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School vaccination requirements may lead to other health disparities

Education improves health and is associated with lower mortality.

With the highest vaccination rates in the country, Massachusetts is largely protected from disease outbreaks.Adam Glanzman/Bloomberg

COVID-19 vaccines illustrate the transformative power of vaccination to control infectious illness, and some schools have implemented mandates. In this context, the Massachusetts Legislature is considering two vaccination bills that would end or limit access to school, day care, or even college for the roughly 1 percent of Massachusetts children or young adults using a religious exemption. One of the bills would also allow vaccination of children without parental consent or knowledge — irrespective of age or capacity—and would also limit medical exemptions. While broad vaccine coverage is important to control infectious illness, it is imperative that citizens appreciate the destructive consequences of these bills.

With the highest vaccination rates in the country, Massachusetts is largely protected from disease outbreaks. Over the past decade, vaccination rates have improved and the religious exemption, used most often to forgo one or two vaccines, has held steady at roughly 1 percent. Simply put, there is no vaccination problem in Massachusetts. Excluding children from school risks creating larger, more serious, public health problems.


Losing access to education is a public health threat in its own right. Education improves health and is associated with lower mortality. Education is crucial for low-income and communities of color to mitigate disparities related to racism and socioeconomic disadvantage. This past year confirms the downsides of school loss, especially for the economically disadvantaged and Black and Latinx students. Special needs students and families would also be hard-hit. They are critically dependent on special education to teach communication, basic skills, and self-regulation. Special needs families have enormous challenges and higher rates of serious mental health symptoms, which require support. Marginalized communities need more educational support, not less.

Even more threatening to many parents, the Community Immunity Act would allow vaccination without parental consent, even if a child is young or intellectually disabled. Parents would never know, since medical records would be hidden unless court-ordered to be released or the child provided written consent. The provision is ripe for errors and abuses, and children experiencing adverse events might be unable to access appropriate medical care. We believe parents would be astonished by this possibility.


The Community Immunity Act also has a troubling provision that would limit all medical exemptions to a CDC list that codifies obvious circumstances in which a vaccine should be skipped. But the list does not and cannot describe all circumstances where a medical exemption might be warranted.

Repeatedly, we’ve heard parents tell us about serious or unexplained reactions to medicines of all kinds, including vaccination. Current safety systems are simply not ideal for assessing individual variability or atypical reactions. People with complex medical histories are mostly excluded from clinical trials and we just don’t have good data about who reacts or why, but we know they exist — we see them in our offices. Data show that vaccines are implicated in 19.5 percent of emergency adverse drug events in children 5 and under. Eliminating clinical judgment by constraining doctors to a one-size-fits-all checklist is simply bad medicine.

We can strengthen Massachusetts immunization by focusing effort on outlier schools with low vaccination rates, mostly in lower-income areas. Support for school nurses could help address documentation challenges, reporting difficulties, or equitable access. Mobile vaccination clinics should also be considered. But one thing is clear: Religious exemptions are not the driver. The schools with the lowest rates of MMR vaccination have almost no religious exemptions on file.


Punitive policies that exclude children from school can have devastating, life-long impact, and it’s not even clear they work. California saw a four-fold increase in homeschooling and a 1.4 percent decrease in kindergarten enrollment since nonmedical exemptions were removed in 2016. Some parents simply cannot comply with the entire vaccine schedule because of deeply held religious beliefs or moral conscience. For others, concerns regarding systemic conflicts of interest and systemic discrimination (including in clinical trials) contribute to distrust.

At the very time our nation is grappling with the scourge of systemic racism and institutionalized socio-economic inequality, taking away access to education — the very tool that marginalized children need to succeed — is not justifiable. If the state’s aim is to keep our population healthy, immunization goals must be balanced against the real risks of losing access to education. Shutting the schoolhouse door and depriving children of the right to an education is not sound public health policy.

Dr. Sylvia Fogel is a psychiatrist at Massachusetts General Hospital and instructor at Harvard Medical School. Dr. Andrew Zimmerman is a pediatric neurologist and a professor of pediatrics and neurology at UMass Medical School. Dr. Charlotte Mao is a pediatric infectious disease physician at Massachusetts General Hospital who cares for children and adolescents with complex Lyme disease and associated infections at the Dean Center for Tickborne Illness at Spaulding Rehabilitation Hospital. Dr. John Gaitanis is the division chief of child neurology at Tufts Children’s Hospital.


Sylvia Fogel, Andrew Zimmerman, Charlotte Mao, and John Gaitanis