Measles Resurgence Makes for Busy Year in Vaccination Policy

August 22, 2019|12:05 p.m.| ASTHO Staff

August is National Immunization Awareness Month, an opportunity to highlight the importance of vaccinations for people of all ages. Vaccination can prevent certain deadly diseases in infants, children, teens, adults, and travelers of all ages. When enough people are vaccinated against a disease, the spread of the disease is limited and exposure decreases. When too many people remain unvaccinated, perhaps due to a lack of access to vaccines or because they are hesitant, vaccine-preventable diseases remain a threat. For example, 2019 saw the greatest number of measles cases reported in the United States since 1992 and since measles as an endemic disease was declared eliminated from the United States in 2000.

With the striking number of measles cases across the country, reaching 1203 by Aug. 15, state policymakers are exploring a variety of ways to increase vaccine coverage and prevent future outbreaks. Legislative trends include maintaining or increasing vaccine coverage through school attendance requirements and eliminating non-medical exemptions to vaccine requirements. In addition, ASTHO reviewed the public health authority to exclude unvaccinated children from schools during a disease outbreak and summarized some of the legal challenges brought against public health orders issued in response to measles outbreaks.

Legislation Eliminating Non-Medical Vaccine Exemptions

Over the past decade, the number of non-medical exemptions has increased, especially in states that allow both religious and philosophical exemptions. Many communities in the United States where non-medical exemptions are clustered have lower-than-ideal vaccination rates among school children. Bills in several states have sought to do away with non-medical exemptions for school vaccination requirements and allow only medical-based exemptions. Soon after state legislative sessions began and the measles outbreak emerged, ASTHO noted several bills to eliminate non-medical exemptions for school vaccinations.

Maintaining and increasing vaccine coverage can be achieved many ways, including by conditioning school attendance on evidence of vaccination. All states require children who attend school to show evidence of immunity against a set of vaccine-preventable diseases. This is typically done by presenting the child’s vaccination records. For those whom vaccines pose a medical risk, states allow an exemption to the school vaccine requirement. A vast majority of states also allow non-medical exemptions, often based on an asserted religious, philosophical, or personal belief of the parents or child opposing vaccinations.

However, the number of states allowing exemptions is beginning to shrink. By the middle of 2019, some of the bills to eliminate non-medical vaccine exemptions made their way to law. Maine and New York joined California, Mississippi, and West Virginia as the only states without non-medical exemptions for school vaccination requirements. In Washington state, the philosophical exemption was eliminated for measles, mumps, and rubella vaccine.

Legislation Excluding Unvaccinated Children from Schools

When a disease outbreak occurs, those who are unvaccinated and who live in communities with low vaccination rates are at a higher risk for infection. In order to stop the spread of measles, children who are not vaccinated are often required to stay home from school and school-related functions until the outbreak ends or they are vaccinated. Many states have laws expressly allowing state and local health officials or school administrators to temporarily exclude children from school during an outbreak.

Early in 2019, ASTHO reviewed the legal authority of state and local public to exclude unvaccinated children from school activities. Many states set out this authority in their statutes and for a health official who does not have express authority to exclude children from school during an outbreak, doing so would be allowable under the official’s general authority to protect the public’s health and well-being, or under quarantine and isolation laws. Excluding unvaccinated children from school during disease outbreaks has been challenged by parents. However, ASTHO noted court decisions affirming such actions as a valid exercise of public health authority.

Legal Challenges to Public Health Orders

As public health agencies began to issue public health orders to address measles outbreaks, ASTHO noted the legal challenges being brought against them. Courts can play a big role during outbreaks of vaccine-preventable diseases. While state and local public health authorities are established legislatively and exercised by the executive branch through state and local health agencies, the judicial branch is sometimes called upon to review the use of public health authority. The legal challenges to public health orders in New York revealed some of the issues public health can face when in court during a disease outbreak. It also illustrates the ever-present need for public health agencies to exhibit legal preparedness.

With the increased use of non-medical vaccine exemptions leading to more outbreaks of measles and other preventable diseases, ASTHO expects more states to eliminate non-medical exemptions. In addition, as we move into the fall and winter months, effective vaccination practices and legislation will be vital to reduce the risk of influenza, especially among populations most vulnerable to serious illness or death—i.e., children under the age of five and adults aged 65 years and older. While effectiveness varies, recent studies show that vaccination reduces the risk of flu by 40 to 60 percent and also reduces the risk of hospitalization and time away from school or work. As 2019 unfolds, ASTHO will continue to monitor legislative activity increasing vaccine coverage for preventable disease and illness.