Nonmedical vaccine exemptions continued to hit record levels among Texas schoolchildren last year amid state lawmakers’ attempts to weaken immunization requirements further.
During the 2022-23 school year, 3.24% of Texas kindergartners received an exemption “for reasons of conscience,” which includes religious beliefs, from at least one immunization required to attend school, according to data from the Texas Department of State Health Services. That’s almost double the rate from 10 years ago, data shows. Texas is one of 41 states that saw an increase in school vaccine exemptions, which reached a record 3% nationally, according to the Centers for Disease Control and Prevention.
Meanwhile, dozens of bills filed during the 2023 legislative session sought to restrict education and access to vaccines or make the exemption process easier, according to The Immunization Partnership, a Texas nonprofit that advocates for evidence-based vaccine policies. For example, HB44, which was signed into law and took effect in September, threatens to withhold Medicaid funding for physicians who don’t offer vaccine exemptions for patients.
The developments are another sign of the post-pandemic momentum behind anti-vaccine messaging, experts say, and threaten to expose Texans to preventable diseases. Childhood vaccinations prevent an estimated 4 million deaths yearly, according to the CDC.
“I’m looking at the unintended consequences that lawmakers aren’t necessarily thinking about because they want to get their win and move on,” said Rekha Lakshmanan, chief strategy officer at The Immunization Partnership. “But then, all of us Texans are left holding the bag.”
A post-pandemic increase
In Texas, school-age children must receive up to seven immunizations for various illnesses, including measles, polio and tetanus. Texas also is one of 16 states that allow parents to request an exemption for religious and philosophical reasons, according to the National Conference of State
However, high rates of exemptions can limit vaccine coverage and become dangerous. Last year, the CDC reported a “staggering” rise in measles cases globally, following a decline in vaccination rates. And some pockets of the U.S. saw measles outbreaks starting in December, according to media reports.
Since Texas first expanded the vaccine exemption criteria in 2003 beyond religious beliefs, nonmedical exemption rates among K-12 students have increased gradually from 2,314 students (0.08%) in the 2003-04 school year to a record high of 100,028 (1.88%) last year.
Change in nonmedical school vaccine exemption rates
Exemptions historically have been most prominent among kindergartners, whose rates had been slowing in Texas when the pandemic started. From the 2018-19 to the 2019-20 school year, conscientious exemption rates among kindergartners rose modestly from 2.17% to 2.24%, before dropping slightly the following year to 2.14% percent. Then, during the 2021-22 school year, when COVID-19 vaccines became widely available, the rate of exemptions spiked to 2.64% before reaching 3.24% in 2022-23.
Private school exemption rates far outpaced that of public schools. Last year, 5.94% of private school students received a conscientious exemption, compared to 2.55% of public school students.
Some private schools saw exemption rates higher than 20%, such as The Connection School of Houston and Second Baptist School University-Model, according to state data. Among public schools in Harris County, Huffman (3.2%), Tomball (3%) and Humble ISDs (2.4%) all had the highest rates last year.
Nationally, Texas didn’t crack the top 20 states regarding the rates of all vaccine exemptions, including medical. With a rate of 3.5%, it was still above the national level.
DSHS spokesperson Chris Van Deusen said in addition to running its typical media campaign around immunizations, the agency is working on starting a new vaccination campaign for adults and developing materials with The University of Texas at El Paso to boost vaccine confidence.
Weakening vaccine policies
While the numbers had been rising before the pandemic, experts say COVID-19 provided a platform for physicians and anti-vaccine groups to bring once-fringe misinformation into the mainstream, accelerating the increase.
For example, the Texas Senate Committee on Health and Human Services in 2022 created a legislative report on the public health response to COVID, relying heavily on the testimony of Drs. Robert Malone and Peter McCullough. Both doctors are reported to have spread false or misleading information about the virus and vaccines. Malone was invited to testify on vaccine-related bills proposed during the 2023 legislative session.
In a lengthy statement, state Sen. Lois Kolkhorst, who chaired the committee, said she heard from health care professionals whose firsthand accounts of the pandemic “were inconsistent with the uniform message being given to the public by federal officials.” She said McCullough brought a perspective “that was nearly absent at the time in media coverage and social media,” and Malone, whom she described as a respected physician and researcher, “provided important context for the effects and efficacy of COVID vaccines.”
“It was critical that any hearing on COVID not censor one scientific view over another, but rather provide a variety of perspectives on the impact of the pandemic, and the debate over the response,” she said.
Lakshmanan called the reliance on their testimony “troubling and worrisome.”
“You have these kinds of individuals who are given such an important public platform in a legislature … that’s making policies for millions and millions of Texans, and using misinformation to inform those policies,” said Lakshmanan, who also is a nonresident scholar at Rice University’s Center for Health and Biosciences.
Doubts about COVID vaccines serve as an “entry point” for hesitancy around other vaccines, said Dr. Dorit Reiss, a professor at the University of California, Hastings College of the Law. She said parents also can take advantage of an easy exemption process in Texas, which doesn’t require an explanation of their reasoning.
“Personally, I think we should call them a personal choice exemption rather than conscientious, because you don’t have to show the issue,” Reiss said.
Even with Texas’ relatively lax laws around vaccine exemptions, lawmakers wanted to go a step further during the 2023 legislative session. State Sen. Bob Hall, who, according to the Texas Tribune, has made false and misleading claims about the pandemic, proposed a bill that would have prevented any school from requiring vaccines. Another bill filed by Hall would have made the exemption process easier. Neither bill received a hearing. Hall did not respond to a request for comment.
An omnibus bill, which was approved by the Senate but never reached the House, sought to shift decision-making on vaccine requirements from the state health department to legislators. The bill also would have prevented DSHS from making additional vaccine recommendations, among other proposed changes.
One bill that was signed into law, HB 44, is “one of the most egregious anti-vaccine bills passed, ever, in Texas,” Lakshmanan said.
Under the law, doctors can only create a policy requiring their patients to get vaccinated if they allow medical or conscientious exemptions. It explicitly does not cover cancer or organ transplant providers, but it could be especially burdensome for doctors who treat other vulnerable patients, such as pediatricians who see babies too young to be vaccinated, Lakshmanan said.
The bill’s author, state Rep. Valoree Swanson, R-Spring, did not respond to a request for comment. State Rep. Penny Morales Shaw, D-Houston, who signed on as a joint author, said in a statement that the pandemic influenced her decision to support the measure. COVID vaccines brought to light “the issue of whether medical care could be denied to children,” she said.
“In that context, I supported the bill because when it comes to vaccines a child does not have a say in what their parent(s) decide for them, and therefore they should not be denied healthcare treatment based on not having a vaccine,” she said.
The passage of bills like HB44 reflect the political momentum behind such legislation after the pandemic, Lakshmanan said. “We’re trying to alert everybody that you need to pay attention to it.”