Creating Vaccination Rules That Stick

Discussions about vaccinations occur regularly within legislatures across the nation. Policymakers aim to protect public health while scrutinizing conflicting information and heeding concerns of constituents, including parents who want options for their children.
In West Virginia, a state with one of the toughest vaccination laws in the country, the topic has been brought up every year for more than a decade, said West Virginia state Sen. Ron Stollings, a physician and former co-chair of The Council of State Governments’ Health Public Policy Committee.
“Every year, there’s been a strong effort to make more lax the vaccination laws in West Virginia,” he said.
During the debate, legislators gather evidence from deans of university schools of medicine on vaccines and immunization rates, obtain information from the American Academy of Pediatrics, and hear from individuals against vaccinations who argue for flexibility. The law in West Virginia has remained strict, Stollings said, but a position created in recent years under the state Bureau for Public Health reviews appeals from parents seeking exemptions.
The way vaccination laws are implemented—no matter how tough or lax—is important, said Daniel Salmon, a professor in the Johns Hopkins Bloomberg School of Public Health and deputy director of the Institute for Vaccine Safety. 
All the states have laws that require vaccinations for school entry. In addition, all states allow medical exemptions. However, the steps required to receive a medical exemption vary from state to state. Furthermore, all states except three—California, Mississippi and West Virginia—allow nonmedical exemptions, including religious exemptions and, in some cases, philosophical or personal belief exemptions.
“What these laws look like on the state level and what they’re called, but more importantly how they’re implemented and enforced, really makes a big difference,” Salmon said.
For example, obtaining a religious exemption is as easy as checking a box on a form in some states, but “when a state has tried to make it hard to get religious exemptions, they get into sticky ground,” Salmon said. In one case that Salmon described, parents sued and the courts struck down a law that attempted to distinguish various religions.
“Rather than trying to distinguish between one religion and another, or religious versus personal belief … instead focus on how you implement and enforce it,” Salmon said.
Implementation strategies could include requiring educational counseling where the person seeking the exemption sits down with a doctor and talks about the risks and benefits of vaccines. States could require annual exemption renewals, taking new evidence or changes in personal belief into consideration.
“State government has a valuable role to play in supporting and maintaining high immunization coverage,” said Melinda Wharton, director of the Immunization Services Division of the Centers for Disease Control and Prevention, or CDC.
Wharton said national immunization coverage is high. The CDC plans to publish updated coverage estimates on their website in the fall for adolescents and young children. There is variation, however, in state coverage and in local coverage.
In a report published in October 2016 about vaccination coverage among children in kindergarten, the median vaccination coverage for the 2015–2016 school year was 94.6 percent for two doses of measles, mumps and rubella vaccine, or MMR. MMR coverage increased in 32 states, and 22 states reported coverage greater than or equal to 95 percent, according to the report.
“In general, coverage for the vaccines that we recommend for young children … is quite high in the United States and consistently has been for many years,” Wharton said. “We are fortunate in the United States in that the providers who take care of young children really value immunization; they work very hard to make it happen.”
The conversation about immunization rates and vaccines often changes or spikes after an outbreak of disease. Even though rates are high at the national level, immunization rates differ locally and sometimes people who reject vaccines are located within close proximity to one another.
Within states, there are variations at the local level, and in communities there are variations at the neighborhood or school level,” Wharton said.
Children might be at risk where coverage is not as high, and some children may be too young or have medical conditions that prevent them from receiving vaccinations.
“With measles we talk about wanting to have at least 95 percent of people immune … and that’s not to say that with 95 percent immunity, you wouldn’t have spread, it just means that you probably wouldn’t have ongoing transmission,” Wharton said.
However, someone can get measles being in a room that someone with measles was in a couple of hours prior, Wharton said. The recommended immunity rate is different for various diseases, depending on how easily the disease can spread. 
The more people in the population who are immune to a disease, the likelier it is that a disease would not continue to spread after it is transmitted.
“With a high level of immunity in the population, the people who can’t be vaccinated can still be protected,” Wharton said.