Vaccination proponents and anti-vaccination activists are watching to see whether some states will follow California, which got rid of religious and personal exemptions for vaccines after a Disneyland-linked outbreak of measles that began in 2014. The only students there who can go without a vaccination without a doctor’s signature are those who are home-schooled.

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High percentages of vaccinated children result in “herd immunity,” which helps prevent contagious diseases from spreading. But some doctors fear that eliminating states’ religious exemptions won’t adequately address the risk of outbreaks tied to geographic clusters of parents who are opting out of vaccinating their children.

That’s partly because a very small percentage of parents who opt out of vaccines for their children are doing so for religious reasons, according to Daniel Salmon, a professor at Johns Hopkins Bloomberg School of Public Health and director of the Institute for Vaccine Safety. Exemptions from vaccines have gradually grown in the past three years to a median 2.2 percent of kindergartners among all states. It’s unclear whether and by how much religious exemptions may have grown nationally, but researchers such as Salmon say more parents are using personal exemptions.

“People think of the Amish as the classic group that doesn’t want to vaccinate,” he said. (However, many Amish in Ohio began vaccinating after a measles outbreak there in 2014.) “Most people who have concerns aren’t ideologically opposed to vaccines. They just don’t trust the science, they’ve been misinformed, or they hold different values.”

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Nearly every state has carved out religious exemptions for parents who wish not to vaccinate their children (West Virginia and Mississippi, in addition to California, have not). West Virginia is considering a new proposal to add personal and religious exemptions.

Washington, which is one of the least religious states in the country, is one of the 17 states that allow a personal or philosophical exemption for the vaccine, which means that most anyone can opt out for any reason. In 2018, just 0.3 percent of Washington’s families with kindergartners used a religious exemption, while 3.7 percent of families used a personal exemption and 0.8 percent used a medical exemption.

Large majorities of Americans from all major religious groups say healthy children should be required to receive vaccinations to attend school, according to the Pew Research Center. Scholars believe no major religious group advocates against vaccinations on the basis of official doctrine. However, some individuals from various faith traditions believe vaccinating goes against their personal religious beliefs.

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The United States experienced 17 measles outbreaks in 2018, according to the Centers for Disease Control and Prevention. Outbreaks in New York and New Jersey occurred primarily among unvaccinated people in ultra-Orthodox Jewish communities where many believe vaccines cause diseases.

Mat Staver, founder of Liberty Counsel, a group that focuses on religious freedom issues, says he has worked with clients who object to vaccines originally made using cells of tissue from aborted fetuses, which some religious institutions have addressed.

The Catholic Church has approved the use of vaccines — such as the rubella vaccine — that may be developed from descendant cells of tissue from aborted fetuses. No fetal tissue has been added since the cell lines were originally created to produce the vaccines. The Southern Baptist Ethics and Religious Liberty Commission compares such use to using organs from a person who was murdered, saying that such vaccines are justifiable.

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Staver also said some of his clients have had a general objection based on a biblical passage that says the body is the temple of the Holy Spirit and do not want vaccines, some of which include small amounts of weak or dead germs to help bodies fight off infections.

Staver is concerned that some people who oppose vaccines on the basis of religion get lumped into the rest of the anti-vaccination movement. The last time Staver’s Liberty Counsel litigated a case, he said, was in 2003-2004 on behalf of a New York seventh-grader. Child Protective Services wanted to take her out of her home, and state officials were going to prohibit her from going to school.

“They were strongly opposed and had reasons consistent with their faith rather than just checking the box,” Staver said of the child’s parents. “That’s different than, ‘I just don’t want to comply.’ ”

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Around the country, how parents receive religious exemptions vary from state to state. Parents in Maryland sign a statement that says, “Because of my bona fide religious beliefs and practices, I object to any vaccine(s) being given to my child. This exemption does not apply during an emergency or epidemic of disease.” Parents in the District must write to the chief official of the school that immunization would violate his or her religious beliefs. Parents in Virginia must sign a notarized form stating that vaccinating conflicts with their religious beliefs and that they understand their child could be excluded from school if an outbreak were to occur.

Researchers believe some parents use states’ religious exemptions even though they don’t necessarily have a religious objection, said Peter Hotez, a vaccination proponent and dean of the National School of Tropical Medicine at the Baylor College of Medicine in Houston.

“As the anti-vaccine movement grows in strength and power, they could use the religious exemption loophole,” he said. “Right now I don’t see it as significant as an issue.”

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Tara McMillan, 40, has a notarized religious exemption in her files in case of an outbreak, when she might need to show she doesn’t vaccinate her four home-schooled children in Woodbridge, Va., about 20 miles south of the District. She said she stopped vaccinating her children when her oldest son, who is now 13, showed signs of a reaction in 2008.

She believes that her son’s autism, which was diagnosed when he was 3, is linked to the vaccines he received as a baby. (Many who oppose vaccines cite autism based on a 1998 study that used falsified data and was later retracted. The idea has been widely completely rejected by overwhelming scientific evidence but persists in some circles.) McMillan said she tried to get a medical exemption, which is available in all 50 states, but couldn’t get a doctor to sign the form.

“We have to go the religious route even though it’s more medical,” she said. “There’s always a fear that [lawmakers will] try to sneak something in to take the religious exemption away.”

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Later, McMillan says she began to read more about vaccines and developed a general religious belief opposing them, in part because she learned some are made using aborted fetal cells.

“I think it’s sacrilegious because it tries to take away what God has already given us,” said McMillan, who goes to an independent fundamental Baptist church. “When we put vaccines in our body, it disrupts your body’s system. You put things in your body, and bad things are going to happen. It’s like the Bible verse — you reap what you sow.”

The biggest battleground for vaccine advocates, Hotez said, is in states that have personal exemptions, not just religious ones. States that have both a personal exemption and a religious exemption have higher rates of whooping cough than states that just have a religious exemption.

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The type of exemption a parents uses to opt out of immunization is not as important as the state’s process for getting one, said Saad B. Omer, a professor of global health, epidemiology and pediatrics at Emory University in Atlanta.

“What often makes the difference is how easy it is to get an exemption,” he said. In some states, he noted, it’s much easier for a parent to check off a box for an exemption than to spend time in a pediatrician’s waiting room.

State guidelines could be stricter if more documentation were required to obtain an exemption on the grounds of conscientious objection, said Charles Haynes, founder of the Religious Freedom Center at the Newseum in Washington.