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Following a multistate measles outbreak that began in Disneyland, California legislators responded to the outbreak by passing legislation repealing exemptions for philosophical and religious beliefs.1 Although the legislation retains medical exemptions, it makes California the largest state to have such strict childhood vaccination requirements, joining only West Virginia and Mississippi. Beginning in the 2016-2017 school year, children whose parents refuse vaccination and are unable to secure a medical exemption must be homeschooled.1 School-aged children who currently claim a nonmedical exemption can maintain it until the time they enter kindergarten or seventh grade, the state’s 2 vaccine checkpoints.1 The law applies to both public and private schools, as well as day care facilities.1
Even though many parents have called for an end to parental choices that could potentially put their children at risk, parents who are reluctant to vaccinate their children maintain that the move to stricter vaccination requirements is an infringement of their rights. These parents who support vaccine exemptions have promised legal challenges to halt implementation of the law, arguing it violates California’s constitutional provision guaranteeing the right to a free and appropriate education.2 Unvaccinated children will have to be homeschooled, which, they argue, is not an option for most families. Additionally, First Amendment challenges based on the Free Exercise Clause, which forbids laws that seek to restrict acts of faith, are likely. However, as long as the law does not target a specific religion, claims of impingement on religious freedom may be difficult to prove. In Jacobson v Massachusetts,3 the US Supreme Court held that the state had the authority to require mandatory vaccinations to protect its citizens from dangerous epidemics. The Court stated that although liberty was the greatest right, it did not provide individuals with the unlimited authority to act as they pleased, constitutionally permitting government to protect the safety of many over the objection of a few. Additionally, in Prince v Massachusetts, the Supreme Court stated that the First Amendment does not include parents’ right to expose a child or community to communicable disease or other harms.4
Despite overwhelming evidence proving that vaccines are effective, the number of unvaccinated children has been increasing, partly because of easily obtained exemptions. The percentage of California kindergarteners with nonmedical exemptions doubled from 1.56% to 3.06% between 2007 and 2013.5 If too many children in a given community are unvaccinated, the herd immunity that helps protect vulnerable individuals and other children from these diseases is diminished. Similarly minded parents who decline vaccines for their children have created pockets (small, often isolated areas or groups) in particular communities where the overall herd immunity level is low. Although California’s overall vaccination rates are stable (estimated measles, mumps, and rubella coverage was 92.3% during the 2013-2014 school year), some suburban pockets of the state have rates hovering near 50%.6 More than 25% of schools in California5 have measles immunization rates for kindergarteners below the 92% to 94% recommended to maintain herd immunity. A large part of this is driven by parents who have opted out of vaccinating their children by claiming a nonmedical exemption. Had the bill failed to pass, a continued and increasing incidence of vaccine-preventable illness in California was likely. As the recent outbreak in Disneyland demonstrated, this is not just a potential danger for Californians but for the entire country. This bill’s passage could help prevent another outbreak. Among the 110 California patients infected during the outbreak, only 8 (7%) were fully vaccinated for measles, and 28 vaccine-eligible patients (67%) were intentionally unvaccinated because of personal beliefs.7
There is substantial variation in state laws on vaccine exemptions.8,9 Today, 48 states have some form of religious exemption to vaccination requirements. Twenty states also provide exemptions based on philosophical objections. The recent measles resurgence led lawmakers in dozens of states to consider modifying existing exemption laws, though none have successfully implemented changes as widely sweeping as California’s. Proposed legislation (Table) included eliminating religious or philosophical exemptions, adding additional steps to the exemption process, expanding vaccine mandates, and requiring schools to publish vaccination rates. Even though many of these bills failed to pass, some were successful, such as a Vermont bill that eliminated the state’s philosophical exemption but kept its religious exemption in place. In contrast, a number of states, including Mississippi and West Virginia, proposed legislation to establish religious or philosophical exemptions, but none gained traction.
In recent years, more states have considered narrower changes to their exemption policies rather than a complete repeal of nonmedical exemptions. For example, Arkansas and Texas included an educational outreach component to the exemption process to inform the citizenry on vaccination. Vermont required an attestation that the exemption applicant had read materials concerning vaccination, while Washington, Oregon, and California required proof of a discussion with a health care practitioner about the risk and benefits of vaccination. The politics of nonmedical vaccine exemptions remain contentious.9
California’s new legislation may represent the beginning of a trend to tighten school immunization laws across the nation. A state as large and influential as California signals the crucial importance of childhood vaccines; other states will inevitably take notice.
Regardless of the intense lobbying by each side, the science supporting vaccines is settled, and opponents remain a small, vocal minority, with only 9% of Californians indicating that they believe vaccines are unsafe.10 Physicians overwhelmingly recommend childhood vaccines, which are credited with the elimination or near elimination of diseases like measles, mumps, and rubella. Other states should follow California’s common sense decision to protect the public’s health, understanding that the state’s interest in protecting children is a higher priority than the freedom of some.