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'Ripe for an Outbreak': Vaccine Exemptions Are on the Rise

By many measures, the anti-vaccination movement is thriving. But not in California, which removed nonmedical exemptions after measles spread throughout the state.

Protesters with anti-vaccine signs.
Protesters rallying against California's vaccine requirements in 2015.
(AP/Steve Yeater)


  • Nonmedical exemptions for vaccine requirements are rising in at least 12 states.
  • Measles outbreaks have hit across the country in recent years.
  • In 2015, California became the third state without religious or personal exemptions.
  • Since then, the percent of kids vaccinated has risen.
By many measures, the anti-vaccination movement is thriving.

All but three states allow parents to exempt their children from vaccine requirements for either religious or personal reasons, or both. Of the 18 states that allow both religious and personal exemptions, 12 have seen a rise in those exemptions since 2009.

“We’re reversing a lot of our gains. In Texas, we’re at around 60,000 kids not getting their vaccines. We are ripe for an outbreak,” says Peter Hotez, Dean of the National School of Tropical Medicine at Baylor College of Medicine.

This month alone, there have been reported measles outbreaks in Ocean County, N.J., and Rockland County, N.Y. Last year, 79 people -- mostly Somali-American children -- were infected with measles in Minnesota, the worst outbreak the state has had in 30 years. The state health department said the outbreak could be traced to anti-vaccination propaganda directed at the immigrant community.

In Arizona, outcry from the anti-immunization community drove the state to cancel a voluntary educational program on vaccines this year. Under the program, parents submitting a nonmedical exemption were asked to watch an online tutorial on the scientific benefits of vaccines.

Even though the program was voluntary, “the reaction to any step to educate is seen as a risk. It’s really hard to reach people who are getting their news from such bad sources. If parents think their kids are getting poisoned, there’s not a lot you can do,” says Dorit Reiss, professor of law at the University of California, Hastings, and an expert on vaccine law. 

The Phoenix-area currently has one of the highest concentrations of unvaccinated children in the country, according to a study in the journal PLOS Medicine.


California's New Vaccine Requirements

But there is at least one place where public health departments are making progress on immunizations: California. 

In 2015, after a measles outbreak linked to Disneyland, the state did away with personal belief exemptions, joining the two other states (Mississippi and West Virginia) that don’t allow personal or religious exemptions to vaccines.

Before the change, only 90 percent of California children were vaccinated, which is below the 94 percent threshold public health experts say is needed to create community immunity to measles. Now, according to a study released last month, 95 percent of California children are vaccinated

But while the number of vaccinated kids in California has gone up, so has the number of medical exemptions -- from 0.2 percent to 0.7 percent. That trend worries the public health community.

“Some [medical exemptions] are legal, but some are also illegal," says Reiss. "The pattern suggests abuse, as many of the exemptions were concentrated in places that had high numbers of personal belief exemptions.”

Personal belief exemptions are generally easier to get than medical exemptions, so without that option, it’s likely that some parents switched to medical exemptions -- legally or not. Medical reasons for forgoing vaccines include undergoing chemotherapy, having a gelatin allergy or suffering from a severe immunodeficiency disorder. 

"When you have a demand of parents who are scared and demanding [exemptions], they'll be going to dispensaries and to doctors where they know they can get them," Reiss says.

Some experts have suggested the state should clamp down on doctors issuing unnecessary exemptions. Reiss, however, isn't one of them. 

“Is it worth more legislation right now? I’m not sure. It might be worth waiting a few years to see if some of these parents just end up vaccinating their kids and moving on,” she says. 

In general, though, Reiss and the majority of the public health community want states to restrict or eliminate personal exemptions to avoid future outbreaks.

“We have to recognize that this is a public health threat, and governments haven’t responded appropriately," says Hotez. "Almost 200 kids died of the flu last season who didn’t have to.”

This appears in the Health newsletter. Subscribe for free.

Mattie covers all things health for Governing.

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