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Eliminate nonmedical immunization exemptions for school entry, says AAP :

August 29, 2016

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 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 pertussis).

Dr. MaldonadoDr. MaldonadoIn 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.”

An aid for advocacy

Earlier this year, attendees at the AAP Annual Leadership Forum passed a resolution calling for the Academy to issue a policy against nonmedical exemptions; the resolution garnered the second-highest number of votes.

The new policy is available for pediatricians working to change laws in their own states.

Dr. HolmesDr. Holmes“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.

Dr. EdwardsDr. Edwards

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 as well.

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.”


The Academy

  • 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 each student;
  • 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.
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