In the Wake of a Pandemic: Revisiting School Approaches to Nonmedical Exemptions to Mandatory Vaccination in the US.

Mandatory school vaccination policies with exclusion of unvaccinated students can be a powerful tool in ensuring high vaccination rates. Some parents may object to mandatory vaccination policies, claiming exemptions based on medical, religious, or philosophical reasons. Individual schools, school systems, or local or regional governments have different policies with respect to whether, and what kind of, exemptions may be allowed. In the setting of the current pandemic, questions regarding the acceptability of exemptions have resurfaced, as schools and local governments struggle with how to safely return children to school. Anticipating that school attendance will be facilitated by the development of a vaccine, school systems will face decisions about whether to mandate vaccination and whether to permit exemptions. The American Academy of Pediatrics promulgates policy favoring the elimination of nonmedical exemptions generally in schools. This discussion considers whether schools should eliminate nonmedical exemptions to vaccination as proposed in the American Academy of Pediatrics policy, ultimately concluding that broad elimination of exemptions is not justified and advocating a more nuanced approach that encourages school attendance while promoting vaccination and broader public health goals.

The role of vaccine exemptions in the resurgence of measles.

ABSTRACT: Measles (rubeola) is a highly contagious, vaccine-preventable illness. Since 2014, a resurging trend has been noted in the incidence of measles, an illness once eliminated. Low vaccination rates contribute to its resurgence. The most compelling reason for low vaccination rates is the availability and prevalence of nonmedical exemptions (NME), which are primarily based on religious and philosophical beliefs. This article reviews the effect of NMEs in measles resurgence and the moral and legal implications of these exemptions. Clinicians should be aware of this trend and be ready to educate and evaluate the validity of NME requests.

The Impact of Michigan's Nonmedical Vaccine Exemption Rule Change on Philosophical Exemption Rates.

To examine school factors associated with philosophical exemption rates among kindergarteners in Michigan from 2014, before Michigan's implementation of administrative rule 325.176 (12), to 2015, after the rule change revising the process for receiving nonmedical exemptions from school entry vaccines. The study explored the extent to which the factors-school type, geographical location, and socioeconomics-were associated with philosophical exemptions among kindergarteners before and after the rule change, using negative binomial regression and Spearman's Rho correlation. Philosophical exemptions decreased from 2014 to 2015 for all school types but remained highest among rural private schools. Urban private schools had the second highest exemptions with rates 2.22 times higher than those of urban public schools. Exemption rates among rural charter schools were double those of urban public schools, while rural public schools' rates were 1.22 times higher than those of urban public schools. Free and reduced school lunch eligibility had a strong inverse association with philosophical exemptions for both 2014 and 2015, with higher philosophical exemptions being associated with higher socioeconomic schools. Philosophical exemption rates decreased in the wake of the rule change; however, high philosophical exemptions, post rule change, were still associated with private schools, rural locations, and high socioeconomic status schools.

Compulsory Vaccination and the Turkish Constitutional Court.

As vaccine hesitancy is on the rise around the world, apex courts in some countries have confronted the difficult task of striking a fair balance between individual rights and the common good. Against this background, the article discusses the compulsory vaccination cases heard by the Turkish Constitutional Court (TCC). The TCC's case law illustrates that any interference with bodily integrity must first comply with the principle of lawfulness and its rulings addressed an important shortage of the current Turkish compulsory childhood vaccination policy. The article suggests that the principle of lawfulness in compulsory vaccination cases should not be taken lightly, even if it serves compelling public interests.

360 Years of Measles: Limiting Liberty Now for a Healthier Future.

The United States Supreme Court has upheld state vaccination mandates as a condition of entry to schools by relying on their police power in protecting public health and safety. Despite this broad authority, many state mandates include exemptions that permit parents to refuse vaccination on behalf of their children for nonmedical reasons, like religious, philosophical, or personal beliefs. A spectrum of these laws currently exists, ranging from California's ban of all nonmedical claims to Ohio's extremely permissive grant of exemptions. This article discusses each of these states' mandates and the relationship between relaxed exemption laws and measles outbreaks using statistical analyses. To curb the spread of this vaccine-preventable disease, states should consider the threat to public health paramount to individual liberty infringement by restricting access to nonmedical exemptions. This approach aligns with a century of case law that has rejected vaccination mandate challenges based on fundamental rights, religious freedom, equal protection, and due process. Now states must act within that authority to safeguard against the persistence of this potentially fatal disease.

[Parental refusal to mandatory vaccination in Chile. Ethical and legal challenges]. / Rechazo de los padres a la vacunación obligatoria en Chile. Desafíos éticos y jurídicos.

This article is an ethical and legal reflection about the current trend of parents to refuse vaccination of their children under a legal regime that establishes mandatory use of certain vaccines. We analyze the main arguments used by parents to refuse obligatory vaccination, i.e., the fear of the negative effects that vaccination may have on the child; the violation of the "right to autonomy"; religious or pseudo-philosophical beliefs; and the resistance to the State intervention in personal or family mat ters. Therefore, this statement implies a necessary ethical analysis of childhood vaccination. Finally, it will be discussed the responsibility of parents and the State -the health authority- in the care of mi nors. Vaccination is a benefit for both the inoculated and the community, the best preventive policy. At the same time, it is considered a complex case that demands a profound debate, whose purpose should be the transition from an apparent conflict between parents and the State, to convergence for the care of minors. In other words, it is emphasized the fact that parents, beyond the fulfillment of a heterogeneous normative duty, must act motivated by voluntary adherence to the best interest of the child and the community.

[Statement from the Immunization Committee of the Chilean Infectious Diseases Society in reference to vaccine refusal and mandatory policy on vaccination]. / Posición del Comité Consultivo de Inmunizaciones de la Sociedad Chilena de Infectología en relación a los cuestionamientos de las vacunas y su obligatoriedad.

Although vaccines have had a tremendous impact in public health they are questioned by certain groups that consider them unnecessary or unsafe and argue in favor of the right to decide to be vacci nated or not. However vaccines must have special considerations because unlike other medical deci sions, not vaccinating has consequences not only for the individual but also for other members of the community. Immunizing a high proportion of the population limits the circulation of an infectious agent attaining what is called community or herd immunity that protects the susceptible members of the group. For this reason many countries consider vaccination mandatory as a responsibility of every citizen. This committee agrees with this view but thinks other strategies should be implemented as well, such as special educational efforts for the public and parents addressing benefits and real risks of vaccinating. Also health care professionals should be trained in vaccines. The notification system for adverse events currently available should be improved and be more accessible. Persons truly affected by adverse events due to vaccination should receive on time responses and be offered psychological and financial support. Finally all stakeholders should make coordinated efforts to work together to deliver messages that answer concerns on vaccines and bring confidence back to the public.

Refusal of Vaccination: A Test to Balance Societal and Individual Interests.

While all states in the United States require certain vaccinations for school attendance, all but three allow for religious exemptions to receiving such vaccinations, and 18 allow for exemptions on the basis of other deeply held personal beliefs. The rights of parents to raise children as they see fit may conflict with the duty of the government and society to protect the welfare of children. In the U.S., these conflicts have not been settled in a uniform and consistent manner. We apply a test that provides a concrete and formal rubric to evaluate such conflicts. For some vaccinations, based on the individual medical characteristics of the disease and the risks of being unvaccinated, the test would suggest that permitting conscientious exemptions is ethical. However, for vaccinations protecting against other diseases that are more severe or easily transmitted, the test would suggest that the federal government may ethically impose laws that deny such exemptions.

Paying for Risky Decisions: Civil Liability of Non-Vaccinators.

Since their widespread introduction in the early 20th century, vaccinations have saved millions of lives worldwide and have near to eradicated some diseases in several countries. Vaccination in Australia, although not mandatory, is strongly and actively encouraged through pervasive education campaigns, financial incentives and administrative requirements. Despite this, approximately 10% of children in Australia are not fully vaccinated against vaccine preventable diseases and every year thousands of Australians are infected with one of these diseases. This article considers the liability in negligence of parents whose unvaccinated children infect and cause harm to others. It argues that policy considerations will ultimately determine decisions about liability in a given case and, in particular, that courts should take into account the reasons for failure to vaccinate in making their determination on liability. The article further argues that if reasons for failure to vaccinate are not regarded as appropriate matters of differentiation for the purposes of tort law, all unreasonable non-vaccinators should nonetheless be liable for physical harm that their failure to vaccinate causes.

Is There a Moral Right to Nonmedical Vaccine Exemption?

A recent measles outbreak in the United States was linked to a single source, yet it spanned eighteen jurisdictions and infected 121 people. 1 Forty-seven states currently allow legal exemption from vaccination on religious grounds, eighteen of which also allow it on philosophical grounds. 2 Recent research usually accepts a fundamental right to vaccine exemption and primarily seeks ways to protect herd immunity while also respecting that right, for example, by keeping the exemption available yet harder to procure or by imposing torts for infection-related injury. 3 We argue that when herd immunity is at risk, any moral claim to exemption from vaccination on conscientious, philosophical, or religious grounds is overridden. Our argument rests on an analogy to a series of situations in which a person puts others at risk through philosophically or religiously motivated choices. In these situations, intuitively, there is no claim-right to compromise the safety of others. Similarly, we propose, there is no claim-right to refuse vaccination, regardless of one's conscience, when refusal is sufficiently likely to seriously affect herd immunity and the safety of others. We also address several counterarguments. The lack of a claim-right to exemption when herd immunity is at risk does not mean, however, that it is always prudent for the state to force vaccination, or even that forcing vaccinations must be legal. Alternatives to forced vaccination may prove wiser and more conducive to high vaccination rates.

Law and Politics, an Emerging Epidemic: A Call for Evidence-Based Public Health Law.

As Jacobson v. Massachusetts recognized in 1905, the basis of public health law, and its ability to limit constitutional rights, is the use of scientific data and empirical evidence. Far too often, this important fact is lost. Fear, misinformation, and politics frequently take center stage and drive the implementation of public health law. In the recent Ebola scare, political leaders passed unnecessary and unconstitutional quarantine measures that defied scientific understanding of the disease and caused many to have their rights needlessly constrained. Looking at HIV criminalization and exemptions to childhood vaccine requirements, it becomes clear that the blame cannot be placed on the hysteria that accompanies emergencies. Indeed, these examples merely illustrate an unfortunate array of examples where empirical evidence is ignored in the hopes of quelling paranoia. These policy approaches are not only constitutionally questionable, they generate their own risk to public health. The ability of the law to jeopardize public health approaches to infectious disease control can, and should, be limited through a renewed emphasis on science as the foundation of public health, coordination through all levels and branches of government, and through a serious commitment by the judiciary to provide oversight. Infectious disease creates public anxiety, but this cannot justify unwarranted dogmatic approaches as a response. If we as a society hope to ensure efficient, constitutional control over the spread of disease, it is imperative that science take its rightful place at the forefront of governmental decision-making and judicial review. Otherwise, the law becomes its own public health threat.

Does Australia need compulsory immunisation?

There are a significant number of factors that influence whether parents choose or refuse to immunise their children. The primary reasons appear to be civic duty, financial incentive, understanding of the medical implications, and complacency. This article considers these factors in light of Australia's immunisation strategy, in particular the National Immunisation Program and the new No Jab No Play campaigns in various Australian jurisdictions. In assessing the effectiveness of these measures, the article concludes that some compulsory measures are required to maintain Australia's immunisation rates against transmissible disease.