Decreases in vaccine coverage paired with subsequent increases in outbreaks of vaccine preventable diseases have captured global attention. Some see limiting non-medical exemptions for school vaccine requirements as a way to curb the trend. On Thursday, June 13, the New York Senate and Assembly passed legislation eliminating religious exemptions for school vaccine requirements; the state now only allows exemptions from vaccinations for medical reasons. A week later, California went further by passing amendments to Senate Bill 276 (SB276), which expands current legislation that eliminated personal belief exemptions. The new amendments include penalties for healthcare providers that issue inappropriate medical exemptions, including penalty of perjury if the information contained in the medical exemption form is found to be untrue. Outbreak Thursday has covered outbreaks of vaccine preventable diseases due to low vaccine coverage in the past, from chicken pox to the global resurgence of measles. In this post, we will analyze the recent legislative changes in New York and California as well as their potential public health impacts.

 

Outbreaks & Exemptions

As of June 20, 2019, the US Centers for Disease Control and Prevention (CDC) has reported 1,077 confirmed cases of measles in 28 states. This represents the most annual cases since 1992 and threatens the status of the United States measles elimination declaration in 2000. Increased incidence of measles as well as other vaccine preventable diseases worldwide has been attributed to decreased vaccine coverage particularly in the United States and Europe. This has led to the examination of potential drivers of decreased coverage including poor access to healthcare, misinformation leading to concerns about vaccine safety, and the vocal anti-vaccine movement. Some states have now turned to legislative solutions to increase coverage and limit outbreaks, specifically turning to school vaccination requirements.

There is a long history of mandated vaccination as an intervention to reduce vaccine preventable diseases in the United States. School vaccination requirements originated in the 1850’s in Massachusetts in an attempt to reduce smallpox cases in schools. Since then, mandated vaccination has become an effective nationwide intervention. Currently, school-based vaccine requirements are determined at the state level, with policies between states varying as to which vaccines are required for a child to be enrolled in school as well as when a child can be exempt. Exemptions to school vaccination requirements take one of three forms: medical, religious, or personal beliefs. States may pass legislation allowing for all or none of these exemptions. 

Personal Belief Exemptions 

The exemptions of greatest controversy, personal belief exemption or philosophical exemptions, are the most inclusive in terms of beliefs qualifying for exemption. These exemptions apply to individuals with conscientious objection to vaccination not associated with recognized religious doctrine and are meant to expand upon the range of beliefs qualifying for exemption from vaccination. Currently, personal belief exemptions are permitted in 15 states. All states which permit personal belief exemption also allow religious and medical exemptions. The difficulty in obtaining a personal belief exemption varies considerably by state but is often as simple as submitting a form from a parent explaining their objection to vaccination. 

Religious Exemptions 

Religious exemptions are granted for individuals with significant religious beliefs opposing vaccination, sometimes requiring a signed affidavit from a religious official. Currently, these exemptions are allowed in 45 states. Prior to the most recent passage of legislation in New York, state law allowed for both medical and religious exemptions to school-based vaccination requirements. New York will now join California, Maine, West Virgina, and Mississippi as states which only allow for medical exemptions.

Religious exemptions have come under scrutiny when a large outbreak of measles amongst ultra-orthodox Jewish communities in New York City and Rockland County caused the largest number of measles cases in New York’s recent history. While prominent Jewish religious leaders have spoken out in favor of vaccination, pockets of unvaccinated individuals have fueled the outbreak. Outbreak Thursday has previously covered some of the unique challenges facing public health officials attempting to interrupt transmission in the insular religious community. Calls for strong action to halt transmission in the outbreak highlighted the appeal of legislative measures as an actionable solution. However, the end of religious exemptions in New York has been highly contentious and highlights the tenuous balance that legislators must maintain between protection of public health and protection of religious freedom. Opponents of the legislation claim the bill is an attack on individuals’ First Amendment rights. However, there is legal precedence to question the validity of these claims. The case of Phillips v. City of New York (2d Cir 2015) 775 F.3d 538 found “the right to practice religion freely does not include liberty to expose the community or the child to communicable disease or the latter to ill health or death.” Additionally cited throughout the legislative hearings when the most recent bill was introduced was the United States Supreme Court 1905 decision in Jacobson v. Massachusetts, 197 U.S. 11(1905) which upholds state's rights to enforce compulsory vaccination.

Medical Exemptions 

Currently all 50 states allow for medical exemptions in which an individual has a physical condition contraindicating receipt of vaccination. This kind of exemption often requires obtaining a letter from a physician. California’s recent amendments to SB276 place greater oversight on the provision of medical exemptions.  

The catalyst for this new legislation came out of studies on the impact of the 2015 Senate Bill 277 (SB277) which eliminated non-medical exemptions (religious and personal belief) to school vaccination requirements. Following the 2015 bill, there have been declining rates of non-medical exemptions and a 2.3% increase in the proportion of children entering kindergarten who have received all required vaccines. However, there has also been an increase in medical exemptions from 0.17% to 0.56%, representing a 250% increase in medical exemptions. Of even greater concern, the counties with previously high numbers of non-medical exemptions had the most sizeable increases in medical exemptions, which suggests the possibility that families who would have previously claimed non-medical exemptions are now seeking medical exemptions to school vaccine requirements. Additional worrisome patterns that have arisen since the 2015 bill’s passage include doctors providing improper contraindications as grounds for a medical exemption, high numbers of medical exemptions coming from a select few healthcare providers, and healthcare providers charging fees for medical exemptions. These findings prompted the amendments to SB276, making California one of the strictest states on school vaccine exemptions along with the policies of West Virginia and Mississippi.

 

Potential Benefits and Fallout From Exemption Elimination

While the study on the aftermath of California’s 2015 legislation to eliminate non-medical exemptions demonstrates the potential positive and negative impacts of similar legislative measures, there are also important considerations regarding potential downstream consequences. It has been suggested that laws limiting vaccine exemptions may increase the number of parents choosing to homeschool their children. In addition, an op-ed published by C. Raina MacIntytre and Daniel Salmon suggests that interventions such as punitive legislation which appear to punish parents may back-fire and deepen anti-vaccine sentiment in turn reducing vaccine coverage and increasing risk of vaccine-preventable outbreaks.

Conclusion

With several other states considering legislation to eliminate non-medical exemptions, it will be very interesting to see how the impacts of California and New York’s legislation play out. Actionable interventions like punitive legislative measures may offer a potential reduction in transmission for vaccine preventable disease. However, long-term productive interventions may require more collaborative approaches at the level of the parent, the healthcare provider, and the community. As the number of cases of vaccine-preventable disease outbreaks increase, it is clear that strong measures and thoughtful research is needed to address the crisis of distrust and misinformation surrounding vaccines in order to maintain and improve vaccine coverage.

Outbreak Observatory aims to collect information on challenges and solutions associated with outbreak response and share it broadly to allow others to learn from these experiences in order to improve global outbreak response capabilities.