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.

Surrogate Decision Making for Children: Who Should Decide?

OBJECTIVE: To identify caregivers' views on preferred surrogate decision makers for their children. STUDY DESIGN: A respondent-anonymous survey was distributed to a convenience sample of adults who accompanied a child to general and subspecialty pediatric care at 2 different institutions or were at the bedside of a child in the pediatric intensive care unit at a third institution in Chicago. RESULTS: We collected 462 valid surveys. The average age of the legal guardian and accompanying child was 36.8 years and 6.6 years, respectively. Most legal guardians designated "other parent with legal authority" as their first choice surrogate decision maker (70%). Respondent's sex, respondent's age, child's age, and child's ethnicity had no effect on first choice surrogate decision maker. "Other parent with legal authority" was less likely to be first choice surrogate if respondents had Medicaid insurance, less than a college degree, or lived in a non-nuclear household (P<.01 for all factors). The surrogacy ladder selected by 31% of legal guardians was "other parent with legal authority," "child's grandparent(s)," and "child's aunt(s) or uncle(s)." No other sequence received more than 10% designation. Study site had no effect on surrogate preference (P = .30). CONCLUSIONS: A surrogacy priority ladder for minors needs to include relatives who are often not included in state surrogacy statutes (eg, grandparents, aunts and uncles). The most popular surrogacy ladder will not be ideal for many families. Parents need to be informed and empowered to choose alternate surrogates, and documented preferences must be easily and widely accessible.