Eliminate nonmedical immunization exemptions for school entry, says AAP
AlysonSulaski Wyckoff, Associate Editor
An AAP policy is calling for all states to use their public health authority to eliminate
nonmedical exemptions from immunization requirements for school entry.
While the Academy has opposed nonmedical or “personal belief” exemptions in the past,
this is the first policy statement on the issue.
Medical Versus Nonmedical Immunization Exemptions for Child Care and School Attendance is authored by the Committee on Practice and Ambulatory Medicine, Committee on Infectious
Diseases, Committee on State Government Affairs, Council on School Health, and Section
on Administration and Practice Management. It is available at http://dx.doi.org/10.1542/peds.2016-2145 and will be published in the September issue of Pediatrics.
The Academy supports medically indicated exemptions but says nonmedical exemptions
are inappropriate for individual, public health and ethical reasons. To protect those
who cannot be vaccinated, community or “herd” immunity requires at least 90% of the
population to be immunized (95% for highly contagious diseases such as measles and
In late 2014 to early 2015, a large measles outbreak linked to a Disneyland park in
California highlighted the dangers of unvaccinated children. Yvonne A. Maldonado,
M.D., FAAP, said because of that experience, people became even more aware of the
need to reduce the number of children at risk of disease.
“I personally — as well as colleagues around the country — have received calls from
parents whose children were immunocompromised … who were really concerned,” said Dr.
Maldonado, vice chair of the AAP Committee on Infectious Diseases.
Still, some vaccine-refusing parents aggressively fight to loosen vaccine mandates,
asserting religious or personal beliefs. Dr. Maldonado said in some schools in her
home state of California, as many as 20% of children were not vaccinated.
It was a long road, but California eventually passed a law in 2015, which took effect
in July, allowing only medical exemptions. “It’s the right thing to do,” she said.
“We have to protect children if we have the means to do so.”
The new policy is available for pediatricians working to change laws in their own
“AAP policy is very helpful to pediatricians at a state and local level to advocate
for children’s health,” said Breena Holmes, M.D., FAAP, chair of the AAP Council on
School Health Executive Committee and a lead author of the policy. “I anticipate —
and hope — that this statement will be used far and wide for that purpose.”
The policy also “removes any ambiguity that the Academy is 100% behind our state chapters
in their efforts to support strong immunization laws currently in effect — and to
bring changes to state laws where reform is needed,” said Anne R. Edwards, M.D., FAAP,
a lead author and a former chair of the AAP Committee on State Government Affairs.
Stronger laws = parental incentives, less disease
In some states, local school boards can set requirements for vaccines, but most are
established at the state level. All states have regulations requiring proof of immunization
for child care and school attendance; virtually all have laws for private school entry
The requirements are a strong incentive for parents and families to immunize their
children according to the recommended schedule, the policy points out, and this results
in less disease.
However, almost all states allow families to cite religious belief exemptions from
the requirements, and nearly half also allow them to obtain philosophical or personal
belief exemptions. Consequently, states with looser requirements and those allowing
permanent medical exemptions end up with more of them — and higher rates of vaccine-preventable
illnesses and disease outbreaks, such as pertussis and measles.
Securing a personal belief exemption in some states is as easy as checking a box or
a signature on a school form. To get around this, a number of states require education
about the benefits of vaccines and the risks of ignoring the recommended schedule.
Whose interest at stake?
Childhood immunization exemption policies should be designed so they clearly service
the best interest of both the individual child and … community, the policy emphasizes.
Yet some vaccine opponents maintain that parents should be the ultimate decider of
what vaccines, if any, their children receive. In response, the AAP policy suggests
parents are expected to consider the best interest of their child in medical decision-making
rather than their own social or emotional interests.
“Judging from what we saw in California,” said Dr. Maldonado, “education is really
critical for those families.”
supports laws and regulatory measures that require certification of immunization to
attend child care and school;
supports medically indicated exemptions to specific immunizations as determined for
recommends all states and the District of Columbia use their public health authority
to eliminate nonmedical exemptions from immunization requirements;
recommends all child care centers and schools comply with state laws and regulations
requiring current and accurate documentation of immunization status and appropriate
medical exemptions of attendees/students; and
recommends public health authorities provide the community with information about
immunization rates in their child care centers and schools and determine if there
are risks to community immunity.