As Long as There Are Laws to Be Followed, People Will Find Ways Around Them

In 2015, California passed Senate Bill 277, a law that did away with personal belief exemptions to vaccination requirements for schoolchildren in the state. After the bill was signed into law, the only exemptions that parents could obtain for their children were medical exemptions by licensed healthcare providers. Normally, these exemptions would only be given in cases where there is a clear history of reactions to vaccines or their ingredients. However, physicians who were “friendly” to vaccine-hesitant and anti-vaccine parents provided these medical exemptions, sometimes without much of a medical reason.

For example, Robert “Bob” Sears, MD, a pediatrician, recently got in trouble with the medical board:

“The complaint, brought by Kimberly Kirchmeyer, executive director of the Medical Board of California, alleges that Sears filed medical vaccination exemptions for a pair of siblings who did not have medically recognized contraindications for any vaccines, based on what he recorded in their medical records.

The patients are a 7-year-old unvaccinated boy with psoriasis and his sister, whose only medical history is a bee sting allergy. Both saw Sears on May 4, 2016, for a complaint of “vaccine exemption appt.”

Sears recorded the children’s family medical history as “autoimmune disorders, lupus, psoriasis (in Dad), inflammatory bowel disease, irritable bowel disease, irritable bowel syndrome (in Dad), gluten sensitivity severe in Mom and Aunt, suspect CD [celiac disease] in aunt, neurodevelopmental disorders, ADD/ADHD (in Dad), psychiatric disorders, schizophrenia (Dad), bipolar, and depression.”

The boy’s exam included “psoriatic plaques on scalp, back of neck and ears,” and the girl’s exam was normal, though Sears documented no vital signs for her (blood pressure and temperature). Both children were diagnosed with “viral infection, unspecified” and “feeding difficulties” despite the purpose of the appointments being solely recorded as “vaccine exemption” visits.

Sears determined that the boy “qualified for medical exemption from vaccines for family history of autoimmune disorders (Dad and others), inflammatory bowel disease (Dad), neurodevelopmental disorders (Dad), psychiatric disorders (Dad), and the child’s own autoimmune disorder.” Sears determined the girl qualified “based on review of her past medical history, family history, and current state of health.” He filed letters for both children “exempting [them] from all vaccines for the rest of [their] childhood.”

None of the conditions or family history, as noted in the children’s records, meet the criteria for contraindications to any CDC-recommended childhood vaccines, according to the CDC. The complaint notes for the boy that a “childhood long medical vaccine exemption… based on diagnosis of psoriasis, without immunosuppressive medication, is a simple departure from standard of care.””

This week, health authorities in Pakistan are reporting that parents there are using special ink pens to mark the pinky fingers of their children. Why? These marks are used to identify children who have already received the polio vaccine. Vaccine-hesitant parents are preemptively marking their children in order to trick the vaccine brigade workers into skipping their children:

“Health workers say parents opposed to the vaccinations are marking their children’s pinkies to make it appear they have been vaccinated when, in fact, they weren’t. The deception causes vaccination teams to skip over children who need to be vaccinated — thereby preventing the disease from being eliminated in the country.

With the disappearance of wild polio cases in Nigeria in recent years, Pakistan and Afghanistan are currently the only countries in the world where new polio cases are found.

The issue with the fake markers in Pakistan highlights the varied obstacles that are keeping Pakistan from eliminating polio — a childhood virus that leads to deformed limbs, paralysis, and even death.

Thorough vaccination campaigns in recent years have dramatically reduced the number of polio cases in Pakistan, with only a dozen cases recorded last year.

But that number has jumped to 45 cases this year. Of those, 35 were found in the northwestern province of Khyber Pakhtunkhwa, a poor and religiously conservative region that was once a stronghold of militant groups like Al-Qaeda and the Pakistani Taliban.

Many residents of the province, which lies along the porous border with Afghanistan, have been suspicious of the polio vaccine, with conservative Islamic clerics and militants claiming it is a Western conspiracy to harm or sterilize children.”

As the article explains, this is a big problem because the last traces of polio are in that part of the world. If polio is allowed to return, it would endanger millions of children in the area, and it could spread beyond Pakistan and Afghanistan to nearby countries. As you can see, the reasons why parents there are hesitant of the polio vaccine are similar to why parents in the United States are hesitant: misinformation and religious objections.

Before the Jacobson v Massachusetts decision by the Supreme Court of the United States, those seeking to avoid vaccination were very reliant on anti-vaccine interpretations of their respective faiths. Others would file court cases and expect the process to be long enough that either the matter was dropped or the child would out-grow the requirements. Others would just simply move to a different location to avoid any requirements where they resided.

With modern technology, anti-vaccine groups and individuals are sharing information online on how to edit official documents like vaccine records to show to school officials. (Especially in the districts where there is no double-checking of immunization records presented by parents against medical or public health records.) In some places in the United States, parents are allowed to claim a personal belief exemption, but they are required to watch informational materials online to acknowledge being educated on the risks of not vaccinating. However, many parents in those places openly admit on social media to “tricking” the system by turning on the video online and walking away, or by getting a certificate of completion from a friend and editing it.

As long as there are laws, people will find a way to get around them. Think of how speed limits brought with them radar guns and radar detectors, then telephone apps to notify drivers of the locations of speed traps. Drinking laws created an entire industry of fake identification cards. And now, it seems, vaccine requirements are leading to creative ways to get around them instead of simply protecting children from infectious diseases.

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Author: René F. Najera, DrPH

I am the editor of the History of Vaccines site, an online project by the College of Physicians of Philadelphia. All opinions expressed on these blog posts are not necessarily those of the College or any of my employers. Check out my professional profile on LinkedIn: https://www.linkedin.com/in/renenajera Feel free to follow me on Twitter: @EpiRen

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