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Will more states ban nonmedical exemptions for childhood vaccination?

Vaccination coverage in Mississippi and West Virginia are the highest in the country

Columbia University's Mailman School of Public Health

For more than 30 years, Mississippi and West Virginia were the only states in the country that disallowed nonmedical exemptions to mandatory school vaccination laws for religious or philosophical reasons, until they were joined by California last year. These exemption laws have provoked debate over the rights of parents versus the responsibility of government to protect public health. Researchers at Columbia University's Mailman School of Public Health, led by James Colgrove, PhD, professor of Sociomedical Sciences, conducted a review of vaccination policies through legislative rulings and accounts by health officials. They found policy changes remain controversial and alternatives exist to eliminating nonmedical exemptions entirely. The paper appears in the February issue of the journal Health Affairs.

While all 50 states allow exemptions for children who have a valid medical reason, and almost all states allow nonmedical exemptions for parents with either religious or philosophical objections, the political climate has recently shifted in favor of making exemptions more difficult to obtain.

In 2015, California, long known as a state with lenient provisions and high rates of opting out, followed the example of Mississippi and West Virginia and eliminated nonmedical exemptions. This move came in response to the widely publicized outbreak of measles in June 2015, traced to two Disneyland theme parks. That same year, at least twelve states considered bills on nonmedical exemptions.

Immunization rates in Mississippi and West Virginia show the benefits of strict exemption policies. In the 2014-15 school year, vaccinations in Mississippi for measles-mumps-rubella and diphtheria-tetanus-pertussis stood at over 99 percent for kindergarteners, the highest rate in the country. Only 17 children of kindergarten age received medical exemptions.

"Contrary to conventional wisdom, it may be politically feasible to limit exemptions to only medical reasons," writes Colgrove. "Health officials in both Mississippi and West Virginia report that overwhelming majorities of the public support their policies and that opposition comes from a very small number of the population. However, while sustaining policies is one thing, revoking a legal right that people have previously enjoyed presents a very different set of political circumstances."

Colgrove and his co-author, Abigail Lowin of Columbia Law School, suggest there are alternatives to eliminating nonmedical exemptions entirely. Many public health professionals are recommending retaining nonmedical exemptions but making them more difficult to obtain, requiring parents to receive educational counseling from a licensed health care provider, or to renew the exemption annually.


About Columbia University's Mailman School of Public Health

Founded in 1922, Columbia University's Mailman School of Public Health pursues an agenda of research, education, and service to address the critical and complex public health issues affecting New Yorkers, the nation and the world. The Mailman School is the third largest recipient of NIH grants among schools of public health. Its over 450 multi-disciplinary faculty members work in more than 100 countries around the world, addressing such issues as preventing infectious and chronic diseases, environmental health, maternal and child health, health policy, climate change & health, and public health preparedness. It is a leader in public health education with over 1,300 graduate students from more than 40 nations pursuing a variety of master's and doctoral degree programs. The Mailman School is also home to numerous world-renowned research centers including ICAP (formerly the International Center for AIDS Care and Treatment Programs) and the Center for Infection and Immunity. For more information, please visit

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