The experience of seeking & granting special medical exemptions for mandated vaccines: A scoping review

Background: Medical exemptions to mandated vaccines are permitted for contraindications, such as anaphylaxis and immunosuppression. However, clinicians encounter ‘special medical exemptions’ when the medical reason for requiring an exemption falls outside strict criteria. Processes for seeking, assessing, and granting these exemptions are often unclear and vary across jurisdictions. Aim: To map the published literature on the experiences of parents, caregivers, or individuals seeking special medical exemptions for mandated childhood vaccines, occupational vaccines for healthcare workers, and COVID-19 vaccines, as well as the experiences of clinicians assessing and granting such exemptions globally. Methods: A scoping review was conducted using PRISMA-ScR and JBI methodology. Databases searched included Embase, Medline, CINAHL, PsycInfo, PubMed, Web of Science, and Google Scholar. Qualitative, quantitative, review articles, and grey literature were included. Screening and data extraction were completed in Covidence by two independent reviewers. Data were analysed using descriptive and inductive content analysis. Results: Eighteen articles met inclusion criteria. Key findings were: (1) special medical exemptions are inconsistently granted; (2) individuals seeking special medical exemptions often support vaccination broadly, but express context-specific health concerns; (3) evidence on how vaccines affect the medical conditions underlying exemption requests were often lacking, leaving key gaps for decision-making not addressed by current criteria; (4) trust in clinicians who prioritised individual health needs over strict policy shaped families' subsequent vaccine decision; and (5) special medical exemptions can have wider implications from an individual or interpersonal level to a broader community and policy level. Conclusion: Special medical exemptions currently lack definitional clarity and standardised criteria, leading to inconsistent and potentially inequitable exemption decisions. More research is needed to inform evidence-based guidance that balances public health protection with individual clinical complexity. Clearer policy frameworks and clinician support are essential to ensure fair and transparent exemptions processes.