Should Hawai‘i Families Be Allowed To Opt Out Of School Vaccines?

Maui pediatrician Cassandra Simonson typically takes a gentle approach with parents who don’t want to vaccinate their children, providing families with an ingredient list so they can see what’s in the shots and encouraging them to ask questions over time.

But lately, she’s needed to take a more aggressive approach. It’s a difficult but necessary conversation to explain how she’s seen children die from meningitis or other preventable diseases, Simonson said, even though parents have accused her of trying to poison their children with vaccines. 

“I really need to warn them about the things that I’ve seen, because they haven’t seen it for themselves,” she said.

Hawaiʻi has seen an explosion in the number of families using religious exemptions to opt out of the state’s mandate that children receive vaccinations to attend school. 

Last year, 4% of Hawaiʻi students in public and private schools had religious exemptions, up from 2% before the Covid-19 pandemic. The increase is even more dramatic over the past decade. From 2013 to 2023, the number of students with a religious exemption grew from 2,100 to 7,500 kids — a roughly 250% increase. 

Escalating misinformation and contempt around vaccines at the national level has driven Hawaiʻi leaders to push for legislation to limit families’ abilities to avoid vaccine requirements in schools, said state Rep. Gregg Takayama, who chairs the House Health Committee. 

The committee recently voted in favor of a bill to end religious exemptions for vaccines in schools and another to appropriate up to $4.5 million for the state to purchase vaccines in bulk. The push to strengthen state protections around immunizations follows concerns that the appointment of Robert F. Kennedy Jr. as head of the U.S. Department of Health and Human Services could reduce federal funding for vaccines and spread misinformation about public health.  

Kennedy has been a longtime critic of vaccines, questioning their efficacy and falsely claiming that they lead to autism in children. Last month, Gov. Josh Green traveled to D.C. to oppose Kennedy’s nomination. 

The vaccine-related bills, which are now awaiting a hearing in the House Finance and Judiciary and Hawaiian Affairs committees, garnered over 1,700 pages of written testimony, largely from people opposed to their passage. 

The Hawaiʻi Department of Health insists the measures are necessary, raising concerns that the state is facing a growing risk for a measles outbreak and predicting that more children will become seriously ill — and even die — from vaccine-preventable diseases. 

But many parents are equally steadfast in their opposition to vaccines, with many arguing the shots are a risk to their children’s health or a violation of religious beliefs. Some have threatened to withdraw their kids from school if Hawaiʻi strengthens its vaccine requirements. 

“We would have no choice but to homeschool,” said John Cunningham, a father of four, “or simply move out of state.”

More Exemptions, More Health Risks

The Hawaiʻi Department of Health mandates that children receive vaccines to attend classes as early as preschool, but — unlike some other states — Hawaiʻi does not require proof of religion or personal beliefs to receive the exemption. 

House Bill 1118 would end the religious exemption in public and private schools, requiring students to receive over 20 vaccinations by middle school or have a medical exemption from their doctors. The bill does not have an effective date, although it allows students who currently have religious exemptions to keep them until graduation. 

The health department strongly supported the bill, pointing out in its testimony that Hawaiʻi’s rate of vaccinated kids has dropped so much that unvaccinated students are no longer protected by their immunized classmates. The trend has put Hawaiʻi at a greater risk for a measles outbreak, said DOH Director Kenneth Fink, and cases of whooping cough are on the rise. 

“Luck is not a good public health strategy,” Fink said at a bill hearing last week. 

Roughly 1 in 5 Hawaiʻi students don’t have all the vaccinations required by the health department. In addition to a growing number of students with religious exemptions, roughly 17% of kids had incomplete vaccinations or no immunization records at all last year.

The rates of unvaccinated students were as high as 70% in some public schools last year.

As the House Health Committee discussed HB 1118 last week, nearly two dozen parents, children and doctors crowded inside the hearing room to testify.

For more than an hour, parents pleaded with lawmakers to oppose the measure, arguing that removing the religious exemption would take away their children’s chances of attending school in Hawaiʻi. Others urged the committee to ignore the testimony of the health department and local doctors.

“You can listen to theatrical white coats with their stories, but we have stories too, of watching people die after they have taken a vaccine,” said Cynthia Bartlett, a mother testifying against the bill. “To take away people’s religious rights is not going to fly in Hawaiʻi.”  

Jessica Montero, a parent of three in Kailua, said the bill unfairly requires families to weigh their religious beliefs against their children’s education. While Montero’s oldest son receives a religious exemption to attend Hawaiʻi Technology Academy, a hybrid charter school, her two younger daughters are currently homeschooled. 

If House Bill 1118 passes, Montero said, her youngest daughters would never be able to attend a traditional school in Hawaiʻi. 

“No family should have to choose between their faith and an education,” Montero said. “We have the right to both of those.” 

‘The Anxiety Is Natural’

Resistance to vaccines isn’t new. When Hawaiʻi first required human papillomavirus shots for middle schoolers beginning in 2020, some families pushed back, believing that their kids would be more likely to have sex if they were vaccinated for the virus, said Vinson Diep, a pediatrician on Oʻahu. 

In 2023, only 68% of Hawaiʻi teens were up-to-date on their HPV vaccinations, compared to the 90% of students who were vaccinated for chickenpox.

But confusion and varying opinions around Covid vaccine requirements fueled families’ hesitance around routine immunizations, Diep said. Misinformation is rampant online, he added, and it’s not always possible to convince families that vaccines are safe and necessary to protect their children from certain diseases. 

The Covid vaccine is not one of the state’s mandated vaccinations for students.

“The anxiety is natural,” said Simonson, who works at Mālama I Ke Ola Health Center but spoke in her personal capacity for this story. “What isn’t natural is the conspiracy theory, and that’s been perpetuated by national politics, and we are not immune from that here in Hawaiʻi.” 

The Hawaiʻi Department of Education — whose schools would mainly be responsible for enforcing vaccine requirements and denying religious exemptions — says it defers to the health department on the issue, but pointed out in testimony that ending the religious exemption could prevent some children from attending school and limit access to public education.

“This could disproportionately affect certain communities with deeply held religious beliefs, cultural practices, or historical mistrust of the medical community, further exacerbating barriers to education,” the department wrote.

For some schools, ending the religious exemption could affect nearly a third of their students. On Kauaʻi, 36% of students received a religious exemption last academic year at Hanalei Elementary, and 32% of students had an exemption at Kīlauea Elementary School. 

While Takayama voted in favor of the bill, he doesn’t think it will pass this year. In addition to strong public opposition to the measure, he said, the state administration hasn’t presented an urgent need for the change that’s likely to persuade his colleagues to support the bill as it passes through the Legislature.

In a written statement, Green said he believes in vaccinations as one of the best ways to keep families safe, but said he was committed to exploring “any and all ways to reach consensus with people of different ideologies, to make sure we are healthy in Hawai‘i.”

Enforcement Challenges Remain

Even if the bill to end the religious exemption does pass, it doesn’t guarantee that more children will receive their vaccines.

When California ended its personal belief vaccine exemption in 2016, families found other ways to avoid the state’s school vaccine requirement, said Paul Delamater, an associate professor at the University of North Carolina at Chapel Hill. The state saw a small uptick in the number of homeschooled kids, he said, and the number of medical exemptions for children quadrupled.  

“People will go to great lengths not to vaccinate their kids,” Delamater said. 

Even as the state tried to crack down on vaccine exemptions, it was still hard for schools to enforce the law. While California students aren’t allowed to attend class if they don’t have their vaccines or a medical exemption, so many kids fell under this category that it’s unlikely they were all expelled, Delamater said, adding that administrators want to keep their campuses safe but also want children to keep attending classes. 

School administrators are facing similar challenges in Hawaiʻi, where roughly 17% of enrolled students are missing vaccinations or have no immunization record at all. 

While students aren’t allowed to attend class if they aren’t up to date on their vaccines and don’t have exemptions on file, state law gives families multiple chances to comply with immunization requirements before they’re removed from school.

Students can attend school for three months as long as they’re actively working toward receiving their vaccinations. Once those three months pass, schools still need to give families a 30-day notice that their child won’t be allowed to attend school.

At the Hawaiʻi Academy of Arts and Sciences, a charter school on the Big Island, 7% of students are currently noncompliant with the state’s vaccine requirements. A third of students receive religious exemptions. 

Aumoana Kanakaole, the registrar at HAAS, said she works closely with families to make sure they’re scheduling appointments with their doctors and getting kids the vaccines they need. She estimated that she needs to send one student home each year who hasn’t received their necessary vaccines, but she urges families to work with their doctors so their kids don’t miss any class time. 

While she’s fine if the state ends its religious exemption for vaccines, Kanakaole said schools will need more time and resources to figure out how to track the vaccine requirements for many more students coming in. 

Steve Hirakami, executive director at HAAS, said some families struggle to find doctors who have all the vaccines their children need. In some cases, families’ pediatricians also may be in Hilo, a 30-minute drive from the school’s campus in Pāhoa. 

Limited access to vaccines is becoming a growing concern for doctors and state lawmakers as the Trump administration has threatened cuts to childhood vaccine programs. The federal Vaccines for Children program currently provides services to roughly half of Hawaiʻi kids whose families can’t afford vaccinations. 

To shore up Hawaiʻi’s vaccine supply, lawmakers are considering another bill that would allow the state to purchase vaccines in bulk and distribute them to providers across the state. Hawaiʻi would still participate in the federal Vaccines for Children program, as long as it’s available, but the state’s own purchasing program would ensure that local doctors have easier access to vaccines, Takayama said. 

DOH has estimated the bulk vaccine purchases approach would cost between $2.8 and $3.6 million, but the state could recoup some of the costs from doctors, who could purchase the vaccines from the state at a low cost. 

Simonson, the pediatrician on Maui, said it’s important for the state to take these precautionary measures, but she also worries that some families won’t understand the value of vaccines until children become seriously ill. With the current drop in vaccine rates, she added, it’s not a matter of if, but when, an outbreak happens. 

“This is a public health problem,” Simonson said. “We see it coming, and we’re terrified.” 

See every public school’s vaccination numbers for the 2023-24 school year here:

Civil Beat’s education reporting is supported by a grant from Chamberlin Family Philanthropy and its community health coverage is supported by the Cooke Foundation, Atherton Family Foundation and Papa Ola Lokahi.