A California law aimed at increasing vaccination rates among schoolchildren by eliminating non-medical exemptions turns out to be a source of considerable frustration among health officials and immunization staff, researchers report in an article published on October 29 in Pediatrics.
Respondents to the study say one of the biggest problems is the lack of authority to override questionable medical exceptions written by physicians who have unprofessional or even unethical behavior in providing them, explain Salini Mohanty, DrPH , MPH, the Department of Family and Community Health, the University of Pennsylvania School of Nursing, Philadelphia and colleagues. They warn that some of these doctors will continue to write unjustified exceptions without aggressive legal challenges, thereby limiting the effectiveness of the law.
Also, Mohanty and colleagues note that the law requires that all medical exceptions be filed directly with the child's school for review, which incriminates the school and has already led to at least one lawsuit.
Overall, the bill, known as Senate Bill 277 (SB277), is a success: since its implementation in 201
A model for other states  Because it is a large and diverse state, California could serve as a model for other states whose governments may have a similar G to consider legislation, the authors explain. They state that their goal in conducting the study "was to describe the experiences of local health jurisdictions while medical exemption for SB277 was being treated."
To this end, Mohanty and colleagues conducted semi-structured telephone interviews with members of California representing health officials in 58 counties and three cities across the state. The final analysis consisted of 34 detailed interviews with 40 participants representing 35 of the 61 local health jurisdictions in California. One participant represented two areas of responsibility. Respondents included 18 health officers, seven communicable disease coordinators, nine vaccination coordinators or directors and six public health nurses
Main topics Emerge
The authors identified four main themes from the interviews: the role of the stakeholders; Review of medical exceptions received by the schools; problematic medical exceptions; and concerns and frustrations associated with these exceptions.
Stakeholders included physicians, schools and the California Medical Board, as well as state and local health departments, explain the authors. Physicians have the authority and discretion to confirm the reason for a ME and to write the exemption, which is then sent to the schools.
The health authorities were expected to assist the schools in reviewing the exceptions, but they have "no authority to question the scientific validity of medical exemptions under California law." Many participants wanted the California Medical Board play a more active role in disciplining physicians who write medical exceptions that they find problematic, "the authors write.
Regarding the exceptions, schools differed in their policies. In some schools, all exceptions were followed up; In other schools, only certain cases were investigated. One of the jurisdictions that routinely pursued all exemptions was named in a federal lawsuit along with the Department of Health, the Ministry of Education, and several local health jurisdictions submitted by a group of parents and nonprofit organizations.
Action, which was eventually withdrawn, is often cited as a reason why some jurisdictions no longer pursue all medical exceptions. One respondent reported receiving hate and death threats for this tracking policy.
Most participants reported few or no medical exceptions that appeared questionable, but there were some notable exceptions, such as the following:
Exceptions in SB277, including a family history of side effects on vaccines, such as "autoimmune diseases, inflammatory bowel disease , allergic diseases, neurological problems, neurodevelopmental disorders, [and] psychiatric disorders "and called for" temporary exemptions "by 2030.
Some exceptions were issued by a doctor who worked in a medical marijuana pharmacy.
Much of the exceptions were written by a doctor who charged patients $ 300 and asked them to watch a video about vaccine safety before vaccination, the Liberation. The exemptions expired after 3 months, forcing patients to return and pay for another exemption.
Some doctors have advertised on the Internet that they will grant medical exemptions for a fee.
The authors warn that the lack of questionable exceptions does not necessarily mean that such exceptions were indeed rare. Since most jurisdictions do not routinely follow the exemptions, participants most likely saw only "the most outrageous examples."
One of the biggest frustrations and concerns mentioned by the interviewees was the lack of authority to impose fines. Englisch: www.wcc-assembly.info/en/theme-issu…duction.html Exemptions and the undue burden SB277 places on school staff to implement the law They also expressed concerns that "medical exemptions could be used to replace PBE" which "limited the intended effect of SB277 on the conservation and protection of herd immunity" ,
In general, SB277 was "a great success, with strong increases in vaccination rates in kindergarten children entering school," write Richard J. Pan, MD, MPH, and Dorit Rubinstein Reiss, LLB, PhD, in an invited comment about the study. The increase in medical exemptions was not unexpected, as PBE was used for some children who also qualified for medical exemptions. But after the law was implemented, the number of medical exemptions "more than tripled, with some schools reporting ME [medical exemption] rates> 20%, which found that many students received inappropriate MEs."
Unjustified exceptions should be considered Unprofessional conduct that could be subject to liability or discipline by the state licensing authority, write Pan, a state senator, and Reiss, a professor at Hastings College of the Law at the University of California, San Francisco. However, several obstacles, including the lack of cooperation among patients' families, who often wish the unjustified exceptions, make it difficult to prosecute these cases.
At least they conclude: "[p] Public health authorities should revoke the power to invalidate unjustified MEs and to transfer the power to grant ME to doctors who abuse them." They also petition paediatricians with Public health lawyers and "prosience parents" work together to legislate "empowering public health agencies to protect our children and our community".
Study restrictions include possible recall distortions on the part of participants and the fact that participation in the study was voluntary and may have attracted respondents with particularly strong views on the subject.
The study was funded by the National Institutes of Health. One of the authors of the study previously received consulting and / or research support from Merck, Pfizer and Walgreens. The other study authors have not disclosed any relevant financial relationships. The family of dr. Reiss owns common shares in GlaxoSmithKline. Dr. Pan is an elected official; he has not disclosed any relevant financial relationships.
Pediatrics. Published online on October 29, 2018. Complete text, commentary