Tennessee legislators will consider two bills Wednesday that could increase the number of families opting out of vaccinations for their children on religious grounds — a growing trend that a recent state report cited as likely driven by anti-vaccine philosophy, not religion.

The U.S. Centers for Disease Control and Prevention recommends that all children are vaccinated against 16 different preventable diseases that can be serious or even deadly, such as influenza, measles, mumps, tetanus and pertussis.

Every state has laws that require specific vaccines for students, which typically also apply to children in day cares, private schools and those that are home-schooled. Colleges and universities may also require vaccines.

Currently, no state requires children to receive the COVID-19 vaccine for school entry, according to the National Conference of State Legislatures. The University of Tennessee system has also stated it will not require COVID-19 vaccines for the coming academic year.

In Tennessee, parents are able to object to immunizations if their child is unable to take them for medical reasons or if vaccines go against their religious beliefs. That said, none of the major faiths in the United States object to vaccinations, and religious leaders have played a key role in promoting vaccinations in recent months.

House Bill 1403 would require any communication provided to students or parents by a school, preschool, child care facility or public institution of higher education regarding immunization requirements to include information about the religious exemption option.

The companion bill, Senate Bill 1175, has already passed the Senate. Both bills were amended to say that the Tennessee Department of Health certificate of immunization, which includes a note about religious exemptions at the top, is an acceptable form of communication after educators and health experts objected to the original bill.

House Bill 1403's sponsor — Rep. Mark Hall, R-Cleveland — said that the bill "isn't about vaccines" but rather transparency and disclosure.

"This bill is about state statute that's already in place but has suffered from information suppression," Hall said.

A 2020 report from the Tennessee Department of Health, which outlines kindergarten immunization rates across the state, found that religious exemptions to vaccines were on the rise before the COVID-19 pandemic, which has brought the topic back into the spotlight. The percentage of kindergarten students in Tennessee claiming a religious exemption has risen from 1% in 2015 to the 1.9% most recently reported in 2020, according to the report.

"The rising number of religious exemptions in the state of Tennessee is likely due to parents filing a religious exemption in lieu of a personal philosophical exemption, despite the Tennessee Code Annotated stating that doing so is subject to penalty of perjury," the report states.

Another bill set to go before the full House Wednesday, House Bill 13, would prohibit state and local governments from requiring medical treatment, including immunizations, for those who object "on religious grounds or by right of conscience."

The bill received criticism from health officials and lawmakers on both sides of the aisle during a House Health Committee last week before ultimately passing. The bill has already passed in the Senate Health Committee.

Rep. Sabi "Doc" Kumar, R-Springfield, who is a surgeon, called the latest amendment to the bill "anti-vaccine on steroids."

"We talk about overreach. This is an overreach on the other side of things, and that's how I read it," Kumar said, expressing concern over how the legislation would affect vaccination rates in schools.

The bill's sponsor, Bud Hulsey, R-Kingsport, contended that the phrase "right of conscience" would not expand the current religious exemption to vaccines because the Tennessee constitution considers religion and "rights of conscience" one and the same.

Patrick Powell, legislative liaison for the Tennessee Department of Health, said that if "right of conscience" is the same as religion, it shouldn't be added to the state law surrounding vaccine exemptions — which now doesn't mention conscience.

"Right of conscience being added, from a legal perspective, means something has to be different," Powell said. "If it means the same thing, and we're just trying to protect religious freedom, I would implore the sponsor and the committee to remove that language and keep it clear. But if the intention is to add something, well then it is broadening the exceptions to vaccines, which causes us a great deal of concern."


Religion and vaccines

There are 45 states — including Tennessee — that grant vaccine exemptions for people with religious objections to immunizations, and 15 states — not including Tennessee — allow philosophical exemptions for children whose parents "object to immunizations because of personal, moral or other beliefs," according to the National Conference of State Legislatures.

At the start of the 2019-2020 school year, 95% of all kindergarten students in Tennessee schools were fully immunized while 1.9% claimed a religious exemption, according to the latest annual report from the Tennessee Department of Health. In state public schools, 1.8% of kindergarten students claimed an exemption, compared to 2.7% of private school kindergarteners.

In the 2019-2020 school year, Hamilton County had the sixth-lowest student vaccination rate in the state among public schools, with 92% of students immunized. Among private school students, the county was in the middle of the statewide rankings, with 93.1% of students fully immunized, according to the statewide report.

For a community to be at low risk for a vaccine-preventable disease outbreak, the childhood vaccination rate should remain above 95%, according to the department of health. High vaccination rates are also needed to protect those who cannot be vaccinated for medical reasons.

Rather than objecting to vaccines, major faiths in the United States argue for the common good achieved by the eradication of preventable diseases. There are slight exceptions, such as the Catholic Church advising its followers to avoid vaccines derived from fetal tissue, given the church's stance on abortion, when other options exist. However, the church advises followers to receive the shots if there are no alternatives, since the potential for good outweighs the bad that has already been committed.

In January, Pope Francis said Catholics have a moral obligation to receive the COVID-19 vaccine.

Similarly, some Muslim ethicists advocate avoiding vaccines that use a pork derivative, such as the shots for measles, mumps and rubella. Pigs are considered unclean in the faith and are avoided. However, few alternatives exist. Ethicists have made an argument similar to the Catholic Church, saying the potential good and the Islamic call to protect life can outweigh concerns if the pork used in the vaccines is diluted or far enough removed from the animal through processing.

Albert Mohler, president of the Southern Baptist Theological Seminary, wrote in a December blog post that there is a moral responsibility to seek the common good through immunization, even as much of modern medicine is built on research related to stem cells. Mohler highlighted the second greatest commandment from Jesus — to love your neighbor as you love yourself — in his argument.

"The general principle of the common good comes down to benevolence, love, care for others, laying down personal priorities for the service of others," Mohler wrote. "Christians thinking about the issue of the vaccine must weigh this key biblical principle as part of their thinking."

Last month, J.D. Greear, president of the Southern Baptist Convention, posted a photo of himself receiving the COVID-19 vaccine on Facebook and encouraged others to do the same.

Despite their religions supporting vaccines, white evangelicals are among the most likely religious Americans to say they will not receive a COVID-19 vaccine, with between 40-45% reporting they will avoid the shot, according to polls from the Pew Research Center and The Associated Press-NORC Center for Public Affairs Research.

A study published December 2020 in the journal Sociological Research for a Dynamic World found that religious and political belief in Christian Nationalism — an individualist Christian ideology that promotes internal politics based on a nationalist interpretation of the faith, as well as being skeptical toward science — was the strongest predictor for anti-vaccine beliefs among Americans, more than any individual religious or political identity on its own.

Meanwhile, vaccine support from trusted clergy, a common public health strategy to overcome hesitancy, was "surprisingly" found to have little influence on those unwilling to take the vaccine, according to a vaccine hesitancy study from the Tennessee Department of Health released last week.


Public health implications

Even before COVID-19, vaccination rates were declining, opening the door for vaccine-preventable diseases that were once well controlled to resurge.

In 2019, the United States reported its highest number of measles cases in 27 years with more than 1,200 reported cases, including some in Tennessee. Nearly two decades earlier, the disease was declared eliminated in the U.S. due to the success of vaccination efforts.

While many states did not enforce or scrutinize requests for religious exemptions, Marci Hamilton, an attorney and professor in the Robert A. Fox Leadership Program at the University of Pennsylvania, said the bill adding an exemption for a "right of conscience" provides cover for people who are antiscience and are not basing their objection on religion.

Creating more carve-outs for immunization will have consequences, she said. In 2015, California reported an outbreak of measles cases related to visits to Disneyland. After the 125 known infections, the California legislature removed personal belief as a reason for immunization exemption. In general, studies since the law was passed have shown increases in childhood vaccination rates.

The U.S. Supreme Court has a history of siding with vaccine mandates in the face of dangerous disease. In 1997, Hamilton represented a city in Texas before the Supreme Court in the case City of Boerne v. Flores, which in part limited the federal government's ability to enforce religious liberty laws on state and local governments.

"Those cases have made it pretty clear that public health is a government interest that can clearly trump any kind of religious objection, and it's partly because everybody has to do it for anybody to benefit from it," she said.

The COVID-19 vaccine, and the string of bills related to vaccine mandates, are a wedge issue to promote broader, anti-vaccination interests, Hamilton said. These bills are foolish, she said.

"They open the door to people not vaccinating and not vaccinating their children. And the result is that the victims of those decisions are the children who can't be vaccinated because of medical problems, the elderly and pregnant women. All of those three categories are at risk of diseases that we otherwise eliminated through vaccines," Hamilton said. "This hard push against vaccines, whether it's for political or religious purposes, is going to increase the death in those categories, because you've got to have herd immunity."

Contact Elizabeth Fite at or follow her on Twitter @ecfite.

Contact Wyatt Massey at or 423-757-6249. Follow him on Twitter @news4mass.