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State vaccine laws and exemptions available in different states, including which states require the signature of a medical doctor or other state-designated health care worker in order to file a non-medical exemption. States with an asterisk next to them are states that have enacted recent restrictions to exemption laws.

Exemptions for Childhood Vaccination in the United States

A vaccine exemption allows children whose guardians or parents have medical, personal beliefs or religious in conflict with required childhood vaccination policies, to have admission, without vaccination, that are required by law. Childhood vaccination policies require that all children receive certain immunizations in order to attend public and private elementary and secondary schools, child care centers, family day care homes, nursery schools, day nurseries, and developmental centers. These establishments are required to enforce immunization requirements for each student, maintaining immunization records and submitting reports to the government. By law, there are certain exemptions, under guidance and recommendation of healthcare professionals, that allow for children to be admitted without required immunization.

Types of Exemptions

Medical Exemptions

Permanent medial exemptions are allowed in the case that a child has a medical condition which permanently rules out one or more vaccines, being exempt from that immunization requirement. In these case of medical exemptions, only one or few immunizations are exempt due to the conflict with a child's health status. Medical exemptions include when a vaccine is contraindicated due to a component ingredient allergy or existing medical condition that may pose harm to the child. In order to receive a medical exemption, a physician must state that there is medical condition which permanently rules out the immunization, or immunizations that the child cannot receive. These exemptions often last for a length of time in which the immunization may be harmful for the child, however, after this this period, under proper medical supervision, the child may be required to resume with his/her immunization schedule. Only in severe cases, such as children with immunodeficiency disorders or those exhibiting severe allergic reactions after a previous dose or vaccine component may vaccination be withheld.

Physicians and healthcare professionals follow federal guidelines published by the Centers for Disease Control and Prevention (CDC) outlining what is and is not considered a medical contraindication to vaccination, guided by extensive scientific research. The vaccination of immunocompromised pediatric patients merits careful consideration because these children are at increased risk for exposure to microbes from frequent association with healthcare settings and for the development of life-threatening vaccine-preventable infections compared to children with normal immune function. The safety and efficacy of these vaccines have been studied in immunosuppressed children with cancer and hematopoietic stem cell transplant.

 The Centers for Disease Control recommends that a medical vaccine exemption should only be granted to one out of every 320,000 children and adults annually receiving chemotherapy; or one of the estimated 47,000 Americans who have had a recent organ or blood cell transplant; or the child is one of the 40 to 100 children born every year with Severe Combined Immune Deficiency (SCID), or other severe immunodeficiency disorders. In general, for children receiving hematopoietic stem cell transplant, recipients should receive all recommended immunizations, preferably prior to transplantation and on accelerated schedules if indicated. Upon recovery or after the medical condition, many vaccines are once again recommended and medical exemption no longer applies. The Centers for Disease Control outlines that after chemotherapy is complete, medical vaccine exemptions no longer apply. After recovering from an organ or blood cell transplant, no medical vaccine applies. If a child is immunosuppressed but does not have have Severe Combined Immune Deficiency (SCID), in most cases, medical exemption does not apply.

Disease Exemptions

If the child is sick or had been sick in the past with the disease that a required immunization is to treat for, they may be exempt from the vaccine. If a child previously had a vaccine-preventable disease he/she can no longer become sick from it. Proof of existing immunity is required to be exempt from vaccination or re-vaccination. If a person has recovered from the natural disease or has been vaccinated, a blood titer test may indicate there are enough naturally acquired or vaccine acquired antibodies to “prove” immunity to a particular disease. Disease exemptions are often for children who have or have had the measles disease, laboratory-confirmed rubella disease, laboratory-confirmed mumps disease, and/or varicella (chickenpox disease).

Personal Belief Exemptions

Personal belief exemptions, also known as philosophical exemptions, apply to children whose parents or guardians have personal beliefs against vaccination. The Personal Belief Exemption (PBE) form is required to exempt children from required by law childhood vaccination. The PBE form must be signed by both a healthcare professional and a parent or guardian of the when seeking exemptions. Authorized healthcare professionals include licensed physicians, nurse practitioners, physician assistants, naturopathic doctors, and credential school nurses.
The form acknowledges that a health care professional has provided information to the parent or guardian regarding the benefits and risks of immunization, including the health risks to the student and the community resulting from declining the recommended immunizations. The health care provider and the parent must each sign the form before the form is turned in to the school. The form also allows for constitutional freedom of religious expression.

Religious Exemptions

Religious exemptions apply to children whose parents or guardians have religious beliefs against vaccination. A religious exemption indicates that there is a provision in the statute that allows parents to exempt their children from vaccination if it contradicts their sincere religious beliefs.

The number of religious exemptions rose greatly in the late 1990s and early 2000s; for example, in Massachusetts, the rate of those seeking exemptions rose from 0.24% in 1996 to 0.60% in 2006. It has been reported that parents and guardians are falsely claiming religious beliefs in order to get exemptions.

Many religious groups selectively reject various forms of modern medical care including vaccination. Notable religious groups that are opposed to vaccination include Christian Science and the Congregation of Universal Wisdom. In a court case citing the Congregation of Universal Wisdom, Turner v. Liverpool Cent. School, the United States District Court in New York affirmed the permissibility of claiming religious exemption from vaccination on the basis of such membership.

Exclusions

By law, during certain circumstances, children who have not been vaccinated may be excluded from attendance or admission. During an outbreak of a communicable disease for which immunization is required, children exempted shall not attend the school or childcare agency threatened by the communicable disease in order for his/her protection and safety.

Policy

All 50 states have legislation requiring childhood vaccination for school entry, however, exemptions are a reason for children to opt out of these requirements. Laws vary from state to state on immunization schedules, vaccinations required, and types of exemptions. Currently, all states immunization requirements include Pertussis, Tetanus, Diphtheria, Polio, Measles, Mumps, Rubella, Varicella, and Hepatitis B vaccines, in order to prevent epidemics. Schools require an updated immunization record for all incoming and returning students. While all states require an immunization record, this does not mean that all students must be vaccinated.

As of 2015, 47 states allow religious exemptions, with some states requiring proof of religious membership. Mississippi, West Virginia and California do not permit religious exemptions. Only 15 states allow personal philosophical opposition to vaccination as a form of exemption; Vermont and California eliminated this exemption in 2015. Fewer than 1% of students have any type of exemption in most states.

Recommendations

The Advisory Committee on Immunization Practices (ACIP) provides advice and guidance on effective control of vaccine-preventable diseases in the U.S. civilian population. ACIP statements are official federal recommendations for the use of vaccines and immune globulins in the U.S., and are published by the Centers for Disease Control and Prevention. Most states in the U.S. have adopted ACIP and CDC vaccine recommendations and mandate immunization before enrollment in public school, while allowing religious or philosophical exemptions to vaccination.

Association of non-medical exemption rates with increased disease incidence

Association between levels of exemption and disease rates have shown that exempt children are at increased risk of acquiring and transmitting disease.

Studies have shown that exempt children were 22.2 times more likely to acquire measles and 5.9 times more likely to acquire pertussis than vaccinated children. At least 11% of vaccinated children in measles outbreaks acquired infection through contact with an exempt child.