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Vaccine-exempt law expands

As Texas joins 18 other states in allowing philosophical objections to vaccination, public health searches for a balance between community and autonomy.

By Susan J. Landers, AMNews staff. July 28, 2003.

Washington -- A new Texas law that broadens the state's school vaccine exemption categories has caused alarms to sound among state physicians with reverberations reaching physicians nationwide.

Last month Texas became the 19th state to allow parents to seek exemptions from state vaccination requirements for school entry for philosophic rather than religious or medical reasons. Although it is likely to remain in place for the time being, the new law was being challenged at press time.

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Still, it's the latest round in an ongoing debate that sometimes pits parental fears against long-held public health objectives. The upshot is that primary care and family physicians who treat young patients are likely to hear more and more questions from parents.

Michael Foulds, MD, a San Antonio pediatrician and president of the Texas Pediatric Society, is concerned that the law could result in more exemptions, pockets of unimmunized children and outbreaks of diseases long thought vanquished.

"Whooping cough, which used to kill a lot of infants, is uncommon in this country. But we are seeing it start to crop up in communities when immunization rates start to drop," he said.

That the Texas law is one among many similar state laws troubles Lou Cooper, MD, immediate past president of the American Academy of Pediatrics. Dr. Cooper believes there has been an increase nationally in the number of parents seeking exemptions for their children. "It tends to be pocketed in some communities more than others, and it is probably putting some communities at significant risk."

Although he doesn't ignore the vaccine safety issues that are behind much of the parental concern, Edward Marcuse, MD, professor of pediatrics at the University of Washington, Seattle, says "There is absolutely no question that where you have low levels of immunization the risk of vaccine-preventable disease is much higher."

The medical community generally considers immunization one of the great public health success stories. But parents don't always embrace this view, sometimes focusing on vaccine adverse reactions and other risks more intently than on the diseases the vaccines prevent -- many of which now are rarely seen. For instance, some children might be predisposed to reactions, or families might feel a certain vaccine isn't necessary for their child, said Dawn Richardson, president of Parents Requesting Open Vaccine Education, or PROVE.

"Each vaccine is different and each child is different," Richardson said. "We are opposed to one-size-fits-all vaccinations."

PROVE is a group of about 3,500 Texas families who have worked for several years to broaden the Texas exemption law. The group supports the addition of a philosophic exemption as does the National Vaccine Information Center, a parent-led advocacy group founded by parents of children injured by vaccines.

Among Richardson's reasons for starting PROVE in 1997 were her difficulties in finding a physician who would address her concerns about vaccinations for her own children. "Some families are frustrated with the medical community for not being in more of a partnership position in discussing this issue intelligently with families," she said.

Dr. Foulds, for one, does spend more time than ever educating parents on the benefits of vaccines, and nurses review potential side effects with parents. "I think the more that parents understand, the better."

Although physicians expect to answer a lot of questions from parents on vaccine adverse reactions, the balance between public health and individual autonomy often is difficult to maintain. "It is far better to educate than to mandate," said Dr. Cooper. "But unfortunately what we have learned in preventive health services is that people put things off."

Parents can only put immunizations off until their children reach school age. All states require that children be vaccinated before entering school. All states also allow for medical exemptions for children who are immunocompromised, allergic to vaccine components or have another condition that makes it medically unwise for them to receive a vaccine.

Forty-eight states allow for religious exemptions, which are generally tightly focused on organized religions with a tenet of beliefs. The philosophical or conscientious exemption laws of 19 states have fewer strings, although most require that parents obtain notarized documentation of their objections to a vaccine.

The AMA would like to see an end to both religious and philosophic exemptions. Its position is that such exemptions present a danger not only to the unvaccinated individual but also to the health of the larger community.

Others see a role for exemptions as long as they are based on thoughtful and sincere consideration and detect the possibility of a backlash if parents who are strongly opposed to vaccines are forced to obtain them.

Still others see a danger posed by broadly drawn exemptions that could make it easier to get a philosophical exemption than to get the shots.

Religious exemptions, which often took the role of a philosophic exemption, also have run into trouble in the courts, adding additional complications to an already complicated situation. Arkansas had to eliminate its religious exemption when a federal judge ruled that it violated the First and Fourteenth Amendments.

Daniel Salmon, MPH, associate director for Policy and Behavioral Research at the Institute for Vaccine Safety at Johns Hopkins University, has conducted several studies on religious and philosophical exemptions, the risks they pose and models for state laws that might incorporate lessons learned from determining conscientious objector status for military service.

"Ultimately, it's a balance between individual rights and parental autonomy and the health of the public," Salmon said.

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