Texas is No. 1 in “Hotspots” For Vaccine Exemptions
By David Doolittle

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Four Texas cities are at high risk of epidemics of vaccine-preventable infections in children, a new study on nonmedical exemptions (NMEs) shows.

Houston, Fort Worth, Plano, and Austin are among the cities in the nation with the highest number of kindergartners who have not received vaccinations because of nonmedical reasons, according to the study published this week in the journal PLOS Medicine.

Researchers studied vaccination rates in the 18 states that allow parents to opt out of vaccinating their children because of philosophical beliefs. Since 2009, NMEs have risen in 12 of those states, including Texas, the study found.

Researchers identified 15 large metropolitan areas where more than 400 kindergarten-aged children have not received their vaccines. Texas has the most “hotspots” with four. Michigan has three (Detroit, Troy, and Warren); Washington has two (Seattle and Spokane); and Utah has two (Salt Lake City and Provo). The other hotspots are Portland, Phoenix, Kansas City, and Pittsburgh.

“The high numbers of NMEs in these densely populated urban centers suggest that outbreaks of vaccine-preventable diseases could either originate from or spread rapidly throughout these populations of unimmunized, unprotected children,” the study says. “The fact that the largest count of vaccine-exempt pediatric populations originate in large cities with busy international airports may further contribute to this risk.”

The study highlighted Texas, which has had a 20-fold increase in NMEs for students of all grades since 2003, when Texas permitted exemptions for religious and personal beliefs. From 2003 to 2016, students with conscientious-objection exemptions jumped from 2,314 to almost 45,000.

Ranking of the leading metropolitan areas with more than 400 total kindergarten NMEs:


One of the areas Texas lags behind the rest of the country is in vaccinations for human papillomavirus (HPV). Although a vaccination for HPV has been around for 12 years, Texas ranks 47th in vaccination rates, studies show. 

To help improve HPV vaccination rates, the Texas Medical Association joined with a coalition of more than 40 other organizations Tuesday to announce a renewed statewide immunization campaign to prevent HPV-related cancers.

TMA also is committed to improving vaccination rates statewide. TMA’s website contains information for you and your patients on vaccines and vaccine-preventable diseases. You can also find details on Be Wise – ImmunizeSM, a TMA program that helps TMA physicians, clinics, medical students, and county medical societies host free or low-cost vaccination events. More than 335,000 shots have been given to Texas children, adolescents, and adults since the program began in 2004. 

Be Wise – Immunize is a joint initiative led by TMA physicians, medical students, and the TMA Alliance. It is funded in 2018 by the Texas Medical Association Foundation thanks to H-E-B, TMF Health Quality Institute, Pfizer Inc., and gifts from physicians and their families.

Be Wise — Immunize is a service mark of the Texas Medical Association.

Last Updated On

September 11, 2023

Originally Published On

June 15, 2018

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