April 16, 2019

Measles cases are on the rise—and so are vaccine exemptions

Daily Briefing

    The United States is on pace to see the most reported measles cases since the disease was eliminated from the country in 2000, and vaccine exemptions are on the rise in some states, as some parents have found end runs around laws requiring vaccinations.

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    Nationwide, measles cases are being reported at a record-setting pace. CDC data show there have been 555 measles cases reported in the United States as of April 11, putting this year on pace to set the record for the largest measles outbreak since the disease was eliminated from the country in 2000. The largest measles outbreak in the United States since 2000 occurred in 2014, when there were 667 measles cases reported.

    As of April 11, measles outbreaks were ongoing in five states, with measles cases in 15 other states reported to CDC.

    Vaccine exemptions rise

    According to federal guidelines, vaccine exemptions should be rare and generally reserved only for children allergic to the components of a vaccine, including children being treated for cancer. CDC notes that general allergies and asthma are not excusable to avoid or delay a vaccine.

    However, 47 states allow parents to opt out of vaccinations for their children because of religious reasons, and 17 states allow parents to opt out of vaccinations for their children because of personal or philosophical beliefs. In most states, children who obtained an exemption and are not vaccinated may still attend public school.

    For example, in Iowa, school districts accept both medical and religious exemptions to vaccines. In the 2017-18 school year, children with medical or religious exemptions to vaccines made up about 1.1% of the Iowa City School District, according to Susie Poulton, the school district's health coordinator. Poulton said the number of religious exemptions in the school district has increased in recent years.

    In Arkansas, school districts accept religious and medical exemptions for vaccines, as well as exemptions based on philosophical objections. According to data from the state's health department, the number of vaccine exemptions in Arkansas has increased by about 25% over the past five years, with just over 8,000 exemptions in 2018. Of those 8,000 exemptions, around 66% were for philosophical objections, while about 32% were religious exemptions and 2% were medical exemptions.

    But some states have cracked down on exemption policies in light of recent measles outbreaks. For example, California passed a law that bars parents from citing personal or religious beliefs to exempt their children from vaccination in response to an outbreak three years ago. Under the law, children could only be exempted by a licensed physician on medical grounds.

    Vaccination rates in California improved during the two years after the law's enactment, with the percentage of vaccinated kindergartners in the state rising from 92.9% in the 2015-16 school year to 95.1% in the 2017-18 school year. However, those increases slowed down, as medical vaccine exemptions have tripled in the state over the past two years.

    Before the law took effect, less than 1% of schoolchildren in California had medical exemptions. But by last year, 105 schools across the state reported that at least 10% of their kindergartners had been granted medical exemptions to vaccines, with 31 of those schools reporting at least 20% of kindergartners having medical exemptions.

    For example, more than half of kindergartners at two public charter schools in Sebastopol, California, received a medical vaccine exemption, and more than 30% of kindergartners at schools in Arcata, Berkeley, Nevada City, Santa Cruz, and Sausalito have been granted such exemptions.

    Why vaccine exemptions are rising

    According to state officials in California, one reason vaccine exemptions are on the rise is the way the state law is worded. The law requires a licensed physician to write a medical vaccine exemption but does not specify which medical conditions qualify a student for an exemption, nor does it require physicians to follow federal guidelines. As a result, many parents have begun sharing the names of doctors who will grant medical exemptions for a variety of reasons, including a family history of eczema or arthritis.

    Brian Prystowsky—a pediatrician in Santa Rosa, California—said the practice is "sort of the Hail Mary of the vaccine refusers who are trying to circumvent [the law]. It's really scary stuff. We have pockets in our community that are just waiting for measles to rip through their schools."

    In Iowa, Poulton said she believes parents might be taking advantage of religious exemptions as a loophole to avoid vaccinating their children for personal reasons. "It just requires that it be notarized, but it doesn't require any religious authority overseeing that," she said, adding, "So I think religious [exemptions] end up being personal."

    How policymakers are trying to address the issue

    Amid concerns about the increasing vaccine exemptions, the California Department of Public Health recently began reviewing schools with "biologically unlikely" amounts of medical exemptions, according to Karen Smith, the department's director. Any doctors found writing questionable exemptions will be referred to the Medical Board of California, which has the authority to levy sanctions against the physicians.

    Since 2013, the board has received 106 complaints about potentially false exemptions, according to Carlos Villatoro, a spokesperson for the board. However, the board has sanctioned only one doctor for writing an improper vaccine exemption.

    In addition, California Sen. Richard Pan (D-Sacramento) has introduced a bill that would require the state's Department of Public Health to sign off on all medical vaccine exemptions. The bill also would give the department the power to revoke exemptions that are not consistent with CDC guidelines.

    "We cannot allow a small number of unethical physicians to put our children back at risk," Pan said. He added, "It's time to stop fake medical exemptions and the doctors who are selling them."

    In Iowa, state lawmakers during their latest legislative session considered a bill that sought to ban vaccine exemptions in the state, but the bill failed to gain traction. According to The Daily Iowan, state lawmakers might "try to address the issue in the future."

    The federal government also might move to crack down on vaccine exemptions. Former FDA Commissioner Scott Gottlieb in February said federal health agencies could look to limit vaccine exemptions if states do not do so. Gottlieb during an interview with CNN said, "Some states are engaging in such wide [vaccine] exemptions that they're creating the opportunity for outbreaks on a scale that is going to have national implications." He added, "[If] certain states continue down the path that they're on, I think they're going to force the hand of the federal health agencies" (Ostrov, Kaiser Health News, 4/5; Lardieri, U.S. News & World Report, 4/8; The Daily Iowan, 4/12; AP/Sacramento Bee, 4/15; Malkin, New York Times, 4/15; Bacon, USA Today, 4/15; CDC website, 4/15).

    The case for improving coordination between behavioral health and pediatrics


    The CDC estimates that nearly $247 billion is spent annually on the treatment and management of childhood mental disorders. Further, pediatric patients and caregivers often struggle to access high-quality behavioral health expertise due to a limited number of specialists and fragmented approaches to behavioral health services.

    In this presentation, we review the case for improving coordination between behavioral health and pediatrics, and describe four successful models that increase access to behavioral health care.

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