Vaccine exemptions scrutinized in wake of measles outbreaks: Non-medical exemptions re-examined
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* Kim Krisberg

Pediatrician Rupin Thakkar has testified at the Washington state Capitol in Olympia many times, but February was the first time he was accompanied by a security escort.

“That was a new experience for me,” said Thakkar, MD, president of the Washington Chapter of the American Academy of Pediatrics, who was at the Capitol to testify in support of a bill to narrow the state’s vaccine exemption laws. “But the scene that day was very...passionate.”

State lawmakers had introduced the bill in January, not long after officials in Clark County, Washington, announced a public health emergency in response to a measles outbreak that would grow to 71 cases before being declared over in late April. The bill became law in May, eliminating the option to claim a personal or philosophical exemption to rules that children be immunized with the measles-mumps-rubella vaccine for school and child care entry.

![Figure1](http://www.thenationshealth.org/https://www.thenationshealth.org/content/nathealth/49/5/1.3/F1.medium.gif)

[Figure1](http://www.thenationshealth.org/content/49/5/1.3/F1)

Michaella, who did not want her last name used, receives a measles-mumps-rubella vaccination at the Provo, Utah, County Health Department in April. The vaccination was the first that Michaella had ever received. Legislators in some states are moving to end non-medical vaccine exemptions as U.S. measles cases increase.

Photo George Frey, courtesy Getty Images

But getting the bill passed was a challenge, Thakkar said, even with a costly, vaccine-preventable outbreak happening just 100 miles away. Opponents of the bill offered dozens of amendments to water it down. The final law applies only to the MMR vaccine, which means parents can still claim personal and philosophical exemptions for other school immunization requirements.

“This was definitely a step in the right direction, but I think it’ll be a heavy lift to get rid of exemptions for other vaccines,” Thakkar told *The Nation’s Health.* “Sometimes, public health wins can come out of public health disasters.”

U.S. measles cases have reached a 25-year high this year, with the Centers for Disease Control and Prevention reporting 880 cases in 24 states as of May 17. At the same time, more than 100 vaccine-related bills were introduced across state legislatures, many of which would end nonmedical exemptions and widen vaccine access.

In New York, for example, where an ongoing measles outbreak hit 278 cases as of mid-May, state lawmakers proposed a bill repealing all nonmedical exemptions for child vaccines. But in Texas, where 15 measles cases were confirmed as of early April and vaccination rates are down, lawmakers filed a number of bills to make exemption easier, including proposals to allow nurses to sign off on exemptions and another to prevent the state health department from tracking exemption rates.

Opposition to vaccine requirements, even in the face of a potentially deadly disease, is almost as old as vaccines themselves, going back to the smallpox vaccine, said James Colgrove, PhD, MPH, interim chair and professor of sociomedical sciences at Columbia University Mailman School of Public Health.

“The problem is inherent to vaccines, which is that any successful vaccination program will eventually be a victim of its own success,” Colgrove told *The Nation’s Health.*

In a study published in December in APHA’s *American Journal of Public Health,* researchers examined 175 vaccine bills introduced in state legislatures between 2011 and 2017. They found that the volume of such bills increased over time, with 53% expanding access to exemptions and 47% limiting vaccine exemptions.

The good news is that 92% of the bills that made it into law narrowed exemptions. According to the National Conference of State Legislatures, every state currently allows for medical exemptions to child vaccine requirements, more than half allow religious exemptions and 16 states permit philosophical exemptions. Only four states — California, Maine, Mississippi and West Virginia — allow medical exemptions only.

Research shows that states with more lenient vaccine rules also tend to have lower rates of MMR vaccine coverage and higher rates of vaccine-preventable diseases. With that evidence, along with science on the lifesaving impacts of vaccines, public health advocates are working to engage hesitant parents in thoughtful discussions and at the same time stand up for strong, evidence-based vaccine laws. The dual efforts are difficult to juggle.

“It’s forcing people to take sides, and that’s not a healthy political discourse — not for public health, anyway,” said Kathleen Hoke, JD, director of the Network for Public Health Law’s Eastern Region. “One of the hallmarks of ethical public health policy is engaging the community. But when an issue of public health becomes this polarized, it makes it very difficult. And that’s terribly unfortunate.”

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[Figure2](http://www.thenationshealth.org/content/49/5/1.3/F2)

A sign warns people about measles in an ultra-Orthodox Jewish community in Williamsburg on April 10 in New York City. As measles cases spread in the community, the city’s mayor declared a public health emergency and mandated that Williamsburg residents be vaccinated against the disease.

Photo by Spencer Platt, courtesy Getty Images

Hoke, also a professor at the University of Maryland Carey School of Law, said philosophical vaccine exemptions began to increase in the 1990s as a way to relieve state officials of the constitutional entanglements that come with determining what is a “bonafide” claim of religious exemption.

Pushed on by anti-vaccine advocates, philosophical exemptions became law in 19 states by 2014. Then, in late 2014, a California measles outbreak linked to visitors at two theme parks sickened nearly 150 people and exposed the risks of lenient vaccine laws.

In response, California lawmakers eliminated exemptions based on personal beliefs, including those based on religious objections. Since then, the California law has withstood legal challenges, and the number of kindergartners who received all required vaccines went up nearly five percentage points since the 2014-2015 school year.

Recently, however, health officials in California have voiced concerns over a rise in medical exemptions and their lack of authority to review physician-issued exemptions. Legislation introduced this year would address such concerns, shifting the authority to grant medical exemptions to the California Department of Public Health.

In Texas, during the 2003-2004 school year only 2,300 students had vaccine exemptions, according to state health data. Then in 2003, the state passed a law allowing for exemptions based on reasons of conscience. Vaccine exemptions topped 64,000 in the 2018-2019 school year.

In May, a study published in *The Lancet Infectious Diseases* named four Texas counties among the 25 U.S. counties most likely to experience a measles outbreak.

“Legislatively, in Texas, there doesn’t seem to be a political appetite to have a constructive, fact-based, science-based discussion about the implications of the national measles outbreak,” Rekha Lakshmanan, MHA, director of advocacy and public policy at the Immunization Partnership, which educates and advocates on vaccine policy across Texas, told *The Nation’s Health.* “Even as (measles) cases were popping up in Texas this year, we saw legislation being introduced that would make it easier to get an exemption. It was just flabbergasting.”

Lakshmanan said Texas is home to an active anti-vaccine movement that is increasingly working to elect candidates with similar views to office. But while anti-vaccine forces are often the loudest voices in the room, she said the majority of Texans support strong vaccination laws. For example, a recent statewide poll from the University of Texas and *Texas Tribune* found that 78% of voters agree that vaccinations for diseases like measles and pertussis should be required.

“People who oppose vaccines really are a small fraction of the population, and most parents who are hesitant are just looking for good information,” Lakshmanan said. “But we all have to stop standing on the sidelines and expecting others to (stand up for vaccines). We all have to participate in the process.”

Policy can offer a more immediate fix to wavering vaccination rates, but a long-term strategy has to include ways to reach parents in a sea of electronic misinformation, said Nadine Gartner, JD, founding executive director of Boost Oregon. Launched in 2015, Boost Oregon uses strategies such as parent-to-parent education and physician-led workshops to reach vaccine-hesitant parents in the state, which is home to the highest kindergarten vaccine exemption rate in the U.S.

During the workshops, for example, physician presenters discuss how vaccines work and are manufactured, and answer questions about safety. Gartner said about half of attendees typically hear about the events via social media and the other half are referred by their health care providers. The point of the workshops is to inform, not to persuade, which Gartner said is likely key to their success. In post-workshop surveys, she reported that 99% of attendees said they intended to fully vaccinate their children.

“We need to change the culture when it comes to vaccination,” Gartner said. “If we don’t do that, we’ll continue to have generations of people who are fearful and suspicious of vaccines.”

In Washington state, as of mid-May, four new measles cases were identified that were unrelated to the outbreak in Clark County, where public health costs to contain the virus ended up topping $1.6 million, said Michele Roberts, MPH, CHES, director of the Office of Immunization and Child Profile at the Washington State Department of Health. She said the new law eliminating personal and philosophical MMR exemptions for children as well as for child care employees and volunteers is a “huge milestone” for vaccination efforts in the state, where MMR vaccination rates among kindergartners are below levels recommended for herd immunity.

“I think public health laws have traditionally been one of the most important drivers of health behavior,” Roberts told *The Nation’s Health*. “But this is a really unique time we’re living in and I don’t think we fully understand what’s going to happen.”

Roberts said there is some concern that people will try to get around the new vaccine law by seeking a religious exemption. But even if that happens, she said the state has a good chance at increasing vaccination rates to more protective levels. During the Clark County outbreak, demand for the measles vaccine skyrocketed among children and adults.

“When there’s an outbreak, people’s risk ratio changes — the risk becomes much more real,” Roberts said. “But we’re all still scared that we could be transitioning into a new normal for measles.”

For more information on U.S. measles cases and vaccinations, visit [www.cdc.gov/measles](http://www.cdc.gov/measles).

*   Copyright The Nation’s Health, American Public Health Association