Exempting Schoolchildren From Immunizations: States With Few Barriers Had Highest Rates Of Nonmedical Exemptions

Abstract

Rates of nonmedical exemptions from school immunizations are increasing and have been associated with resurfacing clusters of vaccine-preventable diseases, such as measles. Historically, state-level school immunization policies successfully suppressed such diseases. We examined state immunization exemption regulations across the United States. We assessed procedures for exempting schoolchildren and whether exemption rates were associated with the complexity of the procedures. We also analyzed legal definitions of religious objections and state legislatures' recent modifications to exemption policies. We found that states with simpler immunization exemption procedures had nonmedical exemption rates that were more than twice as high as those in states with more-complex procedures. We also found that the stringency of legal definitions of religious exemptions was not associated with exemption procedure complexity. Finally, we found that although there were more attempts by state legislatures to broaden exemptions than to tighten them in 2011-13, only bills tightening exemptions passed. Policy makers seeking to control exemption rates to achieve public health goals should consider tightening nonmedical exemption procedures and should add vaccine education components to the procedures by either mandating or encouraging yearly educational sessions in schools for parents reluctant to have their children vaccinated.

Geospatial analysis of nonmedical vaccine exemptions and pertussis outbreaks in the United States

“…Nonmedical vaccine exemptions have been on the rise in the United States (1,(26)(27)(28)(29)(30)(31)(32)(33)(34)(35). The rates of nonmedical vaccine exemptions are not evenly distributed among communities, which indicates that obtaining nonmedical vaccine exemptions tends to be a socially and spatially clustered behavior (27,28,36).…”

“…Several studies have suggested reasons for the resurgence of pertussis in the United States, including waning immunity from the acellular pertussis vaccine that replaced whole cell vaccine (9)(10)(11)(12)(13)(14)(15)(16)(17)(18); medical advancements that have allowed more effective diagnosis and reporting of pertussis cases (19,20); asymptomatic transmission of B. pertussis from individuals vaccinated with the acellular pertussis vaccine (21,22); evolving variant strains of B. pertussis circulating that are less protected by the vaccine (23)(24)(25); and a decrease in vaccine coverage that has compromised herd/community immunity (1,(26)(27)(28)(29)(30)(31)(32)(33)(34)(35). It is clear that the rise in reported pertussis cases in the United States is a multifaceted problem not fully captured in national or state-level data.…”

Personal Belief Exemptions From School Vaccination Requirements

“…In most states, the process of obtaining a vaccine exemption requires considerably less effort than fulfilling vaccination requirements, and the ease with which a personal belief exemption is obtained is directly correlated with the rate at which parents seek an exemption (2,52). Making receipt of a personal belief exemption more difficult is one reasonable solution to rising rates of exemption (19,48).…”

Medical Versus Nonmedical Immunization Exemptions for Child Care and School Attendance

“…15 States that offer personal-belief exemptions have had steady increases in the number of exemptions over time. Religious exemptions have increased for states that do not offer personal-belief/ philosophical exemptions but have, through regulatory language, broadly defined religion for the purposes of obtaining vaccine exemption.…”