Last week, in the run-up to the 4th of July holiday weekend, something happened that I truly never expected to see. SB 277 became law in the state of California when Governor Jerry Brown signed it. In a nutshell, beginning with the 2016-17 school year, the new law eliminates nonmedical exemptions to school vaccine mandates. When last I wrote about SB 277 for this blog three weeks ago, I explained why I thought it was unlikely that SB 277 would ever become law, so that California could join West Virginia and Mississippi as the only states that do not permit religious or personal belief exemptions to school vaccine mandates. Basically, it was because California is not Mississippi or West Virginia. It’s a hotbed of antivaccine activism. Although statewide vaccination rates are high, there are a number of areas where antivaccine and vaccine-averse parents have led to low vaccine uptake with resultant outbreaks of vaccine-preventable diseases. Most recently, a large outbreak centered at Disneyland served as the catalyst that made it politically possible for a bill like SB 277 even to be seriously considered by the California legislature. Even so, given that California is home to a number of antivaccine celebrities such as Rob Schneider, Alicia Silverstone, Bill Maher, Charlie Sheen, Mayim Bialik, and Jim Carrey, antivaccine pediatricians such as “Dr. Jay” Gordon and “Dr. Bob” Sears, and many of the activists at the antivaccine crank blogs Age of Autism and The Thinking Moms’ Revolution, I was not optimistic.

I was mistaken in my pessimism, and I’m happy about that. I’m grateful to all those who didn’t see passing this law as an impossible task, such as Senators Richard Pan and Ben Allen, and who worked tirelessly to see it through, as some of our regular readers did. I was also pleasantly surprised that Governor Jerry Brown didn’t betray California children by watering down the bill with a signing statement, as he did three years ago when an earlier bill (AB 2109) was passed to make it more difficult for parents to obtain personal belief exemptions to school vaccine mandates.

So since SB 277 is law in California, what now?

The backlash

The first issue that will not go away is that antivaccine activists are very, very angry. Already, they are threatening to mount a recall campaign against Sen. Pan, complete with a Recall Pan website. Let’s just put it this way. I don’t get the feeling that this campaign will have much traction. Nor do I think that efforts to overturn the law through a referendum are likely to go very far, particularly if antivaccine activists keep trotting out Andrew Wakefield and Tony Muhammed of the Nation of Islam to speak at their rallies.

Its penchant for publicly featuring discredited scientists and religious cranks aside, the antivaccine movement, although small, is if anything very vocal and quite unafraid to go into full conspiracy mode. For instance, the aforementioned Jim Carrey unleashed a flurry of Tweets after the Governor signed SB 277, calling the law fascist, repeating old antivaccine tropes I like to refer to as the “toxins” and “pharma shill” gambits:

And then:

Next:

Plus:

Concluding with:

There were others, but you get the idea. As I said at the time, to Carrey, apparently Dumb and Dumber is more than just a movie he made with Jeff Daniels. It’s a way of life. Also, either Jenny McCarthy had a more permanent effect on him than previously thought (I always thought he went antivax because he was in love with her), or he was always antivax, which is part of why McCarthy was attracted to him in the first place. Whatever the case, Carrey got so carried away (so to speak) that in one of his Tweets he posted a photo of an autistic boy named Alex Echols without his mother’s permission to illustrate his point of children being “poisoned.” In response, Alex’s mother complained on Instagram and Twitter thusly:

The reason Echols was so unhappy was because her child’s autism was a result of tuberous sclerosis and couldn’t even semi-plausibly be linked to vaccines, as she pointed out on her Instagram account. Carrey ultimately was forced to apologize. Even though Carrey went too far and had to apologize, Reuben over at The Poxes Blog was correct to point out that Carrey’s Twitter meltdown was the perfect microcosm of how the antivaccine movement thinks, if thinking it can be called, by pointing out that “if Jim Carrey is not anti-vaccine, he is just as weird as all the other anti-vaccine cult members who claim to not be anti-vaccine but can’t endorse one single vaccine. Then they run off yelling, ‘Parental choice! Parental choice!'”

Rather like Sandy Fleming, an antivaccine mother who was recently profiled in Los Angeles Magazine:

Why do you oppose SB 277?
Because we don’t have a situation or a pandemic that warrants the government forcing parents to make medical decisions. Being able to make decisions between you and your doctor is a right we have had for all of our lives, and it’s so important. Think about being able to decide with your doctor how you’ll be treated for cancer or a simple flu. There’s never been a one-size-fits-all medicine. This bill breaks the parent-doctor conversation. Don’t even bother reading warning labels, you don’t have an option in this case.

This all sounds reasonable on the surface, but I can’t help but note when reading quotes from parents like Fleming: It’s always about parental rights to them, never about the child’s right to proper medical care that protects them from preventable diseases. Indeed, Rand Paul himself made this argument explicit when he said:

The state doesn’t own the children. Parents own the children, and it is an issue of freedom.

In this, antivaccine activists are very much like the parents who refuse chemotherapy for their child with cancer, who also routinely invoke “parental rights.” In their opposition to SB 277 (or any law that makes it even just slightly more difficult to obtain a personal belief exemption to school vaccine mandates) antivaccine parents like Fleming routinely invoke their rights over those of their children. Actually, they go farther than that. They invoke their rights over not only those of their children, but over those of other people’s children with whom their children will come into contact at school. In this, “health freedom” is simply a dog whistle for the antivaccine movement which, translated, really means, “I invoke the ‘freedom’ to do whatever I want with my children, regardless of the consequences.”

Don’t believe me? Take a look at the reaction to the antivaccine movement to the death of a woman with a compromised immune system from the measles. On Thursday, the Washington State Department of Health issued this press release:

OLYMPIA – The death of a Clallam County woman this spring was due to an undetected measles infection that was discovered at autopsy.

The woman was most likely exposed to measles at a local medical facility during a recent outbreak in Clallam County. She was there at the same time as a person who later developed a rash and was contagious for measles. The woman had several other health conditions and was on medications that contributed to a suppressed immune system. She didn’t have some of the common symptoms of measles such as a rash, so the infection wasn’t discovered until after her death. The cause of death was pneumonia due to measles.

This is a horrible tragedy that I’ve been fearing for a long time, and it has finally happened. The measles has claimed its first victim in the latest series of outbreaks. Indeed, this was the first measles death recorded in the US in 12 years.

I knew right away what antivaccinationists were going to say. They were going to say that they’re sorry, that this is horrible. Then they would make excuses, adding that this woman was immunosuppressed and that’s why she died. Next, they’d claim that measles is a benign disease. Of course, that’s only partially true. The mortality rate from measles in otherwise healthy individuals is quite low (approximately 1 to 2 per 1,000), but it’s not zero. Complications like pneumonia are by no means uncommon. Less common, but still to be feared, are complications such as encephalitis (again, approximately 1 in 1,000) or, even worse, the uniformly-deadly complication of subacute sclerosing panencephalitis (SSPE). This is a rare but fatal disease of the central nervous system that results from a measles virus infection acquired earlier in life, usually developing 7 to 10 years after a person has measles, even though the person seems to have fully recovered from the illness. Elsewhere in the world, measles is far deadlier. It’s also incredibly infectious, caused by one of the most easily-transmissible viruses known to medical science. Moreover, the measles virus itself is temporarily immunosuppressive, and vaccinating against the measles protects against more than just the measles.

But how could this woman have gotten so sick and died before it was realized that she had the measles? After all, the measles is nothing if not recognizable (at least to those who’ve seen it before), thanks to a characteristic rash caused by the disease. Here’s why:

It’s not surprising that the woman had no obvious measles symptoms; people with compromised immune systems often don’t develop a rash when infected with the virus, said Paul Offit, chief of infectious disease at Children’s Hospital of Philadelphia.

The woman’s death was a preventable, but predictable, consequence of falling vaccination rates, said Peter Hotez, president of the Sabin Vaccine Institute and Texas Children’s Hospital Center for Vaccine Development in Houston.

As noted over at io9, rashless measles is rare, but far from unheard of. An overreview of measles warns:

Among immunocompromised persons, diffuse progressive pneumonitis caused by the measles virus is the most common cause of death [97–104]. These patients may first have typical measles with pneumonia, or they may have a nonspecific illness without rash followed by pneumonitis without a rash. In general, signs of pneumonitis develop in the 2 weeks after the first onset of symptoms [90, 96, 105]. Other patients have had reappearance of rash and pneumonitis after long intervals following “classical” measles [97, 106].

In other words, if you’re immunocompromised, you might not know you have the measles until you develop severe viral pneumonitis due to the measles virus. Make no mistake, in immunocompromised patients with the measles, pneumonitis is the most common cause of death.

This woman’s death was not tied to the Disneyland measles outbreak, but Clallam County had a small outbreak of measles earlier this year, which is not surprising given that Washington has been a hotbed of low vaccine uptake and antivaccine activity, to the point that the legislature moved to make it more difficult to obtain nonmedical exemptions. Clallam County has not been immune to parents declining to protect their children from vaccine-preventable diseases by claiming personal belief exemptions.

The bottom line is that there was an outbreak a few months ago in Clallam County, and, even though it wasn’t linked to the Disneyland measles outbreak (health officials report that it was a different strain of the measles), it almost certainly was linked to low vaccine uptake in areas of the county. That is why the antivaccine movement is dangerous.

Not surprisingly, the usual suspects are quick to claim that low vaccine uptake had nothing to do with why this woman died, that this death was not preventable. First up, there’s Dr. Jay Gordon, our favorite “I’m not antivaccine” antivaccine pediatrician, responding to questions on Twitter:

Dr. Jay Gordon Tweet

Yes, that’s Dr. Jay telling someone that this unfortunate woman’s death was not preventable! Not preventable? Nonsense! MMR is very effective at preventing measles, and if MMR uptake is adequately high, herd immunity will protect people who are unfortunate enough to be immunosuppressed. Dr. Jay is basically trying to pass the buck and duck responsibility.

Meanwhile, Dr. Bob Sears, master of the antivaccine dog whistle, is furiously trying to distance the Disneyland measles outbreak from this woman’s death:

MEASLES DEATH NOT LINKED TO DISNEYLAND OUTBREAK, ACCORDING TO ABC NEWS AND WASHINGTON STATE HEALTH DEPT SPOKESMAN

Here is an update from ABC News. Again, our condolences to the family.
According to the last line in the story, this case was NOT linked to the Disneyland outbreak. We don’t yet know what that means. It may have been a measles strain from somewhere else? We don’t know yet. Vaccine strains can also be picked up by immunocompromised people, as this woman was. But be [sic] have no facts about that whatsoever.
Update. One news outlet – king5.com – reports that according to a spokesperson it was the D9 strain, a wild strain that was identified in other people in the county outbreak. Sounds like it was not a vaccine strain.
Again, our heartfelt condolences to the family.

That’s nice. You can almost hear Dr. Bob backing away and saying, “Don’t blame me!” Even worse, he is trying to blame this woman’s death on viral shedding from vaccinated people, which is simply not justified, as secondary transmission of the vaccine strain of measles has not been observed. Of course, it doesn’t matter that this outbreak was due to a different strain of measles virus. It really doesn’t. What matters is MMR uptake. The reason it’s low in certain affluent areas is, at least in part, due to the fear mongering spread by Dr. Bob’s and Dr. Jay’s patients, some of whom are quite active in the antivaccine movement. (Remember, Dr. Jay was Jenny McCarthy’s son’s pediatrician back when she was transforming herself into a “warrior mother” going to war against vaccines.) It’s low because irresponsible pediatricians like Dr. Jay and Dr. Bob are sympathetic to the views of antivaccine parents, to the point where they not-infrequently parrot antivaccine talking points. Indeed, Dr. Jay, relying on his “30 years of clinical experience,” has been known to insist that vaccines cause autism even as he admits that there’s no good evidence to support that belief.

If you want despicable, though, check out this comment by someone named Jen Glover Bishop:

If pneumonia was the cause of death then measles is a non issue. Pneumonia is a complication that can occur after the common cold in an immune compromised person. Anything would have led to pneumonia in a person like that. Life is not illness proof.

This is sort of true. Even if it were totally true, there’s one big difference between the common cold and the measles. We can’t prevent the common cold easily. We can prevent the measles. With a vaccine. And antivaccinationists do everything to deny and minimize their contribution to outbreaks. If you really want to see how low they can go, check out this comment by Christina Wright:

honestly, i call bullshit on this story. i’m sorry if it’s actually true, but its just way too vague and really sketchy that someone just so happens to die from measles as people are starting to wake up about all these bills being introduced. this is a scare tactic to whip the public back into shape. hello pharma pays $$$$$$ for marketing, thats all this is…a marketing strategy to set the tone of what’s to come.

Yes, it’s time for the conspiracy theories to come out. Same as it ever was. Of course, if conspiracy theories aren’t enough, then there’s always outright denying the importance of this story—and even that it’s legitimate—as Colleen Cron Oleksinski does:

With ALL due respect, why is this making national news? People die everyday without national recognition, why is this any different? By the way, Im not buying it either.

Oleksinski was answered by a chorus of Hallelujahs like this:

Setting the stage. They wasted no time. This is tragic absolutely. And what did they say, she passed in the spring? Did they wait this long to have an autopsy? Bring this out now, two days after CA signs BS277 and it is from a different state…perfect to infect the whole country with PANic and misinformation. Federal bill…I can’t wait.

And:

It’s making the news so that the sheep will once again become paralyzed with fear…and they won’t put up a fight when forced vaccinations come to their state.

And:

Getting the fear nice and deep to then roll out adult mandatory vaccines!

You get the idea: It’s not our fault, and this poor woman’s death is nothing more than a conspiracy by big pharma and the government to pave the way for jack booted thugs wielding syringes to force children and adults to be vaccinated. It’s a fantastical, paranoid delusion, but it’s what they believe, even at the expense of denying the human tragedy that has just occurred. What do you expect from people who routinely compare SB 277 to the Fugitive Slave Act and the Holocaust?

This is what we’re up against in trying to build on the success of the pro-SB 277 forces in California and introduce similar laws in other states.

SB 277’s one big weakness

SB 277 is a major improvement in the law regulating vaccination and vaccine exemptions in California that protects children from infectious disease. However, it is not perfect, and we do not know how it will work in practice yet, when it goes into effect next year, because the California Department of Public Health has not yet issued regulations. For example, a question came up for me reading Gov. Brown’s signing message:

The Legislature, after considerable debate, specifically amended SB 277 to exempt a child from immunizations whenever the child’s physician concludes that there are “circumstances, including but not limited to, family medical history, for which the physician does not recommend vaccination.”

Thus, SB 277, while requiring that school children be vaccinated, explicitly provides an exception when a physician believes that circumstances — in the judgment and sound discretion of the physician — so warrant.

What does this mean? I went and took a look at the text of the bill as passed, specifically, Section 5:

SEC. 5. Section 120370 of the Health and Safety Code is amended to read:

120370. (a) If the parent or guardian files with the governing authority a written statement by a licensed physician to the effect that the physical condition of the child is such, or medical circumstances relating to the child are such, that immunization is not considered safe, indicating the specific nature and probable duration of the medical condition or circumstances, including, but not limited to, family medical history, for which the physician does not recommend immunization, that child shall be exempt from the requirements of Chapter 1 (commencing with Section 120325, but excluding Section 120380) and Sections 120400, 120405, 120410, and 120415 to the extent indicated by the physician’s statement.

It’s hard not to wonder whether this means that antivaccine pediatricians in California, like Dr. Bob Sears and Dr. Jay Gordon, are already putting money down on a new Lamborghini. No, that’s not my joke; I stole it from someone on Twitter:

That might be going too far, but it does bring up a point. The biggest weakness in SB 277 is that it appears to leave it pretty much up to a child’s pediatrician regarding whether an exemption to the school vaccine mandate is medically indicated. In that, it is similar to the Mississippi law. In contrast, in West Virginia, it isn’t just the word of the child’s physician that matters; all requests for medical exemptions are reviewed by an Immunization Officer, who determines if they are appropriate “based upon the most recent guidance from the Advisory Committee on Immunization Practices (ACIP), the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP) with respect to medical contraindications or precautions for each vaccine.” In other words, SB 277 does not appear to have any oversight regarding what reasons doctors invoke to issue medical exemptions, and, indeed, in his signing statement Gov. Brown explicitly mentioned that feature of the law as the reason why he was willing to sign it.

On the surface, this provision would indeed seem to be a godsend to antivaccine pediatricians, who will likely see their business boom in the wake of SB 277 as parents, no longer able to obtain nonmedical exemptions, start looking for medical exemptions in much the same way parents in states that allow religious exemptions but not personal belief exemptions suddenly found religion and used it as a justification for not vaccinating. Resistance to vaccination will flow wherever it can. I’m just happy that, in this case at least, only letters from a physician will be valid for obtaining a medical exemption. One can only imagine what would happen if letters from naturopaths and chiropractors, who, unfortunately, are licensed “health care professionals” in the state of California, were permitted. This was the case for AB 2109, where naturopaths were listed as one of the medical professions whose members could counsel parents on the benefits and risks of vaccinating and sign their personal belief exemption.

Be that as it may, there is clearly wide latitude given to California physicians on this issue. Indeed, Dr. Jay himself wrote yesterday:

Governor Brown signed this law because of the strong medical exemption provisions. He recognized that parents with reasonable medical objections—as opposed to personal or religious objections—must still have access to exemptions for their children.

Consult with a physician who knows your child and your family.

No one should scare you into or out of vaccinating.

This is the sort of thing that irritates me about Dr. Jay. He knows that the parents of some of his patients are antivaccine activists. How could he not? He was the pediatrician who took care of Jenny McCarthy’s son Evan back when she was emerging as America’s foremost antivaccine celebrity activist. Does he ever, in the privacy of his office, suggest to these parents that maybe—just maybe—it’s not such a good idea to spread misinformation demonizing vaccines as toxin-laden poisons causing autism, autoimmune diseases, neurodevelopmental disorders, SIDS, and even shaken baby syndrome? Only he and his patients’ parents know for sure, but I sure doubt it. Certainly, he rarely, if ever, publicly calls out anyone on “his side” for promoting such misinformation. Instead, he falls back on a vague false equivalency that paints pro- and anti-vaccine activists both as irrationally trying to frighten people to their position, as he did above. Of course, even if that were true, there would still be a big difference. What pro-vaccine activists say about the dangers of vaccine-preventable diseases is true. What antivaccine activists say about the dangers of vaccine is almost always untrue. In fact, Dr. Jay himself engaged in such fear mongering just a few months ago when he declared that the MMR is not controversial because of Wakefield, and I haven’t forgotten his many articles for The Huffington Post dating back a decade and appearances on TV that spread misinformation and fear about vaccines, invoked the “toxins” gambit, and likened vaccine manufacturers to tobacco companies.

His protestations to the contrary (which, to be fair, I really think he sincerely believes thanks to massive cognitive dissonance), we know what side Dr. Jay is on.

But back to Twitter. There was an exchange just last week in which Dr. Jay asserted:

Dr. Jay replied about “family history” in SB 277 and was asked:

He was therefore asked how he, as a pediatrician, would decide whether to recommend a medical exemption to school vaccine mandates, now that SB 277 basically gives him the power to do that. At first, he said, simply, “Nope”:

After some prodding, he did get one thing right:

Which is a relief.

However, elsewhere, he remained maddeningly vague, going on about “family history” of reactions to vaccines, even though he admits that the AAP does not consider this a contraindication. He sparred with a couple of doctors, who asked him what specific medical conditions he’d consider a contraindication to vaccination. Oddly enough, he didn’t mention any of the contraindications that no one disagrees about, such as the accepted contraindication that children with severe immunosuppression (such as due to chemotherapy or illnesses that compromise the immune system) should not receive attenuated live virus vaccines. It would have been so easy to say that, because such a contraindication is on firm medical ground. But instead, Dr. Jay went here:

And:

And:

So what does this mean? The cynic in me thinks it might mean this:

Certainly, for some physicians, that will be the main criterion. The question will come when it is parents who have a perfectly healthy child with no generally-accepted contraindications to vaccination (such as immunosuppression) or even typical “contraindications” promoted by the antivaccine movement, such as a sibling who had an adverse reaction to vaccination, a sibling with autism, the child having autism himself, and the like. How far will pediatricians like Dr. Jay go to give their patients’ parents what they want? It will be a fascinating question, something to keep an eye on as SB 277 is implemented next year. One thing that I expect to happen is for dubious laboratories, like Doctors Data, to come up with more (and ever more bogus) panels of laboratory tests purported to predict “sensitivity” to adverse reactions from vaccines. Just you watch.

One comforting observation is that there doesn’t seem to be much of a problem with pediatricians writing up dubious recommendations for medical exemptions in Mississippi, whose law doesn’t require review of doctors’ requests for medical exemptions for their patients by an Immunization Officer. But Mississippi is not California, and the law has been in place there for many years. People are used to it. Also, California is one of the great paradises for the many “alternative” practitioners there, including physicians who have gone to the dark side, making the supply of physicians willing—shall we say?—to stretch the boundaries of indications for a medical exemption to vaccines likely much greater in California than it is in Mississippi.

Perhaps the most effective means of making sure that doctors sympathetic to antivaccine parents don’t come up with excessively creative rationales for recommending medical exemptions is vigilance by the state medical board, the federal government, and insurance companies. For instance, one quality metric that is being increasingly examined among pediatricians is the percentage of children who are up-to-date on the recommended vaccines. Pediatricians who fall short on that measure because they issue way more medical exemptions than average could well come under scrutiny. At the very least, they might be risk losing pay-for-performance bonuses. (Not all antivaccine-sympathetic pediatricians are in concierge practices that do not belong to any insurance plans, like Dr. Jay and Dr. Bob.) Unfortunately, state medical boards tend to be toothless so I have little hope that complaints to the Medical Board of California about physicians issuing dubious medical exemptions will have much of an impact.

Don’t think that my pointing out this weakness in SB 277 means that I don’t think it’s an excellent law. It is. Its passage is a major victory in the struggle to protect children from the ravages of infectious disease and a major defeat for the antivaccine movement, which marshaled pretty much everything it had to defeat it and still came up short. The California legislature and Governor Jerry Brown are to be commended, as are the innumerable advocates for children “on the ground” who worked tirelessly for its passage. But it is not perfect. It’s politics. Compromises had to be made.

SB 277 makes the situation in California much better than it was before with respect to child health and should serve as a model for the remaining 47 states that allow religious and personal belief exemptions. It is a beginning, not an end, and part of what needs to be done now is to keep an eye on its implementation. While I suspect that there will be some doctors who profit as a result of the law, fortunately I also suspect that the number of doctors who will be willing to go much beyond the CDC/AAP guidelines for medical contraindications to vaccination is and will remain small.

 

Posted by David Gorski

Dr. Gorski's full information can be found here, along with information for patients. David H. Gorski, MD, PhD, FACS is a surgical oncologist at the Barbara Ann Karmanos Cancer Institute specializing in breast cancer surgery, where he also serves as the American College of Surgeons Committee on Cancer Liaison Physician as well as an Associate Professor of Surgery and member of the faculty of the Graduate Program in Cancer Biology at Wayne State University. If you are a potential patient and found this page through a Google search, please check out Dr. Gorski's biographical information, disclaimers regarding his writings, and notice to patients here.