Vaccine Laws and Medical Exemptions to Vaccines

Vaccine Basics

Vaccine books to help you do your vaccine research.
Reading some of these books will help you to get educated about vaccines, make the right choice for your children, and get them protected against vaccine-preventable diseases. Photo by Vincent Iannelli, MD

California recently passed a new vaccine law that eliminated non-medical vaccine exemptions for kids attending both public and private schools.

But while the law doesn't allow exemptions from immunizations because of personal or religious beliefs, the California law is not as clear as those in some other states about who should get a medical exemption.

The strictest vaccine laws when it comes to getting a medical exemption require a:

  • written physician statement
  • separate medical exemption form
  • health department approval
  • physician certified to practice in-state
  • annual approval (is not temporary)
  • notarization of medical exemption form

Only Arkansas, New Mexico and Wyoming have vaccine laws this strict and not surprisingly, they have lower medical exemptions than many other states.

States with the Strongest Vaccine Laws

That the California law is perhaps not as strict as it could be is easy to see when you read Dr. Bob Sears' response to Governor Jerry Brown's signing the law:

Deep breath. Realize, just to be clear, that nothing goes into effect until the next school year (a year from now). The grandfathering helps. The IEPs help. Options for medical exemptions help.

Options for medical exemptions?

Statements like that make you wonder if we are going to start seeing an abuse of medical exemptions, just like we have seen an abuse of personal belief and religious vaccine exemptions.

After all, the only reason someone should get a medical exemption for a vaccine is that they have a true contraindication or precaution to getting vaccinated.

Mississippi and West Virginia, the only two other states that don't allow non-medical exemptions, are much more clear about getting medical exemptions.

West Virginia states that "a certificate from a reputable physician showing that immunization for any or all is impossible or improper, or sufficient reason why any or all immunizations should not be done"

And in Mississippi, "A certificate of exemption from vaccination for medical reasons may be offered on behalf of a child by a duly licensed physician and may be accepted by the local health officer when, in his opinion, such exemption will not cause undue risk to the community."

But in California, the law states that "If the parent or guardian files with the governing authority a written statement by a licensed physician to the effect that the physical condition of the child is such, or medical circumstances relating to the child are such, that immunization is not considered safe, indicating the specific nature and probable duration of the medical condition or circumstances, including, but not limited to, family medical history, for which the physician does not recommend immunization, that child shall be exempt."

Still, there are only very specific medical circumstances when a child shouldn't get vaccines, so most kids in California with PBEs won't be exempt anymore, even with that added part about family medical history.

It probably shouldn't be surprising that a caution about "family medical history" was added to the California vaccine law. Many parents and some pediatricians believe that the family medical history influences vaccine risks.

It typically doesn't though.

That didn't stop Dr. Jay Gordon, a California pediatrician who testified against the law, from tweeting that he would "not vaccinate a second child if the first lost language and motor skills after a vaccine."

And in a post about "Navigating the New Vaccine Law in California," Dr. Bob Sears suggests that parents might want to seek a medical exemption for their child if distant relatives had a severe reaction to vaccines, if there is autism in the family, even in distant relatives, or if other family members had fibromyalgia, ADHD, asthma, or eczema, etc.

Determining Vaccine Risks from a Family Medical History

However, despite Dr. Bob's very long list of suggestions for medical exemptions, the very few circumstances where a child's family history might actually influence a parent's decision about vaccines should typically only include:

  • a family history of seizures - a precaution against getting ProQuad, the combined MMR/Varicella vaccine is listed. Children should instead get separate MMR and Varicella vaccines, although they can still get them at the same time.
  • a family history of congenital or hereditary immunodeficiency in a parent or siblings - a precaution against getting Varicella is listed, unless you are confident the child doesn't also have an immunodeficiency

    The words "family history" don't even come up in lists of vaccine contraindications.

    In fact, the only other place that family history comes up is in the "Conditions Commonly Misperceived as Contraindications to Vaccination:"

    • family history of seizures = OK to get DTaP
    • family history of sudden infant death syndrome (SIDS) = OK to get DTaP
    • family history of an adverse event after DTP or DTaP administration = OK to get DTaP
    • immunodeficient family member = OK to get MMR and Varicella

    There have even been studies on younger siblings of children with autism that have shown no increased risk to getting vaccinated.

    So when should you seek a medical exemption to getting your kids vaccinated?

    Medical Exemptions for Vaccines

    Medical exemptions to getting vaccines are not common. In many states, fewer than 0.2% of kids in school have medical exemptions. And that's not because medical exemptions are hard to get from pediatricians. It is just that there aren't a lot of reasons to get a medical exemption.

    There certainly are some true medical exemptions or contraindications to getting vaccines.

    Still, it is much more common that parents and some pediatricians misperceive common conditions as being contraindications when they aren't.

    For example, kids can usually still get vaccinated when they have a mild illness without fever, are taking antibiotics, or have a history of a non-vaccine allergy, etc.

    Contraindications for Vaccines

    In most cases, the biggest contraindication to getting a vaccine would be having had a severe allergic reaction after getting a previous dose of vaccine or to a component of the vaccine. This would be a true anaphylactic reaction though, and not the "transient urticaria-like rashes" which "are not a contraindication to subsequent vaccination."

    That would likely be a medical exemption for a specific vaccine though, not all vaccines. Perhaps your child is severely allergic to neomycin, an ingredient in the hepatitis A vaccine. That wouldn't stop her from getting the hepatitis B vaccine and other vaccines that don't contain neomycin.

    Other true medical contraindications to getting vaccines include:

    • having a history of intussusception - rotavirus vaccines
    • having severe combined immunodeficiency (SCID) - rotavirus vaccines
    • developing encephalopathy (not due to another identifiable cause) within 7 days of getting a pertussis containing vaccine - pertussis containing vaccines, DTaP and Tdap
    • having a severe immunodeficiency or being pregnant - MMR and Varicella

    There are other things that are considered to be precautions, but aren't true contraindications.

    Precautions for Vaccines

    When a precaution is present, a vaccine may still be given if the vaccine's benefit outweighs the risk. Fortunately, the biggest precaution, having a 'moderate or severe acute illness with or without fever,' is usually temporary. Your child can simply get his vaccines once the acute illness is over if you decide to delay getting vaccinated while he is sick.

    The main reason to delay getting vaccines in this case isn't what most people suspect it is. It is not because the vaccines might make your child worse or might not work. It is because if your child developed a mild reaction, like a fever, then you wouldn't know if it was a mild side effect of the vaccine or if his illness was getting worse.

    For others precautions, like having a history of thrombocytopenia or thrombocytopenic purpura (MMR vaccine), a seizure or persistent, inconsolable crying lasting three or more hours after a dose of DTP or DTaP, or chronic gastrointestinal disease (rotavirus vaccines), etc., the "benefits of and risks for administering a specific vaccine to a person under these circumstances should be considered."

    Your pediatrician can help look for contraindications and precautions that might put your child at risk for a vaccine reaction.

     

    Sources:

     

    Centers for Disease Control and Prevention. Chart of Contraindications and Precautions to Commonly Used Vaccines. Updated: March 6, 2014. Accessed July 2015.

    Centers for Disease Control and Prevention. Conditions Commonly Misperceived as Contraindications to Vaccination. Updated: July 17, 2012. Accessed July 2015.

    Epidemiology and Prevention of Vaccine-Preventable Diseases. The Pink Book: Course Textbook - 13th Edition (2015)

    Halsey NA, Algorithm to Assess Causality after Individual Adverse Events Following Immunizations, Vaccine. 2012 Apr 13.

    Myléus, Anna, PhD, MD, Early Vaccinations Are Not Risk Factors for Celiac Disease, Pediatrics. 2012 Jul;130(1):e63-70.

    Offit, PA. Addressing parents' concerns: do vaccines cause allergic or autoimmune diseases? Pediatrics. 2003 Mar;111(3):653-9.

    Vaccines (Sixth Edition) 2013

    Wood R et. al., Algorithm for Treatment of Patients with Hypersensitivity Reactions After Vaccines, Pediatrics. 2008 September; 122(3): e771-7.

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