key: cord-0849372-m7qmq7e8 authors: Paquette, Erin Talati title: In the Wake of a Pandemic: Revisiting School Approaches to Non-Medical Exemptions to Mandatory Vaccination in the United States date: 2021-01-20 journal: J Pediatr DOI: 10.1016/j.jpeds.2021.01.022 sha: e3984a7e129901ca3fdc836ccef659d462d3f402 doc_id: 849372 cord_uid: m7qmq7e8 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 non-medical exemptions generally in schools. This discussion considers whether schools should eliminate non-medical exemptions to vaccination as proposed in the AAP 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. 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. School entry represents an important opportunity to ensure compliance with recommended vaccination for children, a critical public health strategy to advance population health. Mandatory school vaccination J o u r n a l P r e -p r o o f with exclusion of students who do not meet this requirement can be a powerful tool in ensuring high vaccination rates within schools. [1] Those seeking exemption for medical reasons are unable to be vaccinated safely. Non-medical exemptions comprise a variety of exemption requests generally based on philosophical or religious beliefs. 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 ongoing COVID-19 pandemic, significant efforts have been directed at determining how to safely return children to school due to ongoing concerns about infectivity and lack of a standardized treatment approach to the disease. Vaccination offers a promising means to permit children to return to school if a safe and effective vaccine were to be developed. If such a vaccine were to be developed, however, schools or local authorities governing schools will need to determine whether vaccination will be mandatory and whether exemptions will be permitted, raising longstanding questions about the balance of public health and individual liberties. This central question we will address is whether-as a matter of policy-schools ought to permit philosophical and religious (non-medical) exemption options to mandatory vaccination policies. We also consider circumstances of a public health emergency and how obligations may change under these conditions. We will describe the role for mandatory vaccination in public health programs, as well as the problem of vaccine hesitancy and the role of mandatory vaccination as a response to vaccine hesitancy and the prevalence and impact of non-medical exemptions to vaccination. The American Academy of Pediatrics (AAP) position favors mandatory vaccination with the elimination of non-medical exemptions in schools; we will describe the legal and ethical arguments for and against the elimination of such exemptions. We conclude that mandatory vaccination is justified when there is an imminent public health threat and there is an effective vaccine demonstrating a favorable benefit to risk profile, while restriction on exemptions to vaccination is justified when no other less restrictive means exists to combat the public health threat and restriction does not disproportionately burden any particular group. Ultimately, we favor this contextualized approach to when non-medical exemptions may be limited and promotes alternative strategies to improve vaccination rates for vaccine preventable diseases . Parents may object to mandatory vaccination for varied reasons. Over the last two decades, rates of non-medical exemption to vaccination have increased, with wide variation in state-level mandates regarding vaccination and exemptions. [10] A number of studies have attempted to describe the impact of non-medical exemption policies on rates of exemption and to evaluate the association between rates of non-medical exemptions and disease incidence for VPD. Where non-medical exemptions have been introduced, some states have seen a shift from medical to non-medical exemption requests. [11] such shifts may occur while the overall rate of exemptions remains the same. [12, 13] There may also be an additive effect when more than one type of non-medical exemption is available leading to higher rates of exemption overall. [14] Increased non-medical exemption rates have demonstrated increased risks of disease outbreaks for unvaccinated children in J o u r n a l P r e -p r o o f absolute, particularly if they placed the child or community at risk for ill health. [35] The policy outlines that ethically, decision making in the best interests of the child ought to lead parents to vaccinate, both for the protection of their child and the community. Because exemptions run counter to the decision to vaccinate, the AAP policy rejects them as detrimental both to the individual child who would not be vaccinated as well as to the community of individuals who cannot be vaccinated for medical reasons. The policy rejects the counterargument to the blanket elimination of non-medical exemptions as violating the "least restrictive means" test for infringing on personal liberty, claiming that the restriction on personal liberty is limited in scope to being restricted from school attendance, and suggesting that this restriction is not overly burdensome because children have alternatives to public school. First, children could attend a private school that permits an exemption. Children could also be home schooled and public schools could offer accommodations like provision of materials to be picked up before or after school hours to minimize exposure. Schools might additionally offer online materials. However, these pedagogical alternatives may not be realistic options for children of parents who do not have the ability to provide for private school or to stay at home to provide home schooling, even with school provided materials. Such accommodations may therefore create additional disparities in educational opportunity. Moreover, these accommodations cannot replace other social and interpersonal benefits that schools provide. There may be strong justifications to disallow non-medical exemptions to vaccination. Although elimination of exemptions can be criticized as an unauthorized infringement on individual liberty, the state's police powers do permit the limitation of such liberties in the interests of public health. [36] Among the strongest motivations for elimination of non-medical exemptions is evidence that elimination of non-medical exemptions leads to increased vaccination rates. [37, 38] Conversely, increased use of non-medical exemptions decrease overall rates of immunization, which correlates with J o u r n a l P r e -p r o o f between religious and philosophical objections break down. [47] [48] [49] Further support for both philosophical and religious objection lies in court cases that restrict questioning the sincerity of deeply held beliefs, whether religious or otherwise. [50] Review of Supreme Court jurisprudence demonstrates, however, that claims for vaccine exemptions based on religious beliefs are not absolute when they conflict with important public or state interests. [51, 52] These arguments have led to restrictive policies for both religious and philosophical exemptions to vaccination in some states. [53] In addition to legal bases for non-medical exemptions to vaccination, ethical arguments also exist to support non-medical exemptions. The strongest argument from an ethical perspective lies in respect for parental authority to raise their children as they see fit. Although, there may be many reasons to object to vaccination, philosophical objections may be grounded in a culture of distrust of government and medical institutions. [54] In general, parents are granted wide latitude in decision making authority for matters concerning their children, unless decision making rises to the level of constituting medical neglect. For parents who object to vaccination, potential harms related to vaccines rather than VPDs themselves emerge as concerns. [54, 55] Mandatory vaccine approaches that disallow philosophical or religious objection may be seen as coercive intrusions into the child rearing authority of parents, while permitting informed refusal may better respect the "autonomy" rights of parents to make decisions on behalf of their children. [56, 57] An additional argument against eliminating exemptions relates to the burdens that may be borne by the child based on parental decisions. Mandatory vaccination without exemption will likely lead to increased vaccination rates, which is in the interests of the public health and the children who become vaccinated as a result of the mandate. However, policies without exemption doubly burden children of persistent refusers, who remain unvaccinated, and are also denied entry to school. Complete elimination of non-medical exemptions runs counter to these ethical arguments. Some have argued that the ethical acceptability of objections rests with the degree of public health threat posed by particular conditions, requiring contextualized assessments to determine conditions when mandatory vaccination without exemption might be applied. [58] In proposing a limited restriction on non-medical exemptions for measles, for example, Opel et al argue that a focused approachrestricting non-medical exemption to a contextualized assessment of the need for a particular vaccination (i.e. the severity of the public health threat)-promotes feasibility, sustainability, and enforceability, while upholding a core public health principle of restricting liberty for the public good using the least restrictive means possible. [59] Under this approach, exemptions should be limited or eliminated when vaccination for the imminent public health threat is necessary to control the threat and is the least restrictive means to do so. A focused approach will be more acceptable because it protects the public health while restricting individual liberty less, will be more sustainable because it may appear less coercive and thereby more palatable to the public, risking less opposition to vaccination generally, and more practically enforceable because of its smaller scope. Moreover, limiting non-medical exemptions under these conditions should only be imposed if it constitutes the least restrictive alternative to improving vaccination rates as this maintains restriction on individual liberty to that which is necessary in scope and kind to achieve the intended public health goal. [60, 61] A contextualized approach such as that proposed by Opel et al respects important principles of public health law and ethics. Legally, interventions such as mandatory vaccination to protect the public health must adhere to the Jacobson court's holding that the state intervention is necessary to prevent an avoidable harm, has a real and substantial relationship to avoiding the harm, avoids burdens disproportionate to benefits, and does not cause the individual undue risk. [33, 62] By articulating these criteria, the Jacobson case both This disproportionate impact risks exacerbating already existing structural determinants of health and runs counter to public health principles to avoid unfair distribution of benefits and burdens among a population. While there may be compelling situations in which it would be reasonable to restrict non-medical exemptions to vaccination, there are important interests to weigh in the balance; the relative weight of these interests will not always support restrictions. Specific interests must be balanced in making these however, require a deeper analysis. The third criteria that burdens are not disproportionate to benefits would likely also support vaccination without exemption since the current incidence of disease is restricting most children from school until additional mitigation occurs. The fourth criterion may be the most difficult to defend currently since most trials are not involving children and it is unclear whether adult safety and efficacy data are generalizable to children. Additional safety and efficacy data in children are needed to assess whether risks to children are significant. In one r study, only 65% of parents have indicated that they would vaccinate their child with 52% of those who would refuse citing the vaccine's novelty. [65] Prematurely anticipating a plan for mandatory vaccination without exemption prior to clear evidence that a safe and effective vaccine has been developed could undermine public trust and risk worsening vaccine hesitancy. Instead of a broad restriction on exemptions, a more contextualized approach, generally allowing vaccine mandates with exemption, and restricting exemptions in the setting of public health emergencies, would better align with public health law. Along with this approach, it is critical to direct attention towards alternative means to increase vaccine compliance, as this will both further goals to protect the public health as well as the individual health interests of children who receive vaccines. While elimination or reduction of non-medical exemptions offers one avenue to counter hesitancy, other strategies may prove more successful overall in increasing vaccination. [66] For example, adoption of Advisory Committee on Immunization Practices recommendations regarding vaccination, introduction of mandatory vaccination policies even with exemption provisions and parental education were associated with higher vaccination rates. [67, 68] Similarly, implementing administrative strategies to make non-medical exemptions more challenging to obtain reduces the number of exemptions without eliminating them and can be ethically acceptable as long as administrative burdens do not disproportionately restrict options for some populations over others. [68] [69] [70] Partnering with schools, pharmaceutical companies, religious leaders and healthcare providers may also facilitate efforts to improve vaccination rates. [12, 71] Central among efforts is education, not only about VPD, but about waivers of vaccination, as well as about general matters of public health. [16, 72] Pediatricians as key educators should embrace this approach to optimize vaccination rates while supporting policies that will keep as many children in school as possible. 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