FORT LAUDERDALE, Fla. (AP) — Florida’s controversial surgeon general is drawing criticism for his handling of an elementary school’s measles outbreak, telling parents of unvaccinated children it is their choice whether their students attend class — a contravention of federal guidelines calling for their mandatory exclusion.

Dr. Joseph Ladapo, nationally known for his outspoken skepticism toward the COVID-19 vaccine, sent a letter this week to parents at Manatee Bay Elementary School near Fort Lauderdale after six students contracted the highly contagious and potentially deadly virus. Such outbreaks are rare in the United States, though reported cases have spiked from 58 for all of 2023 to 35 already this year.

The letter notes that when a school has a measles outbreak, it is “normally recommended” that unvaccinated students who haven’t previously had the disease be kept home for three weeks “because of the high likelihood” they will be infected.

But the letter then says the state won’t turn that recommendation into a mandate, at least for now. The Broward County school district said Friday that 33 of Manatee Bay’s 1,067 students don’t have at least one shot of the two-dose measles vaccine. The vaccine also covers mumps and rubella and is highly effective against measles even after one dose. The school is in Weston, an upper-middle class and wealthy suburb, with a median household annual income of more than $120,000.

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AP AUDIO: Florida refuses to bar unvaccinated students from school suffering a measles outbreak.

AP correspondent Jackie Quinn reports on Florida’s top health official rebuffing federal guidelines on protecting children from the measles.

“Due to the high immunity rate in the community, as well as the burden on families and educational cost of healthy children missing school, (the state health department) is deferring to parents or guardians to make decisions about school attendance,” Ladapo wrote. He was appointed by Republican Gov. Ron DeSantis in September 2021 because of their mutual opposition to COVID-19 vaccine and mask mandates and school closures.

His wording contradicts Centers for Disease Control and Prevention recommendations, which tell school officials that unvaccinated children “must be excluded” for three weeks. States are not required to follow those recommendations, however.

That failure to bar unvaccinated children is sparking criticism from doctors in Florida and around the country, including the American Academy of Pediatrics.

Dr. Rana Alissa, the academy’s Florida vice president, said Friday that the state should follow the CDC guidelines “for the safety of our kids.” Allowing unvaccinated children to attend during the outbreak not only endangers them, but others who might have compromised immune systems and could later catch it from them, she said.

“When you have an outbreak, to contain it you have to follow the public health and safety recommendations, not give people a choice,” she said. “Frankly, giving people a choice is what got us here.”

Jodie Guest, an epidemiologist at Emory University’s Rollins School of Public Health, said the CDC’s guidelines “are based on decades of iterative science” but false information about the measles vaccine’s dangers is spreading. The vaccine in extremely rare circumstances can cause seizures that are not permanent or life-threatening, the CDC says.

“We have a pandemic of science disinformation,” she said.

Ladapo’s office did not respond Friday to a phone call seeking a response to the criticism.

The school district says any decisions about the mandatory exclusion of unvaccinated students rests solely with the health department. Spokesperson John Sullivan would not say if the six ill children are unvaccinated, citing privacy concerns.

Florida law requires that students be vaccinated for measles and several other contagious diseases, but they can be exempted by their doctor for medical reasons or by their parents if they affirm the shots conflict with the family’s “religious tenets and practices.” Officials are not allowed to seek specific information about those beliefs.

Measles spreads when infected people exhale, cough and sneeze the viruses — it can linger in the air and on surfaces for two hours, infecting numerous people. An infected person can be contagious for four days before symptoms appear, including the telltale rash, fever, cough, runny nose and watery eyes.

Vaccinated people rarely catch the disease and if they do, their symptoms are less severe and they are less contagious, the CDC says.

Besides the unvaccinated students, those most at risk to the disease include infants who are too young for the shots; adults and children with compromised immune systems from such diseases as cancer and HIV; and pregnant women, whose fetuses might be adversely affected.

While most people who catch measles recover without significant problems, an unvaccinated person who catches measles has about a 20% chance of being hospitalized, the CDC says.

About 5% of infected children get pneumonia and about 1 in every 1,000 will develop brain swelling, which can cause deafness or intellectual disability. Between 1 and 3 of every 1,000 infected children who weren’t vaccinated will die from the disease, the CDC says.

Before measles vaccinations began in 1963, more than 400,000 Americans annually caught the disease. The numbers dropped dramatically to 47,000 cases in 1970 and 13,000 in 1980. After a bump to 27,000 in 1990, the number of reported infections in 2000 was less than 100.

But then there was a jump to 1,200 cases in 2019 before the COVID-19 lockdowns of 2020 and 2021 caused the numbers to again fall.

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AP Public Health Reporter Devi Shastri in Milwaukee contributed to this report.

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The Associated Press Health and Science Department receives support from the Robert Wood Johnson Foundation. The AP is solely responsible for all content.