Expert Commentary

Religious exemptions and required vaccines: Examining the research

How often do students and employees claim vaccine mandates conflict with their religious beliefs? What are schools doing to discourage exemptions to required childhood vaccines? We look at the research.

religious exemption covid-19 vaccine mandate research
People protest vaccine mandates in New York City in September 2021. (Pamela Drew/Flickr)

Even as national surveys show Americans drawing away from religion, more American children are using religion to skip required school vaccinations. 

Even before some California school districts ordered students in certain age groups to get immunized against COVID-19, research showed the percentage of kindergarteners whose parents claim vaccines conflict with their religious beliefs was on the rise.

A December 2019 analysis published in Pediatrics finds an estimated 1.7% of kindergarteners nationwide received religious exemptions to vaccination during the 2017-18 academic year. Four years earlier, 1.1% of kindergarteners did.

Schools, employers and higher education institutions with vaccination mandates typically permit exemptions based on religion or medical reasons. In many states, public and private schools serving kids in kindergarten through 12th grade also allow exemptions based on personal beliefs or philosophies, which generally allow parents to opt out of vaccines simply because they oppose them.

The American Academy of Pediatrics supports the elimination of childhood vaccine exemptions, except for medical reasons. Six states — California, Connecticut, Maine, Mississippi, New York and West Virginia — prohibit K-12 schools from granting exemptions on religious grounds, according to the National Conference of State Legislatures.

Research, however, suggests that banning one type of exemption leads to an increase in another.

States that offer religious exemptions but do not provide personal belief exemptions are four times as likely to have kindergartners with religious exemptions, compared with states that grant both types of exemption, the December 2019 paper in Pediatrics reveals.  

The authors of that paper note that after Vermont eliminated personal belief exemptions in schools in 2016, the share of kindergartners with religious exemptions increased sevenfold to 3.7%. Scholars call this a “replacement effect,” meaning families seek a different exemption when the type they had been using no longer is available.

“Religious exemptions may be an increasingly problematic or outdated exemption category, and researchers and policy makers must work together to determine how best to balance a respect for religious liberty with the need to protect public health,” write the authors, led by Joshua T. B. Williams, a pediatrician at Denver Health Medical Center and assistant professor of pediatrics at the University of Colorado School of Medicine.

Researchers from Emory University in Atlanta found evidence of a replacement effect when schools prohibit all “nonmedical” exemptions — an umbrella term that applies to religious, philosophical and personal belief exemptions. In 2016, California enacted a law banning nonmedical exemptions in schools. By the second year, medical exemption rates jumped.

“The unintended consequence of an increase in medical exemption rates — which notably tripled in California — highlights a potential pitfall with this approach,” researchers write in the Expert Review of Vaccines in 2019.  

They add that it appears students’ parents and legal guardians “may seek out physicians who are more willing to attest to medical contraindications in the absence of a non-medical exemptions allowance.”

In the wake of the coronavirus pandemic, an increasing number of schools and higher education institutions are ordering students to get inoculated against COVID-19. Dozens of companies, including Delta Airlines, Facebook, Uber and Walmart, have mandated COVID-19 vaccinations for employees.

Government officials nationwide also have announced COVID-19 immunization requirements for government workers. Earlier this month, President Joe Biden signed an executive order directing federal employees to get COVID-19 shots.

Immediately after mandates were announced, students and employees started seeking religious and medical exemptions, even as high-ranking faith leaders worldwide urge people to get their shots.

This week, the Los Angeles Police Department drew criticism after news outlets reported that 2,651 of its employees plan to file for religious exemptions to its new vaccine requirement.

In Oregon, 2,284 state employees requested exemptions to the governor’s COVID-19 vaccine mandate — about 5% of the 42,000 employees affected by the requirement. About 90% of those requests were for religious exemptions.

Administrators at hospitals and nursing homes across the country worry the new immunization requirement will lead to staffing shortages as some employees might quit or let themselves be fired rather than get COVID-19 shots. Earlier this month, a hospital in upstate New York announced it planned to shut down its maternity ward because dozens of staff members quit over the vaccine mandate.

To help journalists get a better understanding of how common religious exemptions are among students and workers and get up to speed on schools’ efforts to improve childhood vaccination rates, we’ve gathered and summarized a sampling of academic studies that examine these topics.

The evidence to date suggests:

  • A small percentage of employees and students receive religious or medical exemptions.
  • When schools stop letting kids skip vaccines for philosophical reasons, more kids seek religious exemptions. When schools ban all exemptions except for medical exemptions, medical exemptions increase.
  • Kindergarteners are less likely to get vaccine exemptions for religious or philosophical reasons when schools require their parents to get medical counseling and a signed form from a health care provider before they can be considered for exemptions.

For more on these findings, keep reading.


Prevalence of religious exemptions

Current Landscape of Nonmedical Vaccination Exemptions in the United States: Impact of Policy Changes
Robert A. Bednarczyk, Adrian R. Kinga, Ariana Lahijania and Saad B. Omer. Expert Review of Vaccines, January 2019.

This paper looks at exemption trends among kindergarten students at public and private schools nationwide between academic years 2011-12 and 2017-18. A main takeaway: Not only are nonmedical exemptions much more common than medical exemptions, a growing percentage of kindergarteners have received nonmedical exemptions.

Nationally, the proportion of kindergarteners who skipped vaccines for reasons connected to religion, philosophy or personal beliefs increased from 1.4% to 1.9% over the study period. The nonmedical exemption rate varied considerably across states. In 2017-18, it ranged from 0.7% of kindergarteners in Indiana to 7.5% in Oregon.

Meanwhile, the percentage of kindergartners with medical exemptions has remained constant — rising by one-tenth of a percentage point between 2011-12 and 2017-18.

The researchers note that private schools historically have higher rates of both types of exemption than have public schools.

They cite three earlier studies to help explain why nonmedical exemptions are on the rise. Those studies, which examine data spanning from 1999 to 2016, indicate a greater number of students obtain nonmedical exemptions when the administrative process is less difficult.

“In three studies, encompassing over 25 years of surveillance, consistent associations were found with higher nonmedical exemption prevalence in states categorized as ‘easy’ or ‘medium’ difficulty for obtaining non-medical exemption, relative to states with higher difficulty … ,” the researchers write.

A Systematic Review of Mandatory Influenza Vaccination in Healthcare Personnel
Samantha I. Pitts; et al. American Journal of Preventive Medicine, September 2014.

For this paper, researchers reviewed 12 observational studies on mandatory flu vaccinations for employees of hospitals, outpatient clinics, surgical centers and other health care facilities. While the paper does not focus on exemptions, it does provide insights into their prevalence in the workplace.

Six of the studies report on the percentage of health care personnel who received religious or medical exemptions to the flu vaccine requirement, finding that religious exemptions were less common than medical exemptions at the health care facilities studied. Most of the 12 studies, published or released between 2006 and 2013, look at vaccine requirements at a single hospital or health system.

The percentage of employees who obtained religious exemptions ranged from 0.02% to 2.3%. Meanwhile, 0.3% to 2.6% received medical exemptions.

Efforts to boost child immunization

Evaluating the Effects of Vaccine Messaging on Immunization Intentions and Behavior: Evidence From Two Randomized Controlled Trials in Vermont
Katherine Clayton; et al. Vaccine, September 2021.

After Vermont stopped allowing kindergarten students to obtain philosophical exemptions to required vaccines in 2015, the percentage of kindergarten students with religious exemptions swelled sevenfold. In this paper, researchers examine the effectiveness of two communication strategies aimed at encouraging vaccine-hesitant parents to immunize their kids and parents whose children are behind on their vaccines to catch up.

What the researchers learned: Parents did not change their attitudes toward vaccines or indicate they would behave differently after reading a message from the state health department promoting immunization as a social norm or after reading a message correcting common misperceptions about vaccines.

The researchers also determined that the pro-vaccine message Vermont public health officials had been promoting to residents statewide was ineffective.

“These findings corroborate previous research finding limited evidence that messaging strategies change how people think about emotionally charged health issues like vaccinations,” they write.

A total of 678 parents with at least one child aged 10 years and younger and who expressed high levels of vaccine hesitancy participated in the first study. The second study focused on 613 parents of children aged 8 months or 20 months who had not yet received all their scheduled immunizations.

The 2016 California Policy to Eliminate Nonmedical Vaccine Exemptions and Changes in Vaccine Coverage: An Empirical Policy Analysis
Sindiso NyathiI; et al. PLOS Medicine, December 2019.

In 2017, the year after California banned nonmedical exemptions in K-12 schools, 3.3% more students entered kindergarten with their measles, mumps and rubella (MMR) vaccinations statewide, compared against states that did not eliminate nonmedical exemptions in schools, this paper finds.

Researchers also learned that while nonmedical exemptions fell in California, the percentage of kindergarteners obtaining medical exemptions grew 0.4%.

“Although the rise in medical exemptions could indicate that some children who may have received nonmedical exemptions in the past are now receiving medical exemptions, the net effect following the California policy was still an increase in vaccination coverage,” the researchers write.

They note that even small increases in vaccine coverage can help communities achieve herd immunity levels of 90% to 95% vaccine coverage. In 2015, 24 counties in California had MMR coverage levels below the range needed for herd immunity, according to the analysis, based on state-level data from the CDC and county-level data provided by state departments of health. In 2017, 12 counties had coverage levels that fell short of herd immunity levels.

Exemptions From Mandatory Immunization After Legally Mandated Parental Counseling
Saad B. Omer; et al. Pediatrics, January 2018.

Fewer students make requests for vaccine exemptions when the process for obtaining one becomes more difficult, this study suggests. The number of Washington kindergarteners who obtained any type of vaccine exemption dropped considerably after the state began requiring parents to get medical counseling and a signed form from a licensed health care provider before kids could be considered for exemptions.

The authors examined exemption rates for kindergarteners statewide from the 1997-98 academic year through 2013-14. After the state enacted Senate Bill 5005 in 2011, the vaccine exemption rate fell 2.9 percentage points statewide and stayed there through the end of the study period.

“This highlights the importance of more stringent polices for obtaining immunization exemptions,” the authors write.

They point out that discussions between health care providers and parents help correct misinformation about vaccines. However, they add that “the effect of this policy change might be caused by an increase in administrative difficulty of obtaining an exemption, rather than by persuasive interpersonal communications.”

Looking for more on COVID-19 vaccines? The Journalist’s Resource also has gathered research on vaccine hesitancy, COVID-19 vaccines during pregnancy and the role teachers and staff play in COVID-19 outbreaks on campus.

Also, please check out our tip sheet on covering religious exemptions.

We obtained this image from the Flickr account of Pamela Drew. It is being used under a Creative Commons license. No changes were made.

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