Essay: The vaccination movement

I. Introduction
This paper will provide a history of the vaccination movement as a whole in Section II. In Section III, this paper will examine states’ vaccination requirements for college students. Section IV will analyze the benefits and drawbacks of imposing stricter vaccine requirements.
II. An Overview of the Vaccination Movement
A. Vaccine Development and the Implementation of Compulsory Vaccination
What is considered the start of the “vaccine era” interestingly enough, did not begin with a vaccine.  Rather, the vaccine movement began with inoculation, a technique where a healthy individual was infected with matter from the wound of a person who had the disease.  This method initially caused the individual to become ill, but they would be protected from the disease after recovering.  In 1796, Edward Jenner inoculated a boy with material from a cowpox lesion.  Months later, Jenner inoculated the same child with matter from a smallpox sore.  The boy did not become ill.  Jenner then showed that transferring cowpox matter from one person to another provided protection from smallpox.  Jenner’s method of using cowpox to defend a person against smallpox was later termed vaccination.
Vaccines came to the United States in 1800, when a professor of medicine, Benjamin Waterhouse, vaccinated his children.  Nine years later, Massachusetts implemented a law making vaccination mandatory.  Massachusetts had the authority to do so as part of the states’ police power to regulate health and safety.  The states were able to delegate this authority to local entities.  States and towns began to require residents to be vaccinated when it would affect residents’ health and safety.  In 1855, Massachusetts extended their compulsory vaccination law to encompass schoolchildren.
It took around 100 years for the next vaccine, rabies, to be developed.  Vaccine development hit a stride in the 20th Century.  When new vaccines were developed, states often made them mandatory for schoolchildren.  It made sense to require children to get these vaccines because diseases such as polio and measles were considered childhood diseases.  In addition, many outbreaks of these preventable diseases occurred in schools.
Presently, there are sixteen diseases that are preventable with proper vaccination.  While some of these diseases still occur in the United States, others have been eradicated.  Vaccination not only protects the individual that receives it, but others around them.  For a complete understanding of the vaccinations and the diseases they protect against, this paper will provide a brief overview of each vaccine that will be discussed in the context of college vaccination laws in later sections.
1. Hepatitis B
Hepatitis B is caused by a virus.  It is spread when bodily fluids containing the virus are transmitted to a healthy person.  The virus can be spread through something as simple as sharing razors or a toothbrush with someone who has the virus.  Hepatitis B can have both short-term and more severe effects.  Side effects can include fever, muscle pain, nausea, and vomiting. However, Hepatitis B can also cause liver damage, cancer, or be fatal.  The vaccination for Hepatitis B does not cause infection with the disease and is administered in two to four doses.
2. Human Papillomavirus (HPV)
The HPV vaccine prevents nine strains of Human Papillomavirus.  These strains cause cancers such as cervical cancer and throat cancer.  HPV is generally transmitted through sexual contact with an infected individual.  Infection is common, with millions of people getting infected every year.  While most cases are not serious, there is the potential for the infection to cause cancer.  The vaccine is given in either two to three doses.
3. Influenza
The flu vaccine can prevent the flu and prevent the flu from spreading to other individuals.  In addition, if a person gets the flu vaccine and still becomes infected with the flu, their symptoms may be lessened.  The flu is transmitted via close contact between people, as well as coughing and sneezing.  Symptoms of the flu include body aches, cough, fever, and sore throat, among others.  However, the flu can cause more severe conditions, such as pneumonia. In thousands of cases each year, the flu is fatal.
4. Measles, Mumps, Rubella (MMR)
The MMR vaccine protects against three viruses: measles, mumps, and rubella. The vaccine is given in two doses.  In case of an outbreak, a third dose may be administered.  Measles is a virus that causes fever and rash.  The virus can lead to more severe symptoms such as diarrhea and pneumonia.  In rare cases, measles has led to brain damage and fatalities. Measles does not require close contact with an infected person.
Mumps and rubella are also transmitted easily.  Mumps can cause common symptoms and side effects that are more severe.  Some symptoms include body aches, fever, and loss of appetite.  More severe symptoms are deafness, swelling of the brain (encephalitis), swelling of the spinal cord covering (meningitis).  In very few cases, mumps may also cause death. Symptoms of rubella are similar to measles.  Additionally, rubella can lead to arthritis in women.
5. Meningococcal
There are two Meningococcal vaccines – Meningococcal ACWY (MenACWY)  and Meningococcal serogroup B (MenB) . A bacterium, Neisseria meningitidis causes meningococcal disease.  The different types of N. meningitidis bacteria are called serogroups. These serogroups are passed from one person to the next by coughing, kissing, or extended contact like living together.  When a person is infected with meningococcal disease, they may get meningitis or another infection.
Meningococcal disease leads to death in ten to fifteen of every 100 cases.  An additional ten to twenty people infected in every 100 cases will end up with complications such as scarring, brain damage, and amputation.  To be protected against the A, C, W, and Y serogroups, two doses are encouraged for teenagers.  Serogroup B vaccines are recommended for groups that are at risk, such as people in places where there has been a serogroup B outbreak.
6. Polio
Thanks to the polio vaccination, polio has been eradicated in the United States.  However, vaccination is crucial because it still exists in other parts of the world.  Polio is a virus that is spread from one person to another.  In some cases, it is transmitted when a person ingests food or drinks that have been contaminated with the fecal matter of someone with polio.
The majority of people diagnosed with polio will not have any symptoms and will recover.  In more severe cases, polio causes paralysis and death.  These symptoms were common before the polio vaccine was developed.  The vaccine is administered in three or four doses, depending on age.
7. Tetanus, Diphtheria, Pertussis (Tdap)
The Tdap vaccine protects against three diseases.  Tdap is usually given once during adolescence and a booster (the Td vaccine) should be administered every 10 years to protect against Tetanus and Diphtheria.  Tetanus, diphtheria, and pertussis are bacterial diseases.  Tetanus is transmitted through open wounds, like cuts or scratches.  Diphtheria and pertussis are transmitted when a person coughs or sneezes near another.
Tetanus and Diphtheria are no longer common diseases in the United States.  Tetanus results in the tightening and stiffening of muscles.  In some cases, the infected individual is unable to open their mouth.  Tetanus is fatal in approximately one out of every ten cases. Diphtheria results in the infected individual’s throat to be covered in a thick coating.  This causes complications with breathing and in severe cases, heart failure, paralysis, and death.  Pertussis is also known as whooping cough.  The coughing can also result in complications with breathing and vomiting.
8. Varicella (Chickenpox)
Chickenpox is caused by a virus.  It is very contagious and leads to a rash. In most cases, a person will have chickenpox for around a week.  Other symptoms include fever, headache, loss of appetite, and fatigue.  In more severe cases, chickenpox can lead to infections such as pneumonia, blood stream infections, meningitis, and encephalitis.  Prior to the availability of the chickenpox vaccine, chickenpox was a very common disease in the United States.  Now, chickenpox can be prevented with a two-dose series of the vaccine.
B. The Anti-Vaccination Movement
Although states implemented compulsory vaccination programs for the benefit of society, there was opposition to the vaccination movement from its inception. In 1822, the Anti-Vaccination League of America convened for the first time in New York.  At the meeting, speakers proposed that smallpox was spread by filth, rather than being a contagious disease.
When Massachusetts enacted a statute allowing local health boards to require residents to be vaccinated, not everyone wished to comply.  In a case brought before the Supreme Court, Jacobson v. Massachusetts, a Massachusetts resident challenged the constitutionality of compulsory smallpox vaccination.  The resident argued that it was a violation of his freedom for the state to be able to punish him with a fine or imprisonment.  He believed that mandatory vaccination was “hostile to the inherent right of every freeman to care for his own body and health in such way as to him seems best.”  The Court held that the statute was constitutional and within the scope of the police power, as the statute was enacted to protect residents’ health and safety.
Just over a decade later, the issue of mandatory vaccination was once again before the Supreme Court with a focus on compulsory vaccination in schools.  In Zucht v. King, a child was barred from attending both public and private schools in San Antonio for her refusal to get the shots required by a city ordinance.  Neither the student nor her parents wanted her to get the vaccine.  The student alleged that the ordinance requiring the vaccination of schoolchildren infringed on her rights.  She did not see the reason for mandatory vaccination because  there was no smallpox epidemic and she was not exposed to unsanitary conditions. Again, the Supreme Court upheld the constitutionality of the statute.
Like the student in the aforementioned case, some in opposition to vaccination do not believe they are in danger of contracting a particular disease.  Others do not oppose vaccines, but do not believe in compulsory vaccination.  Additionally, there are people whose religious beliefs conflict with immunizations.
A new wave of people in opposition to vaccines, now termed “anti-vaxxers”, arose with the availability and accessibility of medical information on the internet.  One anti-vaccination argument that popped up on the internet pinpointed vaccines as the cause of autism.  This theory was based on a scholarly article published by a surgeon named Andrew Wakefield.
Wakefield asserted that proteins in the MMR vaccine traveled through the bloodstream and once in the brain, caused autism.  However, the study was riddled with problems.  Most significantly, the results from the study could not be replicated.  After studies by various researchers and an epidemiological review done by the Institute of Medicine, the scientific community concluded that there was no link between vaccines and autism.  Unfortunately, anti-vaccination groups on the internet continue to assert that vaccines cause autism, along with other misinformation about vaccines.
C. Why Vaccinations Matter in the Scope of Higher Education
When thinking about the anti-vaccination movement, people often refer to parents who refuse to vaccinate their children. What happens when those children get older and go off to college? Students who were not vaccinated as children “pose an increased risk of disease susceptibility” which leads to infectious disease outbreaks.  However, college students are vulnerable to vaccine-preventable diseases even if they are vaccinated.  Diseases such as meningitis and measles are generally transmitted where there are large amounts of people in close quarters, so college campuses are the perfect breeding ground.
Emily Stillman was away at college when she called her mother to complain about a headache.  Just a few days later, Emily was dead.  She had contracted meningococcal disease, a vaccine-preventable disease.  However, at the time, there was no licensed vaccine for meningitis serogroup B, the type Emily contracted.  Within three years, there were two meningitis serogroup B vaccines on the market, both approved by the Food and Drug Administration.
Emily’s case, though tragic, is not rare. In the United States, between 600 and 1000 people are diagnosed with meningococcal disease each year.  The disease is fatal in 10 to 15 percent of cases.  Like Emily, Sara Stelzer contracted bacterial meningitis while away at college.  Sara called her parents one night to say she wasn’t feeling well.  The next morning she called again, saying she had thrown up.  Despite not feeling well, Sara attended one of her classes, since she had to present a speech.  She missed the rest of her classes because she still wasn’t back to normal.  The next day, Sara ended up at the hospital.  By the time her parents arrived at the hospital, Sara was in a coma that she would never come out of.  Sara Stelzer passed away soon after from serogroup B meningococcal disease.
In 2018 alone, five colleges in Massachusetts and one in California have had a serogroup B meningococcal disease outbreak.  Additionally, between 2013 and 2016, five other campuses across the United States experienced a serogroup B meningococcal disease outbreak.  At the University of Oregon, there were seven cases of meningococcal disease, one of which was fatal.  Princeton University had nine cases.  This outbreak resulted in the death of a student from another college, as well as some survivors experiencing neurological complications.  Due to the nature of meningococcal disease transmission, the Centers for Disease Control (CDC) recommends meningitis vaccines for incoming college students who plan to live on campus. According to the CDC, college students are at a slightly higher risk for contracting the disease than other adolescents and young adults that are not in college.
Meningitis is not the only vaccine-preventable disease affecting college campuses. In 2015, college students at five campuses were diagnosed with measles.  At the time, California, one of the states affected by the outbreak, did not require students to be vaccinated for measles, along with at least twenty-one other states.
III. State Laws
While states have the power to impose vaccine mandates , various health organizations provide guidance as to what vaccines states should require. The CDC offers vaccine recommendations for each age level.  The CDC recommends that incoming college students obtain the Meningococcal ACWY (MenACWY), Human Papilloma Virus (HPV), Tetanus, diphtheria, and pertussis (Tdap), and flu vaccines.  In addition, the American College Health Association provides immunization recommendations “to facilitate implementation of a comprehensive institutional immunization policy.”  The ACHA recommendations are based off of guidelines published by the CDC, but also suggest students are vaccinated for the measles, mumps, and rubella (MMR) vaccine, as well as the varicella (chickenpox) vaccine.
Even with these recommendations, college vaccination requirements vary widely by state. Some states regulate vaccine requirements themselves, while others leave it up to the individual institutions. Through a sampling of six states’ requirements, this section serves to illustrate the broad spectrum of vaccination laws and highlight potential areas for reform.
A. State-Mandated Vaccination Requirements
a. Massachusetts
Massachusetts requires that college students provide proof of immunization for the following vaccinations: Tdap, Hepatitis B, MMR, Varicella, and Meningitis.  However, Massachusetts provides medical and religious exemptions.  Under the medical exemption, a student does not have to furnish proof of vaccination if they have a physician’s certification that the student’s health would be endangered by vaccination.  The religious exemption allows students to provide a written statement “that vaccination or immunization conflicts with his sincere religious beliefs” unless there is an epidemic of disease.
b. New Jersey
In New Jersey, vaccine requirements are imposed on students enrolled in twelve or more hours at a two-year institution, as well as part-time and full-time undergraduate and graduate students.  Students are required to be immunized with MMR, meningitis, and Hepatitis B vaccines.  Like Massachusetts, New Jersey has medical and religious exemptions. A student can qualify for a medical exemption with a written statement from a physician or advanced practice nurse.  In order to be eligible for a religious exemption, a student must submit a statement explaining how immunization conflicts with their religious beliefs.
c. New York
New York requires a single immunization for all college students: the MMR vaccine.  Students are exempt from this requirement if a health practitioner finds that a student has a medical contraindication to the vaccine or the vaccine is detrimental to the student’s health.  If the vaccine is no longer deemed a threat to the student’s health, the exemption is no longer valid.  New York also provides a religious exemption for students whose religious beliefs conflict with immunization.
If a student is enrolled in more than six hours in a given semester, they are required to provide proof of the meningitis vaccine.  However, if the student does not wish to comply with this requirement, they can sign a form declining the immunization.  Unlike Massachusetts and New Jersey, New York does not require an exemption for the meningitis vaccine.
d. Texas
Out of the selected states, Texas has the least strict vaccination requirements. Texas only requires proof of the meningitis vaccine for students twenty-two years or younger.   Like the states mentioned previously, Texas provides a medical exemption.  However, Texas also has an exemption for “reasons of conscience, including a religious belief.”  To decline the immunization under this exemption, the student merely provides a signed affidavit that says they are declining the vaccine due to reasons of conscience.  It is important to note that this exemption does not apply during certain events like disasters or public health emergencies.
B. Institution-Dependent Vaccination Requirements
1. West Virginia
The West Virginia Bureau of Public Health provides recommendations for college vaccination requirements.  West Virginia University requires incoming freshman and transfer students to provide proof the following vaccinations: MMR, Meningitis, Polio, Hepatitis B, and Tdap.  Students are not required to provide a physician’s signature or immunization dates.
The University of Charleston, on the other hand, requires just the MMR vaccine for incoming students who were born after 1956.  Students who are living on campus have to provide actual documentation for the Hepatitis B and Meningitis vaccines.
2. California
California has a similar system to West Virginia. The California Department of Public Health (CDPH) has a list of recommended vaccines that it “urges all California colleges and universities with campus housing to implement these recommendations at their campus.”  The University of California requires all students to follow the requirements implemented by the CDPH.  These requirements include MMR, varicella, meningitis, and Tdap vaccines, depending on the student’s age.  California State University requires proof of MMR, Hepatitis B, and Meningitis vaccines.  There are exemptions provided for medical considerations, religious beliefs, and personal beliefs.
IV. Reforming Higher Education Laws by Altering Exemptions
Compulsory vaccination laws are put in place to decrease the threat of a particular disease.  The more people that are vaccinated in a community, the less of a threat the disease poses.  This is due to a concept called herd immunity.  When a person gets vaccinated, they are not only protecting themselves, but others who they come into close contact with.  Even people that are not vaccinated benefit from herd immunity.
If states were to impose stricter vaccination laws on colleges and universities, in theory, this would decrease the risk of outbreaks of diseases such as measles and meningococcal disease. For this to work in practice, as many students would need to be vaccinated as possible. However, with states like Texas, which allows students to refuse a vaccine for conscientious reasons by signing a form saying they decline the vaccine , mandatory vaccination isn’t really all that mandatory. In order to maximize the potential health benefits of vaccination on college campuses, states need to reform the exemption process.
A. Potential Solution #1: Eliminating Some Exemptions Entirely
In a controversial move, California passed Senate Bill 277, which eliminated the personal belief exemption to mandatory vaccination programs for children.  It is important to note that the medical exemption is still in place.  In fact, all fifty states provide medical exemptions.  This is because some people have medical conditions that do not interact safely with vaccinations.  Others develop a reaction after receiving a vaccine.  For these reasons, a medical exemption is necessary.
Senate Bill 277 does not apply to the immunization of college students in California.  While this statute does not affect students in postsecondary institutions, it is certainly one option to consider in the context of vaccination law reform for Higher Education. Discussing the litigation that arose after the implementation of Senate Bill 277 will help determine whether eliminating exemptions is feasible in Higher Education.
a. Whitlow v. Cal. Dep’t of Educ.
The plaintiffs in Whitlow sought a preliminary injunction against the enforcement of Senate Bill 277 (“SB 277”).  SB 277 no longer enabled parents to refuse to comply with California’s vaccination requirements based on their personal beliefs.  According to plaintiffs, there are over 30,000 children that previously utilized the personal belief exemption and are now unable to enroll in school without the proper vaccinations.
Firstly, the parents assert that SB 277 infringes on their right to the free exercise of religion because of three reasons.  One reason is that SB 277 does not provide a religious exemption. Additionally, parents feel that SB 277 makes them “choose between the dictates of their faith and their children’s education.”  The statute also provides other exemptions while declining to offer a religious exemption.
Despite the plaintiffs’ claim, their right to free exercise of religion does not trump the compelling interest of the state to regulate health and safety.  Their claim that SB 277 forces them to choose between their religion and their children’s education also fails for the same reason.  Lastly, just because California provides a medical exemption does not mean California is required to provide an exemption for religious beliefs.
Along with their Free Exercise Claim, plaintiffs assert a claim under the Equal Protection Clause.  The plaintiffs state that SB 277 discriminates against children with personal belief exemptions by forbidding them to attend school.  Children with these exemptions were treated differently than children without exemptions, according to the plaintiffs.  However, the Court concludes that children that qualified for personal belief exemptions are not similarly situated.  Even if the children were similarly situated to those without exemptions, they are not members of a suspect class.  Since the children are not members of a suspect class, rational basis review applies to this case, rather than strict scrutiny.  The Court concludes that there is a rational basis for treating children with personal belief exemptions differently compared to those without the exemption.  Children with exemptions are not fully vaccinated, and in some cases, are not vaccinated at all.  If these unvaccinated children were permitted to go to class, this would go against the State’s compelling interest in public health and safety.
Finally, the plaintiffs brought a due process claim.  Under SB 277, parents whose children used personal belief exemptions were not allowed to make decisions in regard to their own child’s health and education.  However, plaintiffs failed to take into account that the personal belief exemption was not required by law, and thus does not violate due process.
b. Brown v. Smith
The next case also objects to the elimination of the personal belief exemption under SB 277.  In Brown, a group of parents “with ‘sincerely held philosophic, conscientious, and religious objections to state-mandated immunization’” sought to invalidate the amendment to SBB 277.  Plaintiffs in this case also asserted claims of free exercise, equal protection, and due process.  Like the plaintiffs in Whitlow, all claims were dismissed.
B. Potential Solution #2: Imposing Restrictions on Exemptions
States do not have to get rid of exemptions completely. States could also re-examine their criteria for granting exemptions to ensure that only those who need medical exemptions or with sincere religious beliefs are granted exemptions. However, when such restrictions were implemented in K-12 schools, an abundance of litigation followed.
1. Medical Exemptions
Medical exemptions may seem fairly straightforward. They are generally granted when a physician or health practitioner certifies that an immunization would be harmful to a child’s health.   However, getting a certificate from a physician does not always guarantee the exemption.
In Workman v. Mingo, a parent challenged the revocation of her child’s exemption.  One of Workman’s children, S.W., received vaccinations.  Around the same time, S.W. started experiencing health issues.  Since one of her children had health problems that seemed to start when the child was vaccinated, Workman decided not to vaccinate her other child, M.W.
According to West Virginia Law, a child must obtain immunizations to protect against “diphtheria, polio, rubeola, rubella, tetanus, and whooping cough.”  If a child does not obtain these vaccinations, they are unable to attend any school within the state of West Virginia.  However, the law does provide for an exemption.  If a physician certifies that obtaining the vaccination is not proper or possible in that given situation, the child may be granted an exemption.  The physician may also certify that there is another sufficient reason that the vaccines have not been obtained.
Workman sought an exemption for her child, M.W., so M.W. could attend school without the vaccinations.  Workman received a Permanent Medical Exemption certificate for M.W. from a child psychiatrist.  The psychiatrist based his decision upon S.W.’s health issues that appeared around the same time the child was vaccinated.  The psychiatrist thought it was best not to vaccinate M.W. because of what happened to S.W.
Initially, the Permanent Medical Exemption was satisfactory for M.W., the unvaccinated child, to enroll in school.  M.W. was in school for about a month before problems arose.  A nurse at the child’s school was concerned with the medical exemption certificate.  The Superintendent of the school district reached out to the Department of Health and Human Resources.  A top official within the department suggested that the school district deny the medical exemption Workman procured.  Workman was informed that her child would no longer to be able to attend school without the proper vaccinations.
Interestingly, when this case was heard before the United States Court of Appeals, Workman asserted that compulsory vaccination infringed on her right to the free exercise of religion.  However, Workman obtained a medical exemption that was based on her other child’s possible reaction to a vaccine.  The certificate was not for religious beliefs.
The Court first discussed the level of scrutiny necessary for this case.  Workman asserted the case required strict scrutiny because mandatory vaccination is a substantial burden on her ability to freely exercise her religion.  Workman also argued that there was no compelling state interest involved in mandatory vaccinations, because the vaccines required were against diseases with low risk.  The Court concluded that West Virginia’s mandatory vaccination laws are not unconstitutional with regards to the free exercise of religion.  The Court also reasoned that prevention of communicable diseases qualified as a compelling interest.
Workman also alleged a violation of the Equal Protection Clause.  She believed her family was treated differently than similarly situated individuals because the school district challenged the exemption certificate.  However, Workman was the only parent to claim a medical exemption, so she could not prove unequal treatment or discrimination.
Lastly, Workman asserted a Due Process Violation.  The statute did not have an exemption for religious reasons.  Workman believed that the lack of a religious exemption “violates her substantive due process right to do what she reasonably believes is best for her child.”  Again, the Court concluded that there was no violation.  The Court referred back to the state’s compelling interest to combat the spread of diseases with compulsory vaccination.
2. Religious Exemptions
Unlike Workman v. Mingo, where the parent complained about the lack of a religious exemption, the next three cases involve parents attempting to claim a religious exemption that was provided under statute. The first case, Nikolao v. Lyon, challenges the prerequisites to obtaining an exemption.  Secondly, this paper will examine Phillips v. City of New York, a case that looks at the treatment of children who receive a religious exemption.  Lastly, Caviezel v. Great Neck Pub. Sch. explores what happens when parents comply with all requirements to get an exemption and are still denied.
a. Nikolao v. Lyon
Michigan provides exemptions to its mandatory vaccination requirement for schoolchildren.  In addition to medical exemptions, parents can obtain an exemption due to their religious beliefs.  There are certain prerequisites a parent must complete prior to receiving the exemption.  First, parents must go to a county health office and talk to a health worker about their objections to vaccination.  In speaking to a health office employee, this ensures that the parent understands the risks of failing to immunize their child, as well as the advantages of immunization.  The parent is also given responses to objections to vaccination, so they can review them.
When Nikolao went to get an exemption, she explained her religious values as a devout Catholic conflicted with the use of vaccines.  She believed that injecting body-altering chemicals into a person was a violation of the will of God.  The nurses Nikolao spoke to gave her a hard time about her reasons for an exemption.  Ultimately, Nikolao received the exemption, although the exemption certificate did not list her religious objection to vaccination.
When Nikolao brought suit, her first claim alleged that the state and county infringed upon her right to free exercise.  Nikolao claimed that the employees gave her religious information which contradicted her beliefs.  However, in order for Nikolao to succeed on this claim, the state had to coerce her to do something that was in conflict with her religion.  Nikolao was not compelled into receiving vaccinations for her children.  She received the exemption that she sought to obtain.
Nikolao also asserted a violation of the Establishment Clause, because she felt there was “direct and unwelcome contact with a government-sponsored religious object.”  Specifically, Nikolao objected to the Certification Rule requiring parents to speak to health officials about their decision and the Waiver Note that responded to objections to vaccinations.  At Nikolao’s meeting with county health employees, the nurses pressed her to elaborate upon her religious views.  Nikolao tried to refuse going into detail of her objections but was given the Waiver Note and other religious information.
Despite Nikolao’s experience, the Establishment Clause was not violated.  The purpose of the Certification Rule was to ensure that parents knew the dangers of leaving their child unvaccinated.   The overall goal of the Certification Rule is to immunize as many children as possible.  The Certification Rule is also not specific to religious objections – it seeks to educate parents regardless of their objection.  Finally, during the meeting between parents and health employees, the staff is not allowed to deny an exemption if the parent has been educated on the benefits of vaccination.
The Religious Waiver note is not given to parents to prohibit the practice of religion.  The note is also an educational tool, providing parents with additional resources on vaccination.  The Court dismissed Nikolao’s claims.
b. Phillips v. City of New York
Like the plaintiff in Nikolao v. Lyon, the plaintiffs in this case received religious exemptions, although one Plaintiff’s exemption was subsequently denied.  The plaintiffs were not satisfied with the exemptions because their children were not allowed to attend school when another student was diagnosed with a vaccine-preventable disease.
Plaintiffs claimed that the exemption violated their rights to the free exercise of religion. Although plaintiffs state that New York’s mandatory vaccination law infringes on their children’s right to freely exercise their religion, the Court disagrees.  There is no constitutional exemption for those who object to vaccination for religious reasons.
Plaintiffs’ due process and Equal Protection claims were also dismissed.  The due process claim does not hold up because New York has the right to exercise its police power for health and safety reasons – including mandatory vaccination.  Additionally, Plaintiffs have failed to show that they were treated differently than similarly situated individuals, as plaintiffs have no evidence that New York City treated members of one religion differently than others.
Although not discussed in the case, it can also be argued that by keeping unvaccinated children home when another student is sick, it is also for the benefit of the unvaccinated child. If the unvaccinated child were to attend school, they could feasibly catch the disease and have inadequate protection against the disease.
c. Caviezel v. Great Neck Pub. Sch.
While the previous cases dealt with parents who received exemptions, Caviezel examines the suit brought about by a parent who did not qualify for a religious exemption.  The plaintiffs had four children, three of which are vaccinated.  However, as plaintiffs’ religious beliefs changed, Mrs. Caviezel decided vaccination was not necessary due to her belief “that the human body, the way it’s designed, is just perfect. It’s a miracle in itself.”
When it was time to register her daughter for Kindergarten, Mrs. Caviezel hired counsel to assist her in obtaining an exemption to mandatory vaccination.  Counsel helped her write a statement explaining her religious beliefs, which she turned in to her child’s school along with the exemption form.  However, Mrs. Caviezel was informed that her exemption request would probably not be granted.   Her exemption request was then formally denied via a letter.  Mrs. Caviezel did not want to explore other schooling options.  She thought it was important for her children to be in that specific school district.  Therefore, she sought an injunction which would require her child to be registered for school.
While the Court concluded that the Caviezels have a “genuine and sincere” opposition to vaccinations, their beliefs did not fall under the religious exemption.  Firstly, Mrs. Caviezel’s church did not have beliefs that were in conflict with vaccinations.   Secondly, while Mrs. Caviezel questions the safety of vaccination, that is not a religious belief.  Her first three children were immunized.  Additionally, her belief that the body does not need medication, that is a personal belief, rather than a religious one.  Mrs. Caviezel also admitted that she takes medicine, so the belief is a selective one, at that.  Since the plaintiffs did not show that they had genuine religious beliefs that were in opposition to vaccination, the injunction was denied.
V. Reforming Higher Education Vaccination Laws by Imposing Stricter Requirements
Regardless of whether states change their exemption process, it can be argued that some states are not doing enough to protect the health and safety of college students. In order to minimize the risk of disease on college campuses, states should re-examine their current mandatory vaccination requirements, and implement additional vaccination requirements if necessary. This section briefly explores three options for imposing stricter vaccine requirements in certain states.
A. The ACHA Approach
The American College Health Association (ACHA) is the “principal leadership organization for advancing the health of college students and campus communities through advocacy, education, and research.”  The ACHA’s comprehensive recommendations take into account the CDC recommendations discussed below, but have additional vaccinations listed.  The requirements include vaccines that will reduce outbreaks, such as MenB and MMR.  The recommendations also list other vaccines needed by adults and when those vaccines should be administered.
B. The CDC Recommendations
The Centers for Disease Control and Prevention (CDC) is part of the federal government.  Specifically, the CDC is an element of the Department of Health and Human Services.  The CDC publishes vaccination guidelines at the federal level, though these recommendations are not binding on the states.  The CDC recommends that entering college students get four vaccines.  The CDC recommends the MenACWY vaccine, the HPV vaccine, the Tdap vaccine, and the flu vaccine.  While these vaccines are certainly important for incoming college students, these recommendations do not include prevention for two vaccine-preventable diseases commonly associated with outbreaks on college campuses. However, the CDC does recommend that those who are at increased risk due to an outbreak be vaccinated with the necessary vaccine.
C. Outbreak Prevention
The final option has not been published by a health organization. However, it is based on outbreaks that occur on college campuses. As discussed in Section II, there have been multiple outbreaks of Serogroup B meningococcal disease and measles.
Since 2013, there have been more than ten outbreaks of serogroup B meningococcal disease.  There were outbreaks in California, Oregon, Massachusetts, and other campuses around the country.  Students who were at risk during these outbreaks were vaccinated with the MenB vaccine.   However, if schools required the MenB vaccine for incoming students (like the MenACWY vaccine requirement), this could potentially reduce the number of deaths and outbreaks due to bacterial meningitis.
There have also been several measles outbreaks in recent years.  Some of the states affected by the outbreak did not require an MMR vaccine at the time.  California has since changed its requirements  and given the number of measles cases in recent years, it wouldn’t hurt other states to follow suit.