A worrisome rise in the number of cases of measles in Washington prompted that state’s governor to declare a state of emergency on Jan. 25. Even though California has enacted a tough new law that has pushed up vaccination rates here to about 95 percent, doctors remain worried. Why? Because a group of parents appear to be paying for medical exemptions from vaccination, creating geographical hot spots where vaccination rates dip low enough to risk resurgence of life-threatening and preventable disease.
And it’s not a random subset; white, wealthy people are behind the trend that threatens everyone.
From 2007 to 2013, the number of “personal belief” exemptions to the requirement that children receive vaccines prior to starting school doubled in California. That uptick owes to a social movement of vaccine opposition, said Dr. Peter Hotez, a vaccine scientist at Baylor College of Medicine. Our analysis of publicly available data from the 2015-16 school year shows these exemptions were claimed at higher rates in higher-income communities with primarily white residents, including a nearly 30-fold difference between the least white 10 percent of public schools and the whitest one.
Medical exemptions, however, had remained rare and steady over time: 0.3 percent of students in the whitest schools, compared with 0.06 percent of those in the least, and 0.3 percent for the richest versus 0.05 percent for the poorest (as ascertained from federal free and reduced-price meal eligibility).
After Senate Bill 277 eliminated personal belief exemptions, the rate of medical exemptions increased to 4 percent (in the whitest) and to 2.1 percent (in the wealthiest) student bodies. Students in the whitest schools are now claiming medical exemptions nearly 20 times as frequently as those in the least white.
Students who always qualified perhaps used the personal belief process in the past because it was less cumbersome than establishing a medical exemption. But the two most common medical barriers to vaccination are allergy to vaccine components (gelatin, for example) and immunodeficiency. Since research indicates that nonwhite, poorer Americans tend to be more allergic and have weaker immune systems, wealthy white children are, if anything, less likely to require a medical exemption.
They are, however, more likely to have their medical conditions identified. Yet the difference in access to care can only explain the slight imbalance in the pre-SB277 medical exemption numbers, not the current disparity.
That leaves only one logical cause. Hotez said “a very tiny” percentage of the population suffers from qualifying medical conditions, less than 1 percent, which is far from the current medical exemption rate of 19 percent in Nevada City (Nevada County). In his words, the numbers “would suggest there are physicians who are gaming the system, in a sense, and creating medical indications for which there aren’t any.”
Catherine Flores Martin, director of the California Immunization Coalition, which works to maintain full immunization protection, put it bluntly by email: “It is clear that some families are obtaining medical exemptions for a fee.”
A study published in the November 2018 issue of Pediatrics listed among the conditions cited by these doctors not an individual’s allergies or autoimmune disorders, but a family history of such, a contraindication not recognized by the CDC’s Advisory Committee on Immunization Practices.
Does it really matter though, because vaccine-hesitant parents tend to live in enclaves and statewide vaccination rates are high? Yes.
Take, for example, adjoining small cities in Sonoma County. Sebastopol, where only 26 percent of public school kindergartners were eligible for free or reduced-price meals, had not a single medical exemption in 2015. In 2017, however, 15 percent claimed a medical exemption, nearly all from the two public schools in town with more than 80 percent of students identifying as white.
Just to the southeast are Cotati and Rohnert Park, areas which are significantly less white and affluent. On their own, they have a 94 percent up-to-date-vaccination rate. The region in which all three communities are situated, however, now has a rate of 86 percent, below the 95 percent required to make the chance of an infected person encountering a susceptible individual (say, a newborn or chemotherapy recipient) low enough to prevent an outbreak.
The fact that exemptions deemed “fraudulent” by Dr. Richard Pan, co-sponsor of SB277, are increasingly being issued is cause for concern. Unnecessary risk is being imposed by an ethnically and economically privileged group upon the population as a whole.
Dr. Bob Sears, an Orange County pediatrician who once lobbied against SB277, was placed on probation in July by the Medical Board of California in association with an allegation regarding an insufficiently substantiated medical exemption. Hotez said that should continue: “Physicians who are giving out medical exemptions for not truly medical reasons need to be reprimanded.”
Pan has pointed to West Virginia, where every exemption is reviewed by a public health official. The California Legislature could establish something similar or clarify which medical conditions qualify. Or a certain percentage of exemptions in a given school or county could trigger a state audit.
Creating a system to ensure that medical exemptions are scientifically justified isn’t just a public safety issue. It’s also imperative for ensuring that white privilege isn’t given the imprimatur of the medical establishment, using it to sidestep democratically enacted law.
Gail Cornwall is a freelance writer in San Francisco. Dylan Chan is a pediatric otolaryngologist (ear, nose and throat specialist) at UCSF. To comment, submit your letter to the editor at SFChronicle.com/letters.