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A California law aimed at increasing schoolchildren's vaccination rates by removing non-medical exemptions is proving to be a source of considerable frustration for health officials and immunization personnel in the country, researchers said in an article published online Oct. 29 pediatrics.
Those surveyed for the study say that one of the biggest problems is the lack of authority to override questionable medical exemptions written by physicians who engage in unprofessional or even contrary behavior to the ## 147 ## # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # Ethics, say Salini Mohanty, DrPH, MPH, Department of the Family and Community Health, School of Nursing at the University of Pennsylvania, Philadelphia, and colleagues. They warn that without aggressive legal challenge, some of these doctors may continue to write unwarranted exemptions and, in doing so, limit the effectiveness of the law.
Mohanty and his colleagues also point out that the law requires that all medical exemptions be submitted directly to the child's school for examination, which is a burden on the school and has already given rise at least one trial.
Overall, the law, known as Senate Law 277 (SB277), is a success: since its implementation in 2016, the proportion of kindergarten students who have received all required vaccinations has gone from 92.8 % in 2015-2016 to 95.1% in 2017-2018. and Personal Belief Exemption (PBE) rates have declined steadily since the 2013-2014 school year.
However, these promising results were tempered by a concomitant increase in medical exemptions, particularly in counties that previously had high EBP levels. Counties that had high PBE levels prior to SB277 also experienced the largest increase in medical exemptions during the first year of SB277 application, leaving parts of California susceptible to outbreaks that could be prevented by vaccination, "they write.
A model for other states
As this is a large and diverse state, California could serve as a model for other states whose governments might consider adopting similar legislation, say the authors. They explain that their goal in carrying out the study "was to describe the experiences of the local health authorities while responding to SB277 medical waiver requests".
To this end, Mohanty and his colleagues conducted semi-structured telephone interviews with members of the Health Officers Association of California, which represents health officials in 58 counties and three state cities. The final analysis consisted of 34 detailed interviews with 40 participants representing 35 of the 61 local health administrations in California. One participant represented two jurisdictions. Interviewees included 18 health officials, seven communicable disease coordinators, nine immunization coordinators or directors, and six public health nurses.
Major themes emerge
From the interviews, the authors identified four main themes: the role of stakeholders; review of medical exemptions received by schools; problematic medical exemptions; and the concerns and frustrations related to these exemptions.
Speakers included doctors, schools and the California Medical Board, as well as state and local health departments, the authors said. Physicians have the power and discretion to confirm the reason for the EM and write the exemption, which would then be sent to schools.
The health departments were supposed to support the schools in their review of exemptions, but they have "no authority to question the scientific validity of the derogations under California law. Many participants wanted the California Medical Board to play a more active role in research. disciplining doctors who wrote medical exemptions they saw as problematic, "write the authors.
Schools have different policies with respect to exemptions. In some schools, all exemptions were followed; in other schools, only specific cases were examined. One of the jurisdictions that regularly oversaw all exemptions had been appointed in a federal lawsuit, with the Ministry of Health, the Ministry of Education and several local health administrations, which had been filed by a group of parents and non-profit organizations.
The lawsuit, which was eventually withdrawn, is often cited as a reason why some jurisdictions no longer follow all medical exemptions. One interviewee reported receiving hate mail and death threats as a result of this follow-up policy.
Most participants reported few or no medical exemptions that seemed questionable, but there were some striking exceptions, such as the following:
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One of them lists all the exemption criteria mentioned in SB277, including a family history of adverse effects on vaccines, such as "autoimmune disorders, inflammatory diseases of bowel, allergic disorders, neurological problems, neurodevelopmental disorders, [and] psychiatric disorders "and asked for" temporary waivers "until 2030.
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Some exemptions have been granted by a doctor working in a medical marijuana dispensary.
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A doctor who requested US $ 300 from his patients and asked them to watch a video on vaccine safety before receiving this exemption wrote a large number of exemptions. The exemptions expired after 3 months, forcing patients to come back and pay for another exemption.
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Some doctors have announced online that they would provide medical exemptions for a fee.
The authors warn that the lack of dubious exemptions does not necessarily mean that such exemptions were, in fact, rare. Since most jurisdictions do not systematically follow the exemptions, participants probably only saw "the most egregious examples".
Among the greatest frustrations and concerns cited by interviewees was the lack of power to impose sanctions on doctors suspected of writing questionable exemptions and the undue burden that SB277 places on school staff to enforce the law. . They were also concerned that "medical exemptions could be used instead of PBE", which "would limit the expected impact of SB277 on the preservation and protection of herd immunity".
In general, SB277 has been "a great success, with a sharp increase in vaccination rates seen in kindergarten children entering school," Richard J. Pan, MD, MPH, and Dorit Rubinstein Reiss, LLB, PhD, write in a comment on the study. The increase in medical exemptions was not unexpected because PBE had been used for some children who would also have been entitled to medical exemptions. But after the application of the law, the number of medical exemptions "has more than tripled, some schools reporting ME [medical exemption] rate> 20%, revealing that many students received inappropriate MOEs. "
The granting of unjustified waivers should be considered unprofessional behavior that could be punishable by sanctions or disciplinary action by the state licensing board, write to Pan, Senator, and to Reiss, Professor at the Hastings College of Law at the University of California at San Francisco. . However, a number of obstacles, including the lack of cooperation from the families of patients, who often want unjustified derogations, make these cases difficult to pursue.
At the very least, they conclude, "[p]Ublic health officers should have the power to invalidate unjustified MOEs and revoke the delegation of authority of abusing physicians. "They also urge pediatricians to work with public health advocates and" science parents "to legislate" to strengthen public health. officers to protect our children and our community. "
The limitations of the study include the potential recall bias of participants and the fact that participation in the study was voluntary and may have attracted interviewees 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 benefited from advice and / or research support from Merck, Pfizer and Walgreens. The other authors of the study did not reveal any relevant financial relationship. Dr. Reiss' family has regular shares in GlaxoSmithKline. Dr. Pan is an elected representative; he did not reveal any relevant financial relationship.
Pediatrics. Posted online 29th October 2018. Full text, commentary
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