Ensuring Vaccine Coverage with School Vaccination Requirements

June 19, 2019|3:51 p.m.| ASTHO Staff

With the number of measles cases across the country reaching a level not seen in nearly three decades, policymakers continue to explore a variety of ways to increase vaccine coverage and prevent future outbreaks. When enough people are vaccinated against a communicable disease, such as measles, the spread of the disease is limited and exposure to the disease decreases. This is particularly important for those who, because of age or a medical condition, cannot be vaccinated. This community-wide vaccine protection is known as herd immunity. The amount of coverage needed to reach herd immunity varies with the disease and often depends on the disease’s contagiousness. For example, measles, a highly contagious disease, requires a high rate of vaccination, between 93-95 percent by some estimates.

Maintaining and increasing vaccine coverage can be achieved through many ways, including the conditioning of school attendance on evidence of being vaccinated. 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 to whom vaccines pose a medical risk states allow an exemption to the school vaccine requirements. 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, that number is beginning to shrink.

At the beginning of 2019, three states (California, Mississippi, and West Virginia) did not permit any kind of non-medical exemption, allowing medical exemptions only. That number has nearly doubled over the past few weeks with Maine and New York becoming the latest states to limit school vaccine exemptions to medical reasons. The Maine legislation, which takes effect on September 1, 2021, repeals the state’s religious and philosophical exemptions (currently found at 20-A MRSA §6355(3)) while allowing any student who received a non-medical exemption before the law’s effective date to retain the exemption as long as evidence is provided that a healthcare provider was consulted about the benefits and risks of vaccinations. The New York legislation takes effect immediately, repealing the state’s religious exemption and makes no exception for students who currently have an exemption.

Washington state also considered legislation limiting its non-medical exemptions. While attempts to repeal the state’s philosophical exemption for all required school vaccines failed, the legislature did pass a bill to remove the philosophical, but not the religious, exemption to the measles, mumps, and rubella vaccine. The bill also allowed a child to attend school without proof of vaccination if there was evidence of disease immunity through an antibody titer or prior disease history. However, this provision was ultimately vetoed by the governor as being too broad and unnecessary since the state already allows the use of reliable antibody titer tests.

Even in states which only allow medical exemptions research shows the need for continued policy development to ensure adequate vaccine coverage. Since California’s repeal of its non-medical exemption in 2015, one study looking at the law’s implementation found problems with the medical exemptions that were granted, including suspicious conditions being listed as the basis for the exemption, physicians advertising and charging money for medical exemptions, as well as discrepancies in the types of healthcare providers signing the exemption requests. To fix the suspected misuse of medical exemptions, a bill was introduced in the legislature providing the state health agency authority to review and approve the requests for medical exemptions.

Giving the state health agency this role and responsibility is not so unusual. In both West Virginia and Mississippi, the state health agencies review and approve medical exemption requests. West Virginia’s law authorizes the state health officer to appoint an immunization officer who can determine the validity of medical exemption requests while in Mississippi the state epidemiologist reviews the requests and signs the official exemption form. In Delaware, which allows both medical and non-medical exemptions, the state health agency is permitted to review and approve any medical exemption. Limitations on the state health agency’s ability to review and approve medical exemptions are also found. In Montana, a bill was introduced that would have prohibited the state health agency from reviewing medical exemption forms for the purpose of granting or denying the exemption.

In addition, the new Maine law that was discussed above prohibits the state health agency from adopting rules “establishing requirements for medical exemptions and rules requiring review, acceptance or rejection of medical exemptions.” Without adequate oversight of medical exemptions, Maine may end up facing the misuse of medical exemptions as observed in California. As shown by the incredible number of measles cases in 2019, public health and policymakers must remain alert when it comes to vaccine coverage. School vaccination requirements are one way to help increase and maintain vaccine coverage. With adequate vaccine coverage we can ensure that everyone within our community is protected from vaccine-preventable disease.

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