1	Non-Medical Immunization Exemptions: Balancing Parental Autonomy with Protecting the Public’s Health Daniel Salmon, PhD, MPH Associate Director for Policy and Behavioral Research Institute for Vaccine Safety email: dsalmon@jhsph.edu www.vaccinesafety.edu
2	Comparison of 20th Century Annual Morbidity and Current Morbidity Vaccine-Preventable Diseases
3	Compulsory Immunization Laws Massachusetts (1809) General Population Jacobson v. Massachusetts Upheld rights of states to compel vaccination Foundation for public health law Focus on School Populations Zucht v. King (1922)
4	School Immunization Laws Prevent outbreaks
5	Incidence of Measles According to Evidence of Mandatory School Entry Requirements
6	Incidence of Reported Measles in States Enforcing School Immunization Laws
7	Reported Incidence Of Mumps For 5-19 Year Olds By Type Of State Immunization Requirement
8	School Immunization Laws Prevent outbreaks Provide safety net Demonstrates public commitment to immunization Assist introduction of new vaccines
9	Estimated Varicella Vaccination Coverage Among Children 19-35 Months of Age by State US, National Immunization Survey, 2000
10	Growth of State Laws Requiring Vaccination
11	Exemptions To School Immunization Laws
12	State Implementation of Exemptions Wide variability Easy process = High rates
13	Easy Exemption Process Associated with High Rates
14	State Implementation of Exemptions Wide variability Easy process = High rates Easier to claim exemption than fulfill requirement Little contact between parents and health personnel Majority of states (67%) never deny exemptions States rely on schools to implement exemptions
15	Relative Risk of Measles and Pertussis in Exemptors from School Laws
16	School Exemption Rates in Counties With and Without Pertussis Outbreaks COLORADO Counties with outbreaks 4.7% Counties without outbreaks 1.3% p = .001
17	Religious and Medical Exemptions Among Massachusetts Kindergarten Students 1986-1999
18	School Exemption Rates (%) Colorado: 1987-1998
19	Non-Medical Exemptions and Legal Issues States are not required to offer non-medical exemptions If states do offer non-medical exemptions Can create administrative requirements May not be able to focus on nature of religion
20	Arkansas State Permits Religious Exemption (7/02) "immunization conflicts with the religious tenets and practices of a recognized church or religious denomination of which the parent . . . is an adherent or member." Must provide copy of religious doctrine and details of religious organization Parent requests exemption for Hepatitis B State rejects exemption request Parent files lawsuit – goes to US District Court
21	US District Court Three Prong Lemon Test Legislature must have secular purpose Primary effect must not advance nor inhibit religion Must not result in excessive entanglement of government with religion
22	US District Court Ruling Fails 2^nd and 3^rd Prong of Lemon Test, Clearly runs afoul of: Establishment and Free Exercise Clauses of the First Amendment Equal Protection Clause of the Fourteenth Amendment Eliminated Religious Exemption Severed from School Requirement and Medical Exemption Judge suggests legislative relief
23	Arkansas Reaction Momentum gaining for broadly written PE Johns Hopkins Letter to Fay Boozman AR Medical Society requests our assistance
24	Model Legislation for Non-Medical Exemption Parent Furnish signed, personal statement explaining reasons for exemption request Documentation from licensed physician or DOH that parent has received individual educational counseling State weighs strength of parent conviction with risks of granting exemption: Vaccination Rates Community vulnerability to disease outbreaks Prevalence of VPDs
25	Model Legislation for Non-Medical Exemption (cont) State may reject exemption request based on this balance Appeals process for exemptions that have been declined If exemption granted, must be annually renewed
26	Arkansas Non-Medical Exemption DOH rejects authority to deny exemption request Includes assessment of impact of change in law
27	Non-Medical Exemption Schemes With State Examples
28	Non-Medical Immunization Exemptions: Balancing Parental Autonomy with Protecting the Public’s Health Daniel Salmon, PhD, MPH Associate Director for Policy and Behavioral Research Institute for Vaccine Safety email: dsalmon@jhsph.edu www.vaccinesafety.edu