AAP policy states that exemptions from vaccination for school entry should be reserved only for true medical contraindications and is clearly opposed to non-medical exemptions. The 2018 Red Book is clear on what constitutes a valid medical contraindication (Appendix V, pages 1071-1081). The most common reason is a prior anaphylactic reaction to a dose of vaccine or a vaccine component. These types of allergic reactions are quite rare, and in most states, medical exemptions constitute well under 1% of overall vaccine exemptions.
Due to the recent measles outbreaks, legal battles are underway in many states to eliminate non-medical exemptions to vaccination. Currently, three states allow only medical exemptions to vaccination for children attending school or licensed child care. West Virginia and Mississippi have long-standing laws that do not allow religious or personal belief exemptions, with associated high rates of vaccination. California passed legislation allowing only medical exemptions to vaccination after the Disneyland measles outbreak of 2014-’15. Subsequently, vaccination rates have increased.
While adoption of such laws is good for public health, states must put processes in place to ensure medical exemptions are legitimate. In Mississippi and West Virginia, approval for medical exemptions to vaccination must go through a central- or state-level review after submission by a physician. In California, however, medical exemptions may be approved solely by a licensed physician.
Evidence is emerging that some physicians in California are writing bogus medical exemptions for children who do not have a true contraindication to vaccination. These unscrupulous exemption-writing practices by a few medical providers have placed herd immunity at risk and have not gone unnoticed by the Medical Board of California. The agency has placed one individual on probation and continues to review additional cases of physicians who may be inappropriately writing medical exemptions for vaccines. In addition, California Sen. Richard J. Pan, M.D., M.P.H., FAAP, recently introduced a bill that would require physicians to submit medical exemptions to the public health department for approval.
As states consider eliminating non-medical exemptions, they may need to consider oversight of the process for obtaining medical exemptions in order to prevent illegal exemptions by the small proportion of health care providers, who may seek to undermine policies banning non-medical exemptions. These invalid medical exemptions may leave children and those around them unnecessarily at risk for vaccine-preventable diseases.
Dr. O’Leary is a member of the AAP Committee on Infectious Diseases.
