Abuse of Vaccine Exemptions

Every state has laws mandating vaccines to attend school and daycare.

Every state also allows exemptions to those mandates, including:

• medical exemptions – 50 states
• religious exemptions – 45 states
• personal belief exemptions – 19 18 states

The way that  these laws and exemptions are set up leaves a lot of room for abuse though.

Abuse of Religious Exemptions

How many religions are actually against kids getting vaccinated?

That’s right, almost none.

So why are there so many religious vaccine exemptions in most states, especially in states that don’t have a personal belief exemption?

Right again.

Folks who don’t want to vaccinate their kids, and can’t use a personal belief exemption, just say that vaccinating them would be against their religion.

Abuse of Medical Exemptions

There are some children who shouldn’t be vaccinated.

These children can get a true medical exemption to one or more vaccines because they have a real contraindication or precaution to getting vaccinated.

“If a child has a medical exemption to immunization, a physician licensed to practice medicine in New York State must certify that the immunization is detrimental to the child’s health. The medical exemption should specify which immunization is detrimental to the child’s health, provide information as to why the immunization is contraindicated based on current accepted medical practice, and specify the length of time the immunization is medically contraindicated, if known.”

Dear Colleague letter regarding guidelines for use of immunization exemptions

Fortunately, these medical reasons to skip or delay vaccines are not very common and are often temporary. They can include the contraindications and precautions listed in the package insert for each vaccine and by the Advisory Committee on Immunization Practices, with the most common medical exemptions being:

• a severe allergic reaction to a previous dose
• a severe allergic reaction to a vaccine component
• a known severe immunodeficiency and live vaccines
• a moderate or severe acute illness with or without fever (precaution)
• a progressive neurologic disorder (precaution)

Most other things are “incorrectly perceived as contraindications to vaccination” and should not be a medical exemptions, including having :

• a mild acute illness with or without fever
• a mild to moderate local reaction
• relatives with allergies
• a family history of seizures
• a stable neurologic condition
• an autoimmune disease
• a family history of an adverse event after DTP or DTaP administration

A medical exemption can also exist if your child already had the disease and so has natural immunity. In most cases, except for chicken pox disease, titers will likely need to be done to prove that your child already has immunity.

Stopping the Abuse of Vaccine Exemptions

We know that vaccine exemptions are being abused.

How do you stop it?

“Permitting personal belief exemptions and easily granting exemptions are associated with higher and increasing nonmedical US exemption rates. State policies granting personal belief exemptions and states that easily grant exemptions are associated with increased pertussis incidence.”

Omer et al on Nonmedical exemptions to school immunization requirements: secular trends and association of state policies with pertussis incidence.

You likely have to make it harder to get a vaccine exemption.

Strong exemption laws, which are needed in many states, make it clear that:

• many exemptions are temporary
• medical exemptions are based on ACIP guidelines, current accepted medical practice, and evidence based medicine – not anecdotes
• religious exemptions specifically exclude philosophical exemptions and must reflect a sincere religious belief
• exempted students will be excluded from school during outbreaks
• exemptions should include a signed affidavit that is notarized
• exemptions should be recertified each year
• a separate exemption application will be needed for each vaccine

Getting an exemption shouldn’t be easier than getting vaccinated! And it should include some degree of education against the myths and misinformation that scares parents away from vaccinating their kids.

“Because rare medically recognized contraindications for specific individuals to receive specific vaccines exist, legitimate medical exemptions to immunization requirements are important to observe. However, nonmedical exemptions to immunization requirements are problematic because of medical, public health, and ethical reasons and create unnecessary risk to both individual people and communities.”

AAP on Medical Versus Nonmedical Immunization Exemptions for Child Care and School Attendance

You could also get rid of nonmedical vaccine exemptions.

Of course, for that to work, you can’t allow just anything to count as a medical exemption.

“Review of all medical exemption requests will be conducted at the Mississippi State Department of Health by the State Epidemiologist or Deputy State Epidemiologist.”

Mississippi Medical Exemption Policy

In Mississippi, for example, where medical exemptions are reviewed and approved by the State Epidemiologist or Deputy State Epidemiologist, there were just 208 medical exemptions in the whole state during the 2016-17 school year.

In some states, rates of medical exemptions might be six or seven times higher. This is mostly seen in states that don’t allow personal belief exemptions and make it difficult to get a religious exemption.

That seems to be the case in Nebraska, where there are no personal belief exemptions and you have to submit a notarized statement to get a religious exemptions. Their high rates of medical exemptions likely reflect some abuse and the fact that medical exemptions aren’t reviewed or approved by anyone, they just reflect “that, in the health care provider’s opinion, the specified immunization(s) required would be injurious to the health and well – being of the student or any member of the student’s family or household.”

As we are seeing, that simply invites vaccine exemption abuse.

Very few states currently require that exemption applications go to the health department for review. Those that do include Alabama, Arkansas, Michigan, Minnesota, Mississippi, and West Virginia.

California is notably absent. I guess they didn’t see the potential for abuse when they passed their latest vaccine law. I mean, who could have guessed that doctors would actually be selling medical exemptions to parents based on unrelated conditions, like a family history of diabetes, celiac disease, or autism?

At the very least, until we have stronger exemption laws, parents who want to get a nonmedical exemption should acknowledge that they understand the risks they are taking when they skip or delay their child’s vaccines.

What to Know About Abuse of Vaccine Exemptions

While medical exemptions are necessary for kids who have true contraindications to getting vaccinated, stronger laws can help decrease the abuse we see in medical, religious, and personal belief vaccine exemptions.

More Information on Abuse of Vaccine Exemptions

• ACIP – Contraindications and Precautions
• CDC – Who Should NOT Get Vaccinated with these Vaccines?
• AAP – Medical Versus Nonmedical Immunization Exemptions for Child Care and School Attendance
• CDC – State School and Childcare Vaccination Laws
• School Exemption Laws by State
• States With Religious and Philosophical Exemptions From School Immunization Requirements
• Eliminating Personal Belief Exemptions for Vaccines
• Laws Limiting Vaccine Exemptions Work
• Exemptions Permitted For State Immunization Requirements
• CDC – Vaccination Coverage for Selected Vaccines, Exemption Rates, and Provisional Enrollment Among Children in Kindergarten — United States, 2016–17 School Year
• Dear Colleague letter regarding guidelines for use of immunization exemptions
• What is an Exemption and What Does it Mean?
• Vaccination Exemptions
• Mississippi Medical Exemption Policy
• How Many People Aren’t Vaccinating Their Kids in Your State?
• There is a Whole Cottage Industry of Doctors Helping Parents Skip Their Kids’ Vaccines
• Change in Medical Exemptions From Immunization in California After Elimination of Personal Belief Exemptions
• California Doctors Are Advertising Ludicrous Medical Exemptions to Anti-Vaxxers
• After SB 277, medical exemptions for sale, courtesy of Dr. Bob Sears and other antivaccine quacks
• Why hasn’t California cracked down on anti-vaccination doctors?
• After California got rid of personal exemptions for vaccines, medical exemptions went way up
• Why You Shouldn’t Shop for Medical Exemptions
• Colorado’s Non-Medical Vaccine Exemption Form Ruffles Anti-Vaccine Feathers
• Using religion to avoid vaccination
• Religious Exemption: The Law – a Summary
• Non-Medical Vaccine Exemptions: Balancing Parental Rights and Public Health
• Praying, in Vain, for Exemption
• Religious exemptions for vaccination – abuse and reform
• Mandatory School Vaccinations: The Role of Tort Law
• Study – Nonmedical exemptions to school immunization requirements: secular trends and association of state policies with pertussis incidence.
• Study – Rising rates of vaccine exemptions: problems with current policy and more promising remedies.
• Study – A longitudinal analysis of the effect of nonmedical exemption law and vaccine uptake on vaccine-targeted disease rates.
• Legislative Prescriptions for Controlling Nonmedical Vaccine Exemptions
• Why we should eliminate personal belief exemptions to vaccine mandates.
• Measles Outbreak as a Catalyst for Stricter Vaccine Exemption Legislation.
• New Study Emphasizes Harm of Vaccine Refusals
• NY federal court hands triple loss to anti-vaccination ideology
• Battles over non-medical exemptions to vaccination festering in state legislatures

Last Updated on March 10, 2019