Religious Vaccine Exemptions in Kindergartners: 2011–2018

Joshua T.B. Williams, MD,^a,c John Rice, PhD,^b,f Matt Cox-Martin, PhD,^f Elizabeth A. Bayliss, MD, MSPH,^d,g Sean T. O’Leary, MD, MPH^c,e,f 

BACKGROUND: Forty-five states permit religious exemptions to school immunization laws; 15 abstract allow personal belief exemptions. Updated religious exemption estimates are lacking, and it is unclear if personal belief exemption availability impacts religious exemption rates. We aimed to (1) update religious exemption trends in kindergartners, (2) compare states’ proportions of kindergartners with religious exemptions by personal belief exemption availability, and (3) describe whether the proportion of kindergartners with religious exemptions changed in Vermont after it eliminated personal belief exemptions in 2016. METHODS: We analyzed Centers for Disease Control and Prevention data on exemptions for children entering kindergarten from 2011 to 2018, including 295 state-years in our final analysis. Using a quasi-binomial regression analysis, we compared mean proportions of kindergartners with religious exemptions in states allowing both nonmedical exemptions against states with religious exemptions only, adjusting for policy strength and school year. RESULTS: States with religious and personal belief exemptions were one-fourth as likely to have kindergartners with religious exemptions as states with religious exemptions only (risk ratio 0.25; 95% confidence interval 0.16–0.38). After Vermont’s policy change, the mean proportion of kindergartners with a religious exemption increased from 0.5% to 3.7%. States were significantly more likely to have kindergartners with religious exemptions during the 2017–2018 school year compared with the 2011–2012 school year (P = .04). CONCLUSIONS: Religious exemption rates appear to be associated with personal belief exemption availability, may be subject to a replacement effect on personal belief exemption elimination, and are increasing. Researchers and policy makers should confirm findings with individual- level studies and reconsider the purpose and nature of religious exemption laws. 

a_{Department of Pediatrics, Denver Health Medical Center, Denver, Colorado;} b_{Department of Biostatistics and} Informatics, School of Public Health, and ^cDepartments of Pediatrics, ^dFamily Medicine, and ^ePediatric Infectious 

WHAT’S KNOWN ON THIS SUBJECT: Forty-five states permit religious exemptions from school vaccination Diseases, School of Medicine, University of Colorado Denver, Aurora, Colorado; ^fAdult and Child Consortium for 

laws. Fifteen states allow personal belief exemptions. Health Outcomes Research and Delivery Science, Aurora, Colorado; and ^gInstitute for Health Research, Kaiser 

From 2005 to 2013, religious exemption rates among Permanente Colorado, Denver, Colorado 

American kindergartners tripled in states with religious Drs Williams and O’Leary conceptualized and designed the study, drafted the initial manuscript, and reviewed and revised the manuscript; Drs Rice and Cox-Martin performed the data analysis, exemptions only, plateauing during the 2013–2014 through 2015–2016 school years. contributed to the Methods section of the initial manuscript, and reviewed and revised the manuscript; Dr Bayliss critically reviewed the manuscript for important intellectual content and assisted with manuscript revisions; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work. 

WHAT THIS STUDY ADDS: This updated study of state-level exemption data for the 2011–2012 through 2017–2018 school years shows how states’ religious exemption rates differ by personal belief exemption availability, may DOI: https://doi.org/10.1542/peds.2019-2710 

experience a replacement effect after personal belief Accepted for publication Sep 26, 2019 exemption elimination, and are increasing. 

Address correspondence to Joshua T.B. Williams, MD, Department of Pediatrics, Denver Health Medical Center, 301 W 6th Ave, MC #1911, Denver, CO 80204. E-mail: [email protected] 

To cite: Williams JTB, Rice J, Cox-Martin M, et al. Religious Vaccine Exemptions in Kindergartners: 2011–2018. Pediatrics. 2019;144(6):e20192710 

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longitudinal studies of religious exemption data in American kindergartners by analyzing trends for the 2011–2012 through 2017–2018 school years. In addition to providing updated national estimates of religious exemption rates in kindergartners, we sought to compare states’ proportions of kindergartners with religious exemptions by personal belief exemption availability and to observe whether the proportion of exempted kindergartners differed in Vermont before and after its 2016 policy change. 

METHODS 

We performed a cross-sectional, retrospective, state-level analysis of publicly available aggregated data from the Centers for Disease Control and Prevention yearly vaccine reports for kindergartners (2011–2012 through 2017–2018 school years).^12–18 We chose this time frame to extend and provide meaningful comparisons to a previous study of exemption data for kindergartners from 2011–2012 through 2015–2016.⁶ For each report, states provide estimates of the proportion of children with medical and nonmedical (ie, religious and/or personal beliefs) exemptions as well as the proportion of kindergartners who are up to date on several vaccines of interest (eg, measles, mumps, and rubella; diphtheria, tetanus, and acellular pertussis; and varicella). States use different approaches to calculate these proportions, including censuses, 1- or 2-stage cluster surveys, simple random sampling, or mixed designs. However, most states use censuses and sample .80% of their kindergartners, so sampling variability in their estimates should be minimal. Therefore, we assumed these measurements were taken without error in our analyses. School-entry mandatory vaccination 

We calculated the incidence laws are a cornerstone of American 

proportion of kindergartners with public health.¹ Major religions 

religious vaccine exemptions for each support vaccination, but religious 

state-year from these reported exemptions to vaccines required for 

proportions. For states with religious school entry are available in 45 states 

exemptions only, the reported and Washington, District of 

nonmedical exemption incidence Columbia.^2,3 Fifteen states permit 

proportion equaled the incidence personal belief exemptions, also 

proportion of religious exemptions. known as philosophical exemptions; 

For states with religious and personal all states and Washington, District of 

belief exemptions, we calculated the Columbia, offer medical exemptions 

religious exemption proportion by for children with contraindications to 

dividing the state’s number of vaccination.³ Previous multiyear 

children with religious exemptions by assessments of data on exemptions 

the overall number of children with for children entering kindergarten 

nonmedical exemptions and suggest that religious exemption rates 

multiplied by the nonmedical tripled from 2005 to 2013 among 

exemption proportion. kindergartners in states with religious exemptions only, plateauing during the 2013–2014 through 2015–2016 school years.^4–6 High nonmedical exemption rates correlate with increased rates of vaccine- preventable diseases, especially when exempted children cluster in insular communities.^7–9 Recent outbreaks of measles and varicella within religious communities with high exemption rates have demonstrated these risks, renewing attention to the role of religious exemptions in the spread of vaccine-preventable diseases.^10,11 Professional organizations, including the American Academy of Pediatrics, have intensified calls for their elimination, and 2 states, New York and Maine, have recently banned them.^3,11 However, previous longitudinal analyses of religious exemptions in kindergartners ended with data from the 2015–2016 school year and were limited in scope to states with religious exemptions only, missing the opportunity to describe how religious exemptions differ in states with or without an alternative personal belief exemption.^4–6 Also, Vermont eliminated its personal belief exemption in 2016, providing an opportunity to compare religious exemption rates before and after.¹ 

Because the exemption process is heterogeneous, we accounted for the strength of state exemption policies (ie, whether it was “easy,” “medium,” or “difficult” for parents to claim an exemption) on the basis of standards previously reported by Omer et al.⁶ We chose this adjustment because previous studies suggest that nonmedical exemption rates decrease when exemption policies are more difficult to obtain.^5,19 Because many states revised their exemption laws during the study period, we recoded exemption law strengths for each state every year with published exemption law summaries.^1,6 We did not include Mississippi and West Virginia because they did not allow nonmedical exemptions. We also excluded Arizona, which allowed personal belief exemptions only in kindergarten. California eliminated nonmedical exemptions in 2015; we excluded state-years after this change. As noted, Vermont eliminated philosophical exemptions in 2016. In total, we considered 357 state-years for inclusion, excluding 62 state-years for a lack of separate reporting of nonmedical exemptions, a lack of religious exemptions, or a lack of data. There were 295 state-years in the final analysis. 

Thus, we sought to update and 

Our dependent variable of interest enhance existing multiyear 

was the religious exemption 

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incidence proportion for a single state in a given year. We performed univariable analyses by year, calculating mean religious exemption proportions by state policy availability, school year, and exemption policy strength; we calculated robust SEs to account for correlation within states. Because our outcome variable was a proportion between 0 and 1, standard linear regression techniques were not appropriate. Therefore, we performed a quasi-binomial regression analysis with SEs adjusted for correlation within states.²⁰ We chose a log link function to provide estimates of risk ratios rather than odds ratios. Because we used aggregated (state- level rather than individual-level) data, our risk ratios were ratios of mean proportions, or mean population risks, rather than individual risks. We included exemption policy availability (religious only versus religious and personal beliefs), exemption policy strength (easy versus medium and difficult), and school year (treated as a categorical variable) as covariates. All analyses were conducted with R version 3.4.4 (The R Foundation, Vienna, Austria). 

RESULTS 

In unadjusted analyses, states with religious and personal belief exemptions had a significantly lower mean proportion of kindergartners with religious exemptions (0.41%; 95% confidence interval [CI] 0.28%–0.53%) compared with states with religious exemptions only (1.63%; 95% CI 1.30%–1.97%). This phenomenon was stable for each school year during the study period (Fig 1). In adjusted analyses, states with religious and personal belief exemptions were one-fourth as likely to have kindergartners with religious exemptions compared with states with religious exemptions only (risk ratio 0.25; 95% CI 0.16–0.38). After Vermont eliminated personal belief 

FIGURE 1 Mean proportions of kindergartners with religious exemptions with 95% CIs (2011–2018), com- paring mean proportions in states with religious exemptions only against proportions in states with religious and personal belief exemptions. 

exemptions in 2016, the mean proportion of kindergartners with religious exemptions increased from 0.5% (2011–2012 through 2015–2016) to 3.7% (2016–2017 through 2017–2018). Overall, the mean proportion of Vermont kindergartners with any nonmedical exemption decreased from 5.7% to 3.7%. Using 2011–2012 as a reference year, states were more likely to have kindergartners with religious exemptions during the 2017–2018 school year (P = .04). Compared with states with easy exemption policies, states with medium or difficult policies were equally likely to have kindergartners with religious exemptions (Table 1). 

DISCUSSION 

In this retrospective analysis of data on religious exemptions for American kindergartners, we found that states with religious and personal belief exemptions were significantly less likely to have kindergartners with religious exemptions than were states with religious exemptions alone. Next, we observed that Vermont’s mean proportion of kindergartners with 

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religious exemptions increased sevenfold after its elimination of personal belief exemptions, suggesting a replacement effect. Finally, relative to the 2011–2012 school year, we found that states were more likely to have kindergartners with religious exemptions in the 2017–2018 school year. 

First, this study enhances our understanding of how vaccine exemption policies influence state- reported vaccine exemption data. Two recent longitudinal analyses of nonmedical exemption data for kindergartners found that states offering both religious and personal belief exemptions had higher overall rates of nonmedical exemptions than did states with religious exemptions alone.^6,19 However, authors in the first study did not report religious exemption rates separately by state,⁶ and authors in the second study restricted their analyses of religious exemptions to states with religious exemptions only.¹⁹ Thus, both studies did not examine how religious exemption rates differ according to the availability of personal belief exemptions. We augment these 

nonmedical TABLE 1 Mean Unadjusted Incidence Proportions of Religious Exemptions, Reported as Percentages 

exemptions decreased With 95% CIs by State Policy Availability, Study Year, and State Policy Difficulty, and Adjusted 

after its 2016 legislative change. This Risk Ratios With 95% CIs for Comparisons of Interest 

finding aligns with aforementioned Religious Exemption Incidence Proportion 

studies that showed lower overall Comparisons 

nonmedical exemption rates in states with religious exemptions only, and vaccine advocates will likely interpret this as a public health victory.^6,19 In the last year, 10 other states have enacted or proposed legislation to eliminate nonmedical exemptions, and policy makers in other states could consider Vermont’s experience as an instructive example when considering policy changes to decrease exemption rates.²⁵ However, further studies are needed to determine if sudden apparent increases in religious vaccine exemption rates may stigmatize religious groups or alienate religious leaders who support vaccination. 

Third, our data suggest that religious exemptions may be rising again. Whereas previous longitudinal studies of religious exemptions suggested a plateau as of the 2015–2016 school year,⁶ our up-to- date results show an increase for the 2017–2018 school year, most prominently in states with religious exemptions only. Although the increase is not surprising in light of recent outbreaks, it is curious when considering the simultaneous decrease in Americans’ religious affiliations. A 2014 survey found that 22.8% of Americans reported no religious affiliation, up from 16.1% in 2007.²⁴ It may be that insular religious groups are growing more rapidly than secular communities or that they are increasingly falling victim to vaccine misinformation. Yet, the rise of religious exemptions in an increasingly secular society also questions whether the religious exemption category can still serve its intended purpose. Religious vaccine exemptions originated .80 years ago and were formalized in the 1960s to exempt children from specific religious groups whose official teachings prohibited vaccination.^26,27 Unadjusted Mean Proportion (95% CI) % 

Adjusted Risk Ratio (95% CI) 

State policy availability^a 

Religious exemption only 1.63 (1.30–1.97) (Reference) Religious and personal belief 

exemptions 

0.41 (0.28–0.53) 0.25 (0.16–0.38) 

School year 

2011–2012 1.25 (0.84–1.66) (Reference) 2012–2013 1.20 (0.81–1.59) 0.97 (0.84–1.13) 2013–2014 1.10 (0.84–1.36) 0.93 (0.84–1.18) 2014–2015 1.13 (0.86–1.40) 0.95 (0.75–1.19) 2015–2016 1.17 (0.92–1.43) 0.99 (0.79–1.24) 2016–2017 1.42 (1.07–1.76) 1.15 (0.89–1.49) 2017–2018 1.70 (1.31–2.08) 1.31 (1.01–1.69) State policy difficulty 

Easy 1.22 (0.53–1.91) (Reference) Medium 1.21 (0.92–1.50) 0.83 (0.49–1.40) Difficult 1.37 (0.88–1.87) 0.89 (0.51–1.58) 

a _{As of the 2017–2018 school year, states that did not offer religious or personal belief exemptions included the following:} California, Mississippi, and West Virginia. States that offered personal belief exemptions included the following: Arkansas, Arizona, Colorado, Idaho, Louisiana, Maine, Michigan, Minnesota, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Texas, Utah, Washington, and Wisconsin. Missouri permitted personal belief exemptions for child care facilities but not public schools. Statutes in Louisiana and Minnesota did not explicitly recognize religion as a reason for claiming an exemption, although the nonmedical exemption’s language may have encompassed religious beliefs; historically, Louisiana has reported religious exemptions separately, whereas Minnesota has not. Arizona did not permit religious exemptions for children entering kindergarten. 

findings by demonstrating that states 

the first year after the change. with both nonmedical exemption 

However, by the second year, medical policies are significantly less likely to 

exemption rates rose, and geographic have kindergartners with religious 

analyses showed that the areas with exemptions than were states with 

rising medical exemption rates religious exemptions only. Put 

coincided with areas that previously differently, state-level religious 

had high rates of nonmedical exemption rates appear to be 

exemptions. The authors did not a function of personal belief 

study individual-level behavior, but exemption availability, decreasing 

they suggested that their results were significantly when states offer 

evidence of a replacement effect, a personal belief exemption 

whereby parents obtained medical alternative. 

exemptions for their children in the absence of an alternative. We The suggestion of a replacement 

hypothesize a similar effect with effect in Vermont after its 2016 

Vermont’s 2016 change. Although our legislative change provides further 

study was also not at the individual evidence of the impact of policy 

level, at least 2 small individual-level availability on religious exemption 

studies suggest that parents claim rates. Previous studies document 

religious exemptions in the absence a vaccine exemption replacement 

of a personal belief alternative.^22,23 effect in other settings after 

Furthermore, it is interesting to note analogous policy changes. In 2016, 

that Vermont ranked 48th out of 50 California eliminated all nonmedical 

in state religiosity in the year before exemptions.¹ Delamater et al²¹ 

its policy change.²⁴ Ultimately, studied the rate of medical 

additional work at the individual level exemptions in California before and 

must confirm this hypothesis. after the legislative change, finding 

Regardless, the overall proportion of that medical exemptions decreased in 

Vermont kindergartners with 

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could Today, all major religions support 

have resulted in varying 

belief exemption elimination, and vaccination, and fewer Americans are 

precision among reported exemption 

were increasing as of the 2017–2018 religious.^2,24 In contrast, Americans 

proportions, the impact of this on our 

school year. Furthermore, religious are increasingly spiritual, with 27% 

results should be minimal because 

exemptions may be an increasingly of Americans self-identifying as such 

∼75% of states performed censuses 

problematic or outdated exemption in 2014, up from 19% in 2007.²⁴ 

with at least 80% of children counted. 

category, and researchers and Whereas definitions of religion 

Next, our adjusted analyses included 

policy makers must work together emphasize adherence to official 

state policy type availability, 

to determine how best to balance teachings and traditions, definitions 

exemption policy strength, and school 

a respect for religious liberty with of spirituality emphasize one’s 

year only. We did not adjust for state 

the need to protect public health. individual experience of the divine 

religiosity because of a lack of data on 

Researchers should study individual- and individual interpretations of 

this for all years except 2014. We did 

level behaviors to determine why sacred texts or traditions.²⁸ Thus, 

not adjust for race, income, education, 

religious exemption rates might laws formalized in the 1960s may be 

and population density (though other 

change with personal belief increasingly outdated in an 

longitudinal analyses of 

exemption availability, document increasingly secular and spiritual 

kindergartner exemption data have 

whether parents choose religious society that prioritizes individual 

done so^4–6) because state-reported 

exemptions in the absence of experience over dogmatic adherence 

proportions represent aggregated 

a personal belief alternative, and to teachings. Future work is needed 

data, and the interpretation of effects 

differentiate religious from spiritual that explores the rise in religious 

estimated from models including 

concerns. Policy makers must exemptions at the individual level, 

such covariates could be problematic. 

engage key stakeholders to discuss differentiating religious from spiritual 

Finally, because we used state-level 

exemption laws and determine the concerns. 

data and our risk ratios are estimates 

viability of religious exemptions as 

This study has limitations. First, in 16 state-years, states did not report the number of children with exemptions but reported the number of exemptions for each vaccine, which 

of population-level risks, we cannot make individual-level conclusions about parents’ vaccine-related behaviors regarding religious exemptions. 

could count some children more than once. In these instances, reported 

CONCLUSIONS 

State-reported kindergarten religious exemption rates differ by policy availability, may be subject to a replacement effect on personal 

an independent exemption category. This important work will help school vaccine exemption laws evolve in our rapidly changing society, ensuring they remain a cornerstone of public health for decades to come. 

proportions were calculated by using lower-bound estimates of individual vaccine exemption rates. Second, 

ABBREVIATION individual states collected data using 

CI: confidence interval a variety of methods. Although this 

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). 

Copyright © 2019 by the American Academy of Pediatrics 

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. 

FUNDING: Supported with unrestricted fellowship funding from the Denver Health Medical Center Ambulatory Care Services and Department of Pediatrics. 

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose. 

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