World Health Organization encourages everybody to get vaccinations for measles.

With three reported cases of measles in the Bay Area this past month, public health experts are warning that the state’s vaccine requirements still have dangerous loopholes. 

Last week, San Francisco’s Department of Public Health (DPH) reported a confirmed case of the measles afflicting a local resident. The adult individual contracted the viral infection on an SFO-bound international flight in February, on which a fellow passenger and Santa Cruz County resident was already infected. A resident of Santa Clara County also contracted the disease. Veronica Vien, Public Information Officer at SFDPH, stated: “The general public is at very low risk of measles as a result of these cases. No other passengers contracted measles as a result of exposure on that flight.”

Until recently, measles had become an increasingly rare disease thanks to widespread vaccination. That trend began reversing in the past several decades after fraudulent and widely debunked pseudoscience falsely linking vaccines to autism spread fears among parents. California’s rate of vaccination for the Measles, Mumps and Rubella vaccine (MMR) in kindergartens has fallen slightly in the past two years, with fewer schools reporting the 95% rate optimal for preventing outbreaks. The U.S. Centers for Disease Control and Prevention (CDC) has reported five outbreaks in the United States in 2019 so far. Reversing this troubling pattern is a top priority for public health advocates.

In 2015, a year after a massive measles outbreak at Disneyland, State Sen. Richard Pan (D-Sacramento), himself a pediatrician, passed Senate Bill 277, which outlawed “personal belief” exemptions for public school vaccination requirements. This shifted the focus of anti-vaccine parents onto medical exemptions, which are intended for children with serious immune deficiencies who cannot be safely vaccinated.

There are now growing concerns that a black market for fraudulent medical exemptions has emerged in the wake of SB 277. A study in the Journal of Pediatrics found that only 5 local health jurisdictions surveyed were actively tracking medical exemptions.

Joan Edelstein, a professor of nursing at UCSF and California State University, Sacramento, explained that because the measles is highly contagious and can be transmitted without prolonged exposure, the MMR vaccine is critical for school-aged children, even though this outbreak involved three adults. The World Health Organization reported that a majority of the 110,000 measles deaths in 2017 were children under the age of 5.

“People who had personal belief exemptions are able to find physicians who will write a medical exemption for them,” Edelstein said. A list of around twenty physicians who subscribe to unsupported tests that “contraindicate” the vaccine (indicating that the patient should not take the drug) circulate on private Facebook groups and other social media. “We need to make sure that [the California Department of Public Health] has the authority to say, ‘no, this is a fake medical exemption, this is not legitimate and this child should not be exempt from vaccines,’” she explained.

Currently, schools evaluate medical exemptions for completeness of the forms submitted, not medically valid criteria, and very few county health departments provide further oversight. “The way it happens now is that the medical exemptions come to the schools, and the schools have to accept them,” Edelstein said.

Senator Pan indicated in a statement that his office is ready to act, though it is unclear if legislative changes will occur in 2019 or later. In February, the CDC released a report on a 2018 measles outbreak in the Bay Area caused by an unvaccinated teenager returning to California from the UK. Several children with “questionable” medical exemptions were also infected. “The facts of this outbreak requires further action to protect our children and the public from injury due to preventable diseases,” Senator Pan said in a statement.

To date, the Medical Board of California has only placed one physician, “Dr. Bob” Sears, on probation for medical negligence related to vaccine exemptions. Sears has widely promoted his unscientific vaccine views on social media and print.

Cracking down on misinformation online has become a crusade in its own right for public health advocates. “In the short term, city and state, with federal governments need stop vaccine misinformation that is largely spread by corporate entities such as Facebook, Twitter, and other outlets to create misinformation and vaccine ambivalence, hesitation, and anti-vaccination messages,” said Laura Mamo, a professor of public health at UCSF.

Accordingly, after months of high-profile national backlash over security vulnerabilities and targeted misinformation by right-wing groups around the globe, Facebook announced last week that it would be cracking down on vaccine misinformation.

Monica Bickert, Facebook’s VP of Global Policy Management, wrote that the social media giant would be removing ads related to vaccine misinformation, and hiding related groups from search predictions and recommendations. “If these vaccine hoaxes appear on Facebook, we will take action against them,” Bickert wrote. “We are fully committed to the safety of our community and will continue to expand on this work.”

Medical science has overwhelmingly debunked various fringe allegations linking the MMR vaccine to autism—notably, in a 10-year cohort study of over 600,000 Danish children published this month. It’s only a matter of time before public policy catches up.

“A health equity approach for our local and state governments would begin upstream with a well-funded public health and clinical health care infrastructure available to all,” Mamo said. “We need to vaccinate all children.”

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