California disciplining doctors over questionable medical exemptions for vaccines

Less than a year after new vaccine oversight rules for doctors took effect, the California Department of Public Health has reported seven physicians to licensing boards for allegedly issuing dubious medical exemptions to let kids skip school-mandated shots.

Lawmakers in 2015 tightened a public health law by eliminating a personal belief exemption for required vaccines like the measles, mumps and rubella, chickenpox and polio shots, which meant families with kids in school could no longer skip immunizations for their children due to philosophical reasons.

The percentage of students with personal belief exemptions plummeted after that law took effect. Meanwhile, medical exemptions started ticking up enough for the Legislature to notice.

Concerned that a handful of doctors were issuing fraudulent medical waivers in place of personal belief exemptions, legislators in 2019 passed a pair of laws to increase oversight of physicians.

Doctors who want to issue a medical exemption now have to fill out a standardized form and submit it to a statewide vaccine registry that went online at the start of 2021. The laws task Department of Public Health personnel with reviewing exemptions in schools with vaccination rates below 95% and monitoring doctors who issue more than five passes in a calendar year.

If the department rejects five or more exemptions by a single doctor, the agency must flag the physician to either the Medical Board of California or the Osteopathic Medical Board of California, both of which license and discipline physicians.

By Oct. 5, doctors had written 4,149 medical exemptions this year, and the department rejected 182 of them. The Department of Public Health said it has also reviewed medical exemptions written by 165 physicians who've filed five or more in 2021.

As of Dec. 1, "at least" seven physicians have had "at least" five medical exemptions invalidated in 2021 and were reported to the appropriate board.

The Department of Public Health did not provide physician names or exemption details.

Disciplining doctors

The Medical Board has opened 18 immunization standards of care investigations against 15 doctors since 2016, with most of the cases alleging negligence, unprofessional conduct and inadequate record keeping.

It's unclear which investigations are related to the new laws or who the seven doctors are on that list that the public health department reported. The Medical Board said that it could not provide detailed complaint information, but most accusations were filed after the new laws passed in the fall of 2019.

In all, five doctors are now on probation. Two surrendered their licenses, one faced a public reprimand and two had their licenses revoked. Other cases are still pending.

Several of the doctors are currently barred from issuing immunization exemptions for school kids, and have to undergo ethics, record-keeping and education courses.

Medical exemptions for children are usually reserved for extreme circumstances, such as when a kid is immunocompromised with a condition like cancer and can't yet get vaccinated. The Centers for Disease Control and Prevention outlines a list of severe conditions that might warrant additional precaution as ethical criteria for medical exemptions.

Catherine Flores Martin, executive director for the California Immunization Coalition, said the new laws help ensure vulnerable kids who depend on herd immunity against deadly diseases are protected in school.

Flores Martin said the new regulations weren't written to "try to catch (doctors) doing wrong things" or discourage legitimate exemptions.

"It was about making sure that any medical exemption that's written is a valid one," she said. "We were seeing all kinds of invalid medical exemptions that were not based on science or fact. This is about making sure physicians are following the standard of care and protecting their patients the right way."

State Sen. Richard Pan, a Sacramento Democrat and pediatrician who wrote the laws, added that while data are still limited, he's hopeful the new restrictions have worked.

"We are trying to eliminate false and inappropriate medical exemptions," he said. "It has probably discouraged a lot of people in the space."

Exemptions for COVID-19 vaccines

While personal belief exemptions are no longer an option for existing routine school shots, they still stand for the COVID-19 vaccine.

In October, Gov. Gavin Newsom ordered for all students to get immunized against the coronavirus to attend in-person classes once the shots are fully approved by the Food and Drug Administration. Currently, they are allowed via emergency use authorization for younger kids.

That statewide rule will likely take effect for next school year, though some districts have already moved forward with earlier deadlines for certain students.

Because Newsom issued the mandate through regulation instead of legislation, personal belief exemptions are still allowed. That means families who don't want to vaccinate their children against COVID-19 can still petition for a waiver.

That could soon change. Lawmakers are widely expected to examine the personal belief exemption and possibly tighten those rules once the Legislature reconvenes for the 2022 session on Jan. 3.

"How do we keep our schools safe, our schools open? If the Legislature takes action, one of the things could be removal, elimination of the personal belief exception for requirements in schools," Pan said. "There's a lot of things to figure out with COVID."

As with previous vaccine laws, any attempt to regulate who can skip the shots will be controversial.

Several coalitions have organized protests at the Capitol against the vaccine and mask mandates in schools in recent months, with another rally scheduled for the same day legislators return to Sacramento. Protesters often argue that the choice to vaccinate should be left to parents, not the government, and that mandates violate their freedoms.

Some groups are posting religious exemption forms on their websites for followers to use when they apply for waivers.

Arnab Mukherjea, Chair of the Public Health department and an associate professor at California State University-East Bay, said there's a "societal consequence of individual liberty."

"In the case of infectious disease, what an individual chooses to do or not to do not only affects themselves but the people around them," Mukherjea said. "It may be true that kids fare better than adults or those who are immunocompromised, but they serve as vectors for those who don't have that luxury."

Some risks are associated with the vaccines for certain kids. Mukherjea referenced the rare occurrence of blood clots in younger women with the J&J vaccine and myocarditis and pericarditis with the mRNA vaccines for young men.

Mukherjea said the risks largely apply among those who have preexisting conditions and would therefore qualify for a medical exemption. The benefits of getting kids vaccinated against COVID-19, Mukherjea explained, overwhelmingly outweigh the risks.

Dr. Melanie Sabado-Liwag, an assistant professor and director of the Master of Public Health program at California State University-Los Angeles, said it's incumbent upon doctors to equip themselves with the most up-to-date information on COVID-19 vaccines to best serve patients.

That might look like answering questions from parents who express vaccine skepticism or stepping up care in communities with greater health disparities and inequities.

"Everybody is getting different information from different places," Sabado-Liwag said. "Oftentimes, people are not thinking beyond the internal bubble they are choosing to encase themselves in."

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