California Tightens Scrutiny of Medical Vaccine Exemptions

Kerry Dooley Young

October 29, 2019

The Medical Board of California this year has so far accused three physicians of improperly writing exemptions from vaccine requirements for young patients — with one San Diego physician admitting to providing as many as 1000 exemptions. Meanwhile, the state's lawmakers created a new path for closer monitoring of future opt-out cases.

These are the latest steps in California's efforts to reduce exemptions from its vaccine requirements for children. The state ended exemptions made in defense of personal beliefs with Bill 277, signed into law in June 2015 after a measles outbreak that year was linked to the state's Disneyland theme park. 

But an unintended consequence of that 2015 law appears to have been an increase in the use of medical exemptions. Last year, 4812, or 0.9%, of students entered kindergarten with a medical exemption compared with 931, or 0.2%, in 2015, according to the California Health and Human Services Agency. Exemptions tend to be clustered in schools in areas that could place them below the 95% rate considered necessary for herd immunity.

Last month, state lawmakers passed legislation that tasks the California Department of Public Health (CDPH) with checking on physicians who write five or more exemptions in a calendar year. Governor Gavin Newsom signed the bill, SB 276, on September 9. It goes into effect January 1, 2021.

There is no prohibition against writing this many exemptions, but state officials will examine these cases. CDPH may then report cases it finds concerning to the Medical Board of California.

The medical board has spoken about the obstacles it faces in investigating complaints about improperly granted medical exemptions. These include parents' unwillingness to allow the board access to medical records for their children.

Three in the Spotlight

The three physicians the medical board publicly accused of this in recent months had all already attracted significant publicity for their skepticism about vaccination. None of the three responded to Medscape Medical News' request for comment.

On July 29, the board said that Kenneth P. Stoller, MD, had granted medical vaccine exemptions based on genetic variations, an approach not supported by the American Academy of Pediatrics or the Centers for Disease Control and Prevention.

Stoller also relied on unverified histories and failed to maintain adequate records, the board said. The board's formal accusation recaps cases involving 10 unnamed patients, whose ages ranged from 4 months to 12 years. In May, San Francisco City Attorney Dennis Herrera announced that he had issued a subpoena for Stoller's records, citing concerns about his vaccine exemptions.

On September 10, the board said that Robert Sears, MD, had given childhood-long exemptions to three patients whose medical histories did not support these exclusions. In a fourth case, Sears also had issued too broad an exemption to a 12-year-old patient where only a more limited exclusion was needed, the board said.

Sears was already subject to a 35-month probation period due to a past board decision related to medical exemptions he granted to patients.

On October 1, the board said that Tara Zandvliet, MD, granted a 12-year-old patient a medical exemption "based on a remote and irrelevant family medical history." The board also said she did not conduct a physical examination of the patient.

In this case, the child's parents were divorced and disagreed about vaccination. Her father sought the medical exemption through Zandvliet, while the mother later questioned the grounds on which it was given, according to the board's complaint against Zandvliet.

The Voice of San Diego, a nonprofit news organization, in March 2019 reported that Zandvliet — whose practice is located in the city — had written 141 of 486 medical exemptions from vaccinations for the entire San Diego Unified School District since June 2015.

But in the state medical board's complaint against Zandvliet, she claims that, as of June 2019, she "has provided roughly 1,000 medical exemptions since California Senate Bill 227 was passed."

The Voice provided a link to its analysis of public records. These show some physicians issuing exemptions for patients who have been treated for leukemia, while others, including Zandvliet, cite family histories of immune conditions as the reason.

Only about a dozen of the more than 150 physicians and medical practices in the Voice's analysis had given more than four exemptions.

"Very Profitable"

California state Senator Richard Pan, MD, MPH, spearheaded the new exemption law, as he did previous legislation on this topic. In a recent interview with Medscape Medical News, Pan said that some physicians found writing exemptions to be "very profitable."

"They're charging $300, $500 each for them, and they're advertising," he said in the October 25 profile of his work promoting vaccinations.

Pan also has been an advocate for counseling parents about the benefits of vaccines. A previous bill he authored required that parents who wanted to keep their children from being vaccinated first learn about the benefits and risks of the immunization and the health risks of specified communicable diseases.

The rate of vaccine waivers for kindergartners entering school in California declined to 2.5% in 2014 from 3.1% in 2013 — the first reversal of a decades-long increase in use of personal-belief exemptions, Pan said in a state news release.

In a paper in Health Affairs last year, Alison Buttenheim, PhD, MBA, from the University of Pennsylvania School of Nursing in Philadelphia, and coauthors concluded that California's mandatory counseling approach worked. Increasing "the opportunity cost of vaccine exemptions" by requiring the signature of a healthcare provider did reduce these opt-outs, they wrote.

Buttenheim told Medscape Medical News that clinicians face challenges in working with parents who have concerns about vaccines. This is only one topic that may be covered in short visit. Parents may notice physicians getting impatient due to time constraints and misinterpret it as a dismissive attitude about their questions.

There has been significant polarization around the topic of vaccines, making it important to make the most of the limited time allowed in a visit, she said.

One useful technique, Buttenheim said, is for physicians to talk about having their own children vaccinated and take other steps to reassure the parents who raise concerns.

"We really want parents to know that most parents do this," she said. "Nationwide, 95, 96, 97% of parents have their kids vaccinated."

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