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Opinion

VIEWPOINT

Y. Tony Yang, ScD,


LLM, MPH
Department of Health
Administration and
Policy, George Mason
University, Fairfax,
Virginia.
Leila Barraza, JD, MPH
Division of Community,
Environment and
Policy, Mel and Enid
Zuckerman College of
Public Health,
University of Arizona,
Tucson.
Kim Weidenaar, JD
Sandra Day OConnor
College of Law, Arizona
State University,
Tempe.

Corresponding
Author: Y. Tony Yang,
ScD, LLM, MPH,
Department of Health
Administration and
Policy, George Mason
University, Mail Stop
1J3, 4400 University
Dr, Fairfax, VA 22030
(ytyang@gmu.edu).
jama.com

Measles Outbreak as a Catalyst for Stricter Vaccine


Exemption Legislation
Following a multistate measles outbreak that began
in Disneyland, California legislators responded to the
outbreak by passing legislation repealing exemptions
for philosophical and religious beliefs.1 Although the
legislation retains medical exemptions, it makes California the largest state to have such strict childhood
vaccination requirements, joining only West Virginia
and Mississippi. Beginning in the 2016-2017 school
year, children whose parents refuse vaccination and
are unable to secure a medical exemption must be
homeschooled.1 School-aged children who currently
claim a nonmedical exemption can maintain it until
the time they enter kindergarten or seventh grade,
the states 2 vaccine checkpoints.1 The law applies to
both public and private schools, as well as day care
facilities.1

Possible Legal Challenges


Even though many parents have called for an end to
parental choices that could potentially put their children at risk, parents who are reluctant to vaccinate
their children maintain that the move to stricter vaccination requirements is an infringement of their rights.
These parents who support vaccine exemptions have
promised legal challenges to halt implementation of
the law, arguing it violates Californias constitutional
provision guaranteeing the right to a free and appropriate education.2 Unvaccinated children will have to be
homeschooled, which, they argue, is not an option for
most families. Additionally, First Amendment challenges based on the Free Exercise Clause, which forbids
laws that seek to restrict acts of faith, are likely. However, as long as the law does not target a specific religion, claims of impingement on religious freedom may
be difficult to prove. In Jacobson v Massachusetts,3 the
US Supreme Court held that the state had the authority
to require mandatory vaccinations to protect its citizens from dangerous epidemics. The Court stated that
although liberty was the greatest right, it did not provide individuals with the unlimited authority to act as
they pleased, constitutionally permitting government
to protect the safety of many over the objection of a
few. Additionally, in Prince v Massachusetts, the
Supreme Court stated that the First Amendment does
not include parents right to expose a child or community to communicable disease or other harms.4

Potential Trend Setter


Despite overwhelming evidence proving that vaccines
are effective, the number of unvaccinated children
has been increasing, partly because of easily obtained
exemptions. The percentage of California kindergarteners with nonmedical exemptions doubled from

1.56% to 3.06% between 2007 and 2013. 5 If too


many children in a given community are unvaccinated, the herd immunity that helps protect vulnerable individuals and other children from these diseases is diminished. Similarly minded parents who
decline vaccines for their children have created pockets (small, often isolated areas or groups) in particular
communities where the overall herd immunity level is
low. Although Californias overall vaccination rates are
stable (estimated measles, mumps, and rubella coverage was 92.3% during the 2013-2014 school year),
some suburban pockets of the state have rates hovering near 50%. 6 More than 25% of schools in
California5 have measles immunization rates for kindergarteners below the 92% to 94% recommended
to maintain herd immunity. A large part of this is
driven by parents who have opted out of vaccinating
their children by claiming a nonmedical exemption.
Had the bill failed to pass, a continued and increasing
incidence of vaccine-preventable illness in California
was likely. As the recent outbreak in Disneyland demonstrated, this is not just a potential danger for Californians but for the entire country. This bills passage
could help prevent another outbreak. Among the 110
California patients infected during the outbreak, only
8 (7%) were fully vaccinated for measles, and 28
vaccine-eligible patients (67%) were intentionally
unvaccinated because of personal beliefs.7
There is substantial variation in state laws on vaccine exemptions.8,9 Today, 48 states have some form of
religious exemption to vaccination requirements. Twenty
states also provide exemptions based on philosophical
objections. The recent measles resurgence led lawmakers in dozens of states to consider modifying existing exemption laws, though none have successfully implemented changes as widely sweeping as Californias.
Proposed legislation (Table) included eliminating religious or philosophical exemptions, adding additional
steps to the exemption process, expanding vaccine mandates, and requiring schools to publish vaccination rates.
Even though many of these bills failed to pass, some were
successful, such as a Vermont bill that eliminated the
states philosophical exemption but kept its religious exemption in place. In contrast, a number of states, including Mississippi and West Virginia, proposed legislation
to establish religious or philosophical exemptions, but
none gained traction.
In recent years, more states have considered narrower changes to their exemption policies rather than
a complete repeal of nonmedical exemptions. For example, Arkansas and Texas included an educational outreach component to the exemption process to inform
the citizenry on vaccination. Vermont required an attes-

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Opinion Viewpoint

Table. Proposed State Legislation Related to Childhood Vaccine Exemptions From January 1 to July 15, 2015
States (Bill No.)
Passed

Failed to Pass

Under Consideration

Vermont (H 98)

Maine (LD 606), Minnesota (HF 393),


Vermont (S 87)

Pennsylvania (HB 883/SB 696),


Washington (HB 2009)

Eliminate vaccine exemptions


Philosophical
Religious
Both philosophical and religious

North Carolina (SB 346), Texas (HB 2006),


Rhode Island (S 381)
California (SB 277)

Oklahoma (SB 830), Vermont (H 212)

Restrict vaccine exemptions


Medical

Delaware (HB 91),a West Virginia


(SB 286)

Philosophical
Religious

Maine (LD 471), Minnesota (SF 380)


Connecticut (HB 6949), Illinois
(SB 1410)a

Both philosophical and religious

New Mexico (HB 522)

Illinois (SB 1776), New Jersey


(S 1147/A 1931), New York
(A 7016/S 4733)

Oregon (SB 442), Texas (HB 1674)


New York (A 791C/S 4324A),
Pennsylvania (SB 797)

Expand vaccine mandates

Indiana (SB 461), Louisiana (HB 342),


Montana (HB 158), Ohio (SB 121)

Nebraska (LB 18), Nevada (SB 117),


Virginia (SB 1083/HB 2194), Texas
(SB 1114/HB 3875), Texas (SB 298)

Require/expand vaccine
tracking/data sharing

Idaho (S 1121), Missouri (SB 341),


South Dakota (HB 1059)

Maryland (SB 598), New Hampshire (SB 130)

Require exemption and/or


vaccination rates be publicly
available

Oregon (SB 895)a

Arizona (HB 2466), Texas (HB 2474/SB 547)

Michigan (SB 261/SB 260/SB 259)

Philosophical

Mississippi (HB 130/SB 2800), Montana


(HB 158),b New York (S 1536)

Massachusetts (S 317)

Religious

West Virginia (HB 2556)

Establish vaccine exemptions

Bill passed the state legislature but was not yet signed by the governor as of July 15, 2015.

Montana HB 158 was originally introduced to establish a philosophical exemption, which was later stricken, and the bill passed adding varicella to the
vaccine requirements.

tation that the exemption applicant had read materials concerning


vaccination, while Washington, Oregon, and California required proof
of a discussion with a health care practitioner about the risk and benefits of vaccination. The politics of nonmedical vaccine exemptions
remain contentious.9
Californias new legislation may represent the beginning of a
trend to tighten school immunization laws across the nation. A
state as large and influential as California signals the crucial
importance of childhood vaccines; other states will inevitably
take notice.
ARTICLE INFORMATION
Published Online: July 27, 2015.
doi:10.1001/jama.2015.9579.
Conflict of Interest Disclosures: All authors have
completed and submitted the ICMJE Form for
Disclosure of Potential Conflicts of Interest and
none were reported.
REFERENCES
1. SB 277, 2015-2016 Leg, Reg Sess (Ca 2015).
2. Serrano v Priest, 5 Cal3d 584 (1971).
3. Jacobson v Massachusetts, 197 US 11 (1905).
4. Prince v Massachusetts, 321 US 158, 166-167
(1944).

1230

Conclusions
Regardless of the intense lobbying by each side, the science supporting vaccines is settled, and opponents remain a small, vocal minority, with only 9% of Californians indicating that they believe vaccines are unsafe. 10 Physicians overwhelmingly recommend
childhood vaccines, which are credited with the elimination or near
elimination of diseases like measles, mumps, and rubella. Other states
should follow Californias common sense decision to protect the publics health, understanding that the states interest in protecting children is a higher priority than the freedom of some.

5. California Department of Public Health.


Immunization levels in child care and schools.
http://www.cdph.ca.gov/programs/immunize
/pages/immunizationlevels.aspx. Accessed July 1,
2015.
6. Seither R, Masalovich S, Knighton CL, Mellerson
J, Singleton JA, Greby SM; Centers for Disease
Control and Prevention. Vaccination coverage
among children in kindergartenUnited States,
2013-14 school year. MMWR Morb Mortal Wkly Rep.
2014;63(41):913-920.
7. Zipprich J, Winter K, Hacker J, Xia D, Watt J,
Harriman K; Centers for Disease Control and
Prevention. Measles outbreakCalifornia,
December 2014-February 2015. MMWR Morb
Mortal Wkly Rep. 2015;64(6):153-154.

8. Omer SB, Peterson D, Curran EA, Hinman A,


Orenstein WA. Legislative challenges to school
immunization mandates, 2009-2012. JAMA. 2014;
311(6):620-621.
9. Gostin LO. Law, ethics, and public health in the
vaccination debates: politics of the measles
outbreak. JAMA. 2015;313(11):1099-1100.
10. Pew Research Center. 83% Say measles vaccine
is safe for healthy children. February 9, 2015.
http://www.people-press.org/2015/02/09/83
-percent-say-measles-vaccine-is-safe-for-healthy
-children/. Accessed July 1, 2015.

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