DR. BOB'S DAILY:
NAVIGATING THE NEW VACCINE LAW IN CALIFORNIA
So, everyone's freaking out and trying to figure out what to do. Calm down (but stay angry), take a deep breath, and realize two things up front: 1. This law won't apply to the majority of people currently involved in this fight - yet. Most will continue in school as is for many years (unless you leave now in protest). 2. The law allows for some families to continue to opt out of vaccines - forever.
Realize that this bill won't go into effect until the 2016/2017 school year. So there's nothing you need to do this year except submit a Personal Belief Exemption form. That's it. Oh, and try to get every Legislator who voted yes to lose his or her next election. And join every protest and meeting you can to make your voices heard.
Just wanted to get that out so you can calm down and think through the rest of this page. Yes, it all totally sucks, but it doesn't suck quite as bad as it could have. Here's what you need to know:
Parents who prefer to skip vaccines in whole or in part have several options to consider:
Continue in school without vaccines under the "grandfather" clause which allows children who are already enrolled to remain in school (see below). If this applies to you, you don't need to do anything except you must submit a Personal Belief Exemption form before the end of 2015 if you haven't in previous years. At this time, about 90% of current schoolchildren are grandfathered in for next year and won't be subject to this bill yet.
Continue in school as a "conditional entry," which means to obtain a written plan from the doctor that outlines when any missing vaccines will be completed, and gradually begin vaccines (see below for more details). You won't need to do this until next year.
Continue in school utilizing special education services since California is allowing children with special needs who qualify for an IEP to remain in school without vaccines (see below).
Go ahead and complete the required number of vaccines prior to entering daycare or school (see catch-up schedules below).
Homeschool the child.
Get a medical exemption starting NEXT year.
Understand your options
There are many children who will not be subject to the law and various circumstances (besides medical exemption) in which unvaccinated children will be allowed to continue in school.
First, understand the "grandfather" clause which allows unvaccinated children to remain in school until they reach a checkpoint year. These checkpoints typically occur when a child first enrolls in a new school (no matter what age), when a child reaches kindergarten, and when a child reaches 7th grade. For example: a child in second grade who doesn't have all the required vaccines at the time such a law goes into effect can continue to go to school through 6th grade without further vaccines. Upon enrollment into 7th grade, a child would need to either be caught up on all missing vaccines or at least begin to catch up on missing vaccines (called a conditional entry, see below). Another example: a teen enrolled in 7th grade or above will also not be subject to this bill as long as you don't change school districts. Preschoolers can continue without vaccines (if enrolled with a PBE this coming school year) until Kinder. If enrolled in a TK this coming year, and you stay in the same school after that, you are grandfathered.
Second, it is useful to note that states which mandate vaccines for daycare or school attendance can't actually mandate vaccination during infancy. The mandates are only enforced when a child is enrolled into a daycare or school. Families who prefer not to vaccinate during infancy do not need to do so; vaccines can be deferred until a later date as detailed in the section to follow (Vaccine Schedules to Meet Daycare and School Requirements).
Third, realize that the list of vaccines required for school is actually shorter than the number of vaccines on the CDC schedule. For example, in California only six out of the twelve vaccines are required: DTaP, Polio, Hib, Hep B, MMR, and Chickenpox. The other six vaccines are optional.
Fourth, some states (like California) allow what is called a "conditional" entry into school. This means that a child who hasn't met the vaccine requirements can still be enrolled as long as a plan to eventually complete vaccination is in place. Such cases would typically need a written letter from the child's doctor that outlines the plan. Children may be able to spread the required vaccines out over a few years and proceed gradually if the school is flexible. See the last section at the very end for more information. This option would apply to those who don't qualify for a medical exemption and have no other option.
Fifth, a concession made by the lawmakers in California is that children who qualify for an Individualized Education Plan (IEP) will not be subject to the mandatory vaccination law. This means that most children with special needs (mainly for intellectual impairments or learning disorders) will be allowed in school regardless of vaccine status. Certain laws were already in place which protect the rights of such kids to have equal access to education. This may not be the case in all states.
Medical exemptions to vaccination
The guidelines for providing medical exemptions are extremely broad in the new California law. Parents, physicians, legal experts, and some legislators fought to have the term "contraindication" removed from the guidelines, and succeeded. This means that is it up to the personal judgement of each physician and patient to work together to determine if a child qualifies for a medical exemption. The California bill declares that an exemption can be granted if "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 history, for which the physician does not recommend immunization . . ."
I recommend AGAINST seeking medical exemptions at this time because most people won't need one. The grandfathering clause and having an IEP are guarantees. A medical exemption can be challenged. You are much better off sticking to the law and following it's guidelines. I don't see any benefit in trying to secure a medical exemption right now years before you may need one. They are not going to take that right away. If they do, then all medical exemptions would be null and void regardless of when you got them. Getting one now wouldn't help you. I urge people to not overload the system with medical exemptions now. Wait until your grandfathering time has run out. Let those who really need one get one for the next school year.
Here are some of the circumstances which might prompt a doctor to grant a legitimate exemption for a child or family:
A child with a severe vaccine reaction already.
Siblings of a child who had a severe reaction.
Children of a parent who had a severe reaction.
More distant relatives with a severe reaction. Reactions that occur in grandparents, aunts and uncles, or cousins are less of a concern as the genetic risks are not as closely shared. However, parents can and should discuss this with their physician.
Current severe medical conditions or chronic conditions. Children with any chronic medical condition or temporary moderate to severe condition can discuss with a doctor whether or not that condition warrants temporary or permanent exemption.
Family history of severe medical conditions. There is a growing body of research which is finding a small link between vaccination and increased risk of autoimmune disease. Families with lupus, rheumatoid arthritis, celiac disease, fibromyalgia, multiple sclerosis, type I diabetes, and other autoimmune conditions can discuss exemptions. Families with neurodevelopmental or psychiatric conditions can also discuss this with their doctor. The greater the number of familial diseases, and the closer in the family they occur to the child in question, the more likely is the need to consider exemption.
Autism in the family. Despite the lack of published mainstream evidence of a connection between vaccines and autism, many families will consider seeking exemptions for a child with autism and the rest of their children. Autism in more distant relatives would be less of a concern for a baby but can be considered.
Other learning and behavioral disorders in the family. Disorders that are less severe than autism, such as ADHD, ODD, and others, are less of a concern but warrant consideration by families and their doctors.
Allergies in the family. This is perhaps one of the most common disorders for which families may try to get a medical exemption. If a family's challenges are significant, such as multiple close family members with asthma, eczema, and life-threatening food allergies, consideration for exemption could be valid. Yet, some may go a little overboard, such as having a second cousin with asthma, or having a child who is "sensitive" to sugar.
Genetic abnormalities in a family. There is a growing trend to perform genetic testing on families to evaluate current medical problems and to predict future health risks. Some have theorized that genetic defects that impair detoxification and antioxidant function in the body may increase the risk of severe vaccine reactions. It is important to know that no research has yet been done to determine if this is true. One particular gene variation which exists in most families with autism is called the MTHFR gene, and many such families believe this gene defect warrants medical exemption from vaccines. Until research supports this theory, this couldn't be used as a definite reason for exemption. Doctors certainly have the right to consider anything they want to. But I can't find any medical justification for this yet.
It is not my intention to claim that the above scenarios all deserve a medical exemption from vaccines. I simply list the most common reasons that patients have discussed with me and opinions that various colleagues have shared with me. This issue has not yet been sorted out by research.
In California, no specific form exists at this time; the exemption is simply a letter from the doctor. Parents will submit it to the school, and the school administrator will determine whether or not the letter meets the legal guidelines of the state. Since very few school administrators have the medical expertise to understand or contradict a medical doctor's opinion on this, it is likely that most such letters will be accepted. If the letter is not accepted, parents may attempt to enroll the child into another school where the school staff are more understanding. For example, standard public schools will likely be more strict than charter public schools or small private schools.
Bottom line, it is imperative that all families and doctors operate within the guidelines of the law and the standard of medical care. I would say that at this time there is no certain medical standard of care on this issue. That will evolve over time. We can all work together on this. There's no reason whatsoever to go outside of the law, no matter how angry you are.
Homeschooling
Home-based education was already becoming more popular before mandatory vaccination laws were introduced. Some families embrace this lifestyle, and many children and families thrive outside of standard educational systems. These new laws will prompt more families to make this choice.
Homeschoolers don't necessarily need to be isolated and educated alone one-on-one with a parent as a full-time teacher. Co-op programs, in which families group their children together for educational, social, athletic, and cultural experiences will become more popular. Parents won't be the only ones responsible for teaching; they can share duties with other parents, tutors, even private teachers, and such costs can be shared among many families. Parents should be able to work part-time outside the home if desire or needed.
I know we are all pissed. No one wants to homeschool against their wishes. But some may need to. You will meet many like-minded parents in your area who will be looking for the same thing you are.
Vaccine schedules to meet daycare and school requirements
Remember, parents who suddenly find themselves needing to register an unvaccinated or under-vaccinated child for daycare or preschool NEXT YEAR can begin school with a "conditional entry" as described above, and expanded on at the end of this piece. Kids don't need to wait until all doses are complete before they enter school.
Vaccinating to meet daycare or preschool requirements (in a previously-unvaccinated child):
4 DTaP
3 Polios
3 Hep B
1 Hib*
1 MMR
1 Cpox
*Note: only 1 HIB is needed for infants 15 months and older.
Also note: a 5th dose of DTaP and a 4th dose of Polio aren't needed as long as the last doses of each are given at 4 years of age and older.
This process would take about one year to complete. This schedule could be started at any age in preparation for daycare or preschool. The spacing between any of these doses can be prolonged without compromising effectiveness. If a child already had some vaccines during infancy, but then the process was halted, parents would cross each previously-administered vaccine off of the above list and simply begin the schedule with whatever is remaining.
Vaccinating to meet kindergarten requirements (in a previously-unvaccinated child):
4 DTaP
3 Polio
3 Hep B
1 HIB*
1 MMR
1 Cpox
*Note: HIB is only approved by the FDA to be given prior to a child's 5th birthday. If a child turns five before this school requirement is enforced, he or she won't need this vaccine.
**Note: For kindergarten, two doses of MMR and Chickenpox are normally required. However, for most children, one dose works well enough. Families who are trying to minimize the number of vaccines can get a blood test a few months after the first doses to see if they worked. If so, second doses wouldn't be needed. If the blood test shows the first dose failed, the second dose can be given at anytime thereafter.
Vaccinating to meet requirements for kids seven through eleven years (in a previously-unvaccinated child):
1 Tdap*
3 Hep B
3 Polio
1 MMR
1 Cpox
Note: Kids 7 years and older can't get DTaP, and they can't get a series of Tdap. Tdap is only approved as a single dose.
Vaccinating to meet requirements for teenagers and older (in a previously-unvaccinated child):
1 Tdap
3 Polio
1 MMR
1 Cpox
Notice that this is the smallest of all schedules. This is because some states, including California, do not require the Hep B vaccine for teens. Don't forget, a child will need a blood test to prove the MMR and Chickenpox vaccines worked, or get a second dose.
What can you do if you cant get any exemption but still don't want to vaccinate and can't home school and can't move?
Ultimately, some families will be SOL and will need to either move or work the system within the confines of the law. Here are some thoughts:
Homeschool during preschool and kindergarten since full vaccination isn't a consideration for you.
Explore the schools in the area to learn which are more friendly toward families who submit medical exemptions, as these schools are likely to also be more lenient with conditional entry plans (such as public charter schools or small private or religious schools).
Enroll the child into school around seven years of age with a conditional entry plan from the doctor which outlines a vaccine plan which will begin at some point in the near future.
When the school insists that the child begin following the conditional entry plan, do the first vaccine on the seven-year-old schedule above, which would be Tdap.
If the child has a moderate to severe reaction, discuss medical exemption from further vaccines with the doctor.
If no significant reaction occurs, which is very likely to be the case, wait until the school indicates it is time to continue the written plan and then do the first polio vaccine (just polio, not Hep B; see reasoning below). Continue slowly vaccinating as the school prompts you too. Remember, school officials are busy and may not have the time to keep on top of your child's plan. It's your responsibility as a parent to make sure you keep checking the vaccine plan so your child doesn't fall behind. If this process is drawn out until 7th grade, the child will not be required to get the Hep B series. You will need a blood test a few months after completion to make sure the MMR and Chickenpox vaccines worked.
At any point along the way, if the child catches chickenpox, be sure to have it documented with an in-person visit to the doctor (who will usually see the child outside the office to avoid spread of the disease). The vaccine will then not be needed. If repeated exposures to chickenpox have occurred, and the child has not caught chickenpox, a blood test to check immunity could be done in lieu of vaccination.
The child will eventually meet all the vaccination requirements (1 Tdap, 1 MMR, 3 Polios, and possibly 1 Chickenpox) and continue to remain in school.
I want to make it very clear that it is important to work within the guidelines of all rules and laws regarding vaccines and education. Work closely with school administrators and medical providers to find the best educational lifestyle for everyone involved.
WHAT SHOULD YOU DO RIGHT NOW?
If your child is grandfathered in, don't do anything at this time other than stay in the same school if possible. Be sure to get in a PBE form before 2015 ends. When the grandfathering time runs out (your child reaches kinder, 7th grade, or you have to change schools), make an appointment with a doctor to discuss other options.
Get your child into a school this year so you can be grandfathered in for at least a few years.
If your child has an IEP, don't do anything. Stay in school. Never let that IEP go. Your child can remain unvaccinated.
If you feel your child may qualify for a medical exemption, and is NOT grandfathered in, and does NOT have an IEP, make an appointment with a doctor to discuss a medical exemption. Please don't ask for one if your child has another way out at this time (grandfathered, IEP).
If none of these options are available, but you still are trying to opt out of vaccines, make an appointment to discuss a conditional vaccine plan that will at least get your child started in school.
Please try to limit your questions over the phone, as office staff can't do much to try to figure this out for you before your appointment. Save all your questions for your appointment.
Dr. Bob
