Processes for obtaining nonmedical exemptions to state immunization laws

A key strategy to ensure that children receive recommended vaccinations in the United States is the use of state legislative mandates to require proof of immunization upon school entry. State immunization laws are considered a critical element in efforts to increase vaccine coverage among the nation’s children, bringing many diseases to record low levels. 1 Mandatory laws for school entry and attendance have been credited with reductions in the incidence of several vaccine-preventable diseases within states 2,3 and nationwide 4,5 following enforcement of these laws. As new vaccines have become available, laws governing vaccination requirements have evolved within the states; there is no legislation at the national level pertaining to school immunization requirements. While there are national public health recommendations concerning immunizations, state laws have been maintained and expanded with support from state and local health officials. Compulsory immunization laws in the United States date back to state requirements designed to protect the public from smallpox through vaccination of the general population. 6 The vaccinations required by school laws are not provided free of cost by the government, as in some other countries with mandatory vaccination policies. However, childhood vaccinations are supported by government programs that assist lowincome families. The means of enforcement and the authority to whom enforcement is delegated vary among states and may influence the effectiveness of state laws. Local jurisdictions may vary in the vigilance applied to enforcement of the statutes as well as the relative incentives or backing to administer the laws. 2,5‐7 The penalty of exclusion from school for noncompliance with school immunization requirements is an effective method to ensure that parents obtain the necessary immunizations for their children. 5,8 However, the responsibility rests with school officials, often school nurses, to identify students in need of immunizations and to follow up after the state’s allotted period of time to comply has expired. 9