BACKGROUND:
The tremendous success of the US vaccine program has paradoxically led to focus on vaccine rather than disease risks. School immunization laws have contributed to this success, but 48 states offer non-medical exemptions. Some consumer groups have recently organized efforts to undermine school laws and/or expand non-medical exemptions.

OBJECTIVE:
To review current evidence regarding the utility of school laws and pertinent issues regarding non-medical exemptions. Additionally, strategies for balancing parental autonomy with protecting the publics' health will be explored.

METHOD:
Review of published and unpublished data

RESULT:
School immunization laws have assisted in controlling diseases such as measles and in introducing new vaccines such as hepatitis B and varicella. Exemption rates have increased in many states, particularly states that offer philosophical or personal belief exemptions. Exemptors are at increased risk of acquiring and transmitting measles and pertussis. State and local policies are associated with rates of exemptions and, on the state level, measles and pertussis incidence. Vaccine safety concerns seem to be the most important factor contributing to parents claiming exemptions. Some states have tried to limit the number of exemptions by restricting exemptions to ‘recognized religions', but this strategy may be judicially ruled unconstitutional, as was recently the case in Arkansas. A model exemption will be presented that provides strategies to limit the rates of exemptions while affording parental autonomy.

CONCLUSION:
State immunization programs, public health officials and legislators need to recognize the tremendous benefit of school immunization laws and the risks associated with exemptions. State and local policies as well as accurate vaccine information may be useful in balancing public health and autonomy issues.

LEARNING OBJECTIVES:
To understand the evidentiary basis for school immunization requirements and issues surrounding non-medical exemptions. To consider strategies for balancing parental autonomy with the protection of the public's health through school immunization laws.