Public Health and the Politics of School Immunization Requirements

Abstract

Compulsory vaccination has contributed to the enormous success of US immunization programs. Movements to introduce broad "philosophical/personal beliefs" exemptions administered without adequate public health oversight threaten this success. Health professionals and child welfare advocates must address these developments in order to maintain the effectiveness of the nation's mandatory school vaccination programs. We review recent events regarding mandatory immunization in Arkansas and discuss a proposed nonmedical exemption designed to allow constitutionally permissible, reasonable, health-oriented administrative control over exemptions. The proposal may be useful in political environments that preclude the use of only medical exemptions. Our observations may assist states whose current nonmedical exemption provisions are constitutionally suspect as well as states lacking legally appropriate administrative controls on existing, broad non-medical exemptions.

Personal Belief Exemptions From School Vaccination Requirements

“…Some evidence suggests that religious exemptions, as opposed to broader personal belief exemptions, may run afoul of the First Amendment's establishment clause when they provide preferential treatment to particular religious doctrines-those exemptions requiring that parents belong to a recognized religious organization, for example (28,36,55). In 1979, the Mississippi Supreme Court in Brown v. Stone held that although the state's interest in the public health and its duty to protect children from harm were sufficient to override the religious rights of parents seeking to exempt their children from vaccination prior to school entry, the state's religious exemption was unconstitutional because it violated the equal protection rights of those who did not qualify for exemption for religious reasons (4).…”

“…Although eliminating exemptions for religious and personal beliefs would almost certainly increase vaccination rates and serve the goal of maximizing protection from vaccine-preventable disease in the short term, this strategy risks a backlash against school vaccination requirements that could ultimately undermine these laws (55). Some commentators have argued further that unless the exemption rate rises to a level that poses a significant risk of harm to others in the community (through the loss of herd immunity), eliminating exemptions for those with strong philosophical or religious beliefs about vaccination would not be ethically defensible (43,51).…”

HPV Vaccine Decision-Making and Acceptance: Does Religion Play a Role?

“…For example, parents who file vaccine exemptions on the basis of religious or personal beliefs are able to delay or refuse childhood immunizations that are mandated for school entry (Etkind et al 1992; Salmon et al 1999; Kulig et al 2002; Kennedy and Gust 2008). Currently, 48 out of 50 states allow some form of religious exemption for mandatory vaccinations (Salmon et al 2005; Omer et al 2006). Estimates of the prevalence of nonmedical exemptions are low (~1–2%), though rates are as high as 15–18% in some geographic communities or clusters (Omer et al 2006, 2008).…”

Applying Kass's Public Health Ethics Framework to Mandatory Health Care Worker Immunization: The Devil is in the Details

“…The American Journal of Bioethics faced successful legal challenges in the context of childhood immunization mandates (Salmon et al 2005). One practical, but still imperfect, substitute for sincerity of beliefs is strength of beliefs.…”