Sidebar: A Rare Indication: Immunization Exemptions in North Carolina

Every state has requirements for immunizations to protect us from preventable diseases that have caused significant morbidity and mortality. An exemption is a specific exception defined in North Carolina laws and rules that allows an infant, child, or adult to not have to receive one or more of the age-appropriate immunizations that are required to attend a child care setting, school, college, or university in North Carolina.

North Carolina laws only allow for two types of requests for exemptions from immunization requirements: religious and medical. North Carolina has not allowed philosophical or personal belief exemptions since 1976. State rules clearly express that “there is no exception to these requirements for the case of a personal belief or philosophy of a parent or guardian not founded upon a religious belief” [1]. There are 35 states, including North Carolina, that currently do not allow philosophical or personal belief exemptions [2].

North Carolina laws allow requests for exemption from required vaccines based on bona fide religious beliefs [3]. Religious exemptions are defined in state statute as follows: “If the bona fide religious beliefs of an adult or the parent, guardian or person in loco parentis of a child are contrary to the immunization requirements contained in this Chapter, the adult or the child shall be exempt from the requirements” [3]. Requests for religious exemptions are submitted in writing to the child care setting, school, college, university, or facility for review, and not to the state.

North Carolina laws allow requests for medical exemptions based on having one or more medical contraindications to vaccinations. According to the Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP), a contraindication is defined as “a condition in a recipient that increases the risk for a serious adverse reaction” [4]. An example is a severe allergic reaction to a vaccine component. The North Carolina Commission for Public Health adopted in its rules the list of medical contraindications for immunizations, which are described in the most recent “ACIP General Best Practices for Immunization” [5]. North Carolina laws state that “if a physician licensed to practice medicine in this State certifies that a required immunization is or may be detrimental to a person’s health due to the presence of one of the contraindications adopted by the Commission, the person is not required to receive the specified immunization as long as the contraindication persists” [6]. If an individual’s physician believes a medical contraindication exists, then the physician would complete the NC Medical Exemption Statement Form, choose the appropriate contraindication from the list of the current ACIP contraindications, and specify the vaccine(s) the individual should not receive, as well as the length of time of the exemption [6]. The form does not require review by the state health director and is available at https://www.immunize.nc.gov/schools/. The parent, patient, or physician can submit the completed form to the appropriate facility.

North Carolina immunization rules also allow for requests for medical exemptions for contraindications that are “not on the list adopted by the NC Commission for Public Health” [7]. Contraindication exemptions may be requested due to concerns about the course of a disease or a treatment, such as if a child has a kidney transplant and is on chronic immunosuppressive therapy. North Carolina laws also allow for a request for a medical exemption for individuals enrolled in certain clinical trials [8]. With these types of medical exemption requests for contraindications “not on the list,” the physician would complete and submit the NC Physician’s Request for Medical Exemption Form to the state health director for review [9].

The state health director (or his/her delegated designee) has the authority to grant or deny a medical exemption request for any requested vaccine(s). If a request for a medical exemption is denied by the state health director, the decision can be appealed to the North Carolina Office of Administrative Hearings.

The percentages of medical and religious exemptions in North Carolina have been low and below the national medians for medical and non-medical exemptions. The data from the 2017-2018 and 2018-2019 school years showed that 0.2% (284) and 0.1% (167) of children enrolled in kindergarten received medical exemptions in North Carolina compared to the national median, which was 0.2% for both years [10, 11]. The data for those same two school years showed that 1.8% and 1.5% of enrolled kindergartners in North Carolina received nonmedical (religious) exemptions, which was below the national median percentages for nonmedical exemptions of 2% and 2.5% [10, 11]. However, pockets of higher religious exemption rates do exist in North Carolina communities and are concerning as they increase the risk for vaccine-preventable disease outbreaks.

The North Carolina Department of Health and Human Services (NCDHHS), in partnership with local health departments, providers, and other partners, continues to engage in county, regional, and state efforts to promote immunizations and monitor religious and medical exemption rates in our state, which when too high have led to vaccine-preventable disease outbreaks. While on rare occasions individuals may need an exemption, North Carolina laws and rules acknowledge the critical importance of vaccination to maintain the health and well-being of all individuals and communities.

• ©2021 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.