摘要：Compulsory vaccination has contributed to the enormous success of US immunization programs. Movements to introduce broad “philosophical/personal beliefs” exemptions administered without adequate public health oversight threaten this success. Health professionals and child welfare advocates must address these developments in order to maintain the effectiveness of the nation’s mandatory school vaccination programs. We review recent events regarding mandatory immunization in Arkansas and discuss a proposed nonmedical exemption designed to allow constitutionally permissible, reasonable, health-oriented administrative control over exemptions. The proposal may be useful in political environments that preclude the use of only medical exemptions. Our observations may assist states whose current nonmedical exemption provisions are constitutionally suspect as well as states lacking legally appropriate administrative controls on existing, broad non-medical exemptions. COMPULSORY VACCINATION has contributed to the success of US immunization programs in eradicating smallpox, eliminating polio, and reducing by 98–99% the incidence of most other vaccine-preventable diseases. 1– 3 The utility of US school vaccination requirements in preventing disease and introducing new vaccines has been well documented. 4– 9 With the success of immunization programs in effectively controlling vaccine-preventable diseases has come, paradoxically, a problem for future disease prevention: public attention has shifted from the risks of disease to the risks of vaccination. 10 States’ policies for mandatory school immunization are increasingly major focal points for attack owing to increased public and media focus on vaccine safety and public perception of insufficient regulatory oversight. School vaccination programs in the United States form a relatively fragile patchwork of differing state laws—under the US Constitution, most power to protect the public’s health and safety (“police powers”) is reserved for the states. Each state has therefore passed its own laws requiring vaccination before school entrance while permitting various kinds of exemptions. States offer exemptions to mandatory immunization requirements that fall into 2 very broad categories: “medical” (where vaccination is medically contraindicated) and “nonmedical” (where exemptions are given for reasons of social policy). There is no constitutional requirement for states to offer nonmedical exemptions 11 though most states do. Nonmedical exemptions currently used by the states can be characterized broadly as either “religious” (explicitly including religious belief as a criterion for exemption) or “philosophical/personal beliefs” (accepting any secular personal conviction as a criterion for exemption). As of July 2002, 48 states offered religious exemptions and 17 states permitted philosophical/personal beliefs exemptions. The focus of many groups opposed to compulsory vaccination over the last several years has been to expand states’ adoption of broad philosophical/personal beliefs exemptions incorporating minimal or no public health–oriented administrative oversight. Yet unvaccinated children with nonmedical exemptions to immunization requirements are at greater risk of contracting vaccine-preventable diseases while also increasing the risk of disease transmission to others in the community who may have medical contraindications to vaccination (medical exemptions), who are too young to be vaccinated, or who have not developed a protective response to vaccination (vaccine failures). 12, 13 Safeguarding mandatory school vaccination programs should therefore be among the foremost concerns of health professionals and child welfare advocates.
