Medical vaccine exemptions for children not always justified

More than 87,000 were granted nationwide to kindergartners over a seven-year period. Exemptions were more common in states with loose opt-out requirements.

By — Posted Sept. 10, 2012

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Some children are receiving medical exemptions from kindergarten-entry immunization requirements for inappropriate reasons, according to a new study. That could make youths who are too young or too sick to be immunized more susceptible to potentially fatal vaccine-preventable diseases, including measles and pertussis.

“The appropriate use of medical exemptions is important to maintaining sufficient herd immunity,” said Saad B. Omer, PhD, MPH, senior investigator of the study, published online Aug. 29 in The Journal of Infectious Diseases.

Every state allows exemptions for children with medical contraindications that are verified by a physician. Health professionals issued 87,631 such exemptions from immunizations required for kindergarten between the 2004-05 academic year and the 2010-11 school year, the study said.

Fewer than 1% of kindergarteners received medical exemptions. Although the number is small, the research shows that states differ on the criteria they require for patients to opt out of vaccines for health reasons, said Omer, assistant professor in global health, epidemiology and pediatrics in the Hubert Dept. of Global Health at Emory University Rollins School of Public Health in Georgia.

Exemptions were more common in states with loose requirements for opting out of vaccines for health reasons than they were in states with stricter criteria, the study said. The study did not examine non-medical exemptions such as those granted for religious reasons.

Omer recommends states consider eliminating permanent medical exemptions and grant temporary ones instead. That change would encourage physicians to review patient immunization exemptions periodically and determine if they still are warranted.

It’s important that doctors be aware of the medical contraindications for the vaccines they administer, said Andrew T. Pavia, MD, chief of the division of pediatric infectious diseases at the University of Utah School of Medicine in Salt Lake City.

Doctors need to “realize that they’re not doing their patients a favor by granting them a medical exemption when they would have benefitted more by being vaccinated,” he said.

Falling short of vaccination goals

The Healthy People 2020 target is 95% or greater vaccination coverage among kindergartners for the following vaccines: diphtheria, tetanus toxoid, and acellular pertussis; hepatitis B; measles, mumps and rubella; poliovirus; and varicella.

During the 2011-12 academic year, median coverage for the MMR vaccine and varicella immunization fell short of the Healthy People goal, said a study in the Aug. 24 issue of the CDC’s Morbidity and Mortality Weekly Report.

For The Journal of Infectious Diseases study, researchers examined CDC data on state medical exemptions from vaccines required for kindergarten granted between 2004 and 2011. The study assessed the length of the medical exemption that could be granted (permanent, temporary or both) and the criteria required to grant the exemption.

Such criteria include a written physician statement; separate medical exemption form; health department approval; physician certified to practice in the state; annual approval of the exemption; and notarization of medical exemption forms.

States with one criterion were considered to have easy requirements, and having two criteria was said to be medium-level difficulty. States with at least three criteria were described as having difficult requirements.

Researchers found that the annual number of exemptions issued increased from 11,277 in 2004-05 to 13,952 in 2010-11.

In states with easy requirements, the rates of exemptions were more than six times higher compared with states that have difficult procedures, data show.

Difficult requirements were identified in three states: Arkansas, New Mexico and Wyoming.

The study “shows that medical exemptions aren’t being used well,” Dr. Pavia said. “It’s not ethical to give a medical exemption when the evidence doesn’t suggest it’s medically indicated.”

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In most states, it’s easy to get a medical vaccine exemption

View in PDF

Click to see data in PDF.

The difficulty of receiving a medical exemption from recommended vaccines and the length of that exemption vary by state. Exemptions are more common in areas with easy opt-out requirements.

State Difficulty level Exemptions
Alabama Medium Permanent only
Alaska Medium Permanent only
Arizona Easy Permanent/Temporary
Arkansas Difficult Temporary only
California Easy Permanent/Temporary
Colorado Easy Permanent/Temporary
Connecticut Medium Permanent only
Delaware Easy Permanent/Temporary
Florida Easy Permanent/Temporary
Georgia Medium Temporary only
Hawaii Easy Permanent/Temporary
Idaho Easy Permanent/Temporary
Illinois Medium Permanent only
Indiana Medium Permanent/Temporary
Iowa Medium Permanent/Temporary
Kansas Medium Temporary only
Kentucky Easy Permanent/Temporary
Louisiana Easy Permanent/Temporary
Maine Medium Temporary only
Maryland Easy Permanent/Temporary
Massachusetts Medium Permanent/Temporary
Michigan Easy Permanent/Temporary
Minnesota Easy Permanent/Temporary
Mississippi Medium Permanent/Temporary
Missouri Easy Permanent only
Montana Easy Permanent/Temporary
Nebraska Easy Permanent/Temporary
Nevada Easy Permanent/Temporary
New Hampshire Medium Temporary only
New Jersey Easy Permanent/Temporary
New Mexico Difficult Permanent/Temporary
New York Medium Permanent/Temporary
North Carolina Medium Permanent/Temporary
North Dakota Easy Permanent only
Ohio Easy Permanent/Temporary
Oklahoma Medium Permanent/Temporary
Oregon Medium Permanent/Temporary
Pennsylvania Easy Permanent/Temporary
Rhode Island Easy Permanent/Temporary
South Carolina Easy Permanent/Temporary
South Dakota Easy Permanent only
Tennessee Easy Permanent/Temporary
Texas Easy Permanent/Temporary
Utah Easy Permanent/Temporary
Vermont Easy Permanent/Temporary
Virginia Easy Permanent/Temporary
Washington Easy Permanent/Temporary
West Virginia Medium Permanent/Temporary
Wisconsin Easy Permanent/Temporary
Wyoming Difficult Permanent/Temporary

“Medical Exemptions to School Immunization Requirements in the United States — Association of State Policies with Medical Exemption Rates (2004-2011), The Journal of Infectious Diseases, Aug. 29 (link)

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External links

“Medical Exemptions to School Immunization Requirements in the United States — Association of State Policies with Medical Exemption Rates (2004-2011),” The Journal of Infectious Diseases, Aug. 29 (link)

“Keeping the M in Medical Exemptions: Protecting Our Most Vulnerable Children,” The Journal of Infectious Diseases, Aug. 29 (link)

“Vaccination Coverage Among Children in Kindergarten — United States, 2011-12 School Year,” Morbidity and Mortality Weekly Report, Aug. 24 (link)

Vaccine Information Statements, Centers for Disease Control and Prevention (link)

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