School Immunization
Requirements
Daniel Salmon, PhD, MPH
Associate Professor
Johns Hopkins Bloomberg School of Public Health
Compulsory Vaccination Laws
in US
• Massachusetts (1809)
 General Population
 Jacobson v. Massachusetts
• Upheld rights of states to compel
vaccination
• Foundation for public health law
• Focus on School Populations
 Zucht v. King (1922)
Growth of State Laws requiring
Vaccination
• 20 States – 1963
• 29 State – 1970
Incidence of Measles according to
evidence of Mandatory School Entry
Requirements
1973
States
With
Laws
Without
Laws
No. of
States
35
16
1974
Cases 1
26.5
No. of
States
40
Cases 1
33.1
53.9
11
55.4
1 = Cases per 100,000 <18 Years
Adapted from Orenstein et al, JID; 1978.
Incidence of Reported Measles in
States Enforcing School
Immunization Laws
1977
Cases 1
1978
(first 31 wks.)
Cases 1
6 States that Strictly
Enforce Laws
40.6
2.7
Remainder of Nation
90.3
35.2
1 = Reported Measles Cases per 100,000 < 18 years old
Adapted from: Measles and school immunization Requirements – US, 1978, MMWR: 1978
School Immunization Laws
• Prevent outbreaks
• Provide safety net
• Demonstrates public commitment to
immunization
• Assist introduction of new vaccines
80
70
60
50
40
30
20
10
0
Vaccine Coverage (%)
Estimated Varicella Vaccination Coverage
among Children 19-35 Months of Age by State
US, National Immunization Survey, 2000
National Varicella Vaccine Coverage Level 67.8%
90
Idaho
South Dakota
Alaska
Illinois
Washington
Iowa
Utah
Mississippi
Montana
Maine
Wisconsin
Vermont
Wyoming
Kansas
Indiana
North Dakota
West Virginia
Missouri
Ohio
Colorado
Florida
Nevada
Minnesota
Kentucky
Nebraska
Louisiana
Arizona
New Hampshire
New Jersey
New Mexico
Delaware
Michigan
Tennessee- 1999
South Carolina
New York
Oklahoma- 1998
Texas
Pennsylvania
Georgia
Alabama
California
Connecticut
North Carolina
Oregon
Hawaii
Virginia- 1999
Arkansas
Massachusetts-…
Rhode Island- 1999
Maryland- 1998
District of…
State
Indicates that a varicella childcare requirement was implemented prior to 2000. For these states, year of
implementation is given.
How School Immunization
Requirements Work in US
• All State Laws (not Federal)
• Wide Variability in Implementation
 Antigens required
 Process for adding antigens or making
changes
 Applicable Populations
 Who provides documentation
Exemptions to School
Immunization Laws
TYPE OF EXEMPTION(S) ALLOWED
Philosophic, Religious &
Medical (20)
Religious & Medical (29)
Medical only (2)
updated March 2005
www.vaccinesafety.edu
State Implementation of
Exemptions
• Wide variability
• Easy process = High rates
Rota et al. AJPH, 2000
Easy Exemption Process
Associated with High Rates
Exemption Rate
Administrative
Difficulty
Low
(<0.5%)
Medium
(0.5% - 1.0%)
High
(>1.0%)
Easy
RI, OK, MO, HI,
PA
AK, AZ, VT, CA, MD
WA, ID, WI,
MI, OR
Medium
ND, CT, IL, NC,
AL, NY, OH, KS,
NJ, LA
MA
UT, SD, CO
Hard
WY, NH, MT, VA,
IN, AR, MN, KY,
GA, TN
IA, DE, CS, ME, NM, TX, NV,
FL, NE
Rota et al AJPH, 2000.
State Implementation of
Exemptions
•
Wide variability
•
Easy process = High rates
•
Little contact between parents and health personnel
•
Majority of states (67%) never deny exemptions
•
States rely on schools to implement exemptions
Rota et al. AJPH, 2000.
Increased Risk of Disease for
Exemptions
•
•
•
•
•
Measles
Pertussis
Haemophilus influenzae type b
Varicella
Pneumococcal
Relative Risk of Measles and Pertussis
in Exemptors from School Laws
CO (1987-98)1
Measles
Pertussis
22
5.9
U.S. (1985-1992)2 35
1= Feikin et al. JAMA. 2000.
2 = Salmon et al, JAMA. 1999.
School Exemption Rates in Counties
With and Without Pertussis
Outbreaks: Colorado
Counties with outbreaks
4.7%
Counties without outbreaks 1.3%
p = .001
Feikin et al, JAMA. 2000.
Nonmedical Exemptions for States With
Religious Exemptions and With Personal Belief
Exemptions -1991 - 2007
Personal Belief Exemptions Permitted
Exemption Rate
Only Religious Exemptions Permitted
Omer et al., JAMA, 2006 Data Updated
Nonmedical Exemptions by Ease of
Exemption,1991 - 2007
Easy Exemption Policy
Medium Exemption Policy
Omer et al., JAMA,
2006 Data Updated
Difficult Exemption Policy
Mean (95% CI) Rates of Nonmedical Exemptions
by Type & Ease of Exemption, 2006–2011
Omer et al., NEJM, 2012
Associations between State Exemption
Policies and Pertussis Incidence, 19862004
Unadjusted IRR
(95% CI)
Adjusted IRR
(95% CI)
Only Religious Exemption
Reference
Reference
Personal Belief Exemption
2.06 (1.77-2.40)
1.48 (1.03-2.13)
Difficult
Reference
Reference
Medium
1.27 (1.06-1.51)
1.35 (0.96-1.91)
Easy
1.90 (1.60-2.28)
1.53 (1.10-2.14)
Type of exemption
Exemption ease
Adjusting for allowing parental signature for school immunization forms, proportion inside urbanized area, income
(11 categories), and education (7 categories)
Omer et al, JAMA, 2006
Within State Variations in
Implementing Exemptions
• Wide variability in how schools
interpret and enforce exemptions
• Easier processes for granting
exemptions associated with higher
rates of exemptions
• Schools often do not discuss risks
and benefits with parents
considering an exemption
Salmon et al, Pediatrics, 2004
School Personnel KABs Associated
with Children Having Exemption
•
•
•
•
•
•
•
Training of school personnel
Perceived Susceptibility and Severity of Disease
Perceived Safety and Efficacy of Vaccination
Who Benefits from Vaccination (Individual and
Community)
Vaccine Misconceptions
 Children get more immunizations than are good for
them
 Concerned immune system weakened by too many
vaccines
Confidence in local and state health departments
Use of alternative medicine
Salmon et al, AJPH, 2004.
Relative Locations of Pertussis Space-time Clusters &
Exemptions Spatial Clusters (Omer et al, AJE, 2008)
Overlap of
Exemptions
Clusters with
Pertussis Clusters
Unadjusted OR
3.0 (2.5 – 3.6)
Adjusted1 OR
3.4 (2.8 – 4.1)
WA State Counties’ School Exemption Rates 1999
Whatcom
San Juan
Clallam
Skagit
Island
Stevens
Chelan
Douglas
King
Grays
Mason
Harbor
Pierce
Lewis
Cowlitz
Kittitas
Grant
Skamania
Klickitat
2.0-2.9%
Lincoln
Adams
Franklin
Yakima
Clark
<2.0%
Ferry
Snohomish
Jefferson
Pacific
Okanogan
Pend
Oreille
Benton
3.0-3.9%
Source: WA State Department of Health
Walla
Walla
4.0-4.9%
Spokane
Whitman
Garfield
Asotin
≥5.0%
WA State Counties’ School Exemption Rates 2004
Whatcom
San Juan
Clallam
Skagit
Island
Chelan
King
Grays
Harbor Mason
Lewis
Cowlitz
Douglas
Grant
Skamania
2.0-2.9%
Klickitat
3.0-3.9%
Lincoln
Adams
Franklin
Yakima
Clark
<2.0%
Stevens
Kittitas
Pierce
Pacific
Ferry
Okanogan
Snohomish
Jefferson
Pend
Oreille
Walla
Walla
Benton
4.0-4.9%
Source: WA State Department of Health
Spokane
Whitman
Garfield
Asotin
≥5.0%
WA State Counties’ School Entry Exemption Rates, 2005-2006
San Juan
15.2%
Island
11.1%
Whatcom
7.5%
Skagit
7.7%
Clallam
Snohomish
6.1%
Chelan
6.3%
Jefferson
2.3%
Kitsap
19.4%
King
6.4%
5.1%
Grays Mason
Kittitas
Harbor 5.8%
Pierce
Thurston
2.8%
4.8%
3.9%
7%
Pacific
Lewis
Yakima
9.7%
3%
1%
Cowlitz
Wahkiakum
Skamania
2.6%
4.5%
8.5%
Klickitat
Clark
3.9%
5.4%
<2.0%
2.0-2.9%
WA State Dept. of Health
Okanogan
8.2%
Douglas
1%
3.0-3.9%
Grant
3.7%
Benton
3.2%
Ferry
14.3%
Lincoln
7.1%
Adams
1.2%
Pend
Stevens Oreille
12.2% 12%
Spokane
6.8%
Whitman
3.1%
Garfield
Franklin
Columbia
Walla
1.3%
Asotin
4%
Walla
1.9%
2.7%
Statewide Total: 5.1%
4.0-4.9%
>5.0%
WA State Counties’ School Entry Exemption Rates 2006-2007
Whatcom
8.1%
San Juan
13.5%
Clallam
7.9%
Jefferson
14.9%
Island
9.0%
Kitsap
9.5%
Grays Mason
Harbor 7.4%
4.1%
Thurston
8.0%
Pacific
3.6%
Wahkiakum
(no report)
Clark
6.1%
<2.0%
Snohomish
7.5%
Chelan
3.1%
King
5.5%
Kittitas
Pierce
5.1%
6.3%
Lewis
3.7%
Cowlitz
3.8%
Okanogan
10.6%
Skagit
6.7%
Skamania
9.5%
2.0-2.9%
Yakima
1.2%
Klickitat
7.8%
3.0-3.9%
WA State Dept. of Health
Douglas
2.1%
Grant
5.1%
Benton
4.1%
Ferry
30.5%
Lincoln
9.1%
Adams
1.4%
Pend
Stevens Oreille
16.5% 17.8%
Spokane
9.2%
Whitman
5.7%
Garfield
3.7%
Columbia
Asotin
Walla Walla 7.5%
3.5%
3.8%
Franklin
1.5%
Statewide Total: 6.0%
4.0-4.9%
>5.0%
WA State Counties’ School Entry Exemption Rates
2007-2008
Whatcom
San Juan
9.9%
9.9%
Okanogan
Skagit
Island
7.8%
Jefferson
13.7%
Wahkiakum
(No Report)
4.2%
3.7%
4.5%
5.1%
Cowlitz
3.6%
1.8%
5.8%
WA State Dept. of Health – School Status Reports 2007-2008
6.5%
Columbia
Walla Walla
4.9%
(no report)
0.0%
Asotin
4.8%
Klickitat
5.5%
7.2%
2.0-2.9%
Benton
3.7%
Skamania
Whitman
Garfield
Franklin
Yakima
1.7%
Adams
3.5%
Lewis
4.0%
9.2%
10.2%
Grant
Kittitas
Pierce
Clark
<2.0%
19.3%
Spokane
Lincoln
5.5%
Mason
Thurston
Douglas
3.4%
King
10.6%
6.3%
Chelan
3.1%
Kitsap
8.0%
Pacific
13.5%
Snohomish
7.9%
4.9%
25.8%
13.8%
Clallam
Grays
Harbor
Ferry
13.6%
11.7%
Pend
Stevens Oreille
3.0-3.9%
Statewide Total: 6.3%
4.0-4.9%
>5.0%
>10.0%
WA State Counties’ School Entry Exemption Rates
2012-2013
Whatcom
San Juan
7.5%
11.6%
Okanogan
Skagit
5.7%
Island
5.3%
Jefferson
12.4%
Wahkiakum
10.3%
4.4%
Cowlitz
4.7%
1.9%
No Data
WA State Dept. of Health – School Status Reports 2007-2008
4.9%
Columbia
Walla Walla
3.0%
0.0%
0.0%
Asotin
4.3%
Klickitat
7.2%
6.4%
2.0-2.9%
Benton
3.0%
Skamania
Whitman
Garfield
Franklin
Yakima
0.8%
Adams
2.5%
Lewis
3.3%
6.1%
10.6%
1.8%
4.7%
3.4%
Spokane
Grant
Kittitas
Pierce
Clark
<2.0%
14.2%
Lincoln
4.7%
Mason
Thurston
Douglas
0.6%
King
5.4%
3.1%
Chelan
2.9%
Kitsap
4.9%
Pacific
8.7%
Snohomish
4.1%
2.0%
8.2%
Pend
Stevens Oreille
5.1%
Clallam
Grays
Harbor
Ferry
4.9%
3.0-3.9%
Statewide Total: 4.5%
4.0-4.9%
>5.0%
>10.0%
Why Do Parents Claim
Exemptions?
Comparison of Maximum and Current Reported Morbidity,
Selected Vaccine-Preventable Diseases, United States, 2011
Disease
Smallpox
Diphtheria
Measles
Mumps
Pertussis
Polio (paralytic)
Rubella
Cong. Rubella Synd.
Tetanus
H.Influenzae type b and
unknown ( < 5 yrs)
Total
Pre-vaccine Era*
2011
% change
29,005
21,053
530,217
162,344
200,752
16,316
47,745
152
580
20,000
0
0
212
370
15,216
0
4
0
9
8
100%
100%
>99%
>99%
92%
100%
>99%
100%
98%
>99%
1,064,854
15,607
99%
* Estimated because no national reporting existed in the prevaccine era
Comparison of Maximum and Current Reported Morbidity,
Selected Vaccine-Preventable Diseases & Vaccine Adverse
Events, United States, 2011
Disease
Smallpox
Diphtheria
Measles
Mumps
Pertussis
Polio (paralytic)
Rubella
Cong. Rubella Synd.
Tetanus
H.Influenzae type b and
unknown ( < 5 yrs)
Total
Reported Vaccine
Adverse Events**
Pre-vaccine Era*
2011
% change
29,005
21,053
530,217
162,344
200,752
16,316
47,745
152
580
20,000
0
0
212
370
15,216
0
4
0
9
8
100%
100%
>99%
>99%
92%
100%
>99%
100%
98%
>99%
1,064,854
15,607
99%
9,318
100%
0
* Estimated because no national reporting existed in the prevaccine era
** Reported to VAERS – may or may not be due to vaccination
Chen
Why Do Parents Claim
Exemptions?
• Perceived Susceptibility and Severity
of Disease
• Perceived Safety and Effectiveness
of Vaccination
• Trust in Health Care Providers and
the Gov’t
Salmon et al. Archives of Ped and Adolescent Med. 2005.
Non-Medical Exemptions
and Legal Issues
• States are not required to offer
non-medical exemptions
• If states offer non-medical
exemptions
 Can create administrative
requirements
 May not be able to focus on nature
of religion
Arkansas
• State Permits Religious Exemption (7/02)
 "immunization conflicts with the religious
tenets and practices of a recognized church or
religious denomination of which the parent . .
. is an adherent or member."
 Must provide copy of religious doctrine and
details of religious organization
• Parent requests exemption for Hepatitis B
• State rejects exemption request
• Parent files lawsuit – goes to US District
Court
US District Court
• Arkansas religious exemption
violates
 Establishment and Free Exercise
Clauses of the 1st Amendment
 Equal Protection Clause of the 14th
Amendment
• Eliminated Religious Exemption
• Severed from School Requirement and
Medical Exemption
• Judge suggests legislative relief
Lemon v. Kurtzman, 403 U.S. 602
Arkansas Reaction
• Momentum gaining for broadly
written PE
• Johns Hopkins Letter to Fay
Boozman
• AR Medical Society requests
our assistance
Model Legislation for
Non-Medical Exemption
• Parent
 Furnish signed, personal statement
explaining reasons for exemption request
 Documentation from licensed physician or
DOH that parent has received individual
educational counseling
• State weighs strength of parent conviction with
risks of granting exemption:
 Vaccination Rates
 Community vulnerability to disease
outbreaks
 Prevalence of VPDs
Salmon et al, AJPH 2005
Model Legislation for
Non-Medical Exemption (cont)
• State may reject exemption
request based on this balance
• Appeals process for
exemptions that have been
declined
• If exemption granted, must be
annually renewed
Salmon, Sapsin, Teret, Halsey
Arkansas Non-Medical
Exemption
• DOH rejects authority to deny
exemption request
• Includes assessment of impact
of change in law
Impact of Philosophical
Exemption in Arkansas
Exemption
Type
2001-02
2002-03 2003-04 2004-2005
Medical
110
139
64
62
Religious
419
512
297
362
Phil.
0
0
403
721
Total
529
651
764
1145
Thompson et al, AJPM, 2007
Impact of Philosophical
Exemption in Arkansas
Exemptions
2001-02
529
2002-03 2003-04 2004-2005
651
764
1145
% Increase from
Previous Year
23%
17%
50%
Absolute
Increase from
Previous Year
122
113
381
Total
Absolute or % Increase?
Thompson et al, AJPM, 2007
Texas Requires HPV Vaccine
• All 6th grade girls in 2008
• Passed by Governor Order
 No public comment
Texas Requires HPV Vaccine
• All 6th grade girls in 2008
• Passed by Governor Order
 No public comment
• State legislature repealed
School law issues moving
forward
• How to balance parental autonomy
with public health goal of preventing
disease?
• Can states with high exemption
rates and easy exemptions lower
rates through administrative
requirements?
• What to do with new vaccines as
they become available?
School Immunization
Requirements
Daniel Salmon, PhD, MPH
Associate Professor
Johns Hopkins Bloomberg School of Public Health