Legislative prescriptions for controlling nonmedical vaccine exemptions.

During2014,numerouscommunitiesacross theUnited States have been affected by significant, largely avoidable outbreaks of vaccine-preventable illnesses (VPIs), such as measles, mumps, and pertussis.1 These outbreaks have been associated with increasing numbers of familiesactivelydeclining immunizationsagainstVPIs for their children.2 States can require that families submit documentation that their childrenhave receivedmandatory vaccines as a condition of entry to child care and elementary school. These laws routinely include conditions underwhich familiesmayapply forexemption fromvaccination requirements on medical or nonmedical grounds.Althoughstudies showthat stricter rulesonexemptions could help reduce cases of VPI,3 many legislative initiatives have been focused on expanding exemptions.4 However, legislation aimed at strengtheningprotectionsagainstVPIshasbeenproposed lately in many states, frequently focusing on the processes through which parents seek exemptions. The protective strength of a state childhood vaccination exemption law can be assessed by examining 5 broad groups of exemption characteristics5 (Box): (1) the type of exemptions; (2) the populations and entities within the state towhich the law in question applies; (3) the documentationand filingprocessesbywhich individuals submit exemption applications; (4) the review process for exemption applications; and (5) the availability of appeals and applicable penalties.