California’s Senate Bill 277: Local Health Jurisdictions’ Experiences With the Elimination of Nonmedical Vaccine Exemptions

Abstract

Objectives. To understand the experiences of local health jurisdictions with Senate Bill 277 (SB277), the California law that eliminated nonmedical vaccine exemptions for public- and private-school entry. Methods. We conducted semistructured telephone interviews with health officers and local health department (LHD) staff in California between August and September 2017. Results. Two overall themes emerged: (1) vague legislative and regulatory language led to variation in the interpretation and implementation of SB277, and (2) lack of centralized review of medical exemptions allowed medical exemptions that are not consistent with valid contraindications for immunizations to be accepted. Variation in the interpretation and implementation was commonly reported with provisions related to individualized education programs and special education, and independent study programs and homeschooling. Without a centralized review of medical exemption requests, respondents reported variation in the interpretation of which specialties of physicians can write medical exemptions, which conditions constitute a valid contraindication for immunization, and the process for reporting a questionable or suspicious medical exemption. Conclusions. The regulatory language within SB277 led to variation in how the law was interpreted and implemented within and across LHD jurisdictions and school districts.

Spatial Clustering of Vaccine Exemptions on the Risk of a Measles Outbreak

“…In California, lack of clear guidance on qualifying medical conditions, authority to grant medical exemptions, and which institutions, if any, bear responsibility for monitoring medical exemptions has likely contributed to the uneven increases in these exemptions across the state. 36,37 It is essential that those with the authority to grant or review exemptions be aware of the danger that spatial clustering of vaccine refusals presents for both infections in local communities and sustained transmission in the population. 38 Our results confirmed that spatial clustering of exemptions lead to underestimations of outbreak potential.…”

Trends in Homeschooling Rates Following Elimination of Nonmedical Exemptions to Childhood Immunizations, 2012-2020

“…In previous work, we found evidence to suggest that the law was variably interpreted, implemented, and enforced across school districts given vague regulatory language. 11,29 One study found that the number of students "overdue" for vaccination more than quadrupled 3 , suggesting that some parents were being allowed to enroll their children in brick-and-mortar schools despite being under-or unvaccinated.…”

“…Following the implementation of SB 277, data from the California Department of Public Health 9,10 showed that the law proved effective in increasing vaccine uptake with Kindergarten immunization rates increasing from 92.8% in 2015-16 to 95.1% in 2017-18. 11 There was a concern, however, that the law created an incentive for parents who could no longer obtain a nonmedical exemption to either substitute a medical exemption 12 or to homeschool their children in order to circumvent school entry immunization requirements (a new provision of SB277). 13 In fact, the medical exemption rate for Kindergarteners almost tripled between 2015-2016 and 2017-2018 11,14 ; when many of these were suspected of being fraudulent, the legislature passed Senate Bill No.…”

“…11 There was a concern, however, that the law created an incentive for parents who could no longer obtain a nonmedical exemption to either substitute a medical exemption 12 or to homeschool their children in order to circumvent school entry immunization requirements (a new provision of SB277). 13 In fact, the medical exemption rate for Kindergarteners almost tripled between 2015-2016 and 2017-2018 11,14 ; when many of these were suspected of being fraudulent, the legislature passed Senate Bill No. 276 in 2019 to strengthen the requirements to obtain a medical exemption.…”

Evaluation of Trends in Homeschooling Rates After Elimination of Nonmedical Exemptions to Childhood Immunizations in California, 2012-2020

“…After the implementation of SB 277, data from the California Department of Public Health 9,10 showed that the law proved effective in increasing vaccine uptake, with kindergarten immunization rates increasing from 92.8% in the 2015-2016 school year to 95.1% in the 2017-2018 school year. 11 However, investigators were concerned that the law created an incentive for parents who could no longer obtain a nonmedical exemption to either substitute a medical exemption 12 or to homeschool their children and thereby circumvent school entry immunization requirements (a new provision of SB 277). 13 In fact, the medical exemption rate for kindergarteners almost tripled from the 2015-2016 to 2017-2018 school years 11,14 ; when many of these exemptions were suspected of being fraudulent, the legislature passed Senate Bill No.…”