school in Napa four years ago because the vaccination rate was below 50%. Her three school-aged children were fully vaccinated at the time, but she had a toddler who was not yet fully immunized. Being on a campus with a low vaccination rate amid the 2015 measles outbreak made her concerned her toddler could contract a preventable disease. Leaving the school her family loved was difficult, she said. “The silence and dismissal of this issue at some schools has really limited the population who can consider an alternative education like Waldorf,” Henry said. “That’s unfortunate for the school and the community. It’s a beautiful methodology and should be safe for all children.”

No, Rudolf Steiner, whose philosophy forms the entire basis of the teaching methodology of Waldorf Schools, was a mystical crank, whose “medicine” is pure quackery, full of antivaccine ideas. Thus, Waldorf Schools represent anything but a “beautiful methodology” and, not surprisingly, are often the nidus of outbreaks of vaccine-preventable diseases because of low vaccine uptake.

You might ask: Why doesn’t the Medical Board of California go after physicians who write a lot of bogus medical exemption letters? Such physicians are clearly practicing below the standard of care; sanctioning them or even relieving them of their licenses to practice medicine would be an appropriate response to their abuse of their privilege. Indeed, that was, in part, a reason why antivaccine “icon” “Dr. Bob” Sears was sanctioned. Fortunately, that, too, is happening:

Two more doctors are being investigated by the California Medical Board over allegations they signed unnecessary vaccine exemptions for students, according to court records filed by the board. The inquiries into Sacramento-area physicians Kelly Sutton and Michael Fielding Allen raise the number to four doctors who are now the subject of ongoing medical board investigations over their exemption practices. A fifth, Kenneth Stoller, is being investigated by the San Francisco City Attorney’s Office. Together, the five — including Bob Sears of Orange County and Ron Kennedy of Santa Rosa — wrote a third of all exemptions reviewed by this news organization as part of a report on exemptions in eight Bay Area school districts. Last month, the medical board requested a court order to enforce a subpoena filed to Kaiser Permanente, asking the HMO to turn over copies of medical exemptions signed by Sutton and Allen, as first reported by Kaiser Health News.

Dorit Rubinstein has discussed the case of Ron Kennedy before over at our friend Skeptical Raptor’s website. He’s neither a pediatrician nor an family practice doctor. He owns a clinic called the Anti-Aging Medical Clinic in Santa Rosa, CA, which offers, apparently, anti-aging treatments. (Oddly enough, his is one of the most useless practice websites I’ve ever seen, with very little information.)

But what was Kaiser’s involvement? This:

The board opened its investigation in response to a tip from the assistant chief of pediatrics at Kaiser’s Roseville Medical Center, who was concerned by medical exemptions the two doctors had signed for the clinic’s pediatric patients, according to court filings. Kaiser members sought exemptions from Allen and Sutton, neither of whom work for the HMO, and then gave them to their primary care doctors. The medical board initially subpoenaed Kaiser for the records, but the healthcare provider refused to hand over any records that would identify patients. The board is now requesting a court order for the unredacted exemptions.

I discussed Dr. Sutton three years ago. Let’s just say that she, along with Dr. Sears, was a “pioneer” in selling bogus medical exemptions to the new, stricter SB 277 school vaccine mandate. She published webinars for parents instructing them how to avoid the requirements of SB 277 by seeking medical exemptions to school vaccine mandates. Shockingly (that’s sarcasm, obviously), Dr. Sutton practices anthroposophic medicine, one of the quackiest of quack medicines and uses homeopathy:

Dr. Sutton bases her diagnosis in part on conventional medicine: history, physical, laboratory and imaging, and subspecialist consultation when needed. Significant understanding arises from listening to aspects of an individual’s biography, life purpose, the emotional context of illness and health, and understanding the level of vitality and strength of the life forces. She treats acute and chronic illness using the least toxic effective treatment for the condition. Anthroposophic remedies (low potency homeopathic preparations and herbs), diet, nutritional supplements, healthy rhythm, warmth are some of the foundational principles she employs. Anthroposophic therapies play a key role in treatment. Pharmaceutically-prepared mistletoe supports the immune system in a variety of disease processes and specifically lessens side effects of cancer chemotherapy and radiation therapy. Conventional prescriptions are given when needed.

So, yes, she’s definitely a quack; so it’s not surprising that she did this:

In one case, Sutton issued a “lifelong medical exemption from all vaccines” to a boy before his family joined Kaiser Permanente, according to Cerny’s complaint. When one of Cerny’s colleagues refused to write similar exemptions for the boy’s two younger siblings, the mother said she would go back to Sutton to get them, the complaint says. “We feel this doctor and perhaps her colleagues … are making easy money on these exemptions that are not based on true medical need and are actually putting children and other people in the community at risk for contracting and spreading serious infectious diseases,” Cerny wrote in her complaint about Sutton. A physician appointed by the medical board to review exemptions issued by Sutton and Allen described them as “either of questionable validity or patently without medical basis.”

Same as it ever was.

Unfortunately, unless SB 276 passes, what quacks like Dr. Sutton are doing won’t be illegal, and the only recourse that the State of California will have will be for its Medical Board to investigate and sanction physicians who run vaccine exemption mills. It’s good that the Medical Board is actually showing signs of having the will to do this. Most medical boards don’t. However, if the Medical Board of California is anything like most states’ medical boards, it is unlikely to have the resources to pursue any but the most egregious offenders, like Dr. Sutton.

The news isn’t all bad, though. Despite the abuse of medical exemptions by antivaccine parents and physicians, a study hot off the presses in JAMA looking at vaccine uptake between 2000 and 2017 found that the statewide rate of kindergarteners not up-to-date on their required vaccination decreased from 9.84% in 2013 to 4.87% in 2017. The study also found that during the 2014-2015 school year, there were 93 clusters that contained 2,290 schools with high rates of kindergartners without up-to-date vaccination status. During 2016-2017, there were 110 clusters that contained 1613 (95% CI, 1565-1691) schools.

Just imagine, though, how much lower those numbers could be if not for the abuse of medical exemptions by quacks who see a new profit center issuing bogus medical exemptions.