A few years ago some colleagues and I at the Institute for Science in Medicine were debating what our official position should be regarding non-medical vaccine exemptions. We all agreed that the ideal situation would be no non-medical exemptions. There is no legitimate reason for such exemptions and the evidence clearly shows that states who allow non-medical vaccine exemptions have lower vaccination rates.

The debate was about whether or not that should be our only position, to take a strong and uncompromising stance, or should we also advocate that states who do allow non-medical exemptions to make them as difficult as possible (which also is effective in reducing vaccine refusal). The concern was that the perfect solution was politically too difficult and the lesser solution was at least something (like a prosecutor including lesser charges in case they lose on the big charge).

I advocated for the latter position, which is what we ultimately decided. After the Disneyworld measles outbreak, however, I think the political calculus has changed. It is much more politically viable to simply advocate for the elimination of all non-medical exemptions.

The AAP Position Paper

The American Academy of Pediatrics seems to agree that the time is right to take a firm stand in favor of vaccine compliance. They released a position paper on 8/29/2016 that does just that.

In the policy statement, “Medical Versus Nonmedical Immunization Exemptions for Child Care and SchoolAttendance,” published the same day, the AAP recommends only medical exemptions be allowed for vaccine requirements for child care and school attendance.”

Non-medical exemptions to immunizations should be eliminated.

Further, the position paper states that it is acceptable for pediatricians to eject from their practice families who refuse vaccinations. This is still a difficult and controversial strategy, but the AAP is essentially saying that pediatricians can make up their own minds about whether or not this is ever appropriate.

The report was accompanied by another document that advises pediatricians on how to deal with vaccine hesitancy (David Gorski also wrote about this issue earlier this month). Their advice is very practical and evidence-based.

Pediatricians should begin counseling parents early about the safety and benefit of vaccines. They should also personalize the message by stating that their own families are vaccinated. Sometimes a lengthy discussion is necessary to address all the concerns of vaccine-hesitant parents.

For most parents who are vaccine-hesitant, they are perfectly reasonable and willing to listen to evidence. They are just filled with misinformation from dedicated anti-vaccine sources. This is a problem that can be fixed, and it is time well spent if it results in greater vaccine compliance.

Of course there are a minority of parents who hold on to anti-vaccine views with religious fervor and will not be persuaded by evidence.

Eliminating vaccine exemptions

Many of us are watching the fate of SB277, the California law that eliminated non-medical vaccine exemptions. This was the first real indication that the political landscape had shifted following the Disneyworld outbreak. It is unlikely that such a law would have passed in California prior to the outbreak.

Of course, the law is being challenged by the anti-vaccine community, politically and legally. So far the courts are supporting the law, however.

Last week a federal judge upheld SB277 by denying a preliminary injunction request that challenged the right of the state to deny philosophical exemptions. U.S. District Court Judge Dana Sabraw ruled:

Even outside the context of vaccination laws, the Supreme Court has reiterated the fundamental rights under the First Amendment to the United States Constitution do not overcome the State’s interest in protecting a child’s health.


The Constitution does not require the provision of a religious exemption to vaccination requirements, much less a personal belief exemption.

Legal precedence seems very clear here, states have a right to deny non-medical vaccine exemptions, whether based on religion or personal belief. The political climate is now also better than perhaps it has ever been to lobby, state by state, for the elimination of non-medical vaccine exemptions.

Vaccines work

Despite desperate attempts by anti-vaccine ideologues to create doubt and confusion over the safety and effectiveness of vaccines, the scientific data is extremely clear. Vaccines work. They are, in fact, probably the most effective and cost effective public health measure ever devised (rivaled only by basic sanitation).

Over the last century the world has been conducting a giant experiment on the safety and effectiveness of vaccines. Individual countries introduce vaccines to specific diseases at different times, and sometimes their laws change and vaccine compliance changes also. If we look at all the data from this meta-experiment there is a clear and consistent pattern – vaccines reduce the incidence of the diseases they are meant to prevent.

Anti-vaxxers try to dismiss this evidence as coincidence, focusing narrowly on tiny subsets of the data at a time, but the big picture is undeniable.

The most recent example of the efficacy of vaccines comes from the HPV vaccine. In the last decade millions of doses have been administered in 130 countries, and the overall effect has been to cut in half the incidence of cervical cancer. As promised – the HPV vaccine is preventing cancer.

In Australia where HPV vaccine compliance is very high, cervical cancer has been reduced by 70%. The reduction is lower in countries with lower rates of vaccination.

A recent review concludes:

With demonstrated efficacy, cost-effectiveness, and safety, universal HPV vaccination of all young, adolescent women, and with available resources at least high-risk groups of men, should be a global health priority. Failure to do so will result in millions of women dying from avertable cervical cancers, especially in low- and middle-income countries, and many thousands of women and men dying from other HPV-related cancers.

Vaccines not only work, they are a home run. In the end that is the most effective strategy for promoting vaccines, the simple facts. There will always be a fringe who are immune to reality, but they can be marginalized and their political impact minimized.

Because they are fanatical and tireless, the fringe does tend to have a disproportionate effect on policy. They have managed to lobby for vaccine exemption laws in most states. The tide may be turning, but in the long term advocates for child and public health will also have to be as tireless.

The scientific evidence favors eliminating non-medical vaccine exemptions. The legal precedence is also there. Now it seems the political will may be coalescing around an intolerance for vaccine refusal as a public health menace and a willingness to therefore eliminate non-medical exemptions.

Let’s keep the pressure on.


Posted by Steven Novella

Founder and currently Executive Editor of Science-Based Medicine Steven Novella, MD is an academic clinical neurologist at the Yale University School of Medicine. He is also the host and producer of the popular weekly science podcast, The Skeptics’ Guide to the Universe, and the author of the NeuroLogicaBlog, a daily blog that covers news and issues in neuroscience, but also general science, scientific skepticism, philosophy of science, critical thinking, and the intersection of science with the media and society. Dr. Novella also has produced two courses with The Great Courses, and published a book on critical thinking - also called The Skeptics Guide to the Universe.