Saar Kuzi
Alessandra Coutinho Fernandes
William Cope
Richard Tapping
Kashif Ahmad
Reda Sadki
Shubhra Kanti Karmaker Santu
Adam P Rusch
Elle Meisner
Nereyda Ochoa
Landon J. Kunzelman
James DotimasFA16 Immunization Module’s Updates
Public policy obstacles to full vaccination coverage: state-to-state variations
First, some good news... Modern legislation has lessened financial barriers to immunization. As of 2010, the Affordable Care Act requires new health plans and insurance policies to provide coverage (without co-payments) for immunizations recommended by the Advisory Committee on Immunization Practices (https://www.cdc.gov/vaccines/acip/). Children that are uninsured, underinsured, Medicaid-eligible, or Native American/Alaskan Native are eligible to receive free vaccinations through the Vaccines for Children Program (VFC).
The bad news is that even if all financial barriers are eliminated, obstacles to full vaccination coverage still exist. Vaccination laws are made by the states, meaning that there are no universal rules when it comes to children getting vaccinated in the United States.
Vaccination Requirements
Vaccination requirements for children attending school and childcare vary from state to state. Although all states have laws that establish vaccination requirements for public school children and daycare facilities, some do not have these same laws for private school children (Indiana, Michigan, Ohio, & South Dakota have unclear laws in this regard). Furthermore, states vary in which vaccines are required and the schedule that children must follow to meet these requirements.
Some vaccines are not required in all states for school children (K-12):
- Only 13 states mandate HepA
- Alabama, Montana, South Dakota, and Maine do not mandate HepB
- New York has a diphtheria mandate only, tetanus/pertussis not required
- Iowa has a measles/rubella mandate only, mumps not required
Vaccine Exemption Laws
Each state has different immunization exemption laws. The processes for obtaining exemptions are also incredibly varied. Some states require that "enhanced education" about immunizations accompanies an exemption application (purple in graph below). Other states only require that a parent gives a signed form to their child's school; these forms may be available to print online. All states allow exemptions for medical reasons, and 47 states grant religious exemptions. Eighteen states have philosophical exemption laws that allow parents to claim an exemption based on personal, moral, or other beliefs. On the other hand, a few states have laws that explicitly prohibit philosophical exemptions (blue in graph below).
Here is a somewhat overwhelming but colorful graph on state exemption laws for your viewing pleasure:
Since this graph was created in 2015, California has outlawed non-medical exemptions and Vermont has repealed their personal belief exemption.
References: CDC SchoolVaxView; CDC Public Health Law Program; Immunization Action Coalition (immunize.org)
This is a really really good thread. The problem with many exemptions is that they are abused and the bar is low to obtain them; often as simple as signing a piece of paper. California and Vermont recognized this as a growing problem which is why they changed their policies.
I opened this post expecting it to be focused on public policy, but was surprised to find out many of those policies are in fact codified into laws and regulations (with a few exemptions). I am an attorney and had never come across this during my 9 years of practice. The post caused me to spend some time looking through the Illinois Administrative Code at the laws regarding college immunization, healthcare employee vaccination code, and the general immunization code. It seems to me the only method of enforcement/penalties, at least with the immunization code and the college immunization code, is that you will not be able to enroll. Otherwise, I suppose getting sick is a penalty in and of itself! I also found this link interesting: http://www.dph.illinois.gov/sites/default/files/publications/2015-Thimerosal-Exemption-050216.pdf Essentially, by law vaccines shall be free of mercury, but in certain instances like in case of a shortage a temporary exemption may be enacted. The link illustrates an instance when this happened in IL.
I was surprised to find that there are religious objections to being vaccinated. So, of course, I decided to google it. Those who are also interested, follow this link: http://www.historyofvaccines.org/content/articles/cultural-perspectives-vaccination
I have no way of verifying the information found on this site, but this was the most professional piece I could find. Many of the other sites did not seem to give a great summary of the actual issues. Moreover, they seemed to represent a small minority within certain religions that do not necessarily follow the widely held beliefs of their religion.
@AngelaDelano Great question about Illinois! The IL Department of Public Health website states that as of August 2015, a Certificate of Religious Exemption must be signed by a provider confirming that education was provided on benefits of immunization and risks of not vaccinating. No mention of personal exemptions on the site. Another update needed for the donut graph! Oklahoma allows medical, religious, and personal exemptions.
As an aside, the website also has a headline that reads MUMPS BOOSTER SHOT RECOMMENDED FOR UNIVERSITY OF ILLINOIS AT URBANA-CHAMPAIGN STUDENTS (http://dph.illinois.gov/news/mumps-booster-shot-recommended-university-illinois-urbana-champaign-students). Get your boosters everyone!
This is a really great post, Chelsey! Similar to Angela, I'm also interested on the impact of exemption laws (or lack thereof) on immunization rates in each state.
Quick question about the graph: So do IL and OK not consider medical contraindications for vaccinations? Or is that a scenario that is universally considered an exemption?
Thank you for the organized and informative post about state-to-state variation in vaccination requirements! So IL and OK have no exemption laws? I wonder if that increases the vaccination rate among children or, conversely, increases homeschooling. I also didn't realized that this much variation existed within the country. That must have some specific health impacts relative to the number of unvaccinated children.