As measles spread across the nation earlier this year, 71 residents of Vancouver, Wash., fell ill, most of them unvaccinated children. So state Rep. Paul Harris, a Republican representing the district, sponsored a measure to limit exemptions from immunization.
Activists protesting the bill converged on his legislative office; the resulting chaos led security officers to close the entire floor to the public. A death threat was posted on Facebook.
Only a handful of Mr. Harris’ Republican colleagues supported the measure because, they said, it infringed on individual liberties.
“I think there’s a lot of misinformation out there, and people either don’t believe in science or think there are more vaccine injuries than are being reported,” he said.
The nation is struggling with the worst measles outbreak in 25 years, with over 1,000 confirmed cases in 28 states. Medical experts agree that vaccines prevent epidemics, save lives, and are very safe, though complications occur in rare cases.
Yet curbing religious and philosophical exemptions to vaccination has proved extraordinarily difficult, pitting neighbors against neighbors, and sometimes paralyzing statehouses. So far this year, only two states — Maine and New York — have successfully outlawed all exemptions except those granted for medical reasons.
But even in New York, where 80 percent of the nation’s measles cases are concentrated, angry parents shouted and heckled from the Assembly gallery after the vote was called. Several politicians had misgivings about scrapping religious exemptions: The chairman of the health committee, Richard N. Gottfried, voted against the bill, which barely passed the assembly, but Gov. Andrew M. Cuomo, who had initially expressed reservations, signed it immediately.
The wide majority of Americans support routine childhood immunizations. But a small and impassioned group of parents rejects vaccines for religious reasons or fears about their safety, often drawing support from conservatives wary of what they see as government intrusion into personal life decisions.
Opponents describe tighter laws as an assault on their parental rights and religious freedom. In Washington State, opposition was so fierce that legislators managed only to eliminate exemptions based on personal beliefs, not those based on religion — and only for the measles, mumps and rubella vaccine.
Parents may continue to use religious exemptions to avoid the M.M.R. vaccine, and can cite other personal or moral beliefs to avoid other childhood vaccines.
“We would have preferred removing the personal exemption for all vaccines, but we weren’t able to — there was so much political pushback,” said state Rep. Monica Stonier, a Democrat who also represents Vancouver. “We just wanted to get something done.”
Opposition to vaccines has been around for almost as long as vaccines themselves. Massachusetts became the first state of many to make smallpox vaccination compulsory in the early 1800s, and in 1827 Boston became the first city to require the vaccine for school children. Nearly half of all states had vaccine requirements by the early 20th century. But they were not uniformly enforced, and some were repealed after protests.
Officials in Cambridge, Mass., sought to enforce the law during a 1902 outbreak of smallpox, and filed charges against Henning Jacobson, a resident who refused to be vaccinated because, he said, an earlier smallpox vaccination had made him and his son ill. The case went to the Supreme Court, which ruled in 1905 that states had the authority to make vaccinations mandatory.
Today all 50 states require certain vaccinations for students attending school, with exceptions made for children who cannot tolerate them because of underlying medical conditions, according to the National Conference of State Legislatures, a bipartisan organization that tracks vaccine legislation in the 50 states.
Most states also grant exemptions for people who oppose vaccination for religious reasons, and until recently 16 states allowed exemptions based on personal, moral, philosophical or other beliefs as well, according to the N.C.S.L.
But the norm today is to vaccinate.
Over 80 percent of adults agree with experts that childhood vaccines are safe for healthy children, although most parents of young children worry about vaccines’ effects, another survey found. Still, the vast majority vaccinate, and only 2.2 percent of school-age children had a vaccine exemption in 2017, according to a national survey by the Centers for Disease Control and Prevention, a slight increase from the year before.
Unvaccinated children aren’t evenly distributed among the population; instead, they tend to cluster in certain communities, making them particularly susceptible to an outbreak. That the measles outbreak has been concentrated in communities where parents are more likely to take advantage of exemptions, such as among the Orthodox Jews of Brooklyn, has lent new urgency to efforts to limit them.
“A crisis like this is often the catalyst and provides a window of opportunity” for tightening vaccine laws, said James Colgrove, a professor of sociomedical sciences at Columbia University.
“This is a very, very serious outbreak, and I wouldn’t be surprised if it prompted more states to move on this.”
A ‘very personal’ decision
California eliminated nonmedical exemptions to vaccines in 2015, after 159 visitors to Disneyland were infected with measles. Now, with 51 residents infected this year, state lawmakers are mulling a bill to rein in what critics have called bogus medical exemptions authorized by unscrupulous physicians (although most of those sickened with measles were adults).
If the California bill passes, parents will have a much harder time obtaining a medical exemption for their child. Applications for medical exemptions would require approval by the state health department, which must conform toguidelines drawn up by the C.D.C. and the Advisory Committee on Immunization Practices.
The guidelines lay out fairly narrow medical reasons to justify foregoing vaccinations: A child who went into a coma after a pertussis vaccine would be exempt from another pertussis shot, for example. But a child who had seizures for three days would not qualify for an exemption.
California Gov. Gavin Newsom has expressed concern about government officials making decisions traditionally left to parents and physicians, although he did not say he would veto the bill. “I believe in immunizations,” he said. But “I do legitimately have concerns about a bureaucrat making a decision that is very personal.”
Nearly a dozen states have recently proposed getting rid of personal-belief exceptions, but efforts to pass bills have stalled or been derailed in several states. Take Oregon, which has one of the highest rates of vaccine exemptions: six percent of kindergartners were exempt in the 2014-2015 school year. (By contrast, fewer than one percent of kindergartners in New York have an exemption). But a legislative push in Oregon for limiting nonmedical exemptions provoked a furious backlash.
“It was pretty bloody,” said state Rep. Mitch Greenlick, a Democrat representing Portland. “I must have gotten a couple thousand emails and phone calls. We stopped answering the phone, basically.”
Protesters “called us Nazis and wore yellow stars of David to show they were being persecuted by Nazis,” Mr. Greenlick added.
Ultimately, the bill was scuttled when Republicans in the State Senate walked out of the session, and could not be coaxed back until both the vaccine bill and a gun control bill were dropped.
Rising religious exemptions
Maine successfully passed legislation barring all nonmedical exemptions for vaccines this year. The state did not have a measles outbreak, but has persistently had high rates of pertussis, or whooping cough.
Gov. Janet Mills, a Democrat, signed the bill into law last month, making Maine one of only a handful of states with no philosophical or religious exemptions to vaccines. Although the law makes it easier for people to get medical exemptions, “it is a step forward,” said state Rep. Ryan Tipping, a Democrat from Orono, Me., who sponsored the bill.
Vaccine skeptics protested the Maine bill, but parents of children with chronic medical conditions — who cannot be vaccinated — pushed for passage.
Sarah Staffiere of Waterville, Me., has a five-year-old son with a rare condition requiring him to take medication that inactivates his immune system. He takes antibiotics prophylactically to go to day care, where, his mother said, many of his peers are not fully vaccinated.
“Any hard-hitting illness that he receives could lead him to develop complications that other kids wouldn’t,” she said. “For him, just getting the flu can be quite scary. My hope is that he would be surrounded by as many vaccinated kids as possible, to keep him in as healthy an environment as possible.”
Parents in other states defend vaccine exemptions.
Jessica Milner, a mother in Berlin, N.J., who home-schools her four children, said her religious beliefs prohibit vaccinations, but she also worries about vaccine safety. She took her children to Trenton recently to protest a proposal to scrap the state’s religious exemptions.
The number of religious exemptions in New Jersey has increased to 12,300 in the 2017-2018 school year, up from 1,641 in the 2005-2006 school year, according to the state health department.
“Whenever there is a risk of any kind, there needs to be a choice in the matter,” Ms. Milner said. “Vaccines are a medical procedure, and there is a risk in any medical procedure, so there needs to be true and informed consent, and choice.”
One reason the laws nationwide have been slow to change: “People are talking about protecting their kids,” said Mr. Tipping, the Maine lawmaker. “There are few things in the world that elicit that kind of passion.”