From the Journals

Medical exemptions spike after vaccine policy change

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Public health needs more power

Passage of SB277 has had a positive impact on the proportion of California kindergarteners who are fully vaccinated, Richard J. Pan, MD, MPH, and Dorit Rubinstein Reiss, LLB, PhD, wrote in an editorial.

“Vaccines are one of the greatest public health successes in history. Mandating vaccination for school is an effective strategy to prevent outbreaks,” they said. However, “this protection is undermined when unscrupulous physicians monetize their license and abuse the authority delegated to them from the state by granting unwarranted [medical exemptions (MEs)],” they said.

The editorialists emphasized that states have the authority to mandate vaccinations in the interest of public health, and that allowing physicians to grant medical exemptions is appropriate because doctors know their patients and know whether exemptions are needed.

“However, the lack of cooperation by patients’ families who desire unwarranted MEs makes disciplining physicians who are engaged in this unprofessional behavior difficult and costly because licensing boards need to subpoena patient records over families’ objections to obtain evidence. Similarly, professional standard-setting organizations, including professional associations and certification boards, have been reluctant to withdraw credentials or expel members who promote vaccine misinformation and grant unwarranted MEs,” they said. They proposed strategies including establishing a searchable database for MEs, allowing public health officials the option to review and invalidate MEs, and requiring parents to submit MEs to public health departments as well as to schools.

“Pediatricians can partner with public health advocates and proscience parents to pass laws that empower public health officers to protect our children and community. Every child needs community immunity,” they said.

Dr. Pan is a California State Senator, Sacramento, and Dr. Reiss is at the Hastings College of the Law, University of California, San Francisco. Their comments on the article by Mohanty et al. were published in Pediatrics (2018;142[5]:e20182009). Dr. Pan authored legislation (Senate Bill 277) to abolish nonmedical exemption. Dr. Reiss’s family owns regular stock in GlaxoSmithKline.



The change in policy eliminating nonmedical vaccine exemptions in California (Senate Bill 277) led to a 250% increase in requests for medical exemptions, according to data from interviews with health officials and immunization staff after implementation of the policy.

A stack of books with a gavel and stethoscope on top ©LeventKonuk/

In a study published in Pediatrics, Salini Mohanty, DrPH, of the University of Pennsylvania School of Nursing, Philadelphia, and her colleagues conducted semistructured phone interviews with 40 health officers and immunization staff who represented 35 of 61 California heath jurisdictions. The interviews occurred between August 2017 and September 2017, and participants discussed their experiences with medical exemption requests after the policy change.

Although the percentage of fully vaccinated kindergarten students in California increased from 93% in 2015-2016 to 95% in 2017-2018, and the rate of personal belief exemptions declined, overall medical exemption requests rose 250% from 0.2% in 2015-2016 to 0.7% 2017-2018, the researchers noted.

They identified four main issues based on participant responses: the role of stakeholders, the review of medical exemptions received by schools, the medical exemptions perceived as problematic, and the general frustration and concern over medical exemptions.

Based on the interviews, one concerning subtheme involved reports that some physicians wrote medical exemptions for vaccine-hesitant parents based on conditions such as allergies and autoimmune diseases.

“The Internet provides access to physicians who are willing to sign off on exemptions and to websites used to instruct parents on how to get physicians to approve medical exemptions,” the researchers said.

“Understanding how physicians interpret the law is important because they are writing the medical exemptions,” Dr. Mohanty and her associates noted, and they proposed increased outreach and education of physicians about the law to reduce problematic medical exemptions.

Many health officials expressed frustration with their inability to review medical exemptions submitted directly to schools. In fact, interviewees cited one California jurisdiction that was named in a lawsuit for attempting to track medical exemptions, “which had an impact on other jurisdictions decision to track,” they said.

Officials also expressed concern that parents’ use of medical exemptions to replace personal belief exemptions would reduce herd immunity. Overall, regions with high levels of personal belief exemptions showed the largest increases in medical exemptions after SB277, which could put these regions at increased risk for vaccine-preventable outbreaks, the researchers noted.

There also were reports of physicians “who advertised medical exemptions online for a fee.” Officials also reported “receiving medical exemptions signed by physicians who do not typically treat children (cardiologists, dermatologists, surgeons, and physicians at medical marijuana dispensaries) and by unauthorized nonphysician providers, including nurse practitioners,” Dr. Mohanty and her associates said.

The study findings were limited by several factors including small sample size and potential recall bias, the researchers noted. However, the study is the first to include perspectives of local health officials after a change in vaccine exemption policy.

The National Institutes of Health supported the study. Dr. Mohanty had no financial conflicts to disclose; one coauthor disclosed relationships with Merck, Pfizer, and Walgreens.

SOURCE: Mohanty S et al. Pediatrics. 2018. doi: 10.1542/peds.2018-1051.

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