COMMENTARY

Vaccine Exemptions: Time to Tighten the Rules

Sandra Adamson Fryhofer, MD

Disclosures

July 23, 2015

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Hello. I'm Dr Sandra Fryhofer. Welcome to Medicine Matters. The topic: a new policy[1] on nonmedical exemptions to immunization from the American Medical Association (AMA). This segment also includes highlights of a joint report from the AMA Council on Science and Public Health and AMA Council on Ethics and Judicial Affairs, presented to the House of Delegates at its June 2015 meeting. Here's why it matters.

Immunizations are life-savers. Because of them, we've eliminated the spread of epidemic diseases like smallpox and polio. When you get vaccinated, you not only protect yourself, you also help prevent spread of disease to others.

High vaccination rates promote herd immunity which protects the unvaccinated, the undervaccinated, as well as those at highest risk for severe disease, including little babies, pregnant women, people with immune system problems, and people with chronic diseases. Thus, immunization benefits not only the person receiving the vaccine but also the wider community.

We have laws that require immunizations before attending public schools. In some states, immunization can even be a condition of employment. For example, Alabama, Colorado, and New Hampshire have mandated flu vaccination for all healthcare personnel.

The Supreme Court has affirmed that states can mandate immunizations, but they also must allow for medical exemptions. For example, immunocompromised patients should not receive live virus vaccines. Medical exemptions also apply to anyone who's had a severe allergic reaction to a previous dose of a vaccine.

Most states have taken vaccine exemptions a step further and also allow for nonmedical exemptions—for religious, personal, or philosophical reasons. Currently, all states, with the exception of West Virginia and Mississippi, allow for religious exemptions. Until recently, 19 states also made allowances for personal-belief exemptions. However, at the end of May, Vermont's governor signed a bill removing philosophical exemption from vaccine choice. California may be next if the governor signs a bill passed by the assembly. [Editor's note: After recording, the Governor of California did sign a bill eliminating the state's personal-beliefs exemption for school vaccine requirements.] The concept of nonmedical exemptions can be very confusing. Most states aren't very specific about what actually constitutes a religious or personal exemption.

Over the past 20 years, the number of nonmedical exemptions for going to school has almost doubled due to philosophical or religious reasons. In states that allow both, 90% were for philosophical reasons. (Unpublished data: Joint Report of the Council on Science and Public Health and the Council on Ethical and Judicial Affairs; 2015) At the same time, it seems that getting nonmedical exemptions has gotten easier and is more widely available. In some states, parents may have to personally write a letter of explanation. Sign-off by a local health department official may be required. The form may have to be notarized. In other states, all you have to do is sign a pre-written statement on the school form. So it may actually be easier to claim the exemption than to go to the trouble of having the form filled out by a healthcare professional.

One research trend does seem clear: The easier the process, the higher the exemption rates. Certain community pockets have been found to have very high rates of nonmedical exemptions.

Why do some people refuse these lifesaving vaccines? An estimated 1 in 8 parents have refused at least one vaccine recommended for their child. Some parents have become "vaccine hesitant." Exploring the reasons is crucial. Perhaps they don't realize what life was like in the prevaccine era, when many children died. Other reasons include:

  • Lack of information and lack of understanding of how vaccines work.

  • Misinformation, including fear of autism. They may not know that the study linking vaccines to autism was found to be fraudulent; the results were made up. The study has been retracted. Many studies have shown that vaccines do not cause autism!

  • Some parents may have safety concerns. They may not realize that there's an extensive body of credible scientific evidence that supports the safety and effectiveness of immunizations.

For physicians, immunization is a duty. Unless medically contraindicated, the more transmissible the disease, the greater the risk to our patients and the stronger our duty to accept immunization. We physicians also serve as role models for our patients. When we get vaccinated, it sends a powerful and motivating message to our patients.

Here's a quote from the joint report:

Protecting community health requires that individuals not be permitted to opt out of immunization solely as a matter of convenience, whim, or misinformation. The recent measles outbreak at Disneyland - the recent mumps outbreak in the National Hockey League - the recent surge in pertussis cases that has killed little babies - all demonstrate why this is a timely and important public health issue.

At its June 2015 meeting, the AMA House of Delegates adopted new policy that tightens limitations on vaccination opt-outs. The House voted to support legislation eliminating nonmedical exemptions for federally funded educational programs for children. The House of Delegates also voted to support state medical societies in eliminating nonmedical exemptions for childcare and school attendance in state statutes.

For Medicine Matters, I'm Dr Sandra Fryhofer.

Author's Update:
Eliminating nonmedical exemptions for vaccination is now American College of Physicians (ACP) policy. In a communication to members sent on July 29, 2015, the ACP Board of Regents announced new recommendations adopted at its summer meeting.

The ACP Board of Regents said it supports:

  1. The immunization of all children, adolescents, and adults, according to the recommendations and standards established by the US Advisory Committee on Immunization Practices (ACIP), the National Vaccine Advisory Committee (NVAC), and the Centers for Disease Control and Prevention (CDC)

  2. State laws designed to promote all recommended immunizations

  3. States passing legislation to eliminate any existing exemptions, except for medical reasons, from their immunization laws

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