At the start of a new school year, clinicians may encounter questions about vaccine exemptions for students. In one example, a 12-year-old student in New Jersey required documentation because he had not received the Tdap vaccine. His medical history included a severe allergic reaction after his fourth dose of DTaP as a toddler, which led to an episode of anaphylaxis treated in the office.
Medical exemptions from vaccines are permitted in all states for specific reasons. According to guidance, significant adverse reactions or known allergies to vaccine components constitute contraindications and require exemption from further doses of that vaccine. Precautions differ from contraindications; they involve weighing risks and benefits and may result in temporary delays rather than permanent exemptions.
Certain health conditions, such as lifelong immunosuppression following organ transplant, may prevent individuals from receiving live vaccines indefinitely. The Centers for Disease Control and Prevention (CDC) maintains a list of contraindications and precautions for each vaccine on its website: https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/contraindications.html.
Temporary medical contraindications can also occur. For instance, children undergoing cancer treatment might receive exemption letters during therapy but could resume vaccinations later with their oncologist’s guidance. Other examples include children who have received intravenous immune globulin (IVIG) or convalescent plasma, which require waiting periods before certain vaccines like MMR or varicella can be administered.
Approximately half of U.S. states differentiate between temporary and permanent medical exemptions through specific laws that affect how providers must write exemption letters.
Best practices for writing these letters include specifying the patient’s name and date of birth, identifying the relevant vaccine(s), stating clearly that the exemption is medically indicated, providing clinician details and license information, noting the duration if applicable, and including any pertinent medical conditions. States vary on whether standardized forms or individualized letters are needed; providers should follow current state department of health guidelines and retain copies in patient records.
In New Jersey’s case, providers can use a state-issued PDF form to ensure compliance with requirements.
While few children need medical exemptions from immunizations due to health conditions, it is important that these exemptions are used appropriately so as not to impact overall vaccination rates. Families should be informed that exempted children may need to take special precautions during outbreaks due to their vaccination status.
