Legal + Legislative Influence on State Vaccination Requirements

Quick note: I’m not here to debate vaccines — I am a medical student and public health practitioner and I have read a good deal of scientific evidence on this topic. I firmly believe in the safety, efficacy, and public good of vaccination. My goal with this post is to provide you with some of the legal fundamentals that influence vaccination and the impact of pockets of low immunity on individual and public health.

It’s Wednesday and I’m one day closer to my cardio midterm and to my family visiting for my medical school pinning ceremony next week! For those wondering what a pinning ceremony is, it’s my medical schools’ alternative to a white coat ceremony, which are usually held at medical schools in the fall. I’ll report back after mine, but I assume it will be similar to all the others that occurred around the country back in August– a formal ceremony to officially “coat” us with the white coat we wear for clinical experiences.

Before I dive in to a full day in the library, I wanted to spend a little time on the current measles outbreak in the Pacific Northwest. As medical students, we learn how vaccines work and the recommended vaccine schedules for different populations but it’s also important to know the legal and public health issues that influence why state laws vary regarding compulsory vaccination. Let’s use the current measles outbreak as our springboard into this issue.

Source: CDC

Measles is exquisitely contagious — it is spread by aerosol droplets from infected persons sneezing or coughing. The virus can live for up to two hours in the airspace where an infected person sneezed or coughed; up to 90% of non-immune individuals exposed to the virus will become infected. It’s not hard to see how quickly measles can spread among non-vaccinated population. It typically starts with a high fever, cough, runny nose, and and red, watery eyes; within a few days, infected individuals will also break out in a rash. Children younger than five and adults older than 20 are more likely to suffer complications from measles, ranging in severity from ear infections and diarrhea to pneumonia, encephalitis (brain swelling), and death.

Before the measles vaccination program started in 1963 in the U.S., an estimated 3 to 4 million individuals were infected with measles annually. The CDC recommends that children receive two doses of the MMR vaccine; research has shown that two doses are 97% effective at preventing measles. Although the MMR vaccine is considered safe and effective, fraudulent science significantly dented public perception of the vaccine in some communities.

Source: CDC

The measles outbreak occurring in the Pacific Northwest is unlikely to become a national epidemic, but it does have the potential to spread among other communities with low vaccination rates. The national average of children aged 19-35 months vaccinated for measles is 91.1% but there are some states and localities with MMR vaccination rates much lower than the national average. In Clark County, the epicenter of the current outbreak, only 81% of children aged 1-5 have at least one dose of the MMR vaccine.

Why is there a 10% difference between the national MMR vaccination rate and the Clark County rate? Let me introduce you to the 10th Amendment to the United States Constitution and Henning Jacobson.

At the turn of the 20th century, a Massachusetts statute granted city boards of health the authority to require vaccination “when necessary for public health or safety.” When smallpox surged in Cambridge, Massachusetts in 1902, the city board of health issued an order to require mandatory vaccination of all adults against smallpox. The penalty for refusal was $5.

Henning Jacobson refused the mandatory vaccination, claiming he and his son had suffered adverse reactions to previous vaccinations. He was fined $5 and appealed to the U.S. Supreme Court. The Supreme Court upheld the state’s power to grant authority to boards of health to order vaccination during an outbreak. The decision in this case rested on the 10th Amendment, which affirms that states retain all the sovereign authority they had not ceded to the federal government in the Constitution. This authority is called “police power” and it involves the state capacity to pass laws related to the health, safety, morals, and general welfare of the people.

Vaccination requirements vary by state for this precise reason — state laws establish vaccination requirements based on the powers of the 10th Amendment but retain the authority to craft state-specific statutes that can offer exemptions that impact the rates of vaccination. The development and promotion of vaccinations for infectious diseases, and the resulting drop in mortality and morbidity, is one of the major achievements in public health in the 20th century.

States typically mandate vaccination for everything from MMR and Hepatitis A to Varicella (chicken pox) and Polio for school entry. However, some states are more lenient than others when parents seek exemptions from these requirements.

There are three general exemptions:

  • Medical: All 50 states allow medical exemption to vaccination. The CDC has detailed guidelines on who should not receive particular vaccines, often based on severe allergies, weakened immune system, pregnancy, or recent illness. Aside from severe allergies or past medical diagnoses that contraindicate a vaccine, this exemption would not apply to all vaccines for an entire lifetime.
  • Religious (all states except West Virginia, Mississippi, and California): The Constitution grants the right to freely hold and exercise religious beliefs. Some faith traditions hold a sincere religious belief opposing vaccination, to the point where state requirements are an unconstitutional infringement on their religious beliefs. The state must prove a “compelling interest” before this right is infringed. A number of court cases have set precent on the issue — an individual’s religious beliefs are subject to reasonable regulation if the exercise of those beliefs substantially threatens the welfare of society as a whole. The requirements to obtain a religious exemption vary by state but can include submission of a written statement from a religious leader and from the individual seeking the exemption explaining the sincere religious belief.
  • Philosophical/Conscientious/Personal Belief: Fewer than half of states offer this type of exemption, but each state has varying requirements. In some states, parents and children old enough to give consent (usually 12 and older) must seek an exemption to all vaccines, not just one or two. In some states, parents must still obtain a signature from a medical provider to file for a personal belief exemption.

In Oregon, the epicenter of the outbreak I mentioned earlier, parents have two options when seeking a vaccine exemption — watch an online module on vaccination and submit a signed form or talk to a healthcare providers and have them sign a Vaccine Education Certificate. Washington States requires parents to submit a Certificate of Exemption to the school or child care center. Legislators in both states are now seeking to alter vaccine exemption laws. A Washington state House committee recently passed a bill banning philosophical exemptions for the MMR vaccine (a state Senate bill would repeal the exemption for all vaccines) and the Oregon House Health Care and Wellness Committee has advanced a bill that would repeal personal or philosophical exemptions to vaccines.

In response to a measles outbreak linked to Disneyland in California, the state legislature repealed religious and personal belief exemptions. Another outbreak in New York has been linked to ultra-Orthodox Jewish communities. Legislation has recently been introduced in the state legislature to repeal the religious exemption in New York State. Vermont also abandoned their personal exemption in 2015.

If you’ve never seen a case of measles, heard of a case of measles, or even thought about getting measles, thank the MMR vaccine. For my curious readers, you can view pictures of vaccine-preventable diseases here. And if you’re an adult, please make sure to keep your immunizations up to date. Check out the CDC adult vaccine schedule and head to their resource page for more details.


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