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As outbreaks of preventable diseases have spread around the country in recent years, some states have been re-evaluating how and why they allow parents to opt their children out of vaccines required for school attendance.

Requiring vaccines before school admission has been a key component of a decades-long campaign that had nearly rid the United States of some of its most severe illnesses, from the measles to whooping cough, public-health experts say. But they also warn that broad 鈥減ersonal belief鈥� exemptions that don鈥檛 relate to a child鈥檚 medical condition or a family鈥檚 religious beliefs have made it too easy to bypass vaccines, poking a sizable hole in the public-health safety net.

While some parents act out of a sense of personal conviction, others do so simply because they don鈥檛 have time to schedule an appointment, said Stephanie L. Wasserman, the executive director of the Colorado Children鈥檚 Immunization Coalition, an Aurora, Colo.-based group that seeks to increase vaccine coverage in the state.

鈥淲e want to close that convenience loophole,鈥� she said. 鈥淲hen you choose not to immunize, there are consequences not only to your child and your family; there are consequences to your community as well.鈥�

Since 2011, Washington, Oregon, California, and Vermont have revised their personal exemption processes.

In Colorado鈥攁 state with one of the highest opt-out rates in the country and the most recent one to examine its vaccine-exemption policies鈥攁 bill passed this month would draw schools into the public health fight.

House Bill 1288, which has not yet been signed by the governor, will require schools to collect information about their vaccination rates and to provide it to parents upon request. The state鈥檚 permissive school choice laws would allow parents to transfer their children鈥攊ncluding immune-compromised children who are not able to be vaccinated鈥攖o schools with higher vaccination rates, advocates for the legislation said.

And making the information publicly available could hold schools accountable for enforcing existing laws and encourage them to promote vaccinations through efforts like school-based health centers and pop-up clinics at school registration events, Ms. Wasserman said.

鈥淲e think it fits in the education reform model that places parents in the role of making decisions based on quality,鈥� Ms. Wasserman said of the reporting requirement. 鈥淚t鈥檚 an innovative part of the bill, and other states are already taking a look at it.鈥�

National Picture

All states require a schedule of vaccines that a child must have before he or she can be enrolled in school. Every state allows exemptions from vaccines for medical reasons, and all but Mississippi and West Virginia allow exemptions for religious reasons, according to the Centers for Disease Control and Prevention in Atlanta.

Public health experts find the most fault with personal exemptions, also known as philosophical exemptions, which are in place in 19 states. Those exemptions typically allow parents to opt out of vaccinating their children by signing a one-time form and without disclosing a reason.

And the number of parents claiming such exemptions has grown over the last decade, with high concentrations of exemptions in states with especially permissive policies.

Some parents, including those who opposed tightening restrictions on Colorado鈥檚 personal exemption, argue that it鈥檚 their right to make medical decisions for their children, regardless of the reason.

The movement to opt out of all or some vaccines has spiked in recent years, in part because of scientifically unproven claims that vaccines are linked to autism and because of misinformation spread online, vaccine proponents say.

And as vaccines have been effective at largely wiping out the diseases they are designed to prevent, the public has grown less concerned about those diseases, Glen J. Nowak, the director of the Center for Health & Risk Communication at the University of Georgia in Athens said in a conference call with public-health advocates.

For some parents, that kind of progress tips the scale of concern away from illnesses and toward any possible side effects associated with the vaccines.

鈥淥ne of the things that happens with low disease awareness is increased focus on risks鈥� of vaccines, Mr. Nowak said.

In addition, immunization schedules have grown more complicated, and some people are resistant to any form of government mandate, Mr. Nowak said.

Waning 鈥楬erd Immunity鈥�

Data from the federal Centers for Disease Control and Prevention show that, in 2012, between 90 percent and 95 percent of kindergarten students in most states had received two doses of the measles, mumps, and rubella (MMR) vaccine. The data showed the same range of coverage for most states for the diphtheria, tetanus toxoid, and acellular pertussis (DTaP) vaccination.

By contrast, just 85.7 percent of Colorado kindergartners had received the MMR vaccine, and just 82.9 percent had the DTaP vaccination, the data show. Of the Colorado students whose parents claimed an exemption, 93 percent chose the personal belief exemption.

Vaccination rates that low fall below the threshold of what is required for what鈥檚 known as 鈥渉erd immunity鈥� or 鈥渃ommunity immunity,鈥� which requires immunization rates of between 90 and 95 percent for most vaccines, Ms. Wasserman said.

A portion of every population is unable to be vaccinated because they are too young or because their immune systems are too fragile. Through 鈥渉erd immunity,鈥� a critical mass of the population is immunized, helping to protect those without vaccines and to slow potential contagious outbreaks, according to the CDC.

Low immunization rates can directly affect schools, Ms. Wasserman said. In many states, public health officials have required unvaccinated students to stay home during outbreaks. In April, local health officials in Ohio warned parents that unvaccinated students may have to stay home for 25 days or longer if the region鈥檚 mumps outbreak spreads into schools.

鈥淏y not having kids in seats, you鈥檙e impacting their ability to have the instruction time and the teaching time,鈥� Ms. Wasserman said.

In Colorado, many students missed extended periods of school in 2012 and 2013 as the state faced a surge of cases of pertussis, or whooping cough. The state鈥檚 health department reported 415 cases of pertussis in 2011, a number that grew to 1,494 in 2012 and 1,035 in 2013.

Public health officials blamed low vaccination rates and a change in the vaccine in the 1990s that made it less effective for some.

Other Approaches

States with permissive personal exemption policies have opted to amend them in recent years, rather than eliminating them all together. In 2011, Washington passed a bill requiring parents to obtain a doctor鈥檚 signature before claiming a personal exemption. In 2012, California passed a similar law.

Under Oregon鈥檚 law, passed last year, parents must now obtain a doctor鈥檚 signature or complete an online education module before claiming a personal exemption.

Colorado鈥檚 bill originally included a similar 鈥渋nformed exemption鈥� requirement, but lawmakers amended that portion out of the bill after hours of emotional testimony from parents who oppose vaccinations and appeals from parents and medical professionals who support them.

Opponents called the medical counseling requirement 鈥渁 re-education campaign,鈥� 鈥渂rainwashing,鈥� and 鈥減ropaganda.鈥�

The National Vaccine Information Center, a Sterling, Va.-based organization 鈥渄edicated to the prevention of vaccine injuries and deaths,鈥� said that, 鈥渦nder the guise of public education,鈥� the bill 鈥渕akes it legal for the state to brand a minority of citizens as intellectually or morally inferior and serves to harass and coerce citizens making health care decisions for their minor children.鈥�

After the amendments, the bill still would require the Colorado Department of Public Health and Environment to create a process for sharing and analyzing immunization data. It would also require the state鈥檚 board of health to create an online education module that parents can consult for information about vaccines and to re-evaluate how frequently parents have to submit exemption forms.

Discussion groups assembled by the Colorado Children鈥檚 Immunization Coalition to evaluate the state鈥檚 policies supported requiring parents to reauthorize exemptions on a schedule that mirrors a child鈥檚 vaccination schedule, Ms. Wasserman said.

This would give parents an opportunity to reconsider their decision and remind those who opted out for reasons of convenience that they still need to vaccinate their children, she said.

鈥淧eople are often adopting this option without having a deeply held personal belief,鈥� she said of the personal exemption. 鈥淲e wanted to close that convenience loophole and also offer opportunities to get science-based, research-based, credible information out there about the importance of vaccines.鈥�

A spokesman for Colorado Gov. John Hickenlooper, a Democrat, said last week that his office has not yet received the bill, and he will review it before signing it.