Childhood Vaccine Exemption Policy: The Case for a Less Restrictive Alternative

* Abbreviations: MV — : measles vaccine NME — : nonmedical exemption VPD — : vaccine-preventable disease Efforts to restrict parents’ ability to exempt children from receiving vaccinations required for school entry have recently reached a pinnacle. The American Medical Association voiced support for eliminating nonmedical exemptions (NMEs) from school vaccine requirements,1 and California enacted legislation doing so.2 Although laudable in their objective, policies eliminating NMEs from all vaccines are scientifically and ethically problematic. In the present article, we argue for an exemption policy that eliminates NMEs just for the measles vaccine (MV) and is pursued only after other less restrictive approaches have been implemented and deemed unsuccessful. A policy to eliminate NMEs just from MV is based on the premise that the nature and scope of the immediate threat to public health posed by measles and the ability to avert that threat with MV is distinct among vaccine-preventable diseases (VPDs). There are 3 features that, when considered in combination, support this premise. First, measles virus is extraordinarily contagious. Its basic reproduction number is 12 to 18.3 Only 1 other vaccine-preventable infectious agent is as contagious ( Bordetella pertussis ); all others have a basic reproduction number that ranges from 4 to 7. Due to this contagiousness, a very high rate of community immunity (∼92%–94%) must be achieved and sustained to prevent spread of the disease.4 Second, measles remains an important public health burden.5 Although other VPDs may be more common (eg, pertussis6) or have more severe typical cases (eg, invasive Haemophilus influenzae type b disease7), measles disease is severe enough,8,9 outbreaks common enough,10 … Address correspondence to Douglas J. Opel, MD, MPH, Seattle Children’s Research Institute, 1900 Ninth Ave, M/S: JMB-6, Seattle, WA 98101. E-mail: douglas.opel{at}seattlechildrens.org