Vaccination exemption rates in Washington State decreased after parents seeking exemptions were required to provide documentation of counseling from a health care provider. While immunization coverage is high nationally, rates of immunization and exemptions vary by state. All 50 states and the District of Columbia permit medical exemptions; 29 states allow religious and medical exemptions; and 18 permit religious, personal belief, and medical exemptions.

The ease of obtaining exemptions also varies by state. States where the process is simple have almost twice the rate of exemptions as those with more stringent requirements. States are developing new procedures to limit nonmedical exemptions. To directly address what's known as vaccine hesitancy-parental delay or decline of vaccination-several states now require documentation of health care provider counseling before granting an exemption. The counseling intervention is intended to provide parents with information about vaccine safety and the risks of not vaccinating.

Washington was the first state in recent years to mandate counseling for parents seeking exemptions for their children. The 2011 law requires parents to submit a Certificate of Exemption signed by a Washington-licensed health care provider documenting discussion of "the benefits and risks of immunizations."

In this first study of the effect of a counseling requirement, vaccination rates and vaccine exemption rates among kindergartners in Washington were compared before and after implementation of the law, using data from 1997 through 2014. During that time, the rates of all immunization exemptions statewide decreased by 40%. Vaccine coverage for each required vaccine either remained the same or increased. The number of kindergartners who were out of compliance with state vaccine requirements decreased, although there was a slight increase in students permitted to start school on the condition they would later provide evidence of vaccination.-Joan Zolot, PA

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