In 2015, California outlawed non-medical vaccine exemptions for school entry. At the time, only 90.4 percent of kindergartners in our state’s public schools were fully immunized. The law (SB 277) seems to have worked, since 95.1 percent of California kindergartners had all their required shots by the 2017-18 school year, according to the California Department of Public Health.
However, medical exemptions from vaccines are rising sharply, and not all may be legitimate.
“San Diego Unified School District (SDUSD) has been diligently tracking medical exemptions, and has noticed some physicians issuing exemptions that appear to be excessively frequent and based on criteria that are not aligned with guidelines from the Centers for Disease Control and Prevention (CDC),” SDUSD spokesperson Maureen Magee wrote in an e-mail to the Light.
Since 2015, SDUSD accepted 487 medical exemptions from vaccination, according to SDUSD records. Of these, 28 excused students attend La Jolla’s public schools: La Jolla Elementary (8), Muirlands Middle (7), Bird Rock Elementary (6), Torrey Pines Elementary (6) and La Jolla High (1).
As a percentage of La Jolla’s total public-school enrollment, these exemptions represent just under 0.7 percent, which is higher than the percentage of total unvaccinated SDUSD students, 0.4, although both percentages are actually high since the data encompasses all medical excuses accepted from July 2015 to January 2019.
La Jolla’s granted medical exemptions included one at Torrey Pines for “family history of vaccine reactions,” one at Muirlands for “family history hyperimmune conditions” and one at La Jolla Elementary that merely read: “no details specified.”
According to Dr. Mark Sawyer, an infectious disease specialist at Rady Children’s Hospital, these exemptions — and probably many more — do not appear medically legitimate.
“Anything based on family history is not something recognized by the CDC or the American Academy of Pediatrics as a legitimate reason to avoid vaccination,” Sawyer said. “There is no clear connection between one generation and another. If your parents had an allergic reaction to a vaccine, that doesn’t mean that you will.”
(Another physician interviewed for this article, Scripps Clinic Carmel Valley pediatrician Dr. Daniel Lichtmann, noted that the CDC does allow a family-history medical exemption, but only in the incredibly rare case of “a family history of immunodeficiency that’s due to heredity.” While Lichtmann agreed that under-vaccination is becoming an issue, he stopped short of calling any specific exemption from the SDUSD data illegitimate “based on the small amount of details it provided.”)
There are legitimate medical reasons for vaccine exemption — the most common being immuno-suppression caused by either disease or treatment for cancer, severe allergic reactions to a previous dose of the same vaccine, and serious side effects such as Guillain-Barre syndrome.
But every legitimate reason Sawyer said he knows of adds up together to less than 1.2 percent. That’s the percentage of SDUSD kindergartners currently unvaccinated due to medical exemptions, according to the California Department of Public Health, and it represents an increase of six-fold since 2015, when medical exemptions totaled 0.2 percent.
“Where were all these medical exemptions before if they are all legitimate reasons?” Sawyer asked. (Lichtmann said he “couldn’t say” whether legitimate medical exemptions should total more or less than 1.2 percent.)
Who’s to blame?
Whatever threat is currently mounting in local schools, it cannot be blamed on SDUSD or its individual principals or nurses. The 2015 law does not authorize school districts, or any school personnel, to overrule or even review any exemption issued by a licensed medical doctor.
“Any physician can use any reason,” Sawyer said. “In other states, they sometimes have the public-health officer make the final call — someone with no personal relationship with the family that might pressure a doctor to make a certain decision.”
As proof of his assertion, Sawyer points out how many of the SDUSD medical exemptions were written by the same doctors.
“You would expect to see an even distribution of all family doctors and pediatricians across San Diego issuing one or two each,” Sawyer said. Yet, according to the SDUSD data, a single San Diego pediatrician wrote nearly one-third of all 487 medical exemptions since 2015. According to that doctor’s website, a child can be considered for a medical exemption for “allergies to food (or) bee stings (or) medicines that include hives/swelling/wheezing.” (According to both Sawyer and Lichtmann, these are not medically accepted reasons for exemption.)
La Jolla’s data is still troubling, but less so than the data for the County as a whole. Here, one doctor excused four public school students, one excused three and three others excused two each. (Because identifying information was not included in the SDUSD data, some of these exemptions may even have been granted to the same students across different schools.)
Measles — a highly contagious virus whose side effects can include pneumonia and encephalitis — kills one in every 1,000 of the (mostly) children who contract it. In Madagascar this year alone, nearly 1,000 measles deaths have occurred, according to the World Health Organization, which cited vaccine hesitancy as one of the top 10 global threats of 2019.
Federal guidelines typically recommend that children get their first measles vaccine dose at 12 to 15 months of age and their second when they are 4 to 6 years old. Yet measles outbreaks are now occurring in the U.S. due to gaps in vaccination coverage — including two in San Diego. In 2008, an unvaccinated 7-year-old, who received treatment in Bird Rock after contracting the virus in Europe, exposed 800 people — including 11 unvaccinated children who contracted it. And in December 2014, San Diego reported more than 20 measles cases caused by a single exposure at Disneyland that infected 131 people statewide.
Vaccines not only protect individuals from contracting diseases, Sawyer explained, they protect large groups of individuals occupying closed quarters such as schools. This so-called “herd immunity” decreases the risk of an outbreak because the overwhelmingly resistant majority prevents the disease from establishing a foothold. However, once the immunization rate in a school dips below 95 percent, herd immunity is compromised.
“Even some people who are immunized will get the disease in that case, due to the 2 to 5 percent who normally don’t respond to a given vaccine,” Sawyer said, “and the few in the school who cannot receive the vaccine because they have a legitimate reason — all these people are now susceptible.”
Of all the kindergarten classes in SDUSD, 12 have vaccination rates below 95 percent, according to the health department data, and one school’s rate is only 50 percent. (None of these schools is in La Jolla.)
What can be done
In her e-mail, Magee wrote that “the district’s physician has raised concerns about this trend with legislators and the local chapter of the American Academy of Pediatrics, among other medical professionals.”
Currently, however, the only mechanism for holding under-vaccinating doctors accountable is the state medical board, which is charged with imposing sanctions including license suspensions and revocations.
But sanctions are difficult to impose without access to family medical records, which the board cannot force a family to hand over. (In fact, the only California doctor to receive a sanction for under-vaccinating was a Capistrano Beach pediatrician who is still practicing and wrote two exemptions for Bird Rock Elementary students since 2015. He received 35 months’ probation for, the board charged, exempting a 2-year-old from all future vaccinations without reviewing any of the child’s medical records.)
Is there a better way of insuring the legitimacy of all medical exemptions issued for vaccines in San Diego and elsewhere in California?
A study of statewide medical-exemption requests under the 2015 law, conducted last year and published in the journal Pediatrics, acknowledged a serious health risk in California public schools and recommended “legal changes including a standardized review of medical exemptions.”
Sawyer agreed, suggesting that the law be rewritten either to allow review by a public-health officer or “to follow the already-publicized, widely accepted reasons to exempt people — and unless you have one of these things, you don’t get an exemption.”
UPDATE! As the issue containing this story went to press on Tuesday, March 26, a state measure (SB 276) was introduced by State Senator Richard Pan and Assembly member Lorena Gonzalez giving public-health officials, instead of local doctors, the power to decide which medical exemptions to issue for vaccination.