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Number of Bills Related to Personal Belief Exemptions (PBE) and Number of Administrative Requirements Contained Within, by Strength, and by State, 2009-2012
Omer  SB, Richards  JL, Ward  M, Bednarczyk  RA.  Vaccination policies and rates of exemption from immunization, 2005-2011. N Engl J Med. 2012;367(12):1170-1171.
Omer  SB, Pan  WKY, Halsey  NA,  et al.  Nonmedical exemptions to school immunization requirements: secular trends and association of state policies with pertussis incidence. JAMA. 2006;296(14):1757-1763.
Research Letter
February 12, 2014

Legislative Challenges to School Immunization Mandates, 2009-2012

Author Affiliations
  • 1Rollins School of Public Health, Emory University, Atlanta, Georgia
  • 2Immunization Action Coalition, St Paul, Minnesota
  • 3Task Force for Global Health, Decatur, Georgia
  • 4School of Medicine, Emory University, Atlanta, Georgia

Copyright 2014 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.

JAMA. 2014;311(6):620-621. doi:10.1001/jama.2013.282869

School immunization mandates, implemented through state-level legislation, have played an important role in maintaining high immunization coverage in the United States. Immunization mandates permit exemptions that vary from state to state in terms of type of exemption (eg, religious, personal belief, medical), and administrative ease of obtaining these exemptions. Certain types of exemptions (especially personal belief exemptions) and the ease of obtaining them are predictive of high rates of vaccine exemptions and increased disease risk among exemptors themselves and in the communities in which they reside.1,2

Legislation has been proposed in recent years to modify exemptions to school immunization requirements. We analyzed such legislation at the state level.


The Immunization Action Coalition, a nongovernmental organization focused on vaccine education and advocacy, maintains a database of vaccine-related state legislation. This information is obtained from government affairs and public policy workers, medical groups, state immunization program managers, and news items.

For our study, we counted each bill introduced from 2009 through 2012 by the year it was first introduced. We first classified the bills into 2 groups: bills introduced in states that either did or did not have a personal belief exemption (PBE). We then listed administrative requirements included in each bill. An administrative requirement was defined as one that would require action from the child’s parent or guardian beyond merely signing an exemption form (see Table footnote a).

Bills were also classified as expanding exemptions or restricting exemptions. Bills considered as expanding exemptions either introduced a PBE that was not already in place or made a PBE easier to obtain by removing 1 or more administrative requirements. Bills were considered as restricting exemptions if an administrative requirement was added to an existing PBE. Bills were also categorized based on the number of administrative requirements.


Eighteen states introduced 1 or more exemption-related bills (Table). There were a total of 36 bills introduced regarding immunization during the study period, including 30 in 12 states that did not currently have a PBE, and 6 in states that did have a PBE. Among the 36 bills, 15 (42%) contained no administrative requirements, 7 (19%) had 1 or 2 administrative requirements, and the remaining 14 (39%) contained between 3 and 5 administrative requirements. The most common administrative requirement was to use a specific health department form (17 of 36 bills), followed by the requirement for the parent or guardian to receive education about vaccine risks and benefits (14 bills).

Of 20 states with a current PBE, 5 (25%) saw a bill introduced to restrict exemptions and 1 (5%) saw a bill introduced to expand exemptions. Among the 30 states without a PBE, none saw a bill introduced to restrict exemptions and 13 (43%) saw a bill introduced to expand exemptions. Of the 36 bills introduced, 5 (14%) were categorized as restricting exemptions and 31 (86%) as expanding exemptions. Thirty of the 31 bills to expand exemptions proposed introducing a PBE and 1 proposed removing the requirement for notarization from an existing PBE. None of the bills categorized as expanding exemptions were passed. Three of the 5 bills categorized as restricting exemptions were passed (Washington, California, and Vermont).


Exemptions to school immunization requirements continue to be an issue for discussion and debate in many state legislatures. Even though the majority of bills introduced would have expanded exemptions, 14% were designed to strengthen an existing nonmedical exemption. All of the legislative efforts to expand exemptions failed; however, the majority of bills to restrict exemptions passed.

This study has limitations. Although it is based on a comprehensive and multisource database, we may have missed a few of the bills proposed in various state legislatures. However, it is unlikely that this limitation favors 1 type of proposed legislation (ie, restricting vs expanding exemptions) over another.

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Article Information
Section Editor: Jody W. Zylke, MD, Senior Editor.

Corresponding Author: Saad B. Omer, MBBS, MPH, PhD, Emory University, 1518 Clifton Rd NE, Room 7017 (CNR Building), Atlanta, GA 30322 (

Author Contributions: Dr Omer and Ms Curran had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Omer, Hinman, Orenstein.

Acquisition of data: Omer, Peterson.

Analysis and interpretation of data: Omer, Curran, Hinman, Orenstein.

Drafting of the manuscript: Omer, Curran.

Critical revision of the manuscript for important intellectual content: Omer, Peterson, Curran, Hinman, Orenstein.

Statistical analysis: Curran.

Administrative, technical, and material support: Omer, Orenstein.

Study supervision: Omer.

Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Hinman reported receiving institutional grant funding from the US Centers for Disease Control and Prevention, the Bill & Melinda Gates Foundation, Novartis Vaccines, and the Merck Company Foundation. No other disclosures were reported.

Additional Contributions: We thank Christine Finley, MPH (Vermont Department of Public Health), Catherine Martin, BS (California Immunization Coalition), and Daniel A. Salmon, PhD (Johns Hopkins University Bloomberg School of Public Health), for their input. None received compensation for their contribution.

Omer  SB, Richards  JL, Ward  M, Bednarczyk  RA.  Vaccination policies and rates of exemption from immunization, 2005-2011. N Engl J Med. 2012;367(12):1170-1171.
Omer  SB, Pan  WKY, Halsey  NA,  et al.  Nonmedical exemptions to school immunization requirements: secular trends and association of state policies with pertussis incidence. JAMA. 2006;296(14):1757-1763.