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Jeanne M. Santoli, MD, MPH and Alan R. Hinman, MD, MPH

Jeanne M. Santoli is with the National Immunization Program, Centers for Disease Control and Prevention, Atlanta, Ga. Alan R. Hinman is with All Kids Count, Decatur, Ga.

Correspondence: Requests for reprints should be sent to Jeanne M. Santoli, MD, MPH, National Immunization Program, Centers for Disease Control and Prevention, 1600 Clifton Rd NE, Mail Stop E-52, Atlanta, GA 30333 (e-mail: jsantoli{at}cdc.gov).

We read with interest the recent article by Rota et al.¹ The article is useful and timely, particularly given the recent heightened visibility of state immunization laws. Groups opposed to current vaccination policy are mounting challenges to these laws and are becoming more sophisticated in communicating their messages to the public.

State immunization laws, whose history in this country dates back to the middle of the 19th century, are a powerful means of protecting the populace (particularly children) from morbidity and mortality due to vaccine-preventable diseases. Immunization requirements are particularly important as we enter the 21st century, since the incidence of vaccine-preventable disease is very low and public familiarity with these diseases has begun to fade.

School immunization requirements have repeatedly been shown to be effective in reducing the incidence of vaccine-preventable diseases.² The benefit of these requirements extends beyond the children who are immunized, by reducing the risk of exposure to disease on the part of those who have medical contraindications to vaccination and those who have been vaccinated but who were not protected (primary vaccine failure, which affects a small proportion of those immunized). This "herd immunity" protects the community at large.

One aspect of the implementation of state immunization laws not discussed by Rota et al. is the role of the health care provider. Although in most states the actual decision making about exemptions does not involve the child's health care provider, many providers who care for children encounter parents who are concerned about the safety of vaccinating their children. By listening to the concerns of these parents, answering their questions, and addressing their hesitancy in a straightforward, nonconfrontational manner, providers can have an important impact on the frequency with which such exemptions are claimed.³

The value of state immunization laws depends on their ability to ensure immunization of all children who do not have valid exemptions. The authors find that use of formal procedures to receive requests for nonmedical exemptions decreases the number of exemptions claimed. These procedures act as a validation of the strength of the parents' beliefs and reduce the number of parents who might claim an exemption rather than go to the effort of finding the immunization record or getting the child immunized.

Courts at various levels have determined that there is no constitutional right to a religious or philosophical exemption (memorandum from K. Malone, senior attorney, Centers for Disease Control and Prevention, to W. A. Orenstein, MD, director, National Immunization Program; February 1, 2000). Although it is useful to allow parents the option of religious or philosophical exemptions to immunization, it should not be easier to obtain an exemption than it is to have a child immunized.

References

1. Rota JS, Salmon DA, Rodewald LE, Chen RT, Hibbs BF, Gangarosa EJ. Processes for obtaining nonmedical exemptions to state immunization laws. Am J Public Health.2001;91:645–648.[Abstract]

2. Task Force on Community Preventive Services. Recommendations regarding interventions to improve vaccination coverage in children, adolescents, and adults. Am J Prev Med.2000;18(suppl 1):92–96.[Medline]

3. Dias M, Marcuse EK. When parents resist immunizations. Contemp Pediatr.2000;17:75–86.

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