Least Effective Vaccination Exemption Laws

School vaccination requirements have traditionally helped boost immunization rates, but in most states, parents may seek exemptions for religious, medical, or philosophical reasons.

Some states make it easy for parents to opt out of vaccinations. In these states, parents can essentially check off a box if they wish to forgo vaccinations for their child.

In other states, it is harder for parents to opt out. There may be punishment for the child, such as expulsion, or for the parent, such as criminal charges of negligence.

To identify states with the strictest and most lenient vaccination exemptions, University of Georgia researchers used data from the State Vaccination Requirements and Exemption Law Database and the US Centers for Disease Control and Prevention’s annual school assessment reports from 2002 to 2012. They pinpointed the 18 states with the most effective exemption policies—meaning, stricter laws—and the 9 states with the least effective policies.

The states with the most effective vaccination exemption policies were Montana, Nevada, New Mexico, South Dakota, Nebraska, Kansas, Iowa, Missouri, Arkansas, Indiana, Kentucky, Tennessee, Alabama, Florida, North Carolina, Delaware, Maryland, and Massachusetts.

Those with the least effective policies were Washington, Idaho, Utah, Colorado, Texas, Minnesota, Wisconsin, Michigan, and Vermont.

Meanwhile, Mississippi and West Virginia were not given a rating because they do not allow nonmedical exemptions. The rest of the states were categorized as either “less effective” or “somewhat effective.”

Having a state health department approve applications for nonmedical vaccination exemptions was strongly linked with fewer vaccine exemptions, mainly because these departments have an interest in maintaining herd immunity, according to the researchers.

Allowing individuals to choose specific vaccines to be exempt from, rather than a blanket exemption for all vaccines, was also associated with a lower rate of exemptions. Criminal and civil punishment, such as expulsion from school and charges of negligence for the parents, reduced exemption rates by 0.6%, as well.

“Such policies could be of particular interest to policy makers interested in decreasing the exemption rate in their state,” the researchers said.

States that allowed philosophical objections to vaccinations had exemption rates that were 0.1% higher than those that prohibited them. These objections may include doubts about the efficacy of vaccines or the belief of a link between autism and vaccines, even though there has been no scientific evidence of this association.

When the researchers looked at pertussis incidence, specifically, they found that states with more stringent exemption measures had an average incidence of 7.30 cases from 2002 to 2012, while those with looser exemption policies had an incidence of 16.06 cases. Looking only at 2012, pertussis incidence was 16.45 in stricter states and 54.19 in less strict states.

“As vaccination exemption rates fall well below the levels required for herd immunity in many areas, our findings suggest that states with weaker overall exemption standards may wish to reconsider those vaccine laws and policies,” the researchers concluded.

Study author W. David Bradford, PhD, told Pharmacy Times that pharmacists are uniquely well-positioned to affect their patients’ health behaviors. This is because patients have more frequent contact with pharmacists than nearly any other health care professional, he said.

“So, it seems to me that if pharmacists can find ways to work in positive health messages, such as ‘make sure to get your child vaccinated,’ then that could make a significant contribution to public health,” Dr. Bradford said.

Dr. Bradford added that those who should not be vaccinated due to compromised immune systems are very small in number, but they still depend on herd immunity to avoid contracting serious and preventable diseases. Pharmacists can help boost herd immunity by discouraging patients from seeking vaccination exemptions and promoting vaccination, he said.

“This will in part involve convincing parents that there is no link between vaccines and conditions like autism, that the danger of temporary discomfort (very rare) from a vaccine is much, much lower than the danger of contracting whooping cough or measles, and that any philosophical disagreement with the notion of vaccination really should take a back seat to the societal imperative of keeping vulnerable people safe by maintaining herd immunity,” he said. “Really, philosophical objections should stop when they impose real costs and dangers on other people; not vaccinating your kids is just such a circumstance.”

The research was published in the August issue of Health Affairs.