State-by-State Vaccination Exemptions

Although federal public health officials at the Centers for Disease Control and Prevention (CDC) make national vaccination policy recommendations, actual legislation regarding their enforcement is decided at the state level. This creates a state-to-state variance, which in turn impacts Americans’ decisions on whether or not to vaccinate themselves and their children. It also affects primary health care providers such as Nurse Practitioners, who are tasked with giving vaccinations and educating their patients on the vaccines.

Individual states allow for various exemptions to vaccination requirements. Exemptions vary among states but can include medical, religious, and philosophical reasons.

Parents who choose vaccination exemption for their children, are significantly more likely to believe “children get too many shots,” and fear serious side effects, such as autism. In the CDC’s many studies on vaccine safety, a direct correlation between vaccines and autism has yet to be demonstrated.

Parents who choose to delay vaccination, or refuse it altogether, feel differently about the safety of vaccines than their vaccinating counterparts. According to the National Immunization Survey, when presented with the statement “vaccines are safe,” 84.9 percent of parents who chose to vaccinate agreed. In contrast, parents who had delayed or refused vaccinations for their children only agreed at a rate of 50.4 percent.

Parents who delay vaccination, or choose vaccination exemption for their children also had different views on the effects their decision would have. One of the other statements parents were presented with was, “If I do not vaccinate my child, he/she may get a disease such as measles and cause other children or adults to also to get the disease.” Of parents who had vaccinated their children, 90 percent agreed with this statement. In the group of parents who had opted to delay or refuse vaccination, agreement dropped to 71 percent.

Evidence suggests that higher rates of nonmedical exemptions are correlated with an increased incidence of vaccine-preventable diseases (VPDs). Recent findings also indicate that the use of philosophical exemptions tend to occur in geographical clusters, leaving these communities at a greater risk of VPDs. The CDC notes that this grouping of exemptions is associated with higher risk in those areas for vaccine-preventable diseases, such as pertussis and measles. VPDs pose significant health risks to the unvaccinated, and primary care providers are ideally situated to explain those risks.

The variance that exists in state-level vaccination exemptions adds complexity to an already controversial topic. Since the ability to create and regulate exemptions lies with the states, the CDC encourages states to “strengthen the rigor of the application process” for exemptions, and analyze their enforcement policies in an effort to limit the overuse of exemptions. While much of the responsibility for improving state vaccination rates falls on legislators, primary care providers are uniquely positioned to delivery trustworthy information concerning vaccines to their patients. The CDC recommends that primary care providers also exercise “stronger health care practices,” such as having conversations with parents and maintaining vaccination as the default option. Primary care providers have a responsibility to remain informed of their state’s vaccination policies and exemptions so they can provide clarity and evidence-based care to their patients.

With increased collaboration between legislators, health care providers, parents, and communities, we can reduce the rates of vaccination exemptions and vaccine preventable diseases.