The Impact of Non-Medical Vaccine Exemptions on Childhood Vaccination Rates

March 16, 2023 | Heather Tomlinson

A doctor prepares a happy toddler for a childhood vaccination.  ASTHO Health Policy Update banner in the upper rightVaccines are recognized as one of the ten greatest modern public health achievements for their role in substantially decreasing disease, hospitalization, death, and healthcare-associated costs. Established routine childhood vaccinations are part of every state’s school enrollment process as schools and childcare facilities are often the first-time children will be in large groups and exposed to vaccine-preventable diseases (VPDs). School vaccinations are crucial to maintaining high vaccination coverage in a community and keeping children protected from VPDs.

Vaccination protocols and allowable exemptions to routine vaccines vary by state. There are two main categories of exemptions to school entry requirements—medical and non-medical. Medical exemptions are permitted by all states and apply when someone has a contraindication or other precaution that requires avoiding the vaccine.

With many legislatures seeking to expand vaccine exemptions, it’s important to understand the fundamental differences in exemption type and their impact on a community.

Non-Medical Exemptions

Non-medical exemptions can greatly vary, but broadly include religious and personal belief exemptions. Religious belief exemptions allow a person to object to a vaccine requirement based on religious convictions while personal belief exemptions allow objection based on secular convictions. As of May 2022, 44 states grant religious exemptions and 15 states allow personal belief exemptions. Although many states offer religious exemptions, current legal precedent does not require a religious exemption.

In recent years, the United States has seen a resurgence of VPDs as non-medical exemptions have grown in popularity. Studies show that, in areas with greater numbers of vaccine exemptions, there is an associated increased risk of infection and death from VPDs in that population. One study demonstrated that children exempt from vaccines were 22.2 times more likely to acquire measles and 5.9 times more likely to acquire whooping cough than vaccinated children. Additionally, at least 11% of vaccinated children in measles outbreaks acquired infection through contact with an exempt child.

As of March 2023, at least 13 states (CT, KY, ID, IL, KY, ME, MN, MS, MT, NY, SD, VA, WV) have introduced bills related to non-medical exemptions in childcare or school immunization requirements. On March 3, the Montana house passed HB 715 which would require schools and the department of health to accept all requests for religious exemptions to student vaccinations requirement, removing the health department’s authority to deny false claims. West Virginia legislators considered several bills (SB 535, HB 2036, and HB 3143), to add non-medical exemptions to school immunization requirements. These proposals were unsuccessful, with West Virginia maintaining its current vaccine policy of only allowing medical exemptions for routine school vaccinations.

In Minnesota, HF 367 would give childcare facilities the ability to ensure the children in their care are adequately vaccinated by allowing them to opt out of accepting non-medical exemptions.

Impact of Low Vaccine Coverage Rates

Despite measles being declared eliminated from the United States in 2000, outbreaks have been reemerging in communities with low vaccine coverage rates. One recent example is the Ohio 2022 – 2023 outbreak involving 85 cases of measles. In this case, 71% of children that contracted measles were age-eligible for the measles, mumps, and rubella (MMR) vaccine but had not received a dose, making them vulnerable to measles.

Vaccine preventable disease outbreaks can be extremely costly to a community. The cost of a whooping cough outbreak in a single school in Nebraska was $52,000 and the cost of a measles outbreak in Minnesota in 2017 was $1.3 million. An economic analysis of the 2017 U.S. birth cohort indicated that vaccination of that cohort with the childhood immunization schedule prevents approximately 31,000 deaths and 17 million cases of disease, with a net savings of $13.7 billion in direct costs and $55.1 billion in total societal costs.

Strategies to Reduce Vaccine Exemptions

In the 2020 – 2021 school year, the states with the highest MMR vaccine coverage rates (above 97%) were Mississippi, New York, and Rhode Island—with all of these states having total vaccine exemption rates below 1%. Meanwhile, the states with more than 5% of non-medical exemptions (Idaho, Arizona, Oregon, Utah) failed to reach the 95% vaccine coverage rate needed to achieve measles herd immunity. Increased usage of vaccine exemptions in these states highlights the consequences to the collective community’s ability to be protected from disease.

States have adopted a variety of strategies to reduce the impact of vaccine exemptions and help parents make informed decisions about childhood vaccinations. One effective method of decreasing exemption utilization is to increase the rigor of the exemption process. Requiring yearly exemption renewal submissions (Georgia rule, New Mexico form), notarized statements in the exemption application (Minnesota statute, Virginia code), or requiring parents to use specific paperwork with physician approval can greatly reduce the ease of obtaining exemptions.

Bills introduced in Massachusetts (HD 2749 and SD 1491) would create standardized exemption forms for religious and medical exemptions with both forms requiring signatures from a guardian and physician. These bills would require annual reporting and dissemination of immunization and exemption data of all schools and covered programs. Covered programs that do “…not achieve herd immunity will be designated as elevated risk programs…” and will be required to educate parents of immunization safety, efficacy, and the importance of herd immunity.

Educating parents about the importance of vaccines and the risks associated with not vaccinating a child is another method of reducing exemptions. Some states (Vermont statute, Oregon statute) include parental education as part of the exemption application process. Preparing providers for in-depth discussions with their patients can help build community vaccine confidence and address any concerns or questions that parents may have.

Lastly, states can reduce the risk of unvaccinated students contracting a VPD by limiting their exposure during an outbreak (Georgia form, Arkansas rule). At least 12 states have laws to limit vaccine exemptions during epidemics (with some of these laws allowing health officials to limit religious exemptions during an epidemic.

Childhood vaccinations are a cornerstone of keeping communities and the most vulnerable populations protected from vaccine-preventable diseases. ASTHO supports states and territories in maintaining strong vaccine policies related to vaccine access, safety, and effectiveness. ASTHO will continue to monitor and report on this important public health issue.