Don’t take away religious exemption for vaccines

Focus on non-coercive efforts to promote vaccinations

I AM AN IVY LEAGUE-TRAINED physician who currently treats families of children and adults with developmental disabilities. I come in frequent contact with parents who use the religious exemption for vaccination.

I believe these parents are being unfairly marginalized and maligned. In my clinical experience, they are not “anti-science” or “anti-vaxxers” who deny the benefits of vaccination. They don’t base their decisions on Hollywood celebrities, discredited scientists, or “on-line conspiracy.”

Many witnessed adverse reactions to vaccination (high fever, seizures, prolonged screaming, acute behavioral changes) that may have had neurological and immune-mediated consequences.  Because of the dictates of their faith, to follow their moral conscience and protect their children from further harm, and the extremely narrow availability of CDC-recognized medical exemptions (one academic pediatric neurologist lamented to me, “It’s as if the guidelines were written by people without any clinical experience”), many of these families rely on the religious exemption.

I approach these parents with empathy and humility. Empathy in appreciating the overwhelming challenges they face. Humility from knowing medical practice is imperfect and science is continually evolving. History presents multiple instances when experts, including trusted health authorities, have gotten it wrong. The opioid crisis is but one recent and tragic example. Shaming those who believe they witnessed adverse events or who express concerns will only increase alienation and mistrust and erode vaccine confidence.

Vaccines have decreased the incidence and morbidity of vaccine-preventable illness and saved millions of lives worldwide. There are multiple epidemiologic studies that indicate the MMR is not associated with autism. Post-marketing surveillance studies support the safety of vaccination for the majority of people.

So why do these parents continue to question? Is it simply to assuage unbearable grief and loss? What do they find when they scour the science?

Multiple large reviews suggest that those who may be at increased risk of reacting to vaccines (vulnerable sub-populations) have been understudied. We may also be under-estimating who reacts in real-world settings. Reportable vaccine reactions may be as high as 2.6 percent.  Data-driven estimates suggest that 2.2 percent of the population will have a vaccine reaction leading to an ER visit. Recent data about possible non-specific effects of vaccination suggest that vaccines impact the immune system more broadly than previously understood, both positively and negatively. Emerging data regarding aluminum adjuvant also deserves attention, as has been recognized by the Cochrane Collaboration. Study of aluminum adjuvant is particularly important since vaccine safety trials are often conducted using aluminum adjuvant as the placebo.

It’s essential to note that Massachusetts is not facing a vaccination crisis, or even a vaccination problem. Massachusetts has the highest vaccination rates in the country, with 97 percent of kindergartners and 99 percent of seventh graders having two doses of the MMR.  Our rates of MMR vaccination have been increasing and are at all-time highs, despite modest increases in religious exemptions, which were used by 1.15 percent of kindergarteners in 2018.

In 2019, we had three cases of measles, two in adults. Over the past decade, we have had an average of four cases of measles per year, mainly among adults, in a population of 6.9 million.  That means we’re not at risk for large outbreaks. And schools have additional protections. Under-vaccinated students are excluded from school when vaccine-preventable illness is suspected among the school population, similar to sending a feverish child home to prevent transmission.

I urge the Legislature to emphasize non-coercive means to increase vaccine uptake. We should mandate reporting from schools; consider targeted education and outreach at schools with lower MMR vaccination rates; offer families school-based vaccination clinics, free of cost; and address the reality of waning adult immunity.

Adding the possibility of free, school-based vaccination for consenting families is a particularly important consideration.  The top 10 schools with the lowest MMR vaccination have zero exemptions on file.  And in almost 75 percent of the schools without ideal MMR vaccination rates, the number of children without adequate documentation (called the “gap population” by the Massachusetts Department of Health) exceeds the number of children with exemptions.

With further study, we may be able to ascertain if these gap populations may relate to socio-economic issues or some other unknown factor.  Small pockets of under-vaccination in Massachusetts are simply not being driven by the 1.15 percent of families that use the religious exemption, who, according to the Department of Public Health, “have an exemption to only one or two vaccines, and are otherwise immunized.”

If addressing gap populations is not adequate, then the Legislature should consider removing the religious exemption for the MMR only. Free and informed consent, a cornerstone of medical ethics since World War II, is not possible with coercion.  We should not be trampling religious liberties and violating the principals of free consent to mandate vaccines that pose little immediate public health threat and are not communicable in the school setting, like the Hepatitis B vaccine.

Finally, removal of the religious exemption would deny education to some of our most vulnerable children with severe neurological disabilities: non-speaking, self-injurious, behaviorally dysregulated. Children with special needs and their parents suffer higher rates of depression, anxiety, and suicidality. Their lives depend on critical specialized education and therapies, not replicable in a home-school setting. Denying these services could lead to tragic public health outcomes that would likely outweigh a speculative and marginal increase in vaccination rates.

Meet the Author

Sylvia Fogel

Psychiatrist, Works with parents of children with autism, development disabilities
We need to reconsider our assumptions about vaccine hesitancy, adverse events, and the religious exemption. Where there is marginalization and shaming, let there be empathy. Where there is coercion and censorship, let there be dialogue. Excluding families from school because they choose not to vaccinate is not the answer. We must retain the religious exemption for vaccination and focus on non-coercive measures to promote vaccination.

Dr. Sylvia Fogel is a psychiatrist who works with the parents of children with autism and other developmental disabilities at a major academic medical center in the Boston area.  She attended Cornell University Medical College and completed her residency at Columbia University.  These opinions are hers and do not reflect the opinions of her employer or academic affiliation.