Process for obtaining nonmedical exemptions to state immunization laws

Article (PDF Available)inAmerican Journal of Public Health 91(4):645-8 · May 2001with 227 Reads
DOI: 10.2105/AJPH.91.4.645 · Source: PubMed
Abstract
This study sought to determine the specific processes required for obtaining religious and philosophical exemptions to school immunization laws. State health department immunization program managers in the 48 states that offer nonmedical exemptions were surveyed. Categories were assigned to reflect the complexity of the procedure within a state for obtaining an exemption. Sixteen of the states delegated sole authority for processing exemptions to school officials. Nine states had written policies informing parents who seek an exemption of the risks of not immunizing. The complexity of the exemption process, in terms of paperwork or effort required, was inversely associated with the proportion of exemptions field. In many states, the process of claiming a nonmedical exemption requires less effort than fulfilling immunization requirements.
Processes for Obtaining Nonmedical
Exemptions to State Immunization Laws
Jennifer S. Rota, MPH, Daniel A. Salmon, MPH, Lance E. Rodewald, MD,
Robert T. Chen, MD, MA, Beth F. Hibbs, MPH, and Eugene J. Gangarosa, MD, MS
AB
STRACT
April 2001, Vol. 91, No. 4 American Journal of Public Health 645
A key strategy to ensure that children re-
ceive recommended vaccinations in the United
States is the use of state legislative mandates
to require proof of immunization upon school
entry. State immunization laws are considered
a critical element in efforts to increase vac-
cine coverage among the nation’s children,
bringing many diseases to record low levels.
1
Mandatory laws for school entry and atten-
dance have been credited with reductions in
the incidence of several vaccine-preventable
diseases within states
2,3
and nationwide
4,5
fol-
lowing enforcement of these laws.
As new vaccines have become available,
laws governing vaccination requirements have
evolved within the states; there is no legisla-
tion at the national level pertaining to school
immunization requirements. While there are
national public health recommendations con-
cerning immunizations, state laws have been
maintained and expanded with support from
state and local health officials. Compulsory
immunization laws in the United States date
back to state requirements designed to protect
the public from smallpox through vaccination
of the general population.
6
The vaccinations
required by school laws are not provided free
of cost by the government, as in some other
countries with mandatory vaccination policies.
However, childhood vaccinations are supported
by government programs that assist low-
income families.
The means of enforcement and the au-
thority to whom enforcement is delegated vary
among states and may influence the effective-
ness of state laws. Local jurisdictions may vary
in the vigilance applied to enforcement of the
statutes as well as the relative incentives or
backing to administer the laws.
2,5–7
The penalty
of exclusion from school for noncompliance
with school immunization requirements is an
effective method to ensure that parents obtain
the necessary immunizations for their chil-
dren.
5,8
However, the responsibility rests with
school officials, often school nurses, to iden-
tify students in need of immunizations and to
follow up after the state’s allotted period of
time to comply has expired.
9
All states allow medical exemptions; 48
states grant exemptions for religious reasons.
In addition, 15 states either have an additional
provision for philosophical exemptions or offer
a personal conviction clause that encompasses
religious beliefs.
10
Waivers designated as reli-
gious exemptions originally were available so
that followers of certain recognized religions
whose tenets do not admit modern medical
practices such as immunization have legal re-
course to observe their beliefs.
The availability of philosophical or per-
sonal exemptions raises concern that the im-
plied broader interpretation might result in in-
creased numbers of exemptions relative to
waivers granted specifically for religious rea-
sons. Although a 1997 National Vaccine Advi-
sory Committee ecologic study conducted to
assess the impact of philosophical exemptions
did not detect decreased immunization coverage
or increased frequency of exemptions among
states that allow philosophical or personal ex-
emptions, further studies were recommended.
11
The dramatic resurgence of measles dur-
ing 1989 through 1991 in the United States
demonstrated the need to maintain high levels
of vaccination coverage among all members
of the population. Salmon et al. reported that
individuals with religious and philosophical
exemptions are at increased risk of contract-
ing measles and that, according to models,
those claiming exemptions increase the risk of
disease among nonexempt individuals.
12
A re-
port published by Gangarosa and colleagues
documented the increase in pertussis cases in
several countries when vaccination programs
were compromised following negative reports
and public uncertainty over the safety of the
whole-cell pertussis vaccine.
13
As the incidence of vaccine-preventable
diseases declines, a lack of appreciation for the
severity of such diseases, often in conjunction
with public misconceptions of vaccine risks,
is of concern to those involved in public health
and to health providers.
14,15
Some consumer
advocacy groups have focused on efforts to
weaken state legislation regarding immuniza-
Jennifer S. Rota, Daniel A. Salmon, Lance E. Rode-
wald, Robert T. Chen, and Beth F. Hibbs are with the
Centers for Disease Control and Prevention, Atlanta,
Ga. Jennifer S. Rota is with the National Center for
Infectious Diseases, Daniel A. Salmon is with the
National Vaccine Program Office, and Lance E.
Rodewald, Robert T. Chen, and Beth F. Hibbs are
with the National Immunization Program. Eugene J.
Gangarosa is with the Rollins School of Public
Health, Emory University, and the Gangarosa In-
ternational Health Foundation, Atlanta, Ga.
Requests for reprints should be sent to Jennifer
S. Rota, MPH, Centers for Disease Control and Pre-
vention, Measles Virus Section, Mail Stop C-22,
1600 Clifton Rd, Atlanta, GA 30333 (e-mail: [email protected]
cdc.gov).
This brief was accepted July 18, 2000.
Objectives. This study sought to de-
termine the specific processes required
for obtaining religious and philosophi-
cal exemptions to school immunization
laws.
Methods. State health department
immunization program managers in the
48 states that offer nonmedical exemp-
tions were surveyed. Categories were as-
signed to reflect the complexity of the
procedure within a state for obtaining an
exemption.
Results. Sixteen of the states dele-
gated sole authority for processing ex-
emptions to school officials. Nine states
had written policies informing parents
who seek an exemption of the risks of
not immunizing. The complexity of the
exemption process, in terms of paper-
work or effort required, was inversely as-
sociated with the proportion of exemp-
tions filed.
Conclusions. In many states, the
process of claiming a nonmedical ex-
emption requires less effort than fulfill-
ing immunization requirements. (Am J
Public Health. 2001;91:645–648)
April 2001, Vol. 91, No. 4646 American Journal of Public Health
TABLE 1—Designation and Extent of Authority Within States to Administer
Religious or Philosophical Exemptions: United States, 1998
Authority to Authority to Deny,
Agency Designated Approve, No. No. (Ever Denied
a
)
School 16 12 (5)
School and local (or state) health department 6 4 (3)
Local and/or state health department 11 9 (8)
No agency given authority 15 23 (0)
Total 48 48 (16)
a
Number of states with authority to deny that reported that exemption requests were ever
denied.
tion laws and to actively encourage the use of
exemption clauses for circumventing the law.
16
Therefore, we developed a questionnaire de-
signed to provide a better understanding of in-
dividual state practices regarding administration
of nonmedical exemptions to school immu-
nization laws and the parental involvement re-
quired to obtain exemptions. This study ex-
amined the variations in state requirements and
the impact such policies may have on the use
of nonmedical exemptions.
Methods
A 6-page questionnaire was distributed
in January 1998 to state health department im-
munization program managers in the 48 states
that allow religious exemptions, philosophical
(personal conviction) exemptions, or both. The
reporting areas of New York City, Chicago, and
the District of Columbia were not included.
The survey identified who was given author-
ity to administer exemptions and the steps re-
quired in the state to obtain a religious or philo-
sophical exemption. Immunization program
managers were asked whether requests for ex-
emptions were ever denied, the location of sites
for maintaining exemption records, the length
of time for which these records were kept, and
whether changes in the administration of ex-
emptions had been made during the previous
5 years (1993–1998).
We also inquired about the methods used
(if any) to communicate the risks and benefits
of immunization to parents seeking exemp-
tions and procedures in the states to assess im-
munization status among home-schooled chil-
dren. Responses that required clarification were
followed up by telephone. Epi Info (version
6.03)
17
was used in entering and analyzing sur-
vey responses.
The levels of complexity of the exemp-
tion processes, by state, were categorized ac-
cording to the formality of the procedures and
the time and effort required to claim an ex-
emption. Several criteria were used in assess-
ing “complexity.
Complexity level 1 was assigned to states
using a form that requires only the signature
of a parent or guardian. The form is available
through the school, and the signature does not
need to be notarized. No research by the par-
ent is required, and no special visits need to be
made.
Complexity level 2 was assigned to states
requiring no notarization but requiring that the
form be obtained from the local health de-
partment or that a letter or statement be pro-
vided by the parent. A visit to the health de-
partment is required, or extra effort or time on
the part of the parent is needed to determine
how the statement must be worded.
Complexity level 3 was assigned to states
requiring that the signature on the form or let-
ter be notarized or requiring both a form, ob-
tained from the health department, and a let-
ter. Some states require an additional letter from
a religious official or the signature of a state
official.
States were also categorized by fre-
quency of exemptions, as determined by the
percentage of new school entrants claiming
exemptions. These data were obtained from
state vaccination coverage surveys conducted
during 1994 through 1996.
11
Among the
states, the average percentage of children
claiming exemptions was 0.58%. In regard to
frequency, states were categorized as follows:
low (less than 0.5% exemptions), medium
(0.5%–1.0% exemptions), and high (more
than 1.0% exemptions).
Results
Completed questionnaires were returned
by all immunization managers from whom par-
ticipation was requested (n=48). The alloca-
tion of states into exemption groups (as de-
scribed in the Methods section) was as follows:
low exemption group, 25 states; medium ex-
emption group, 15 states; and high exemption
group, 8 states.
Recent Changes or Modifications
Program managers from 14 states re-
ported that a philosophical exemption option
was available. Four states had discontinued
philosophical exemptions during 1993 to
1998. Respondents from 2 states reported
that a requirement for exemption requests to
include the signature of a local health de-
partment official had been added. None of
the states had added a philosophical exemp-
tion option during 1993 to 1998. The pro-
gram manager from 1 state indicated that the
requirements for obtaining an exemption had
been simplified.
Information Provided to Parents
Respondents from 9 states (19%) reported
that there was a written policy to inform parents
who request an exemption of the risks of not
immunizing. Three of the states provided writ-
ten information at schools. The other 6 states ei-
ther referred parents to health services for coun-
seling or arranged for an interview with a public
health nurse when parents were acquiring
needed forms at the health department.
Twelve states (25%) had a written policy
to inform parents of the availability of exemp-
tion options, beyond having the option listed on
the immunization form. Nine of the states made
the information available at schools.
Administrative Issues
Once obtained, exemptions did not need
to be renewed in 34 states. However, in 5 states,
requests for religious or philosophical exemp-
tions had to be renewed annually at each grade
level. The remaining 9 states required renewal
only upon transfer to another school. Thirty-
eight (79%) of the state immunization officials
reported that their offices received periodic re-
ports or summaries regarding exemptions from
schools, local boards of education, or local health
departments. Exemption status data were kept at
state health departments as computerized records
in 13 states. Respondents from 9 states reported
the presence of a mechanism to assess the im-
munization status of home-schooled children.
Delegation of Authority
Respondents from 16 states indicated that
school officials had final authority to approve
an exemption. An additional 6 states assigned
initial responsibility to school officials but re-
tained a mechanism for referral to a local or
state health department in the case of an ex-
emption claim disputed at the school level.
Eleven states delegated authority for approval
to local health agencies or state health person-
nel (Table 1). One state stipulated that all ex-
April 2001, Vol. 91, No. 4 American Journal of Public Health 647
Note. The proportion of exemptions filed for a state was based on the percentage of
school entrants claiming exemptions in school surveys (see inset). Complexity level 1
corresponds to the simplest procedure (signing a school immunization form),
whereas complexity level 3 involves the most requirements to obtain an exemption.
The association between the percentage of exemptions claimed and the complexity
of obtaining an exemption was significant (P =.0167, χ
2
test).
FIGURE 1—Proportions of exemptions claimed among states, by complexity
level (1–3): United States, 1998.
emption requests (letters) must be sent to state
officials for approval and signature. In 15 states,
no agency was specifically delegated to “ap-
prove” exemption requests; the claim for an
exemption is accepted, and the exemption is
automatic.
Respondents from 16 (33%) states re-
ported that exemption requests were denied in
some cases. We did not inquire as to the basis
for the denial; however, many respondents
added that exemptions were denied if the forms
or letters were incomplete or if a required state-
ment from the parent was not worded in such
a way as to meet the terms of the statute. Four
respondents commented that decisions were
made at the school level and that discretionary
practices depended on school policy.
In 23 states, no authority was given by the
state to deny an exemption. Of these states, 10
offered philosophical exemptions, and the re-
maining 13 allowed only religious exemptions.
Therefore, if the forms, statements, or letters
were completed according to state require-
ments, no additional judgment of eligibility
based on religious tenets was made.
Filing Requirements
The documentation required and ease of
securing an exemption varied among states. A
preprinted form was used in 32 states, but 20
states required a letter. (Both a letter and a form
were required in 4 states.) The signature re-
quirements among states ranged from a non-
notarized parent/guardian signature to re-
quirements for up to 2 notarized signatures.
When forms were used, they were generally
available from the school (n =23) as part of the
immunization record. In 9 states, a parent
needed to visit the local health department to
obtain the form.
On the basis of the criteria described in
the Methods section, 15 states were assigned to
complexity level 1, 14 states met complexity
level 2 criteria, and 19 states were grouped in
complexity level 3 (Figure 1). These states var-
ied in their distribution (P = .0167, χ
2
test)
within the 3 exemption categories (low, me-
dium, high). Of the 8 states in the high ex-
emption group, 5 (63%) had simple procedures
(complexity level 1), and the remaining 3 had
additional requirements (complexity level 2).
None of the 19 states assigned to complexity
level 3 had high exemption rates. No other vari-
ables, including whether claims were ever de-
nied or the specific authority delegated to ad-
minister exemptions, were determined to have
an association with frequency of exemptions.
Comments Regarding Interpretation
Respondents from 7 states that offered
only religious exemptions indicated that the
exemption criteria were defined very broadly
or that strong personal beliefs against immu-
nization were accepted as constituting a reli-
gious exemption. Some of these comments in-
cluded a reference to advice from legal counsel
for the state. In contrast, respondents from 2
states described strict criteria for religious ex-
emptions or reported that “bona fide” religious
reasons were required. One state immuniza-
tion manager commented that one of the state’s
health districts kept a list of approved religions,
but the state itself did not.
Discussion
We have shown that there are differences
among states in the administration of non-
medical exemptions to school-based immu-
nization laws. These differences result in vary-
ing levels of complexity or amounts of effort
required for parents who seek exemptions. An
inverse relationship was observed between the
complexity of requirements and the propor-
tion of children claiming exemptions.
The existence of simple procedures for
obtaining exemptions should have little bear-
ing on most parents’ decisions to immunize.
However, our results suggest that adherence to
policies that require some effort on the part of
the parent may ensure that parental resolve to
choose the exemption option is deeply held
and that such resolve is not a matter of con-
venience and does not stem from an impression
that vaccination is no longer necessary. While
the services of a notary public may be provided
free of charge or rendered for a nominal fee, the
act of securing a notarized signature adds a de-
gree of effort and formality to the process.
When opposition to immunization aris-
ing from religious or personal beliefs is not the
underlying motivation, the decision not to vac-
cinate at the individual level is influenced by
perceived risk of disease as well as other fac-
tors.
12,18–20
Lack of knowledge about disease
risk or susceptibility, along with the increased
attention given to mild or rare reactions from
vaccination, can reduce the immediate incen-
tive for parents to have their child fully immu-
nized. The impression given by health providers
and officials of the consequences of not vac-
cinating can be particularly influential to par-
ents when the perceived risk of disease is low.
Similarly, the details or steps involved in ob-
taining an exemption on religious or philo-
sophical grounds may serve as an indication
to parents of the seriousness of a decision to
bypass recommended immunizations.
The use of nonmedical exemptions has
prompted some states to modify existing pro-
cedures. Six states enacted changes during
1993 to 1998 either to limit the type of ex-
emption or to increase the effort needed to ob-
tain an exemption. The rationale for these
changes may reflect concern that the exemption
process was either too permissive or not ade-
quate in limiting approval to only those for
whom the law was intended.
April 2001, Vol. 91, No. 4648 American Journal of Public Health
The decision of some states to offer a
philosophical as well as a religious exemption
may be less important when individual state
practices in regard to interpretation of religious
exemptions are considered. Seven respondents
reported that the concept of religious beliefs
pertaining to immunization has been expanded
to include parents’ secular beliefs. Therefore,
the distinction between a religious exemption,
interpreted in this manner, and the philosoph-
ical or personal conviction waiver may be neg-
ligible in actual practice.
Only a few states designed the exemption
process to include an opportunity for a direct
educational intervention by public health pro-
fessionals. Although many schools have vac-
cine information pamphlets for distribution,
only 6 states had policies that referred parents
who request exemptions to counseling with
school or local health personnel. When required
forms are available exclusively at the health
department, an opportunity exists to ensure
that parents are accurately informed of the risks
and benefits of immunizations by public health
personnel.
Responsibility for assessing immuniza-
tion status by collection of immunization rec-
ords or forms from parents rests with school of-
ficials. Before this study, it was not known to
what degree states involve public health per-
sonnel in exemption application processing. If
an exemption was requested, 16 states dele-
gated processing authority entirely to school
officials, while another 6 states assigned initial
responsibility to schools to process religious
or philosophical exemptions. Therefore, school
nurses in particular have an important role in
maintaining exemption records and providing
immunization information.
19
Although there are no data indicating that
home-schooled children are underimmunized
or that their parents subscribe to a particular
philosophy regarding immunization, our sur-
vey results indicated that only 9 states had a
mechanism to assess the vaccination status of
these children. Because many home-schooled
children participate in public school activities,
attention should be given to the immunization
status of these children to reduce the likelihood
of transmission of vaccine-preventable diseases.
Limitations of this study stem primarily
from the difficulty in determining the exemp-
tion groups for states. The methods used to
keep records varied among states; there is no
federal tracking of exemptions. Also, the ex-
emption data for some states include medical
exemptions. Salmon et al. determined that the
average percentage of medical exemptions is
.16%, which should not have substantially af-
fected the placement of states into our exemp-
tion groups.
12
However, the observed associa-
tion between frequency of exemptions and
complexity of requirements in the exemption
process may be due to adoption of simple pro-
cedures to limit administrative burden in re-
sponse to existing high numbers of exemption
requests.
Whereas earlier generations of parents
experienced the seriousness of vaccine-pre-
ventable diseases, young parents today may
not view these diseases with the same con-
cern and therefore may be inclined to ques-
tion the need to vaccinate. The existence of
mandatory vaccination policies, even with
exemptions available, compels parents ei-
ther to fulfill immunization requirements or
to take the necessary steps to file an ex-
emption.
21
The results of this study suggest
that in many states, the actions required to
obtain an exemption are simpler and less
time consuming than the effort needed to
meet the immunization requirements. The
process of obtaining an exemption must
properly reflect the importance that society
has accorded immunization through its
laws.
Contributors
J. S. Rota, D. A. Salmon, and E. J. Gangarosa planned
the study. J. S. Rota analyzed the data and wrote the
paper. All authors contributed to the design and con-
tent of the survey instrument, interpretation of the
results, and writing of the manuscript.
Acknowledgments
We thank Dennis O’Mara for guidance and assistance
with the survey. We also thank Jennifer Von Bargen
for discussions and advice and the state immuniza-
tion program managers for helpful comments.
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    Background Vaccination coverage among children entering kindergarten in the United States is high, but interstate variations exist. The relationship between state immunization laws and vaccination coverage has not been fully assessed. We evaluated associations of state laws on both MMR and DTaP vaccination coverage, and exemptions to school immunization requirements. Methods We conducted a retrospective, longitudinal analysis of the effect of state immunization laws on vaccination coverage and exemptions among US kindergarteners from SY 2008 to SY 2014. The primary outcome measures were state-level kindergarten entry vaccination coverage rates for 2-dose measles, mumps and rubella (MMR) and 4-dose DTaP vaccines. Secondary outcome measures included rates of state-level exemptions (i.e., medical, religious, philosophical) to school immunization requirements. Results We found that state policies that reference Advisory Committee on Immunization Practices recommendations were associated with 3.5% and 2.8% increases in MMR and DTaP vaccination rates. Health Department-led parental education was associated with a 5.1% and 4.5% increase in vaccination rates. Permission of religious and philosophical exemptions was associated with a 2.3% and 1.9% decrease in MMR and DTaP coverage, respectively, and 1.5% increase in both total exemptions and non-medical exemptions, respectively. Conclusions We found higher vaccination coverage and lower non-medical exemption rates for MMR and DTaP vaccines in states adopting ACIP guidelines for school entry. Adherence to these best practices was a successful strategy to increase vaccination coverage and reduce vaccination exemptions.
  • Article
    Background: In 2015, Michigan implemented an education requirement for parents who requested nonmedical exemptions from school or daycare immunization mandates. Michigan required parents to receive education from public health staff, unlike other states, whose vaccine education requirements could be completed online or at physicians' offices. Methods and findings: Results of focus group interviews with 39 of Michigan's vaccine waiver educators, conducted during 2016 and 2017, were analyzed to identify themes describing educators' experiences of waiver education. The core theme that emerged from the data was that educators changed their perception of the purpose of waiver education, from convincing vaccine-refusing parents to vaccinate their children to promoting more diffuse and forward-looking goals. Conclusions: Michigan, and other communities that require vaccine waiver education, ought to investigate whether and how waiver education contributes to public health goals other than short-term vaccination compliance. Research shows that education requirements can decrease nonmedical exemption rates by discouraging some parents from applying for exemptions, but further studies are needed to identify ways in which waiver education can promote other public health goals, while minimizing costs and burdens on staff.
  • Article
    Full-text available
    Some communities that exempt parents from vaccine mandates have recently reformed their exemption policies by eliminating nonmedical exemptions, allowing nonmedical exemptions only for parents who object to vaccination for religious reasons, or making exemptions more difficult to obtain. We argue against eliminating nonmedical exemptions because there are weighty moral reasons to offer these exemptions and because eliminating them will likely have unfortunate social and political consequences. We also argue against allowing nonmedical exemptions only for parents who object to vaccination for religious reasons, on the grounds that doing so is likely to be unfair or ineffective. We conclude that nonmedical exemptions should (continue to) be available to people who object for both religious and secular reasons, and that the best way to decrease exemption rates is to make the application process more burdensome. We illustrate our arguments with examples of recent policy changes in three US states.
  • Article
    Introduction: Little is known about associations between the reasons parents refuse or delay vaccines for their children, their responsiveness to vaccine counseling, and their children's vaccination status at various ages. Since 2015, Michigan has required parents to attend education sessions at local health departments to receive nonmedical exemptions. This requirement provides an opportunity to study otherwise opaque aspects of vaccine refusal. Methods: In 2017 and 2018, researchers analyzed a combined data set that included electronic medical records (n=4,098) generated by one Michigan health department during 2015 immunization education sessions, and immunization records from an August 2016 report of the Michigan Care Improvement Registry immunization registry. Analyses employed difference of proportions and ANOVAs to explore group differences in vaccination behaviors after education sessions and on-time vaccination status at various ages. Results: Children whose parents stated a commitment to an alternative schedule at the education session subsequently received a vaccine their parents had refused at a much higher rate (39.2%) than did children whose parents refused for reasons of religion (4.4%), concerns about the risks of vaccines (8.1%), or beliefs that vaccines provide little benefit (10.5%). Conclusions: Different reasons for refusal are associated with different patterns of vaccination behavior. Furthermore, results suggest that education sessions may overcome vaccine refusal in some cases, and that distinct refusal reasons mark real differences in parental motivations regarding vaccination choices. These differences in parental motivations may indicate the existence of different sites for potential pro-vaccination interventions.
  • The introduction of punitive measures to control outbreaks of measles in Europe has sparked debate and public protest about the ethical justification of penalties and exclusionary processes for non-immunisation. This article advances an ethics framework related to compulsory vaccination policies, which we use to analyse three case studies: of mandatory policies that are enforced by fines; of policies that require vaccination for the provision of social goods; and of community-led policies in which communities themselves decide how to enforce vaccination compliance. We report on contemporary, ongoing and past measures that have been used to increase vaccine uptake, consider their rationale and the related public responses, elaborate on socio-cultural and contextual influences, and discuss the ethical justification for mandatory vaccination. We argue for a measured approach that protects fundamental human rights to evidence-based information and medical counsel to support health decision making and that simultaneously raises awareness about the role of immunisation in protecting the wider community. We think more emphasis needs to be placed on immunisation as a means of promoting social good, reducing harm and protecting vulnerable groups.
  • Chapter
    This chapter presents an argument for compulsory vaccination and against allowing non-medical vaccine exemptions. The argument is based on the idea that the proper aim of vaccination policies should be not only herd immunity but also a fair distribution of the burdens entailed by its realization. I argue that a fairness requirement need not and should not be constrained by a principle of liberty and a principle of least restrictive alternative. Indeed, I argue how compulsory vaccination is more successful than other types of vaccination policies at satisfying the principles of fairness, least restrictive alternative, and maximizing expected utility, once these principles have been properly understood.
  • Article
    OBJECTIVES: In 2015, California passed Senate Bill 227 (SB277), eliminating nonmedical vaccine exemptions for school entry. Our objective for this study was to describe the experiences of health officers and immunization staff addressing medical exemption requests under SB277. METHODS: We conducted semistructured telephone interviews between August 2017 and September 2017 with health officers and immunization staff from local health jurisdictions in California. Interviews were recorded, transcribed, and analyzed for key themes. RESULTS: We conducted 34 interviews with 40 health officers and immunization staff representing 35 of the 61 local health jurisdictions in California. Four main themes emerged related to experiences with medical exemptions: (1) the role of stakeholders, (2) reviewing medical exemptions received by schools, (3) medical exemptions that were perceived as problematic, and (4) frustration and concern over medical exemptions. Generally, local health jurisdictions described a narrow role in providing support and technical assistance to schools. Only 5 jurisdictions actively tracked medical exemptions received by schools, with 1 jurisdiction facing a lawsuit as a result. Examples were provided of medical exemptions that listed family history of allergies and autoimmune diseases as contraindications for immunization and of physicians charging steep fees for medical exemptions. Participants also reported concerns about the increase in medical exemptions after the implementation of SB277. CONCLUSIONS: Participants reported many challenges and concerns with medical exemptions under SB277. Without additional legal changes, including a standardized review of medical exemptions, some physicians may continue to write medical exemptions for vaccinehesitant parents, potentially limiting the long-term impact of SB277.
  • Chapter
    The story of the anti-vaccination movements, which have opposed vaccinations for health, religious and political reasons, is a story that is as old as the very practice of inoculating smallpox (Moulin 1996). In this long story, however, there has not been a single case where the movements have raised fears that the scientific community has deemed as having any grounds. However, they have at times reached results both in a legal context, obtaining in some cases exemption from compulsory vaccinations, and in the context of the pharmaceutical production. In one case, they succeeded having a preservative, unjustly deemed toxic, eliminated. Similar results, as will be seen, represent an apparent victory because they have not given any effective advantage to the anti-vaccination movements and, most importantly, at times they have even decreased herd immunity by causing new outbreaks of epidemics.
  • Article
    Norman Begg and colleagues assess how adverse publicity damages vaccination programmes Once again the media have succeeded in denting parents' confidence in childhood immunisation. Coverage of the first dose of MMR vaccine in the United Kingdom fell last quarter after adverse publicity in the press linking MMR vaccine to Crohn's disease (Communicable Disease Report 1998;8:41). The national fall in vaccine coverage was 1%, although in 25 (20%) districts and health boards coverage fell by 2% or more. Altogether, about 2000 fewer children were vaccinated than in the previous quarter. The weight of scientific evidence has subsequently shown that these media reports were unfounded (BMJ 1998;316:166) and that there is no causal link between MMR vaccine and Crohn's disease. Nevertheless, the damage to parents' confidence has been done. The press rarely give …
  • Article
    The pre-inoculation program review of the school immunization records in fall, 1974 found that only 60 per cent of the 63,000 children in the Cincinnati primary school system were adequately immunized. Following a program based upon their legal authority to require immunizations, the Board of Health in collaboration with the Board of Education was able to obtain in a two-year effort a 91 per cent immunization level.
  • Article
    Achieving fully immunized status in the nation's pediatric population remains an elusive goal. A new campaign is underway to improve immunization coverage, and the nation's schools are logical sites to implement these projects.
  • Article
    In my article that appeared in the May 1991 issue of the American Journal of Diseases of Children,1 I mentioned several factors responsible for the low levels of immunization in inner-city preschool children, including the lack of a uniform data system, missed opportunities, overinterpretation of contraindications, and administrative barriers. I recommended the development of an effective tracking system, parent education, removal of barriers and increased access to services, incentives (positive or negative), and provider education. At least 10 actions and initiatives that have occurred through the end of 1992 should help us achieve our goals. They include the following: Direct involvement of the president. On June 13,1991, and again on May 11, 1992, President George Bush held Rose Garden ceremonies emphasizing White House concern about low immunization levels in preschool children. The first of these ceremonies led to visits to six cities by the highest-level federal health officials: the
  • Article
    Full-text available
    Data collected by the Immunization Unit of the California Department of Health Services from 1979 to 1987 were analyzed to determine the effects of changes in state policy on the immunization levels of children in California. By December 1986, 90% of all children entering kindergarten in California were adequately immunized, representing a 15% increase from 1979. Although California has shown substantial improvements, it still lags behind the national weighted average. Even with high levels of immunization at kindergarten entry, many toddlers of 7 months and 2 years old remain inadequately immunized. Children immunized solely in the private sector were more adequately immunized than those served by public health clinics; the public-private difference for infants aged 7 months was nearly twofold.
  • Article
    There is a tendency for governments to decide whether or not to offer routine vaccination on the basis of arguments of financial cost, whereas individuals decide whether or not to accept vaccination on the basis of their perception of the risks involved. Furthermore, some vaccines impart, or appear to impart, a degree of indirect protection to nonvaccinated individuals in the community. For both of these reasons, public motives concerning vaccination differ from those of the individual. The quantitative implications of these differences are explored in this paper. It is found that, under a broad range of conditions, rational informed individuals would "choose" a lower vaccine uptake than would the community if it acted as a whole. The result is applied to the pertussis situation in England over the past 30 years and provides a measure of a public's changing perception of the risks associated with that vaccine.
  • Article
    A review of State compulsory immunization laws revealed that 26 States and the District of Columbia now have legislation requiring immunization against a disease or diseases as a prerequisite to school entry. The legal base for such laws is the U.S. Supreme Court ruling of 1905 that upheld the constitutionality of the Massachusetts compulsory law on smallpox vaccination. Although initial State legislation on compulsory immunization pertained to smallpox only, by the late 1930's compulsory laws including other diseases were enacted. Analysis of the structure of State laws on compulsory immunization revealed that most State laws of this type now require compliance from the parents of children in public, private, or parochial schools. Almost all diseases that can be prevented by immunization are included. The children of parents who object because of medical or religious reasons are exempted. The penalty for non-compliance is considered a misdemeanor and usually is not enforced. The value of State compulsory immunization laws continues to be controversial. Arguments for and against such legislation are analyzed.
  • Article
    Of 54 federal immunization project areas in the United States, 13 areas with low measles incidence rates in 1977 and 1978 and 10 with high measles incidence rates were compared for differences in surveillance systems, demography, vaccine utilization, school immunization laws, and immunity levels. There was no significant difference between the low incidence and high incidence group for any examined parameter of demographic characteristics, vaccine utilization, or surveillance systems. However, in the low incidence group, school immunization laws were found to be more comprehensive and more strictly enforced with a statewide policy of exclusion from school of noncompliant students. Furthermore, immunization levels were similar for two-year-olds in both groups but were significantly higher for school entrants in the low incidence group. In all public health efforts to control or eliminate measles, priority should be given to establishing and strictly enforcing comprehensive school immunization laws.