1. Kaplan, Louise PhD, ARNP, FNP-BC, FAAN, FAANP

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Between January 1, 2019, and May 31, 2019, the CDC reported 981 individual cases of measles that have been confirmed in 26 states.1 This is the greatest number of cases in the US since 1992 and since measles was declared eliminated in 2000.1 In New York, Brooklyn, and Queens, 566 cases of measles were confirmed between October 2018 and June 3, 2019.2 The initial case involved an unvaccinated child who visited Israel where there was a large measles outbreak.2 Clark County, Washington, had 71 confirmed cases between January 3, 2019, and April 29, 2019. The initial confirmed case originated from a child who had traveled to the Ukraine; however, it was not determined if this child was the source of the outbreak.3


Immunization rates

The percent of children ages 19 to 35 months who are immunized varies by type of immunization. For example, 91.9% have received three or more doses of the polio vaccine, whereas only 81.8% have received the Haemophilus influenzae type b and pneumococcal conjugate vaccines.4 The median two-dose measles, mumps, and rubella (MMR) vaccine rate was 94.3%, with a range of 81.3% in the District of Columbia and 99.4% in Mississippi.4


Vaccination rates are affected by state law. All states' school immunization laws allow exemptions for medical purposes, almost all allow exemptions for religious beliefs, and 16 allow philosophical exemptions because of personal, moral, or other beliefs.5


Response to philosophical exemptions

In 2015, both Vermont and California eliminated nonmedical vaccine exemptions.5 Implementation of the law in California was complicated due to variable interpretation of the legislative and regulatory language, particularly as the law related to individualized education programs, special education, independent study, and homeschooling.6 Although the proportion of kindergarten students who had received all required vaccines increased from 92.8% in 2015-2016 to 95.1% in 2017-2018, medical exemptions increased from 0.2% to 0.7% in the same time period.6


Participants in one California study identified some medical exemptions as suspicious. Examples of suspicious exemptions included medical conditions that were not valid contraindications to immunizations, physicians who advertised online they would provide an exemption for a fee, and physicians (such as adult cardiologists) who signed exemptions despite not typically treating children.7


The Washington State Legislature convened in January 2019 at the onset of the measles outbreak in Clark County. A bill to remove philosophical exemptions for all immunizations failed. However, a bill to remove the philosophical exemption for the MMR was signed into law. This bill applies to children attending schools and day-care centers as well as employees and volunteers at day-care centers.8


In rare instances, immunizations have been compulsory. In 1991, Philadelphia had 1,400 cases of measles with 9 deaths. Compulsory measles vaccinations were court ordered for unimmunized children.9 In response to the 2019 outbreak, New York City's Health Commission ordered all individuals who are not immune to or immunized for measles, mumps, and rubella in affected communities to be vaccinated. Failure to comply with the requirement could result in a $1,000 fine.2


NP advocacy

NPs play a pivotal role in promoting immunizations to prevent communicable diseases. NPs must decide how to approach parents who are opposed to vaccines for philosophical reasons. Eliminating children from a practice who are not immunized is one of the ways clinicians have approached this problem.10 This, however, leaves children vulnerable without well-child and illness care that is easily accessible. The CDC provides resources for vaccine conversations with parents online ( Dr. Jennifer Reich's book, Calling the Shots: Why Parents Reject Vaccines, provides insight into the beliefs and concerns of parents who opt out of vaccines as well as the perspective of healthcare professionals and policy makers who strive to create healthy communities.11


The 1944 ruling of the US Supreme Court supports states that have limited vaccine exemptions and provides guidance to NPs. The court ruled a state may restrict a parent's control in several ways, such as requiring school attendance or prohibiting or regulating child labor. "The right to practice religion freely does not include liberty to expose the community or child to communicable disease or the latter to ill health or death."12 The ruling further stated, "Parents may be free to become martyrs themselves. But it does not follow they are free, in identical circumstances, to make martyrs of their children before they have reached the age of full and legal discretion when they can make that choice for themselves."12




1. Centers for Disease Control and Prevention. Measles cases and Outbreaks. 2019. [Context Link]


2. New York City Health. Measles. 2019. [Context Link]


3. Clark County Washington Public Health. Measles investigation. 2019. [Context Link]


4. Mellerson JL, Maxwell CB, Knighton CL, Kriss JL, Seither R, Black CL. Centers for Disease Control and Prevention. Vaccination coverage for selected vaccines and exemption rates among children in kindergarten-United States, 2017-18 school year. 2018. [Context Link]


5. National Conference of State Legislatures. States with religious and philosophical exemptions from school immunization requirements. 2017. [Context Link]


6. Mohanty S, Buttenheim AM, Joyce CM, Howa AC, Salmon D, Omer SB. California's senate bill 277: local health jurisdictions' experiences with the elimination of nonmedical vaccine exemptions. Am J Public Health. 2019;109(1):96-101. [Context Link]


7. Mohanty S, Buttenheim AM, Joyce CM, Howa AC, Salmon D, Omer SB. Experiences with medical exemptions after a change in vaccine exemption policy in California. Pediatrics. 2018;142(5):e20181051. [Context Link]


8. Washington State Legislature. House Bill 1638. 2019. [Context Link]


9. Pfeiffer S. How Philadelphia mandated vaccinations in 1991. National Public Radio. 2019. [Context Link]


10. Alexander K, Lacy TA, Myers AL, Lantos JD. Should pediatric practices have policies to not care for children with vaccine-hesitant parents. Pediatrics. 2016;138(4):e20161597. [Context Link]


11. NYU Press. 2019. [Context Link]


12. US Supreme Court. (1944) Prince vs. Massachusetts, 321 U.S. 158, 64 S Ct. 438, 88 L.Ed. 645. [Context Link]