Repeal of Vaccine Exemption and Increased Vaccination Rates

Source: Bald A, Gold S, Yang YT. State repeal of nonmedical vaccine exemptions and kindergarten vaccination rates. JAMA Pediatr. 2026;180(1);56-63; doi: 10.1001/jamapediatrics.2025.4185.Investigators from multiple institutions conducted a retrospective, cross-sectional study to assess the impact of elimination of nonmedical vaccine exemptions on kindergarten immunization rates. For the study, they abstracted state-level data on exemption rates and kindergarten vaccine coverage rates from the CDC National Center for Immunization and Respiratory Diseases for the 2011–2023 school years. Information on total, medical, and nonmedical vaccine exemption rates and vaccine coverage for diptheria, tetanus, and pertussis (DTaP); hepatitis B; measles, mumps, and rubella (MMR); and polio were collected yearly for each state. Data on changes to state exemption laws were assessed by reviewing the National Conference of State Legislature database. States with total and partial elimination of nonmedical exemptions were identified. The primary study outcomes were changes in vaccine exemption and immunization rates in the years following total elimination of nonmedical exemptions. Changes in exemptions and vaccination rates following partial elimination of nonmedical exemptions were evaluated as secondary outcomes.Vaccination rates for DTaP, hepatitis B, MMR, and polio all decreased between 2011 and 2023. As an example, MMR coverage was 94.7% in 2011 and 92.7% in 2023. During this same period, total exemptions increased from 1.6% to 3.3%, primarily because of increases in nonmedical exemptions. Four states—California (2015), New York (2019), Maine (2019), and Connecticut (2021)— eliminated nonmedical vaccine exemptions. In these states, nonmedical exemptions declined by 3.6 percentage points (95% confidence interval [CI], 2.0, 5.1) within 3 years of elimination. There was minimal corresponding increase in medical exemptions in these states (0.4 percentage points; 95% CI, 0.04, 0.7). Within 3 years of elimination of nonmedical exemption, kindergarten coverage rates for DTaP increased by 4.1 percentage points (95% CI, 3.3, 4.9), MMR by 4.0 percentage points (95% CI, 3.1, 4.9), polio by 3.8 percentage points (95% CI, 2.9, 4.6), and hepatitis B by 2.8 percentage points (95% CI, 2.1, 3.5). In the corresponding period, in states with continuation of nonmedical exemptions, vaccine coverage rates decreased, and exemption rates increased. In 2015, Vermont eliminated philosophical vaccine exemptions, and in 2019, Washington eliminated nonmedical exemptions, but only for MMR. In these 2 states, following the changes, total exemptions decreased by 2.2 percentage points (95% CI, 0.4, 4.5), mostly attributable to a decline in nonmedical exemptions. MMR rates increased by 2.4 percentage points (95% CI, 0.4, 4.5) during the 3 years after partial elimination of non-medical exemptions, with smaller and less sustained increases in coverage rates for DTaP, hepatitis B, and polio.The authors conclude that repeal of nonmedical vaccine exemptions was associated with increased kindergarten immunization rates.Dr Doolittle has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.In 2025, the United States experienced the highest number of measles cases in more than 30 years, with 1,723 confirmed cases.1 Of those cases, 92% were in patients who were unvaccinated or whose vaccine status was unknown.1 From 2023 to 2024, the United States experienced a 5-fold increase in pertussis infections, from 7,063 to 35,493.2 There have been similar spikes in meningococcal disease.3 These outbreaks are due to decreased vaccine adherence, driven by religious or philosophical objections, and growing suspicion about vaccine safety and efficacy.4 Even small reductions in vaccine uptake have an important impact on public health. When vaccine adherence drops below 92%, the community loses herd immunity, and the risk of highly contagious outbreaks increases.4Parental objection about vaccine administration has become an increasingly challenging issue for health care providers.5 Pediatricians cite several reasons for vaccine hesitancy: safety concerns, influence of flawed information sources, low perceived risk of contracting an infection, overall lack of trust, and religious objection.5 While addressing these issues within the provider-patient relationship is critical, a broader systemic approach also is needed.The current authors describe the impact of recent legislation to discontinue nonmedical exemption in several states. Within 3 years, rates of nonmedical exemption decreased, and vaccine adherence increased. While the results of this study demonstrate effective policy, legal mandates cannot legislate public trust. Health policy has become increasingly politicized. The rise of spurious information sources fuel a public distrust of health care. A robust response from both local and national governing bodies, emphasizing trust-building, is needed to address the smoldering skepticism among so many of our patients.The repeal of nonmedical exemptions for vaccine administration is associated with modest increases in kindergarten vaccination coverage.