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finding is consistent with previous studies that found that the ease of obtaining nonmedical religious or philosophical exemptions was associated with higher rates of exemptions [2, 3]. Interestingly, states with more difficult procedures for nonmedical exemptions had higher rates of medical exemptions, suggesting that some parents may be opting for medical exemptions when it is difficult to obtain nonmedical exemptions. This observation is consistent with our unpublished observation that many of the reasons parents reported as medical exemptions for vaccines were not consistent with the recommendations of the Advisory Committee on Immunization Practices. Nonmedical exemptions can compromise efforts to control or eliminate vaccine-preventable diseases, but they recognize the role of parental autonomy in making some medical decisions for their children [4]. Medical exemptions are intended to prevent adverse events in children who are at increased risk of adverse events because of underlying conditions. Many of these underlying conditions also place children at increased risk of complications from infectious diseases. Children with valid medical exemptions need to be protected from exposure to vaccine-preventable diseases by insuring high coverage rates among the rest of the population. Granting medical exemptions for invalid medical contraindications may promote unfounded vaccine safety concerns. Although states may wish to allow parents who make decisions based on poor science or perceptions to withhold vaccines from their children, these exemptions should be distinguished from valid medical exemptions. Stadlin et al also found that rates of medical exemptions were higher in states that allowed permanent rather than temporary exemptions. Because medical contraindications may change, children with medical exemptions should be reviewed periodically. For example, egg allergy was considered to be a contraindication to receipt of influenza vaccines for many years, but changes in vaccine production have resulted in lower amounts of egg protein in vaccines, and abundant evidence has been generated showing that most children with egg allergy can safely receive influenza vaccines [5]. During the 7-year study period exam

Keeping the M in Medical Exemptions: Protecting Our Most Vulnerable Children