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America’s Epidemic of Vaccine Exemptions

New York and Washington allow parents to refuse vaccinations for non-medical reasons. Both states are experiencing major measles outbreaks. This is not a coincidence.

Sean Gallup/Getty Images

To be a parent in the 1950s was to know that your child would at some point contract measles, a highly contagious virus characterized by fever and rash. When it happened, most parents needed only to plan for a few days of care. But about 500 every year planned funerals.

The first measles vaccine in the U.S. was introduced in 1963, and the disease was officially eliminated in 2000. Since 2008, however, it has been creeping back. Nearly 350 measles cases were diagnosed in the country last year, the second-highest number since its eradication. Just one month into 2019, it seems certain that this year will be even worse.

At least 35 people, mostly children, have been diagnosed with measles in Washington state since January 1, prompting the state’s governor, Jay Inslee, to declare a state of emergency. Around 40 more have been diagnosed in New York this month, part of an outbreak there that’s seen at least 186 cases since October. Public health officials expect the outbreaks to spread further, and attribute both of them to the same problem: An increasing number of parents are refusing vaccinations for their kids.

Across the United States, children are required to be immunized from life-threatening diseases before they’re allowed to enter school or daycare. This not only protects the child from disease, but ensures that schools are safe places for immune-compromised kids and adults, as well as kids and adults who are medically unable to get vaccines. Vulnerable groups such as these rely on herd immunity, which is achieved when around 90 to 95 percent of the population is vaccinated.

The majority of parents who reject these requirements today, however, aren’t from vulnerable groups. They’re opting out for their own religious or personal beliefs. Parents aren’t legally allowed to do that in every state, but can in the two states experiencing major measles outbreaks. Religious exemptions are permitted in New York, where the outbreak is primarily affecting the ultra-Orthodox Jewish community. Both personal and religious exemptions are allowed in Washington, which according to one infectious disease researcher has become “a major anti-vaccine hot spot due to non-medical vaccine exemptions that have nothing to do with religion.”

Routine childhood vaccination programs have been shown to prevent approximately 42,000 early deaths and 20 million cases of disease per year, saving $13.5 billion in direct costs. That’s why non-medical exemption laws are opposed by the American Medical Association, the American Academy of Pediatrics, the Infectious Diseases Society of America—basically every reputable medical organization out there. But nearly every state has them in some form. There is also “tremendous variability in the rigor with which such beliefs must be proved or documented,” according to the Pediatric Infectious Diseases Society (PIDS). In some states, “parents simply need to state that ‘their religion’ is against vaccination to be granted an exemption, even though no major religions specifically discourage vaccination.”

These problems are being compounded by the growth of the anti-vaccine movement, which argues that vaccines are more dangerous than the government and medical community claim, and thus no vaccines should be mandatory. Neither their facts nor their logic holds up. “Parents cannot be exempted from placing infants in car seats simply because they do not ‘believe’ in them,” argues PIDS. States also don’t allow belief exemptions for laws intended to protect other people, like driving a car without a license. “Whether or not children should be vaccinated before childcare or school entry ought not be a matter of ‘belief,’” the group argues. “Rather, it should be a matter of public policy based on the best available scientific evidence, and in this case the science is definitive: vaccines are safe and they save lives.”

So why doesn’t Congress just pass a vaccination law outlawing non-medical exemptions? “We would love it if they could do something at the federal level,” said Rich Greenaway, the director of operations for the advocacy group Vaccinate Your Family. “We’d be 100 percent behind it.” But it’s not clear that Congress has that legal authority. According to the Congressional Research Service, “the preservation of the public health has been the primary responsibility of state and local governments, and the authority to enact laws relevant to the protection of the public health derives from the state’s general police powers.” Creating a federal vaccination law would turn that historical precedent on its head.

A federal vaccination law would also set the stage for a fierce legal battle with vaccine opponents that would almost certainly make its way to the Supreme Court. The risk of losing that battle, while providing a major platform for anti-vaxxers, might not be worth it. Besides, the state’s authority to set vaccination requirements was already confirmed by the U.S. Supreme Court over 100 years ago, and federal lawmakers also don’t have much interest in taking that authority away, Greenaway said. “The legislators at the federal level, they kind of know that their states want to handle this and they step back from it.”

But there are other ways the federal government can influence vaccination policy. The feds provide most of the funding for state public health agencies, and the Centers for Disease Control and Prevention provides states with nearly all their funding to buy vaccines for children whose parents don’t have medical insurance to cover the costs. They could put restrictions on the money—say that they won’t provide funding to states if their vaccine programs allow personal belief exemptions—but that’s a risky approach. What if states accuse of the government of overreach and reject funding instead of comply? Would they then have no vaccine program at all?

The best approach, Greenaway says, is to provide states with bigger rewards for success in preventing the spread of diseases. “In a perfect world, we’d love to see more incentives, where a state might get a higher percentage of federal funding when they do well so they can continue to work toward getting the numbers even higher,” he said. The CDC could also offer grants to private health insurance companies or doctors who demonstrate that they’ve kept a high percentage of their patients up to date on vaccinations. The Department of Education could offer financial incentives to schools that consistently demonstrate a highly vaccinated population.

But for the most part, Greenaway thinks vaccination is an area where the federal government is doing nearly everything it can. “The CDC works really hard on this,” he said. “They’re constantly coming up with public information campaigns, and trying to put in money into research to see whether or not certain things work.”

It will be up to individual states, then, to do more to prevent outbreaks—and perhaps the surest way of accomplishing that is by tightening exemptions. The California legislature eliminated personal belief exemptions in 2015 after an outbreak that originated at Disneyland infected at least 111 people, nearly half of whom were unvaccinated. Since then, vaccination rates among kindergartners increased by nearly 5 percent—though so have medical exemptions.

Paul Harris, a state representative in Washington, is hoping for the same outcome in his state. This week, he introduced a bill that would eliminate the personal exemption. It won’t be an easy sell, even though it preserves the religious exemption and comes amid a measles outbreak. A similar bill in 2015, prompted by the Disneyland outbreak and supported by Inslee, failed in the state House. Less than four months later, Washington was home to the first measles death in America in a dozen years.