Vaccine Medical Exemptions Are a Delegated Public Health Authority Richard J

VaccineRichard J. Pan, MD, MPH, aMedical Dorit Rubinstein Reiss, LLB,Exemptions PhDb Are a Delegated Public Health Authority

Vaccines are safe, >1000 times safer kindergarten full-vaccination rate rose3 than the diseases they prevent. to >95% for the past 2 school years. Protection from vaccines extends Given the laxity of the previous beyond individuals when vaccination personal belief exemption, experts rates are high enough to confer anticipated a rise in medical community immunity. However, exemptions (MEs) because some vaccine risks may be too high for a few parents whose children qualified for people, for example, those with a known MEs had previously used the more severe allergy to a vaccine. Public health convenient personal belief exemption. and medical experts have identified However, MEs more than tripled, contraindications and precautions a with some4 schools reporting ME rates California State Senator, Sacramento, California; and for each vaccine based on data from >20%, revealing that many students bHastings College of the Law, University of California, San Francisco, California extensive postapproval monitoring 1 received inappropriate MEs. that reveal actual or theoretical risk. SB277 made no major changes to Opinions expressed in these commentaries are Some conditions are so uncommon those of the authors and not necessarily those that despite years of administration California law regarding granting MEs, of the American Academy of Pediatrics or its of millions of vaccine doses, it is still a power that lies solely in the discretion Committees. unclear whether the condition is truly of any physician licensed by the Medical DOI: https://doi.org/10.1542/peds.2018-2009 Board of California or the Osteopathic associated with the vaccine; but out Accepted for publication Aug 2, 2018 of an abundance of caution, those Medical5 Board of California. Mohanty et al interviewed California health Address correspondence to Richard J. Pan, MD, conditions may be listed as a vaccine MPH, State Capitol, Room 5114, Sacramento, CA precaution. officers after the passage of SB277 95814. E-mail: [email protected] regarding their role in and observations The passage of Senate Bill 277 (SB277) PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, of granting MEs. Health officers expressed 1098-4275). in 2015 abolished all nonmedical frustration with their lack of authority exemptions in California. SB277 proved Copyright © 2018 by the American Academy of to limit unprofessional behavior by Pediatrics to be a great success, with sharp physicians granting large numbers of increases in vaccination rates seen in FINANCIAL DISCLOSURE: Dr Reiss’s family owns – unwarranted MEs and thus putting kindergarteners entering school. For regular stock in GlaxoSmithKline; as Dr Pan is an students at risk. A local health officer elected official, all of his campaign disclosures the 2014 2015 school year, when the who tracked MEs faced a failed lawsuit can be found on the California Secretary of State Disneyland measles outbreak occurred and personal attacks by antivaccine Web site (http://cal-access.sos.ca.gov/Campaign/ and SB277 was introduced and passed extremists. Health officers also felt it is Candidates/#senate), and he has indicated he has no financial relationships relevant to this article to into law, the statewide kindergarten 2 was unfair for school staff to review MEs. full-vaccination rate was only 90.4%, disclose. below the 94% needed for community Our constitutional jurisprudence FUNDING: No external funding. immunity to measles. After the passage recognizes state authority to mandate POTENTIAL CONFLICT OF INTEREST: Dr Pan – authored legislation (Senate Bill 277) to abolish of SB277, the kindergarten full- vaccination6 to protect public health vaccination rate for the 2015 2016 and safety. Historically, courts nonmedical exemptions; Dr Reiss’s family owns 2 regular stock in GlaxoSmithKline. school year rose to 92.6%, which has granted states extensive leeway to been attributed to families receiving set conditions7 attached to school information about the importance mandates. Policymakers should To cite: Pan RJ and Reiss DR. Vaccine Medical of vaccination from the widespread recognize that granting MEs to legally Exemptions Are a Delegated Public Health Authority. press coverage of SB277 and the required vaccines is not the practice Pediatrics. 2018;142(5):e20182009 measles outbreak; and after the actual of medicine but a delegation of state implementation of SB277 in 2016, the authority to licensed physicians to Downloaded from www.aappublications.org/news by guest on September 23, 2021 PEDIATRICS Volume 142, number 5, November 2018:e20182009 COMMENTARY protect public health and individuals. Public health officers should have the These data allow for public health Essentially, physicians are fulfilling authority to invalidate unwarranted officers to assess public health risks an administrative role: certifying MEs and revoke the delegation of from a congregation of unvaccinated to the state that a patient meets authority to grant MEs from physicians children and limit the risk of ’ professionally recognized criteria that who abuse it. These powers maintain outbreaks. justify granting an ME. This delegation the state s constitutional authority to Vaccines are one of the greatest makes sense because physicians protect public health and safety. For public health successes in history. already evaluate patients for existing example, West Virginia, another state ’ Mandating vaccination for school health conditions and can identify with only MEs, requires physicians is an effective strategy to prevent which of their patients warrant MEs. to provide information to the state s outbreaks. This protection is In addition, standards of care for public health8 department, which then undermined when unscrupulous vaccination that are established by grants MEs. With this model, the physicians monetize their license medical professional associations state avoids putting school personnel and abuse the authority delegated make granting unwarranted MEs in the position of reviewing the to them from the state by granting unprofessional behavior that is appropriateness of MEs. unwarranted MEs. Public health subject to potential liability and officers need the information to discipline by a state licensing board. Unfortunately, currently, only 6 ’ identify these physicians and the However, the lack of cooperation states require the involvement authority to withdraw their ability by patients families who desire of public health departments in to grant MEs and to invalidate unwarranted MEs makes disciplining reviewing MEs. Thus, most health unwarranted MEs to protect children physicians who are engaged in officers and licensing boards do not and public health. Pediatricians can this unprofessional behavior have direct access to data on MEs. To partner with public health advocates difficult and costly because licensing protect public health, this situation ’ and proscience parents to pass boards need to subpoena patient needs to change. States can collect laws that empower public health records over families objections and maintain searchable records officers to protect our children to obtain evidence. Similarly, of MEs, which could be included as and community. Every child needs professional standard-setting part of state immunization registries. community immunity. organizations, including professional This information would both benefit associations and certification patients with valid MEs by alerting ABBREVIATIONS boards, have been reluctant to clinicians of patient MEs and provide withdraw credentials or expel important data for public health. members who promote vaccine Laws should also require parents ME: medical exemption misinformation and grant to submit MEs to public health SB277: Senate Bill 277 unwarranted MEs. departments as well as schools. COMPANION PAPER: A companion to this article can be found online at www.pediatrics. org/cgi/doi/10.1542/peds.2018-1051.

REFERENCES 1. Centers for Diseases Control and https://www.cdph.ca.gov/Programs/CID/ medical exemptions. Pediatrics. Prevention. Vaccine recommendations and DCDC/CDPH%20Document%20Library/ 2018;142(5):e20181051 guidelines of the ACIP: contraindications Immunization/2017-2018KindergartenS 6. Jacobson v Massachusetts, 197 US 11 and precautions. 2018. Available at: https:// ummaryReport.pdf. Accessed June 24, 2018 (1905) www.cdc. gov/ vaccines/ hcp/ acip- recs/ 4. Karlamangla S, Poindexter S. Despite general-recs/ contraindications . html. 7. Mello MM, Studdert DM, Parmet WE. California s strict new law, hundreds Accessed June 24, 2018 ’ Shifting vaccination politics — the of schools still don’t have enough end of personal-belief exemptions 2. California Department of Public Health, vaccinated kids. Los Angeles Times. in California. N Engl J Med. Immunization Branch. Kindergarten August 13, 2017. Available at: www. 2015;373(9):785–787 school reporting data. Available at: www. latimes.com/health/la-me-kindergarten- 8. West Virginia Department of Health and shotsforschool.org/k-12/reporting-data/. vaccination-20170813-htmlstory.html. Human Services, Office of Epidemiology and Accessed June 28, 2018 Accessed June 24, 2018 Prevention Services. Medical exemptions 3. California Department of Public Health, 5. Mohanty S, Buttenheim A, Joyce C, information. Available at: https://dhhr .wv . Immunization Branch. 2017-2018 Howa A, Salmon D, Omar S. Elimination gov/oeps/immunization/requirements/ kindergarten immunization assessment – of nonmedical vaccine exemptions Pages/Medical-Exemption-Resource-Center. executive summary. 2018. Available at: in California: experiences with aspx. Accessed July 5, 2018

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Updated Information & including high resolution figures, can be found at: Services http://pediatrics.aappublications.org/content/early/2018/10/25/peds.2 018-2009 References This article cites 2 articles, 1 of which you can access for free at: http://pediatrics.aappublications.org/content/early/2018/10/25/peds.2 018-2009#BIBL Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Infectious Disease http://www.aappublications.org/cgi/collection/infectious_diseases_su b Vaccine/Immunization http://www.aappublications.org/cgi/collection/vaccine:immunization _sub Advocacy http://www.aappublications.org/cgi/collection/advocacy_sub Legislation http://www.aappublications.org/cgi/collection/legislation_sub Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.aappublications.org/site/misc/Permissions.xhtml Reprints Information about ordering reprints can be found online: http://www.aappublications.org/site/misc/reprints.xhtml

Downloaded from www.aappublications.org/news by guest on September 23, 2021 Vaccine Medical Exemptions Are a Delegated Public Health Authority Richard J. Pan and Dorit Rubinstein Reiss Pediatrics originally published online October 29, 2018;

The online version of this article, along with updated information and services, is located on the World Wide Web at: http://pediatrics.aappublications.org/content/early/2018/10/25/peds.2018-2009

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. Pediatrics is owned, published, and trademarked by the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2018 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

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