In the JournalsPerspective

Frequent review needed for medical exemptions to school immunizations

More than 13,000 children entering kindergarten were granted medical exemptions to immunizations required for school entry for the 2010-2011 school year, and nearly 88,000 medical exemptions were granted between 2004 and 2011, according to recent study findings.

Although medical exemption rates are considered to be low, they exceed 1% of kindergarten children in some states. The total annual medical exemptions to kindergarten school-entry requirements increased from 11,277 in 2004-2005 to 13,952 in 2010-2011. During the 7-year study period, 87,631 medical exemptions were granted, according to the study data published in the Journal of Infectious Diseases.

Medical exemption rates across the country ranged from a low of 263/100,000 children during the 2006-2007 school year to a high of 411/100,000 children during the 2008-2009 school year, according to the study data.

Saad B. Omer, MBBS, MPH, PhD, of Emory University Schools of Public Health and Medicine in Atlanta, and colleagues said medical exemption rates should be monitored and continuously evaluated to ensure that medical exemptions to school-entry immunizations are not granted solely because they are easier to obtain than other types of exemptions.

“Judicious use of the medical exemption option helps ensure that individual children and the broader community can benefit from high immunization coverage,” the researchers wrote.

The researchers concluded that their findings lend some evidence that parents who live in states with more stringent requirements for nonmedical exemptions may then seek medical exemptions because medical exemption rates were higher in states with more difficult administrative requirements to nonmedical exemption.

According to the study findings, medical exemption rates were significantly higher in states with easy or medium criteria (adjusted incidence rate ratio [IRR]=6.4; 95% CI, 2.7-15.6; and IRR=4.4; 95% CI, 1.8-11.1, respectively) compared with states with difficult medical exemption criteria.

“Our findings suggest that administrative requirements requiring accountability of the physician and parent(s) for granting medical exemptions can be effective in ensuring they are used when there are valid contraindications, and not just as a replacement for nonmedical exemptions,” they study researchers wrote.

In an accompanying editorial, Daniel A. Salmon, PhD, MPH, and Neal A. Halsey, MD, of Johns Hopkins Bloomberg School of Public Health in Baltimore, said, “Children with valid medical exemptions need to be protected from exposure to vaccine-preventable diseases by insuring high coverage rates among the rest of the population.”

Salmon and Halsey also said, “Medical exemptions are intended to prevent adverse events in children who are at increased risk of adverse events because of underlying conditions. Many of these underlying conditions also place children at increased risk of complications from infectious diseases.”

However, they said, “Health care providers should be made aware of the consequences of providing false contraindications for vaccines as a justification for not vaccinating children.”

For more information:

  • Salmon DA. J Infect Dis. 2012;doi:10.1093/infdis/jis437.

  • Stadlin S. J Infect Dis. 2012;doi:10.1093/infdis/jis436.

More than 13,000 children entering kindergarten were granted medical exemptions to immunizations required for school entry for the 2010-2011 school year, and nearly 88,000 medical exemptions were granted between 2004 and 2011, according to recent study findings.

Although medical exemption rates are considered to be low, they exceed 1% of kindergarten children in some states. The total annual medical exemptions to kindergarten school-entry requirements increased from 11,277 in 2004-2005 to 13,952 in 2010-2011. During the 7-year study period, 87,631 medical exemptions were granted, according to the study data published in the Journal of Infectious Diseases.

Medical exemption rates across the country ranged from a low of 263/100,000 children during the 2006-2007 school year to a high of 411/100,000 children during the 2008-2009 school year, according to the study data.

Saad B. Omer, MBBS, MPH, PhD, of Emory University Schools of Public Health and Medicine in Atlanta, and colleagues said medical exemption rates should be monitored and continuously evaluated to ensure that medical exemptions to school-entry immunizations are not granted solely because they are easier to obtain than other types of exemptions.

“Judicious use of the medical exemption option helps ensure that individual children and the broader community can benefit from high immunization coverage,” the researchers wrote.

The researchers concluded that their findings lend some evidence that parents who live in states with more stringent requirements for nonmedical exemptions may then seek medical exemptions because medical exemption rates were higher in states with more difficult administrative requirements to nonmedical exemption.

According to the study findings, medical exemption rates were significantly higher in states with easy or medium criteria (adjusted incidence rate ratio [IRR]=6.4; 95% CI, 2.7-15.6; and IRR=4.4; 95% CI, 1.8-11.1, respectively) compared with states with difficult medical exemption criteria.

“Our findings suggest that administrative requirements requiring accountability of the physician and parent(s) for granting medical exemptions can be effective in ensuring they are used when there are valid contraindications, and not just as a replacement for nonmedical exemptions,” they study researchers wrote.

In an accompanying editorial, Daniel A. Salmon, PhD, MPH, and Neal A. Halsey, MD, of Johns Hopkins Bloomberg School of Public Health in Baltimore, said, “Children with valid medical exemptions need to be protected from exposure to vaccine-preventable diseases by insuring high coverage rates among the rest of the population.”

Salmon and Halsey also said, “Medical exemptions are intended to prevent adverse events in children who are at increased risk of adverse events because of underlying conditions. Many of these underlying conditions also place children at increased risk of complications from infectious diseases.”

However, they said, “Health care providers should be made aware of the consequences of providing false contraindications for vaccines as a justification for not vaccinating children.”

For more information:

  • Salmon DA. J Infect Dis. 2012;doi:10.1093/infdis/jis437.

  • Stadlin S. J Infect Dis. 2012;doi:10.1093/infdis/jis436.

    Perspective
    Paul Offit

    Paul Offit

    Currently, 20 states allow philosophical exemptions to vaccination, 48 states allow religious exemptions and 50 states allow medical exemptions. Previous studies have suggested that some parents might use religious exemptions to vaccination in states that do not have philosophical exemptions. The study by Stadlin, Bednarczyk and Omer make a rather surprising observation: Some parents might be using medical exemptions in states that have difficult-to-obtain nonmedical exemptions. Given that vaccine-preventable diseases such as pertussis and measles have increased in recent years, medical providers, school administrators and state health officials should be vigilant about making sure that medical exemptions are valid; otherwise, children will be put at unnecessary risk of preventable illnesses.

    • Paul Offit, MD
    • Infectious Diseases in Children Editorial Board member

    Disclosures: Dr. Offit reports no relevant financial disclosures.