Striking a Balance with Vaccine Safety

Vaccines save lives. They've eradicated smallpox and greatly reduced the incidence of measles and polio. Nonetheless, the number of American parents requesting exemptions for mandatory vaccinations for their children is rising. A central reason, according to a survey conducted by researchers from the Bloomberg School? Parental concern about vaccine safety.

"People fear what they know, not what they don't know," says Daniel Salmon, PhD, lead author of the study that appeared in the May 2005 issue of  Archives of Pediatrics & Adolescent Medicine. "People aren't afraid of measles [anymore] because they don't know measles, but they're afraid of vaccines because they've heard stories."

Stories about adverse effects of certain vaccines lurk on official-looking websites. Stories link immunizations to the rise in autism. (The Institute, as well as nearly all medical and public health authorities, says there is no correlation.) Stories are often the product of junk science.

There is no federal law requiring vaccinations for schoolchildren. The shots required, as well as who must get them, vary by state.

All states have medical exemptions to protect kids whose health may be compromised by a physical condition. It's the non-medical exemptions that get tricky. Some 48 states have exemptions based on religion, and 19 have them based on philosophical or personal beliefs. In some states, it's easier to get an exemption than the vaccination. "Maryland is a great example," says Salmon, associate director for policy and behavioral research at the Institute for Vaccine Safety at the Bloomberg School. "There's a sentence on the immunization form that says 'Immunizations are contrary to my religious beliefs.' Sign that statement, and you're done."

Groups opposed to mandatory vaccinations want more philosophical exemptions. But expanding the criteria for vaccination refusal can endanger public health—particularly when there are clusters of unvaccinated kids. The issue becomes one of recognizing individual rights while protecting public health.

That's the balance that researchers at the Institute and the Center for Law and the Public's Health (run in conjunction with Georgetown University Law Center) were trying to strike when they drafted a new exemption provision for Arkansas. In 2002, a federal court ruled Arkansas' religious exemption unconstitutional because it required "a recognized church or religious denomination," which the Court held as discriminatory against nondenominational faiths. After the decision, several bills proposing broad non-medical exemptions were introduced to the legislature. Health advocacy groups feared these new bills could endanger immunization programs. The Institute and the Center worked in consultation with the Arkansas Medical Society to come up with a new, balanced provision.

Modeled after the criteria for conscientious objectors to military conscription, the exemption the Institute drafted, which Arkansas adopted with a few changes, focuses not on religion but on the strength of the person's conviction. The state will not explicitly deny exemptions, but it does require Arkansans to meet some administrative requirements to get them. They must write a letter, notarized, stating why they want the exemption; complete an educational component on the risk and benefits of vaccination; and sign a statement of "informed consent." Moreover, they must reapply for the exemption annually.

The Institute hopes that the draft exemption will be useful to other states struggling with the constitutionality of school immunization requirements.