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Posted on November 19, 2019 at 10:22 AM


The topic of childhood vaccination has
become increasingly tendentious in recent years.  While ‘vaccine hesitancy’—a term that
encompasses a wide range of attitudes, from those who have some misgivings
about vaccination to those who refuse all vaccinations for their children—has
existed ever since Edward Jenner developed the smallpox vaccine in 1798, many
point to a now retracted 1998 paper in The Lancet as the origin of today’s
particular brand of vaccine hesitancy.

In the United States, there are three ways
by which a child can be exempt from vaccination.  State
laws differ
with regard to which types of exemptions are recognized.  In five states, the only children who are
exempt from vaccine requirements are those with medical exemptions, meaning
they must have a medical condition that makes their receipt of a vaccine
contraindicated.  The remaining 45 states
also authorize religious exemptions, whereby parents can refuse to have their
children vaccinated on grounds that vaccination goes against their religious
beliefs.  And fifteen of these states
further recognize a philosophical exemption, whereby parents can refuse
vaccination by appeal to its discordance with their non-religious beliefs.

Recent outbreaks of measles in the U.S.
have prompted some states to reconsider their policies on non-medical
exemptions. Earlier this year, New York joined Maine, California, Mississippi,
and West Virginia in implementing
that eliminates religious exemptions for children in childcare
centers and classroom-based schools.  Those
with an unvaccinated child entering kindergarten had two choices: initiate
vaccination for the child (and ensure that the child is up to date by the end
of the school year) or remove the child from the school.  Those who select the latter option must then
decide whether to home school or move to a different state.

Supporters of the legislation claim that the
law will ensure that vaccines’ immense public health benefits are actually
realized.  Critics of the law claim that
it infringes on personal and parental rights, favoring the interests of the
public over the rights of individuals. 
And then there are those who fall in the middle—they are supportive of
the law’s aims but skeptical of the law’s methods and/or efficacy. 

There is evidence to suggest that skepticism
about the law’s efficacy may be warranted. 
In a
2018 article in Pediatrics,
Delamater et al. study the effects of a
2016 law in California that eliminated all non-religious exemptions to
vaccination.   The authors found that an
initial decrease in the percentage of unvaccinated kindergarteners in the first
year of the law’s effect did not persist into the next year.  They point to phenomena like fraudulent use
of medical exemptions, the presence of grandfather clauses, and inconsistent
enforcement of the rules as reasons for the law’s limited effects.  They also suggest that the initial decrease
in unvaccinated kindergarteners might be explained by something other than the

In light of this, what ought researchers
and policymakers do?  First, further data
collection is key; with the passage of similar legislation in Maine and New
York this year, we will have more data to analyze in the next few years to begin
to understand the efficacy of these laws. 
But it is also worth considering what other policy strategies are
available.  Further brainstorming is
prudent not only because of the limited efficacy of the current laws but also
because some states are unlikely to pass this type of legislation.

What might some of these alternatives look
like?  Stay tuned—I’ll discuss one possible
strategy in my next blog post.  

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