Now what? Will SB 277 enrich antivaccine doctors?

Undoubtedly some physicians will abuse the privilege, and we all know who some of them are.

The key is to make sure that school districts and day care centers understand that they can and should file complaints with the Board of Medical Examiners against physicians who provide unacceptably large numbers of medical exemptions and to make sure that the board takes action against those physicians when appropriate.

I am sure that, once it becomes clear that abusing the privilege will risk their licenses, most of them will either tow the line or leave the state. I just hope they stay away from New Jersey.

California's medical marihuana laws have already created a class of MDs who may very well be ready for a fee to hand out vaccine exemptions.

Exemptions may come from unexpected places, not just the boutique practices; lowlife physicians seeing the opportunity to expand their practices. Much like doctor-shopping for rx pain meds.

Just to clarify: physician discretion in medical exemptions existed before sb277.

Sb277 tinkered with the language to make it clear and added the medical history language, which I'm not sure would change anything and is very vague. But this is not a change in the law.

However, under pre sb277 the temptation to abuse was less because non medical exemptions were so easy to get. So the abuse issue really comes up more now (though Renee DiResta highlighted that medical exemptions increased some after AB2109 too).

I'm afraid that it's very likely that the family history language will be a huge "foot in the door" for antivaccine docs to justify medical exemptions, particularly given how vague it is. If that weren't the case, why would Dr. Jay be tap touting it so much and then tap dancing around answering questions asking him how he would specifically apply such a criterion?

Unfortunately, I made the mistake of reading Mike Adams' latest screed at Natural News:
"Governor Brown mandates a mass medical vaccine experiment on blacks ... ... brings back Tuskegee era medical crimes"

Of course, he makes much of the whistleblower's 'data' and imagines that further harm is done because exemptions like home schooling apply predominantly to white families.

Even more atrociously, he identifies the Bear flag as the new 'symbol of medical oppression of blacks' and THEN
does some artwork upon it ( if you hate his material to much to look, he has the bear eating a black child under crossed hypodermics - which I imagine is supposed to resemble a swastika or the image from 'The Wall' )

Oddly enough, it's posts like these that seem to get him the highest numbers, so I'll have to look later and see how he does this time. Vaccines/ fascism/ evil doctors are his winning set of topics.
'

So a child who receives a medical exemption from vaccination and therefore is not vaccinated will be allowed to attend school and spread preventable diseases? I hope the next measles or flu season shows how stupid this clause is and we see some kind of overview as is the case in West Virginia.

The loose language around medical exemptions makes me wonder why they anti-vaxxers bothered to raise such a fuss. Is making a doctor's appointment so much of an inconvenience?

I suspect the Sears/Gordon brigade will supply them over the phone for existing patients.

I wonder if medical exemptions will somehow mutate into a new physician-enabled form of philosophical exemption much as religious exemptions transformed into the same when those weren't allowed.
In other words, " I don't like vaccines so I'll dream up a religious or medical reason to avoid them"

My guess, the ME business will recommend: Get one vaccination for the first child, e g. the hepB shot after birth. File a free entry in the VAERS database - doesn't cost anything, isn't verified. Afterwards the MD can write exemptions for every kid in the family due to "documented history of adverse vaccination reaction in the immediate family".

Man, reading that twitter exchange makes my blood boil. Pretty clear Dr Gordon knows damn well that he is going to making a mockery of medical exemptions, all while sending bags of money to his personal accountant.

Explain to me again how only pro-vax doctors are all about the money?

The family history language may be abused. But then, there's nothing in the law that prevents abuse generally. It's just that the incentive wasn't there before. I expect we will see some people getting unjustified medical exemptions - but I'd be surprised if it will be as bad as the PBEs, because I do hope most doctors take their gatekeeping wrong seriously.

When it comes to docs like Dr. Jay and Dr. Bob, "gatekeeping wrong" is an apt description. :-)

I suspect the effect will be to concentrate those seeking boutique medical exemptions into a few compliant practices, such as Dr. Jay's and Dr'. Sears.

Of course, that increases the odds that the next index cases for outbreaks will be from one of a limited number of practices, and if we start seeing outbreaks consistently associated with patients in the same few practices I would hope the California Medical board would be moved to intervene. Dr. Sears already has one strike against him (the index case for the 2008 Claifornian measles outbreak).

I would interpret exemption based on family medical history as an acknowledgement of a genetic component to supposed risk, which is kind of contrary to the "it can't be genetic because my spouse and I have superior genes and so does our little snowflake" attitude.

It also seems to me that the language of section 120370 requires the physician document tthe basis for recommending the medical exemption, so should the board be moved to determine if a physician actually was complying with standard of care with resepct to exemption there'd be a convenient paper trail to consider.

I suppose this could be a double-edged sword for anti-vaccine doctors. On the one hand, they will have parents flocking to their practices requesting medical exemptions. On the other hand, this will mean they will have to blatantly invent medical diagnoses in healthy children in order to grant those exemptions. Hopefully they will think twice about doing so.

In slightly more cheerful news, at the staff meeting this morning our child care consultant nurse reported that she's already being contacted by local franchises to schedule flu shot clinics for staff AND parents.

We piloted the program last year -- having an RN and vaccines available at the child care center at key pickup times. I was dubious at first, but evidently we did enough business among parents to make it worth repeating.

Of course, this is not California.

Of course this system can and will be gamed. But it's an improvement over what was in place before.

I agree that the insurance companies are going to be the best check on abuses of medical exemptions. Paying for a vaccination is much less expensive than paying for treatment of a vaccine preventable disease, and they will come down like a ton of bricks on in-network physicians who are too blatant in helping parents game the system. It won't stop the sort of parent who can afford to pay out-of-pocket, as most of Dr. Gordon's and Dr.Sears's clients do. But it will help to limit the damage: the doctors who don't run boutique practices need patients with insurance coverage, so those doctors will document their reasons for granting medical exemptions, just to cover their own posteriors.

@Orac #13: Sigh. Gatekeeping role. Sorry, a little distracted these days.

I have a feeling that gatekeeper is likely to turn to gatecreeper, as the gate gets pushed to giving exemptions for such things as emotional trauma ('the child will be harmed by the trauma inflicted on the parent due to the worry about the damage a vaccine may cause', or some such nonsense)

@Pediatricians,

If I say I'm worried that natural rubber latex exposure will cause allergies, and the vaccine has a natural rubber latex warning, would you give my kids a medical exemption?

I've been wondering how much of an issue medical exemptions are going to be ever since Orac reported Dr. Bob's descent into full-Godwin antivax crazy: it occurred to me at the time that he may have been preemptively advertising himself as an antivax sympathetic doctor in order to drum up business writing bogus medical exemptions when and if SB277 passed.

On the one hand, just making exemptions harder to get reduces non-medical exemptions by over half, so SB277 will definitely increase vaccination rates. On the other hand, over-all vaccination rates were never the problem; the problem is opinion clusters creating areas where the rate is below the herd immunity threshold. If Drs. Jay and Bob are planning on rubber-stamping exemptions for anyone with a distant relative who had a low-grade fever following vaccination, some of the wealthier areas may be able to maintain their low vaccination rates. I guess we'll just have to see how it plays out.

If the child when presented has an existing diagnosis of allergy to natural latex, that would represent a valid medical exemption.

If the child is not known to be allergic to latex, I don't see how the fear they might develop such an allergy post vacination could be considered a valid reason for exemption.

I doubt that what Gordon tweets has an resemblance to what he actually does with his families and patients in the exam room. He does not have to disclose his vaccination rates for his practice (though Sears did in an LA Times article last year stating 50% of his patients were unvaccinated--horrible!), so Gordon can play his stupid "I'm a tweeting twit" game with us to his heart's content, knowing that whatever he says can't be verified, which is a shame.

#22: it goes without saying that a latex allergic child (or a child with spina bifida) should not be exposed to vaccines that could have latex allergens in them.

JGC say (#24),

I don’t see how the fear they might develop such an allergy post vacination could be considered a valid reason for exemption.

MjD say,

It is well known that repeated exposure to natural rubber latex dramatically increases allergy development.

@Pediatricians,

How many vaccines, having natural rubber latex warnings, can my child receive before developing allergies?

@MJD: first, prove to us that any vaccine has caused a latex allergy in ANY child.

MI Dawn, make sure MJD includes the PubMed indexed case report by someone else and not his own kid.

MjD in re comment 22 and 27:
Your questions reveal your gross ignorance of the subject of allergies. It seems like you're searching for an excuse for people not to vaccinate, because induced allergic reaction to latex is not a wide-spread documented side effect of vaccination. See acaai.org/allergies/types/latex-allergy which states that people at highest risk of latex allergies have occupational exposure to latex (i.e. work with it daily) or have had multiple surgeries, and concludes with "Hospitals and clinics that use only low protein latex gloves and non-latex gloves have experienced dramatic declines in new cases of latex allergy." No mention of vaccines, ever. As far as your highly worried follow-up questions, let me note that your modus operandi seems to be "just asking questions", which is not so fondly known as JAQing off. If you really want to know the answers to your questions, then go to reputable sources yourself (like I did) and read, or quit pretending you're actually open to new information that contradicts your tiring anti-vaccine mindset. You always seem to be "worried" in a direction that leads to woo and anti-vax nonsense. (The only reason I answered you is in the hope that other people don't take your so-called concerns and JAQing seriously.)

@MikeMa

The loose language around medical exemptions makes me wonder why they anti-vaxxers bothered to raise such a fuss. Is making a doctor’s appointment so much of an inconvenience?

Yes. Yes it is. Just look at the hue and cry they made over AB2109, which only required them to get information from a health care provider on the benefits and risks of vaccines and the diseases they prevent. Hell, I'd be willing to bet that they would have raised a huge stink if the only thing that happened was going from zero requirements to required vaccines but with easy to get PBEs (where all you have to do is fill out a form and send it with your kid).

MJD, your evidence that, at exposure levels achievable by routine childhood vaccination, natural latex rubber results in allergy would be...what, exactly? Be specific.

I mean, you do have some? Your concern does take some other form than "Oooooh--latex! Scary stuff!", right?

MJD, how is exposure to latex in vaccines any greater than exposure a young child would get from wearing diapers, using nipples on bottles, chewing on teething toys, playing with toys, elastic in clothing, erasers or any of the other myriad latex containing things in day to day existence for children?

For whatever it is worth

Latex in Vaccine Packaging
“
If a person reports a severe (anaphylactic) allergy to latex, vaccines supplied in vials or syringes that contain natural rubber, or whose product information does not say “not made with natural rubber latex”should not be administered unless the benefit of vaccination outweighs the risk for a potential
allergic reaction. In these cases, providers should be prepared to treat patients who are having an allergic reaction.
For latex allergies other than anaphylactic allergies (e.g., a history of contact allergy to latex gloves),vaccines supplied in vials or syringes that contain dry natural rubber or rubber latex may be administered.(ACIP General Recommendations on Immunization. 2011)

The following table is accurate, to the best of our knowledge, as of July 2014
http://latexallergyresources.org/sites/default/files/article-attachment…

2014-15 Flu Vaccine Information
September 1, 2014
It's time to get prepared for the Flu Season!
2014 – 2015 Flu Vaccine Information

It’s nearly flu season again and time to start thinking about flu vaccines. Each year, we receive several queries about the latex content of the available vaccines. The 2014-2015 flu vaccine includes an A/California/7/2009 (H1N1)pdm09-like virus, an A/Texas/50/2012 (H3N2)-like virus, an A/California/7/2009 (H1N1)pdm09-like virus, an A/Texas/50/2012 (H3N2)-like virus. The information below was obtained from the manufacturers, and although it is accurate to the best of our knowledge, it should not be relied upon instead of your own research or advice from your physician. If in doubt, please check with the manufacturer.
- See more at: http://latexallergyresources.org/news/2014-15-flu-vaccine-information#s…
If in doubt, check the
package insert for the vaccine in question.

Thanks Roger, I have certainly seen those warnings when I get flu shots each year, but still want to hear from MJD. He seems concerned that repeated exposure through vaccines could cause latex allergy, but he does not say whether he is concerned about all the other latex a child might be exposed to far more often than just getting a vaccine from a syringe made from latex.

@Kochanski: MJD has a bee in his bonnet about latex, and yes, he is concerned about all latex if you read his multiple screeds, but since this is vaccines, he asks about that. (If you read his story, his son had a severe asthma attack, NOT an anaphylactic attack. Not that those aren't scary, but his vaccines did not cause the problem - party balloons did.)

Yes, MJD is obsessed with latex. Whenever he shows up, which he does periodically, all he does is to repeatedly go on and on about latex allergies and vaccines. It's best to ignore him when possible, because he never changes and nothing ever changes his mind.

Epigenetics? Wasn't he a contemporary of Plato's?

It would seem to me that Dr. Bob had better figure out what to do if one of his "exemptions" spreads the measles to a few more people and those twitters are still around.

I understand that the USA is very litigious. Would his med insurance company stand behind him?

If the child is not known to be allergic to latex, I don’t see how the fear they might develop such an allergy post vacination could be considered a valid reason for exemption.

And just when does one realize the 'allergic to latex', JGC #24? Latex allergy follows a pattern of *asymptomatic sensitization* with repeated exposure. One may not know how far along the gilded, immunoresponsive path they are on before they pull a *Buddy Ebsen*. I'd guess that intrusive exposure is the most likely time (IMHO) for it to reveal itself.
-----------------------------

Are you sure it's not a 'Gish Gallop', JerryA #30?

To Tim in comment 122:
I’m willing to be corrected on microwave skin penetration depth- you’re right that cellphone radiation does not go much deeper than the skin (which weakens your case, actually). However, I noticed that you’re not willing to be corrected on… pretty much anything. You’re just doubling down, throwing out yet more semi-plausible sounding hypotheses while not admitting your previous ideas were dead wrong. (That’s called the Gish Gallop)

They were all 'dead wrong'? Don't miss the punchline:

http://phys.org/news/2015-04-electromagnetism-enable-antennas-chip.html

...Now, what was I saying about ‘wires’ again?? oh yea:

… If the protoplasm can be considered a dielectric within these small scales then the coiled molecule might constitute an ‘antenna’

… It is a discontinuity within a dielectric.

… An antenna-dimensioned discontinuity within a dielectric can, in some ways, appear as a tuned antenna.
#64, #101, #135;
Neener. Neener.
http://phys.org/news/2015-04-electromagnetism-enable-antennas-chip.html

http://scienceblogs.com/insolence/2015/03/19/the-new-york-times-and-fea…

Yvette@17

On the other hand, this will mean they will have to blatantly invent medical diagnoses in healthy children in order to grant those exemptions. Hopefully they will think twice about doing so.

It certainly seems to up the risk level for them. Even if it isn't so much inventing diagnoses as it is making up new cintraindications (not sure about California but in Illinois where I live our department of public health has a guide to vaccine contraindications) I'd imagine that needing to take an active role opens the doctors up to more liability.

Ohh! Not the blockquote and link fail 'punchline':

… However, this theory becomes problematic when dealing with radio wave emission from a dielectric solid, a material which normally acts as an insulator, meaning that electrons are not free to move around. Despite this, dielectric resonators are already used as antennas in mobile phones, for example.

http://scienceblogs.com/insolence/2015/03/19/the-new-york-times-and-fea…

Jay Gordon, MD, FAAP @JayGordonMDFAAP wrote:

@davidjuurlink @gorskon An adverse reaction to previous vaccine in patient or sibling is one good example.

Cash in hand would be another.

Uh, Tim @39: most of your comment is unrelated to the topic of conversation. And can you give us peer-reviewed journal articles that the latex on a vaccine bottle can *cause* sensitivity? No one denies if a person is already sensitized that they should not be exposed.

Orac writes (#37),

...he never changes and nothing ever changes his mind.

MJD says,

The FDA has reinforced my concerns for natural rubber latex in vaccines.

http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm342641.htm

@Konchaski (#33, 35),

The FDA and CDC can only do so much to warn about unnecessary exposure to natural rubber latex in consumer products (e.g., vaccines). Ignoring its hazard is an ignorant "blind trust".

Michael J. Dochniak@22:

@Pediatricians,

If I say I’m worried that natural rubber latex exposure will cause allergies, and the vaccine has a natural rubber latex warning, would you give my kids a medical exemption?

Hopefully a good pediatrician would suggest you get a psych evaluation, as what you've got there sounds suspiciously like what the head doctors would call a "fixed delusion", and those things are not much fun for anyone.

Latex allergy follows a pattern of *asymptomatic sensitization* with repeated exposure.

Tim, I'll ask you the same question i asked MJD: do you have any evidence that latex exposure as a consequence of routine vaccination is causally associated with increased risk of developing an allergiy to latex? or are you also falling back on nothing other than "Latex--scary stuff!"?

The FDA has reinforced my concerns for natural rubber latex in vaccines.

Not at the link you provided, they haven't: it's make no mention of a causal association ebtween routine childhood vaccination and risk of developing an alergy to latex.

do you have any evidence that latex exposure as a consequence of routine vaccination is causally associated with increased risk of developing an allergiy to latex?

I surmize that everyone is 'allergic' to latex... It is just a matter of to what degree each exposure brings one closer to the tipping point -- Ask my monocytes what evidence they have that I've finally screwed the pooch too many times with something other than sheepskin condoms.

What do you get when the natural rubber latex proteins associate with aluminum hydroxide (immunologic adjutant) in vaccines?

A antigen-adjutant complex that becomes more susceptible to immune recognition.

Aluminum hydroxide is used to remove the proteins in natural rubber latex. See U.S. Pat # 8,048,951 (Doyle et al.)

@JGC (#46),

it’s make no mention of a causal association ebtween routine childhood vaccination and risk of developing an alergy to latex.

MjD say,

In my opinion, the FDA is giving vaccine manufacturers some time to replace natural rubber latex. It's no secret...

@ MJD

A antigen-adjutant complex that becomes more susceptible to immune recognition.

Immune recognition does't equate with allergy formation, MJD. Actually, most of the stuff our immune system encounters end up being treated as bits of invading bugs, not as whatever should be treated by an allergy reaction.
Pathogen proteins injected with the vaccine are also bound to the aluminium hydorxide, and usually don't create allergies.
From the little I remember from my immunology lessons, a strong reaction to an antigen is actually less likely to lead to allergy. Aluminium hydroxide may reduce the risk of getting an allergy rather than increasing it.

--------------------------------------
Trying to be back on topic...

@ doug #15

kind of contrary to the “it can’t be genetic because my spouse and I have superior genes and so does our little snowflake” attitude.

Unfortunately, "our child is so sensitive to chemicalz" is a much approved alternative attitude, already seen at work now and then with the "one-size-fit-all vaccine schedule" and "personalized approach" battle cry.
In this context, genetics are a badge of honor.

In my opinion, the FDA is giving vaccine manufacturers some time to replace natural rubber latex. It’s no secret…

What evidence does your opinion derive from? If it is in fact 'no secret' you should have no trouble producing some. Again, be specific.

JGC says (#50),

What evidence does your opinion derive from? If it is in fact ‘no secret’ you should have no trouble producing some. Again, be specific.

MjD says,

http://latexallergyresources.org/fda-warns-latex-reactions-flu-vaccines

Helianthus says (#49),

From the little I remember from my immunology lessons, a strong reaction to an antigen is actually less likely to lead to allergy.

MjD sites,

http://www.nature.com/icb/journal/v82/n5/full/icb200475a.html

Michael, the FDA warning addressed people who areknown to be allergic to latex, therefore might have a reaction to flu vaccine vials which incorporate natural latex tips, and tehrefore would not be sutibale candidates to receive those vaccines. That's entirely consistent with my post @24.

What the FDA has not indicated is that exposure to latex as a consequence of routine vaccination conveys any signficant risk of developing a altex allergies. In the absence of evidence of such a causal association fear that your child might develop a latex allergy post vaccination does not represent a valid basis for assigning a medical exemption.

Any Californians forced to home school because of SB277 might want to look into this scholarship:
https://www.aophomeschooling.com/blog/aop-offers-scholarship-for-homesc…

Once again, a one trick pony....

http://americanloons.blogspot.com/2013/07/628-michael-j-dochniak-denise…

In the absence of evidence of such a causal association fear that your child might develop a latex allergy post vaccination does not represent a valid basis for assigning a medical exemption.

Just wait until the secret peanut-oil adjuvant crazies start demanding exemptions (here's looking at you, Hayes).

JGC repeats (#53),

In the absence of evidence of such a causal association fear that your child might develop a latex allergy post vaccination does not represent a valid basis for assigning a medical exemption.

MjD says,

It is well known that the numerous proteins in natural rubber latex have structure homology to many food proteins.

Thus, adverse immune responses (i.e., cross reactivity) based on structure homology conveys a significant risk.

@Pediatricians,

If my child has food allergies, and the vaccine has a natural rubber latex warning, would you give my kid a medical exemption?

Given the "waning" factor of many (if not all) vaccines, isn't the only reliable method to PROVE student immunity, a titer test?
Shouldn't all parents of school age children ask for a titer test BEFORE vaccinating? After all, it was only after the measles vaccine proved to be "waning" that a "booster" was added to the schedule. ORIGINALLY, ONLY ONE SHOT WAS SUPPOSED TO BE NECESSARY. Are the school booster jabs offered at HALF PRICE?
"Epidemiologic Basis for Eradication of Measles in 1967” (CDC)
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1919891/pdf/pubhealthrepori…
http://cmr.asm.org/content/8/2/260.full.pdf

"Is the mumps vaccine effective?
Yes, despite my earlier concerns that the vaccine may have been ineffective, it appears that the best possible way to be protected remains receiving 2 DOSES of vaccine. However, the vaccine does not always “take” and since there is a “wear“ off” phenomenon, this allows for even VACCINATED individuals to CONTRACT the mumps.

Children who have been given a dose of MMR at age 1 and again at age 4 SEEM to be protected in the vast majority of cases up until around age 12.

Beyond age 12 (including adults) IMMUNITY SEEMS TO WEAR OFF to levels that are NOT PROTECTIVE in a significant percentage of individuals. "
http://crownheights.info/psa/24436/mumps-virus-alert-dr-rosen-addresses…

"Two former Merck & Co Inc scientists accusing the drugmaker of falsifying tests of its exclusive mumps vaccine said in a court filing on Monday that Merck is refusing to respond to questions about the efficacy of the vaccine."
http://www.reuters.com/article/2015/06/04/health-vaccine-idUSL1N0YQ0W82…

Mr. Dochniak: Give it a rest with your crank idea, at least for a while. I'm just not in the mood today.

Everyone else: What did I just say about not feeding the troll? :-)

Thanks.

THE STATUTE:"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,"

ANALYSIS

IMHO key words are "physical condition" which is decidely NOT momma's anxieties and false cognitions and "medical circumstance" which is very broad but nevertheless refers to something which is "medical" as pertains to the patient - not phobias on the part of the parent. ..

"relating to the patient" and it says "the" patient, not patients in general" or"speshul snowflakes worried about theoretical unverified allergies".

Generalized suspicion of the vax schedule does not meet this test . It must be a medical issue with that particular patient, not a philosophy or belief system on the part of the clinician or parent.

The physiican must write out and thus stake her/his rep on a statement

"indicating the specific nature and probable duration of the medical condition or circumstances".

Operative term is "specific".

In sum, I think that there is some deliberate ambiguity written in to allow this thing to get passed. Dr Bob types will exploit that ambiguity. Any one persons might file a lawsuit alleging challenging exemptions, but a more likely scenario is that the vast majority of clinicians will not want to attract contempt from their colleagues and only a few disreputable pediatricians or GP's will cater to the antivaccine crowd.

General public shaming of the free riders may be more powerful than any litigation or any action by the licensing board.

Social media and blogs, great places for people to refine their arguments. Give it a few days and I'm sure BJ (Bob and Jay) will find their groove that will allow them to defend their actions and bring them mucho extra patients and exposure in the AV world.
Again, rather than looking at the evidence and the law (especially wrt to the spirit of the law), they will be seeking the cherries wherever they can to justify their actions.
Moral cowards at the very least.

There is no doubt that the likes of Sears and Gordon will exploit the wording to do what the parents' of their patients want. They have made a career out of telling rich parents what they want to hear, so why should there be any expectation they would change now. After all ka-ching, ka-ching, ka-ching has been the overriding factor in their business models.

What is good about this bill is that parents will now have to seek out a medical practitioner to get their exemption. For some the effort, as opposed to getting a PBE form from their chiropractor, will be a step to far and may decide that vaccinating their children is the lesser of two evils.

I was hugely surprised, but delighted, when first the Legislature passed SB277 without gutting it to pacify the antivax know-nothings who protested (but perhaps the fact that some of the legislators got death threats for supporting the bill gave others a reason to think that the opposition was less scientific than terroristic); and even more surprised and delighted that Gov. Brown signed it without weasel-wording it. I'd have liked a WVa-type section on Health Department review of exemption approvals, but perhaps the sponsors of the bill thought that it would have compromised the chance of passage.
Surely some quacks will sell their signatures on medical exemptions, and that will be a problem (as it is in disability claims, for example) - but I think that most doctors will do the right thing and limit exemptions to those that are truly justified, and practice groups (HMOs like Kaiser and the big clinics that support them, like Sutter Health) are likely to keep an eye on their physicians and pressure them not to give dubious exemptions. Also, it may be that the CA Department of Health can, within the context of the law, establish procedures to keep some sort of handle on exemption claims.
And, whatever happens, SB277 beats what preceded it.

#61
"General public shaming of the free riders..."
https://www.youtube.com/watch?v=K-hb2mX8YEc
Are these the ones of which you speak?
http://www.timesofisrael.com/measles-vaccine-developer-warns-jewish-ant…

Revenge of the CALIFORNIA 100+...
Calling all Disney Measlescateers. The Creator has blessed those who briefly suffered from a bout with the measles. You now have a STRONG LIFELONG IMMUNITY, unlike your cowardly pro-vaxxers. Have your child's titer tested and DEMAND a measles vaccine exemption.
http://drtenpenny.com/titer-tests/

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,”

Note that this is not an "and" statement, but an "or" statement. You also left something important:

...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...

So either a physical condition or "medical circumstances" can be used to justify an exemption, and those "medical circumstances" can include family history. That's a loophole big enough to steer an aircraft carrier through. Antivaxers have all sorts of fantasy "specific" conditions that, or so they claim, make vaccination contraindicated, and the duration will be easy: Life.

@Toto (#66):
"Dr. " (scare quotes not because she isn't an MD, but because she's an antivaxer) Tenpenny is no doubt going to make a pretty penny from the referrals from people who click over from her site to those who order the vaccine titer tests. Hardly the best recommendation.
The Creator (whoever that is) may have blessed some of those who had measles with immunity (STRONG and LIFELONG are uncertain), but it has also "blessed" some of those who had measles with such lovely complications as ear infections (1 in 10 children, some with permanent hearing loss), pneumonia (1 out of 20), encephalitis (1 out of 1000), and of course STRONG LIFELONG DEATH (1 or 2 per 1000).
Don't be a f**king idiot!

As long as we are on the subject of epigenetics and autism,I would like to call your attention to two blogs.Read the older one here first.Then follow over here if you are interested.

This is the work of a woman named Jill Escher.Ms.Escher is the mother of two children with severe autism.She believes the increase in autism,ADHD,etc is very real,but has nothing to do with vaccines.Based on the records Ms. Escher has from her own mother while her mother was carrying her,she believes the increase in autism in the 21st Century,is due to epigenetic changes brought on by drugs pregnant women were taking in the 1950s and 60s,when the grandmothers of today's kids were in the womb.Her newer blog collects case histories of families.

Does anybody here think this woman is onto something,or is she just full of it?

What is it about anti-vaccine and anti-Semitism? Are there more anti-Semites among the anti-vaccine population? Or are they just more revolting?

Toto "the Troll" seems to be a perfect illustration of what incredibly obnoxious and bigotted people anti-vaccine people can be.

I said something like this in the comments of another post, but it is apropos here - if within six months we aren't seeing sleazy advertising from doctors offering "easy" access to medical exemptions, I'll eat my hat.

Toto @ 66
This one's for you

Just today, Dr. Jay asked why some of his patients are testing negative for mumps titers. When asked about the context of his question, he flat-out told us (myself and a group of pediatricians) that he is doing titers on children instead of the second dose of MMR. When pressed by the pediatricians on why, he said it was good medical practice. They then asked him to show where in the guidances (CDC, AAP, etc.) it states that doing titers instead of the second MMR is accepted practice. He hasn't responded.

Or, if he did, he decided not to include me on the conversation anymore.

I'm in Colombia for a bit. I've been here a week. When I told some of the people at the local university about this bill, and about the anti-vaccine people, they laughed. They said that at least people here in Colombia who are anti-vaccine have an excuse. They either are illiterate or had no education. Or they live in places where the government is not trusted as part of the ongoing civil war. Very, very few are like American antivaxxers. Very few are like Jay and Bob, who should know better.

Since I know Dr. Jay reads this blog, perhaps he can drop in and tell us where in the pediatric recommendations it is good medical practice to do titers instead of the second MMR.

Reading some antivax comments, it's funny how they keep conflating the parents and their children.
Pediatrician whose patients are the parents, not the children. Parents who are all about freedom, except that their children have none. It's the children who got sick (and sometimes die), but it's the parents which were blessed, or something...

@Ren (#73):
I was listening to, I think, NPR one day a week or three ago - the car radio is usually on when I'm driving, and someone was talking about vaccination in Mexico. If I recall it right, vaccination is free to all and uptake is nearly 100%: the idea of antivax is treated with the scorn it deserves. Colombia sounds similar.
How is it that our fair country can be so dumb?

@Helianthus (#74):
Haven't you heard that leading libertarian Rand Paul: "The government doesn't own our children. Parents own their children" (or something close to that)?

@Roger Kulp #69: I think she's full of it. The case histories don't contain any really useful data from either a medical history or even a historiographical sense to indicate that anything in particular is causative for autism. Just because autism is heritable doesn't mean drugs used during a certain time frame made it any more or less likely that a child would be autistic, much less a grand child. In at least one case, the child didn't have autism but did have other birth defects, and then the grand kid ended up with autism. Saying one caused the other is a stretch without any real evidence to support it.

http://m.youtube.com/watch?v=5wBTdfAkqGU

Since I know Dr. Jay reads this blog, perhaps he can drop in and tell us where in the pediatric recommendations it is good medical practice to do titers instead of the second MMR.

What does a doctor charge for providing a 2nd dose of MMR?

What does a doctor charge for checking titers, and then having the patient come back for another office visit to discuss the results, and maybe or maybe not providing a 2nd dose of MMR?

Would the delta, multiplied by the number of patients, make a payment or two on a Lamborghini?

Because, hey, I'm just asking questions.

Titers? Really?!

I've been immunized against rubella at least 5 times. My Titers were drawn when I was pregnant. I don't seroconvert. Have been exposed multiple times during childhood and subsequent work in developing countries and never caught rubella. I can't believe Jay is doing that. Actually, yes I can.

Mr Woo of course dissolved into fits of "religious persecution! they are coming for us next!" at this...

I suspect that there are people everywhere motivated to avoid regulations, and one like this more than most. I have to almost feel "played" by the likes of Drs. Bob and Jay in an ironic twist...

I had started to address MjD, but remembered our blinky box's instructions to abstain from troll feeding... MjD is at least memorable with his solitary fixation...

MjD is at least memorable with his solitary fixation…

That, and some really bad poetry.

#80
"I’ve been immunized against rubella at least 5 times. My Titers were drawn when I was pregnant. I don’t seroconvert. Have been exposed multiple times during childhood and subsequent work in developing countries and never caught rubella."

Oh, but isn't that what the FDA uses to measure the effectiveness of a vaccine? 95%? Talk about QUACKERY. LOL!

I can’t believe Jay is doing that. Actually, yes I can.

The old ka-ching, ka-ching, ka-ching business model again.

#70
I'm all ears...WOOF!
Please answer your questions with documented evidence. Thanks!
My furry friend Aslan has a word for you......
https://www.youtube.com/watch?v=zgl4tqw2OKs

#72
I'm sorry, but the science is already SETTLED.

3 OUT OF 3 CDC doctors agree:
"The clinical disease (measles) is a characteristic syndrome of notable constancy and only moderate severity. Complications are infrequent, and with adequate medical care, fatality is rare. Susceptibility to the disease after the waning of MATERNAL IMMUNITY is universal; immunity following recovery is solid and LIFELONG in duration. (NOTE: Newborns were immune)
..essentially all children experience the infection some time before adolescence."
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1919891/pdf/pubhealthrepori…
Mercury poisoning is not a benefit.

#77
"Saying one caused the other is a stretch without any real evidence to support it."

1999 CDC Thimerosal safety report by Dr. Verstraeten
http://www.ashotoftruth.org/sites/default/files/exhibit_22_-_verstraete…

After 10 years, this CDC FOIA requested document was released in Feb. 2014 by court order: The above link is now dead. This is what I transcribed while it was still working:
“FILE 10 25 of 334
“Verstraeten, Thomas M, MD, NIP, Division of Epidemiology and Surveillance, Vaccine Safety and Development Branch, Mailstop E-61, 770-639-8327.
EIS Class Year of Entry: 1999…”

“Thomas M. Verstraeten, R. Davies, D. Gu, F. DeStefano” (note: same Dr. DeStefano who co-authored Thompson’s claimed to be fraudulent 2004 paper)

“Increased risk of developmental neurologic impairment after high exposure to thimerosal-containing vaccine in first month of life…”

“Results: ….The relative risk of developing a neurologic development disorder was 1.8 (95% confidence intervals…) when comparing the highest exposure group at 1 month of age (cumulative dose greater than 25 micrograms) to the unexposed group. Within this group we also found an elevated risk for the following disorders: autism (RR 7.6…), non-organic sleep disorders (RR 5.0 …), and speech disorders (RR 2.1…).”

"What does a doctor charge for providing a 2nd dose of MMR?"

The real question is what does Merck charge the government for up to THREE MMR jabs, when the original SETTLED SCIENCE said only ONE (measles) dose for LIFELONG IMMUNITY?

"The availability of potent and effective measles vaccines, which have been tested extensively over the past 4 years, provides the basis for the eradication of measles in any community that will raise its immune thresholds to readily attainable levels. Effective use of these vaccines during the coming winter and spring should insure the eradication of measles from the United States in 1967."
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1919891/pdf/pubhealthrepori…

Delphine: "I can’t believe Jay is doing that. Actually, yes I can."

ChrisP: "The old ka-ching, ka-ching, ka-ching business model again"

Exactly. Especially since Dr. Jay does not accept insurance. I would not say it is a "Cash Only" practice because I guess he does accept all major credit cards.

Johnny (the only one to trust): "That, and some really bad poetry."

So he is a Vogon?

(So I did a Google to make sure I had the spelling correct, and what to I find... that there are several Vogon poetry generators)

So he is a Vogon?

See, e.g., (real) Johnny's comment here.

(So I did a Google to make sure I had the spelling correct, and what to I find… that there are several Vogon poetry generators)

If you would like some pointers toward good poetry, you know who to ask. ;)

Narad: "See, e.g., (real) Johnny’s comment here."

I was there... I was there before Photon in the Darkness went dark! Forgive me for not thinking of the Vogon references a few months ago when I was in the depths trying to get my adult child a viable diagnosis. Like Prometheus I am dealing with a real person who needs services (which for those who are just tuning is is one reason why his very excellent blog may be only available on the Wayback Machine, though thankfully SkepdicDad is still paying the bills that had my online musings).

Jim Carrey has spoken out against SB 277. He doesn't even need to say this stuff anymore to keep the peace at home with Jenny. That's Wahlberg's problem now.

I really thought Carrey had abandoned the "vaccines = bad" mantra when he split up with Jenny. I guess he was brainwashed by her and it hasn't worn off yet.

“California Gov says yes to poisoning more children with mercury and aluminum in manditory (sic) vaccines,” Carrey wrote. “This corporate fascist must be stopped. They say mercury in fish is dangerous but forcing all of our children to be injected with mercury in thimerosol is no risk. Make sense? I am not anti-vaccine. I am anti-thimerosal, anti-mercury. They have taken some of the mercury laden thimerosal out of vaccines. NOT ALL! The CDC can’t solve a problem they helped start. It’s too risky to admit they have been wrong about mercury/thimerasol. They are corrupt. Go to traceamounts.com watch the documentary and judge for yourselves. If you really care about the kids you will. It’s shocking!”

http://www.montrealgazette.com/news/world/Carrey+denounces+mandatory+va…

"though thankfully SkepdicDad is still paying the bills that had my online musings)."

Though the Google algorithms do not like those words, but it is: skepticdad.wordpress.com/. Notice as the updates diminish after major surgery during n a visit to a Midwestern medical mecca. Funny how that works.

"It’s full of outraged antivaccine activists shouting about how Gov. Brown “has blood on his hands,” how his entire legacy will be defined by this single act of signing SB 277 (really, they do have a vastly inflated view of their own importance), and rants about medical tyranny and how there will now be armed revolution."
A prophecy:
http://www.naturalblaze.com/2015/07/murdered-3rd-alternative-prominent…

Roger #69

You will be well familiar with all the reasons why autism has been recognised far more since the '80s than it ever was before.

Comparisons with previous generations are fraught with difficulties as there will not be accurate information about prevalence of developmental issues, especially at the higher functioning end of the spectrum.

Some of those blog posts also appear to conflate a number of different conditions, then leap off into maybe autism.

I'm not at all sure she is on to anything: too much reads like someone who has a bee in their bonnet and is trying to make history fir their narrative.

Thus, adverse immune responses (i.e., cross reactivity) based on structure homology conveys a significant risk

Show your math, Michael: how have you calculated the excess risk of developing alergies to latex proteins associated with routine childhood vaccination, from what dataset, and what p-value do you obtain?

Oops--sorry. Didn't see the "Don't feed the trolls" post.

JIm Carrey's proclivities for woo extend beyond vaccination. There is a video of Carrey that went viral a few years ago of him speaking at a university's graduation commencement. It was the Maharishi University of Management which is essentially an Ayurvedic based program.

https://www.youtube.com/watch?v=V80-gPkpH6M

It's actually a pretty good speech where he makes some pretty astute points. Too bad the context it was in...

Ayurvedic management?
What do they do drip warm oil on balance sheets?

"Ayurvedic management?
What do they do drip warm oil on balance sheets?"

They call it 'consciousness based education. I didn't realize that my schooling was all accomplished while I was unconscious...

https://www.mum.edu/

"Since I know Dr. Jay reads this blog, perhaps he can drop in and tell us where in the pediatric recommendations it is good medical practice to do titers instead of the second MMR."

Well, it's good for the bottom line of this lab:

https://www.accesalabs.com/titers?gclid=CNDx4aXlvMYCFUGRHwod0mMMIQ

Not only do they do testing of antibody titers for mumps and other viral diseases, they have loads of nifty tests that should clarify most everything that could possibly ail you - including Candida IgG antibody testing (listed under "Toxins"), a urine test to detect leaky gut, and the Platinum version of ALCAT food sensitivity testing (for only $999 - you're sure to be sensitive to something!

Wonder what arrangement Jay Gordon has for getting mumps titer testing done and who's paying the freight.

Murmur @98
I am one of those previous generations of autistics.I seem to tell parts of my story quite a bit.My autism was severe enough to be diagnosed the first time in 1971,under the DSM-II.I had many serious developmental and learning disabilities and far more medical problems than most autism families could ever dream of.I am in my 50s,and I have survived a number of close brushes with death to get here.

I have never worked,and I lived with my mother right up until she died.I had to drag her half naked body out to the ambulance as she was dying of a stroke.I know all too how autistics were treated back in the day.The lack of proper educational support,the ignorance of the medical problems,the "refrigerator mother" garbage and all the rest.I lived it.

I was verbal,low functioning,with many behavioral issues.My mother was unique in that she refused to put me in an institution or group home,in spite of the insistence of school psychologists,doctors,teachers,police,etc.But before the mid to late 1980s,most parents were not like my mother.I think one big reason the antivaccine movement was able to get established in the first place,was because older generations of more severely disabled autistics are hidden from the public,and still are.Would Andrew Wakefield have even undertook his study of deceit and fraud if the millions or hundreds of thousands of more seriously disabled older autistics had not been shut away in group homes,nursing homes,or other institutions? Who can say,but I think the way we see autism would be very different today had they not.

In the last six years,I have been piling up medical diagnoses.Many are diagnoses that were not known to exist when I was growing up.Inborn errors of metabolism,cerebral folate deficiency,diagnosed by blood tests at SUNY Downstate not by spinal tap,mitochondrial disease.The dramatic reversal of my autism,at my age,by treating my metabolic disease has stunned several top neurometabolic specialists,at major hospitals.

Seeing these doctors has been kind of awkward at first.I have become an accidental trail blazer.Their programs and departments are set up for children.Most of their patients are preschoolers.I am the only adult.It gets back to what I was saying.I believe if the more severely disabled autistics had lived at home with family all their lives,and had eventually been able to get medical care like I had,the Anne Daschels,Sherry Tenpennys,and the legions of internet trolls that support them,may have been little more than a brief blip on the cultural radar,if their movement could have even gotten started in the first place.I firmly believe the legacy of the way autistics were treated in the 1940s-early 80s is as much to blame for the antivax movement as Andrew Wakefield.

#80
“I’ve been immunized against rubella at least 5 times. My Titers were drawn when I was pregnant. I don’t seroconvert. Have been exposed multiple times during childhood and subsequent work in developing countries and never caught rubella.”

Oh, but isn’t that what the FDA uses to measure the effectiveness of a vaccine? 95%? Talk about QUACKERY. LOL!

Hold the line, Toto.

" I didn’t realize that my schooling was all accomplished while I was unconscious…"

I must confess that a certain amount of my schooling was accomplished while I was semi-conscious.

Delphine, the head of our WIC program is in the same boat. Since she is around small children on a daily basis, I can only keep my fingers crossed and hope that our county's good immunization rates will continue to protect her.

On the "family history" thing: I have some friends who told me that when(if) they have kids they plan to give the first couple of vaccines one at a time. when I asked why they reminded me that they both have a lot of (real) allergies, and he once had a terrifying reaction to a tetanus shot (temporary paralysis).

They're not anti-vaxx at all, they're just (reasonably) afraid that any kid of theirs might inherit a tendency to allergic reactions.

That seems like a sensible position to me, and as long as you get the rest of the shots if the kids doesn't react, then it's fine. It doesn't seem like a great reason not to vaccinate at all.

Fatality from measles may be "rare," but that's no comfort to the family of the Washington woman who recently died of measles.

Besides, if all you care about is fatalities, why are you so bothered by autism?

Toto told you so....
LAWYERS line up to get in on the ground floor!
http://philadelphia.cbslocal.com/2015/07/02/countrys-first-gay-divorce-…

Atlantic slave trade / measles - small pox connection...
THAT'S WHY THE CDC IS LOCATED IN THE SOUTH!
IMAGINE HOW MUCH BETTER THE MIDDLE PASSAGE WOULD HAVE BEEN WITH VACCINES!
"Most contemporary historians estimate that between 9.4 and 12 million Africans arrived in the New World.[12][13] Disease and starvation due to the length of the passage were the main contributors to the death toll with amoebic dysentery and scurvy causing the majority of deaths. Additionally, outbreaks of smallpox, syphilis, measles, and other diseases spread rapidly in the close-quarter compartments."

#109
There was no proof the woman died of measles or even had them. She died of PNEUMONIA. The woman had been vaccinated for measles as a child. She did not have a rash. She had other major health issues.
Please, find something that isn't NLP pulp fiction....HA HA!

DON'T SHED ON ME!

"It has now been openly declared that the DTaP vaccine is causing the uptick in whooping cough. Out of the hypotheses, asymptomatic shedding was the final detectable problem. However, the authors have more to say on it, some of which sounds very contradictory coming from researchers who have proven that the mechanism of the acellular DTaP is, in part responsible for the spread of a dangerous bacterium. - See more at: http://www.naturalblaze.com/2015/06/study-dtap-vaccine-is-causing-whoop…"

Why is there no "thumbs down" option for you Orac? You're so long winded it took me a year to get to the comments option.

Dr. G---

I am always flattered when you devote so much time, space and energy to me. It elevates my stature in the medical and online community far above what it should be: I am a pediatrician in private practice with just the required credentials (MD, FAAP) and certainly not worthy of being noted as incredibly influential as you deem me to be. Thank you.

Since I know Dr. Jay reads this blog, perhaps he can drop in and tell us where in the pediatric recommendations it is good medical practice to do titers instead of the second MMR.

What does a doctor charge for providing a 2nd dose of MMR?

What does a doctor charge for checking titers, and then having the patient come back for another office visit to discuss the results, and maybe or maybe not providing a 2nd dose of MMR?

Would the delta, multiplied by the number of patients, make a payment or two on a Lamborghini?

Excellent questions!

I don't have the exact numbers in front of me, but I believe my office charges about $125 for an MMR.

When I order blood tests of any kind, including MMR titers, I do not bill the patient at all and the interpretation of these tests is done on the phone, also at no charge.

Obviously, my Lamborghini(s) will not be purchased with the latter scenario. The former practice (giving the second MMR) will get me there much faster.

David! I intend to give medical exemptions whenever I think they are warranted. I will follow both the letter and the spirit of the law. And, it will be none of your business and none of anybody else's business either. The law is very clear about that.

Happy Fourth, Everyone!!

You missed the first question, Dr. Gordon. It starts with "Since" if you'd like to answer it, please and thanks.

Dr Jay Gordon

And, it will be none of your business and none of anybody else’s business either.

It will be when we find out one of your “medical exemptions” infects another child.
This goes for Dr Bob, too – will you let him know, since he doesn’t grace us with his presence here?

Thank you, Delphine. I forgot to answer that first question:

"Since I know Dr. Jay reads this blog, perhaps he can drop in and tell us where in the pediatric recommendations it is good medical practice to do titers instead of the second MMR."

Either of those two meets CDC /IAC criteria and is satisfactory for college admissions offices. I prefer not to give unnecessary shots so I'm happy to either do the blood test or give a second MMR if that's what parents or patients prefer.

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6204a1.htm (Table 3)

http://www.immunize.org/askexperts/experts_mmr.asp

http://www.cdc.gov/mmwr/preview/mmwrhtml/00053391.htm

"Although some persons who develop normal antibody titers in response to a single dose of MMR vaccine will develop higher antibody titers to the three component vaccines when administered a second dose of vaccine, these increased antibody levels typically do not persist (57)."

Sorry Jay, I'm just not seeing in the links you provided where the CDC says it's good practice to skip a second MMR dose and do titers instead. The CDC link says:

"...postvaccination serologic testing to verify an immune response is not recommended."

The immunize.org link reinforces this, suggesting that the CDC Advisory Committee on Immunization Practices would not agree with your practice of doing titers to avoid "unnecessary shots":

"ACIP does not recommend serologic testing after vaccination because commercial tests may not be sensitive enough to reliably detect vaccine-induced immunity."

The link also notes that there is no harm involved in giving an additional MMR shot to someone who is already immune.

Jay: " I intend to give medical exemptions whenever I think they are warranted. I will follow both the letter and the spirit of the law. And, it will be none of your business and none of anybody else’s business either. The law is very clear about that."

Where in SB277 does it say that the media and health care regulators may not investigate the possibility of antivax physicians handing out bogus exemptions?

Jay: "I prefer not to give unnecessary shots so I’m happy to either do the blood test or give a second MMR if that’s what parents or patients prefer."

Sadly, we've already seen ample evidence that you prefer not to give most vaccinations at all, unless parents "prefer" it - i.e. having to push you into following the pediatric standard of care.

Ever so flattered that you stopped by, though. :)

Dr. Jay, you realise that what you recommend in your tiny microcosm of affluence is not really germane nor practicable to the majority, right?

I have this theory about you and Bill Sears. I think that at one point, you and Bill were probably pretty good pediatricians. Then, you got corrupted by money and ego. I have said this before and I will say it again: your advice on infant sleep (on an earlier version of your website) made me stop feeling like I had the world's worst baby and start doing what was right for my family at that time. And I thank you for that, I really do.

But you are dead wrong on immunizations. What's more, I think you know it, and I think you no longer care.

David! I intend to give medical exemptions whenever I think they are warranted. I will follow both the letter and the spirit of the law. And, it will be none of your business and none of anybody else’s business either. The law is very clear about that.

Actually, you are mistaken, Dr. Jay. It will be very much the business of the California medical board if you are granting exemptions that are not medically warranted—as well it should be! Your claim that you will honor the "letter and spirit" of the law rings rather hollow in light of your persistent dancing around or outright refusal to answer some very reasonable questions about what criteria you will use to grant medical exemptions. this is particularly true in light of your saying you would check titers before giving a second MMR even though no guidelines recommend that.

Seriously, Dr. Jay. You're not fooling anybody.

Ever so flattered that you stopped by, though.

I'm surprised it took him so long, given that this post is three days old.

Jay Gordon, MD, FAAP@115

I intend to give medical exemptions whenever I think they are warranted.

I'm curious if you intend to follow the national standards for contraindications and precautions in the AICP's recommendations. If not why do you think you know better? As I'm sure you know autism or family history of autism is nowhere to be found as either a contraindication or a precaution.

Either of those two meets CDC /IAC criteria and is satisfactory for college admissions offices.

Am I the only one who finds this to be an odd juxtaposition?

Narad, I believe that what Jay is referring to is immunization requirements for incoming students (freshmen, transfers) who intend to live in university student housing.

The requirements vary by university. Some of the diseases for which evidence of immunity are required include: measles, mumps, rubella, hepatitis B, and Meningococcal disease.

Jay Gordon, MD, FAAP@118

I prefer not to give unnecessary shots so I’m happy to either do the blood test or give a second MMR if that’s what parents or patients prefer.

This is hella weasely. You (should) know that blood draws are also not perfectly safe procedures as this seems to imply. Given the incredibly low rate of adverse reactions from vaccinations I wouldn't be surprised if they are on par with those from blood draws (though in a very brief search I didn't find numbers for blood draws).

Yes, Gordon gets to retirement a lot faster than I do with what he charges for an MMR, which is at least double what he would get if he took health insurance instead of running a parent-pandering, fame-seeking, high-price, ca$h-only clinic.

Correction for #123. AICP should be ACIP. I don't think the Android Ice Cold Project publishes vaccination recommendations.

@Chris Hickie: I agree, Dr Hickie. I was actually pretty shocked at Dr Jay's rates for an MMR. I don't believe they cost me more than $35 or so for my children. According to the Healthcare Blue Book, the MMR WITH office visit should cost $115. The fact that Dr Jay is charging $125 for the MMR alone makes me wonder what he charges for an office visit.

Maybe he meant the titers cost.

Dr. Hickie, I won't retire. Please make more sense in your posts instead of just . . . "going off." And, for Dog's sake, join the American Academy of Pediatrics and become a voice for reason! You don't have to take a rather difficult test, but you can do it!!

Liz, yes, I have patients going off to college and the most rigorous requirements I see each day involve those teens. Either MMR #2 or protective titers required.

Capnkrunch, I need to see your data on the danger of venipuncture. ALL of your data with links. And none of that whale.to stuff you usually post. I have always considered blood draws quite safe.

MI Dawn, my fees for MMRs are completely in line with those charged by every single office in my geographic area. My routine office visits, by the way, are at least one hour long and I bill less per hour than most docs.

Typo to Dr. Hickie: You do have to take a rather difficult test . . .

The MMR is either free or based on the family's ability to pay at the Orange County Health Department.

MI Dawn, my fees for MMRs are completely in line with those charged by every single office in my geographic area. My routine office visits, by the way, are at least one hour long and I bill less per hour than most docs.

Of course, as every doctor here knows, insurance often pays much less for specific services than what doctors bill for them. So your comment about what you bill for an office visit means little if you don't take insurance. Other doctors, taking insurance, might bill more for an hour long visit, but they almost certainly collect far less from the insurance companies and other third party payers.

For those of you with questions about how SB277 will affect schoolchildren, the California Public Agency Labor & Employment Blog has a rather comprehensive Q&A post up.

http://www.calpublicagencylaboremploymentblog.com/legislation/governor-…

Jay Gordon, MD, FAAP@131

Capnkrunch, I need to see your data on the danger of venipuncture. ALL of your data with links. And none of that whale.to stuff you usually post. I have always considered blood draws quite safe.

Like I said, I could not find data on rates of but the fact that you are apparently ignorant of any potential complications doesn't speak very highly of your compentence. Complications which can include "nerve injury, vasovagal reaction and infections". Sure they may be vanishingly rare, but so are serious complications from MMR. Hopefully your nurses are more informed than you because you can't possibly obtain informed consent without explaining potential complications for all procedures, even ones you consider "quite safe". That said, ethics doesn't appear to be your strong suite.

I'd also like to note you ignored my other comment. I assume it's because you fully intend to deviate from the standard of care as outlined in the ACIP's guidelines yet you are too much of a coward to own it.

Jay Gordon, MD, FAAP@131

Capnkrunch, I need to see your data on the danger of venipuncture.

Also, when you want to break from well established standards, which the second dose of MMR is, the onus is on you to prove that there is a clear reduction in risk or improvement in outcome, not on me to prove otherwise.

Jay Gordon, MD, FAAP@131

Liz, yes, I have patients going off to college and the most rigorous requirements I see each day involve those teens. Either MMR #2 or protective titers required.

It's certainly news to me that college entrace/housing requirements were also meant to be guidelines for healthcare workers to follow when vaccinating children. CDPH follows the CDC guidelines. I don't know why you don't.

The CDC recommendations for MMR are pretty clear:

Currently, ACIP recommends 2 doses of MMR vaccine routinely for children with the first dose administered at age 12 through 15 months and the second dose administered at age 4 through 6 years before school entry.

And as far as titers are concerned:

Serologic screening for measles, rubella, or mumps immunity before vaccination is not necessary and not recommended if a person has other acceptable evidence of immunity to these diseases (Table 3). Similarly, postvaccination serologic testing to verify an immune response is not recommended.

Documented age-appropriate vaccination supersedes the results of subsequent serologic testing.

Jay: "join the American Academy of Pediatrics and become a voice for reason! You (do) have to take a rather difficult test, but you can do it!!"

Jay is apparently referring to the board certification exam for pediatricians, which over 100,000 of them have passed. I am unaware of any separate exam to join the AAP (all you need to be a FAAP is to have passed the board exam like the vast majority of other peds, pay dues and maybe attest that you haven't been convicted of a felony, though maybe they're more liberal about admitting felons than my own specialty organizations).

Anyone else notice how Jay posted links to back up his claim that the CDC supports the idea of obtaining patient titers as a substitute for a second MMR dose - but failed to respond when it was pointed out to him that those links explicitly show that the CDC does NOT recommend this? To refresh Jay's memory, the money quote from his CDC link:

“…postvaccination serologic testing to verify an immune response is not recommended.”

And from Jay's immunize.org link:

“ACIP does not recommend serologic testing after vaccination because commercial tests may not be sensitive enough to reliably detect vaccine-induced immunity.”

So why, Jay, are you doing something the CDC explicitly calls on physicians NOT to do?

A quick Google search on phlebotomy side effects turned up Pubmed16296336.

I wonder if Dr Jay informs patients of the possibility of permanent motor and/or sensory nerve dysfunction as an alternative to a quick jab in the muscle tissue.

Jay's latest tweet:

Two MMRs are not a guarantee of immunity. Positive titers are much more certain. (Maybe that's not what you meant.)

https://twitter.com/JayGordonMDFAAP/status/617860805829111808

@capnkrunch:

You asked above how Dr. Jay, Pediatrician to the Stars (tm), thinks he knows better than the CDC about vaccination schedules. Heck, this is a guy who thinks he knows better than the entire Enlightenment. See him here declare that his anecdotes are superior to data: http://scienceblogs.com/insolence/2009/10/06/cries-the-antivaccinationi…

(linky might not go straight to that comment; it's #112 on that page)

Gosh, that little incident was almost six years ago, and he still hasn't defended that textual vomitus.

LIz Ditz@141
One wonders if he's dishonest or just ignorant given that the CDC feels differently.

Documented age-appropriate vaccination supersedes the results of subsequent serologic testing.

protective titers

Wait a minute, is Dr. Gordon trying to claim titers are somehow *protective* rather than merely diagnostic?

Jud@144

Wait a minute, is Dr. Gordon trying to claim titers are somehow *protective* rather than merely diagnostic?

I imagine he meant "positive" but it's kind of hard to say for sure given badly he's misrepresented other things about this whole titer debacle.

@capnkrunch and Jud

I believe Dr. Jay is saying that because a positive titer result is considered acceptable evidence of immunity, it is therefore accepted recommended practice to do either titers or a second MMR. He's wrong, of course, but that seems to be his argument.

If Gordon thinks passing pediatric boards is hard, he truly isn't very bright (as noted by Dangerous Bacon above). I whizzed though mine on the first try in 2003*

However, Jay, being the two-faced carpetbagger he is, did not disclose that he, being rather old, is grandfathered into "permanent" board certification in pediatrics and never has to re-certify again: https://www.evernote.com/shard/s15/sh/27f68e1f-9774-430f-9ff0-bc3bcccc6…

*on the other hand, I have refused to re-certify in pediatrics because I feel MOC for pediatrics is one the dumbest things ever done by the ABP and see no point in doing a CQI project to ask my parents if I washed my hands before touching their child. Duh. However, as to whether an anti-vaccine conspiracy theorist like Gordon washes his hands before touching patients (do you even believe in germ theory, Gordon?) would be worth a CQI project in his office.

I believe Dr. Jay is saying that because a positive titer result is considered acceptable evidence of immunity

It seems to be his position, as well as the position of a number of anti-vaxers when the topic is the need for a vaccine jab.

Conveniently, when the topic is about vaccine effectiveness, suddenly antibody titers are not acceptable anymore as evidence of immunity.

Positive titers against MMR create more certainty of immunity and protection than does getting the second MMR. This is probably true for any vaccine preventable illness.

Hi Chris. Yes, recertification might be difficult but it'd be worth it to have you back on board.

Jay Gordon, MD, FAAP@149

Positive titers against MMR create more certainty of immunity and protection than does getting the second MMR. This is probably true for any vaccine preventable illness.

As I said before, the CDC feels differently.

Documented age-appropriate vaccination supersedes the results of subsequent serologic testing.

It's pretty clear that you believe you know better but I'd challenge you to reexamine that belief.

Positive titers against MMR create more certainty of immunity and protection than does getting the second MMR. This is probably true for any vaccine preventable illness.

Oh really "Dr." Jay? And how pratell will titres taken at 6 years old be applicable to say, when they are 40? You are more than old enough to remember a time ~1989-1991 when there was a massive outbreak of measles that occured primarily in the unvaccinated and also in those with one dose of MMR or the inactivated measles vaccine administered in the late '60's. Why was that "Dr." Jay and what was the recommendation that followed which had reduced the number of measles cases to the low hundreds? What about rubella and mumps "Dr." Jay? I guess some congenital rubella syndrome would make for some more interesting patients for you than the snotty, white over-privileged special snowflakes you see.

For someone who allegedly "researches" the topic, you sure are ignorant of epidemiology and pathology.

Positive titers against MMR create more certainty of immunity and protection than does getting the second MMR. This is probably true for any vaccine preventable illness.

You don't say. Could you break that out in quantitative terms with a focus on avidity and affinity?

As a person born between 1956 and 1970 I just took the easy route and got an MMR at my local pharmacy before a trip to Northern California. I personally hate blood draws and getting an almost painless skin prick was preferable.

Anyone who prescribes painful blood draws over minimal skin pricks by the vaccine is not only after cold titer cash, but sadistic. Really? An expensive non-preventative blood draw is better than getting a mostly painless skin prick MMR? What planet do you live on Dr. Jay? Htrae?

As a person born between 1956 and 1970 I just took the easy route and got an MMR at my local pharmacy

Yah, I similarly need to get on that, but it's not pharmacy-simple for me.

@ Chris

Anyone who prescribes painful blood draws over minimal skin pricks by the vaccine is not only after cold titer cash, but sadistic.

Now that you put it this way...
(not that I really needed more convincing)

It made me thinking of a few nurses who were unlucky enough to have to draw blood from me or my mom. We don't have very prominent arm veins in the family.
It may not have been exactly painful, but it's always a bit embarrassing when the nurse, already holding the arm garrote with both hands, start putting a foot on the chair for added leverage.
(and then the lab boss/chief nurse came in, and 2 minutes after had the blood drawn - the virtue of experience)

Given a choice between blood draw or vaccination, these nurses would certainly have preferred we came for a vaccine.

----------------------------------
@ all

Re: antibody titers vs second vaccine injection
Correct me if I'm wrong, but I was under the impression that the second MMR (or whatever) injection is not just a second chance to catch those who didn't react the first time, but it is also meant to boost (hence, booster) the already existing immune response.
The objective is not only to have higher quantities of antibodies, but also a longer-lasting immunity (yet a favorite complaint of antivaxers), by pushing for the creation of more memory B-cells.
In this context, antibody titers may be the wrong test to do.

As usual, Gordon, you skirt/dodge/duck the fact that were you not grandfathered into permanent board certification in pediatrics, you would not be board-certified in pediatrics under the current MOC guidelines--nor would you be allowed to be an FAAP under the membership rules of the FAAP which require board certification in pediatrics.

Do you disclose this to your patients?

So let me get this straight. Dr. Jay thinks doing a blood draw to determine titers is better than getting a second MMR (leaving aside, for a moment, that this is not the current recommendations regarding measles prevention, seeing as only having 1 dose of MMR is less effective than getting the complete 2-dose series). Tell me, doc. What happens when the titers come back equivocal or negative? Do you then give them the second MMR?

Let's count the pricks (needles, that is), shall we? One from MMR dose 1. One (larger gauge) from the blood draw. One from the second MMR. Dr. Jay would rather risk having to give a child three jabs with a needle rather than just two. And remember, that, though uncommon, every needle stick is an invasive procedure with non-zero risks.

"Tell me, doc. What happens when the titers come back equivocal or negative? Do you then give them the second MMR?"

Interesting question. I doubt Jay will be any more forthcoming than he's been about why he ignores CDC recommendations against post-vaccination titering. Seeing that the CDC notes that commercial lab testing may not be sensitive enough to detect significant positive titers, Jay seems to be setting up his patients for what he and they would view as unnecessary shots.

Todd W.@147

And remember, that, though uncommon, every needle stick is an invasive procedure with non-zero risks.

Dr. Gorden thinks differently (#131):

Capnkrunch, I need to see your data on the danger of venipuncture. ALL of your data with links. And none of that whale.to stuff you usually post. I have always considered blood draws quite safe.

@ capnkrunch

And none of that whale.to stuff you usually post.

I missed this. Dr Gordon is really accusing you of posting whale.to stuff?
That's rich, coming from the good doctor.

There's a review of adverse events after venepuncture in adults here. It's a low but not zero risk procedure, which can have serious sequelae, such as a nerve damage, in rare cases.

Approximately one week after a botched blood draw. Can't find the image from two days after, when it looked like I'd been beaten.

[img]http://i.imgur.com/YbFVUpF.jpg[/img]

Sigh. http://i.imgur.com/YbFVUpF.jpg%5B/img%5D

Delphine,
That looks similar to what a colleague once did to me; I think he went straight through the vein on his first attempt. I developed a large bulging hematoma that scared the crap out of me but another medically qualified colleague told me to just keep pressure on it and reassured me I would live. Apparently he was correct. I have seen one account of a fatal embolism after venepuncture (? causation), but if it does occur it's very rare.

Years ago I was something of a pincushion in one of the labs I worked in, partly because of my easy-to-access veins, partly because I have some unusual minor blood groups and partly because we were conjoined with a Medical Research Council lab full of research associates with an endless thirst for 'normal' human blood. In the end I figured out how to bleed myself, which is fiddly, even with a Vacutainer system, but possible.

I should add to what I wrote in my previous comment. The study I cited was on adults, and in children venepuncture is, obviously, a great deal more difficult, and I am certain leads to more traumatic injuries than in adults.

Dr. Jay would rather risk having to give a child three jabs with a needle rather than just two.

Well, no. Gordon would rather not give the kid any needle pokes, and only does it if the parents really, really want it. Then there are the kids who pass the titer check, and only get the MMR and the blood draw.

Please understand that I'm not defending the guy. I think he's very much wrong in his reasoning, and two MMRs are better than one MMR and a blood draw.

Krebiozen, I didn't get a big lump, but she did hit something as there was a jolt during the draw. I was 9 months pregnant, the increased blood volume may have had something to do with the bruising. In any event, it was unpleasant.

Dear hubby had some nice bruising after he had a fasting blood draw the other week. Of course the reason for that is to monitor his blood sugar, checking to see if his diet and exercise is keeping it under diabetes level. After two years it is still working.

Jay Gordon, MD, FAAP@51

It’s a poorly written unintelligent law and deserves your scrutiny and disdain.

Dr. Gordon! Good to see you again after you bravely ran away last time. I would argue that you are the one that deserves scrutiny and disdain.