Medical Exemptions Research Articles

1620. Effectiveness of the 2016 California Policy Eliminating Non-Medical Exemptions on Vaccine Coverage: A Synthetic Control Analysis

BackgroundVaccine hesitancy in low vaccine coverage “hot spots” has led to recent outbreaks of vaccine-preventable diseases across the United States. State policies to improve vaccine coverage by restricting non-medical (personal belief) exemptions are heavily debated and their effectiveness is unclear due to limited rigorous policy analysis. In 2016, a California policy (SB 277) eliminated non-medical exemptions from kindergarten requirements. To address the ongoing debate on such policies, we performed a quasi-experimental, controlled analysis of the policy’s impact on vaccine and exemption outcomes.MethodsWe used state vaccine coverage and exemption data (2011–2017) from the CDC and health data from public sources. We prespecified a primary outcome of MMR coverage (%) and secondary outcomes of medical and non-medical exemptions (%). We included covariates related to socioeconomic and health measures (e.g., insurance, well child visits) and pre-2016 mean coverage. Using the synthetic control method, with 2016 as the treatment year and a 2-year post-policy period, we constructed a “control” California, from a weighted sum of states. We used permutation testing to repeat the process for each of the other states and their unique synthetic control, to determine whether there was a meaningful difference in California (i.e., a change in California’s coverage relative to its control in the top 5th percentile of states). We tested the model’s sensitivity to various analytical assumptions.ResultsOf 43 control states, synthetic California was predominantly comprised of Idaho, Mississippi, and Arkansas, and had a good pre-policy match on outcomes. MMR coverage in California increased by 3.2% relative to synthetic California in the post period (Top 1 of 44 states, Figure 1). Medical exemptions increased by 0.4%, while non-medical exemptions decreased by 2.2% in the post-period (Top 1 of 43 states). The model was robust to changes in covariates and control states.ConclusionThe policy resulted in a meaningful increase in MMR coverage and reduction in non-medical exemptions. We measured a modest increase in medical exemptions, but this was offset by the larger reduction in non-medical exemptions. State policies removing non-medical exemptions can be effective in increasing vaccination coverage. Disclosures All authors: No reported disclosures.

1611. Interventions to Decrease the Absolute Number of Individuals Not Immune to Measles at Princeton University (PU)

BackgroundPU’s dormitories house ~100% of undergraduate and ~70% of graduate students. MMR is required for all students by NJ law, allowing for medical and religious exemptions (RE). Information on immunization requirements is widely available and accessible. If a student is found not compliant, measures include monetary fines, class registration holds, and contact by residential staff. Visiting short-term students should submit immunization records, but, due to rolling matriculation dates, enforcement measures may not be applicable. In the fall of 2018, a measles outbreak was reported close to campus. We sought to engage all students not immune to measles with proactive messaging.MethodsStarting on December 3, 2018, the electronic health record (EHR) was used to generate a weekly report of active students not immune to measles following the CDC’s immunity criteria. Notifications and education material were sent via secure messaging and/or email. Students with no immunization data were provided instructions on record submission. Reminders were sent to those due for second MMR. Students with RE were offered blood tests for measles immunity. Alerts were placed in the EHR of all non-immune students so every encounter would serve as reminder. Student travelers on PU sponsored trips were informed about measles outbreaks and, often, MMR became a trip requirement.ResultsOn December 3, 2018, 84 students were measles non-immune: 2 with medical and 23 with RE; 59 lacking second MMR or with no immunization data.The 23 RE became 24 when a student in absentia returned. Since, 3 of the students with RE had blood tests revealing measles immunity; 2 received MMR to travel; 3 decided that their RE was not current. On 4/22/19, there were 18 students lacking second MMR or with no immunization data, most of them new visiting students. Overall, 57% reduction of absolute number of measles nonimmune students.ConclusionThis community intervention shows that students who remained measles non-immune despite the regular immunization compliance activities, could become compliant through active messaging, education and continued engagement. Importantly, 8 of 24 students with RE, when engaged and provided with information and potential consequences of unimmunized status, were found either already immunized or not opposed to receiving immunizations. Disclosures All authors: No reported disclosures.

2774. Impact of Yellow Fever Vaccine and Recombinant Zoster Vaccine Shortages on Patients Presenting to a Travel Clinic

BackgroundIn 2017, the United States experienced a national shortage of the yellow fever vaccine (YF-Vax). In response to this, the US Food and Drug Administration (FDA) approved the use of Stamaril in a limited number of clinics across the country. This was soon followed by a shortage of the recently approved recombinant zoster vaccine (RZV) in 2018. This project describes the impact of both vaccine shortages on patients presenting to the Travel Health Clinic at Froedtert and the Medical College of Wisconsin.MethodsA retrospective review of Travel Health Clinic medical records between January and December of 2018 was performed. Information regarding patient demographics, travel destination, vaccination rates, reasons for not vaccinating, and referral information was obtained.ResultsOf the 306 patients seen in 2018, 98 were traveling to countries with active yellow fever transmission. Due to the YF-Vax shortage, 59.2% of these patients were referred to another clinic for Stamaril and 7.1% were unable to get the vaccine before departure. The remaining patients qualified for a medical exemption, had an itinerary that was lower risk for yellow fever, or their subsequent vaccine history was unknown. Additional cost for Stamaril at referral locations ranged from $169.50-$315.00 per person with a travel distance of 15–272 miles to the referred clinic. Regarding RZV, 134 clinic patients were qualified to receive the vaccine. 57.5% did not receive RZV due to vaccine shortage, 15.7% were referred to another clinic for RZV, while 15.7% were able to receive the vaccine during their appointment. Of these patients, 31.3% were covered under Medicare, thus necessitating referral to a pharmacy for vaccine coverage.ConclusionWe encountered high rates of unvaccinated travelers who would have qualified for and benefitted from YF-Vax and RZV in 2018. Even among those who could receive the recommended vaccines, there was substantial additional cost and inconvenience. This illustrates the considerable negative impact of the YF-Vax and RZV vaccine shortages. Further efforts are necessary to make these vaccines more accessible to the community.Disclosures All authors: No reported disclosures.

Estimation of 13-valent Pneumococcal Conjugate Vaccine Efficiency in Infants within National Immunization Schedule

Background. Vaccination of infants with 13-valent pneumococcal conjugate vaccine (PCV) was implemented in national immunization schedule in 2014. In this regard epidemiological monitoring of routine immunization results with vaccination coverage and efficiency control is required. Objective. Our aim was to study correlation between pneumococcal disease routine immunization in infants and morbidity and mortality rates due to community-acquired pneumonia in children under 18 years of age and morbidity rate due to acute otitis media in children under 14 years of age. Methods. Morbidity (Form № 2, 2011–2017 yrs) and mortality (Form № 51S, 2009–2017 yrs) rates due to community-acquired pneumonia, morbidity rate (Form № 12, 2009–2017 yrs) due to acute otitis media, vaccination coverage rate (Form № 5, 2014–2017 yrs, and Form № 6, 2016–2017 yrs) were analysed according to the data of Forms of Federal Statistical Monitoring. Medical exemptions and refusals to vaccinate rates were estimated according to the data from doctors who was performing infants vaccination. Results. During PCV routine vaccination within national immunization schedule in Russian Federation the 35% reduction of mortality due to community-acquired pneumonia in children under 1 year of age as well as reduction of morbidity with acute otitis media have been established. Moreover, low percentage of etiology clear community-acquired pneumonias (29%) complicates the estimation of vaccination efficiency. It has been revealed that despite the high pneumococcal disease vaccination coverage rate of infants under 2 years of age (87%), considerable part of children (73%) are vaccinated untimely in most Russian Federation regions. 9.3% (3.4% due to medical exemptions) of children (among 1st year infants) remained unvaccinated due to medical exemptions and refusals to vaccinate in 2016, and 8% (3.4%) in 2017 respectively. Conclusion. Implementation of PCV routine immunisation for three years in a row leads to reduction of morbidity rate due to acute otitis media among children under 14 years of age and infant mortality rate due to community-acquired pneumonias. Though, the estimation of routine immunisation efficiency can be difficult due to such factors as untimely start of vaccination, medical exemptions and refusals to vaccinate and limited laboratory diagnostics of community-acquired pneumonias etiology.

Assessment of Medicaid Beneficiaries Included in Community Engagement Requirements in Kentucky

States are pursuing Section 1115 Medicaid demonstration waiver authority to apply community engagement (CE) requirements (eg, participation in work, volunteer activities, or training) to beneficiaries deemed able-bodied as a condition of coverage. Understanding the size and characteristics of the populations included in these requirements can help inform policy initiatives and anticipate effects. To estimate the number and characteristics of Kentucky Medicaid beneficiaries who would have to meet CE requirements. Cross-sectional study in which administrative records for the entire population of Medicaid beneficiaries in Kentucky as of February 2018 and original survey data, based on responses from 9396 Medicaid beneficiaries included in the waiver program, were analyzed. Eligibility for Kentucky's Medicaid demonstration waiver as of the originally planned implementation date (July 2018). Number of beneficiaries included in CE requirements, including those already meeting vs not meeting hour quotas and those who may qualify for medical frailty exemptions. Among the 9396 individuals included in the Section 1115 waiver program who participated in the survey, the mean weighted (SD) age was 36.1 (11.9) years; a weighted 47.2% of respondents were female, and most beneficiaries (weighted percentage, 78.2%) were non-Hispanic white participants. We estimated that 132 790 (95% CI, 129 132-136 449) beneficiaries would have been required to meet CE requirements in July 2018, amounting to 40.2% of Medicaid beneficiaries included in the demonstration waiver. Of this group, 25 422 (95% CI, 23 135-27 710) beneficiaries may have qualified for a medical frailty exemption either by self-attestation (after confirmation by their Medicaid insurer) or by being identified as eligible by physicians or their insurer. Another 58 943 (95% CI, 55 687-62 196) beneficiaries likely would have met CE hour requirements and been required to report compliance. Ultimately, 48 427 (95% CI, 45 281-51 574) individuals would have had to add new activities to meet CE requirements, amounting to 14.7% of those included in the demonstration waiver as a whole and 36.3% of those included in the CE component of the waiver. Beneficiaries in the potentially medically frail group reported worse socioeconomic status, poorer health outcomes, and higher rates of hospital admission and emergency department use than those meeting CE requirements. Similarly, the group currently not meeting and not exempt from CE hour requirements reported worse socioeconomic status than those meeting the CE requirements, although magnitudes of the differences were smaller. Findings suggest that most beneficiaries who would be included in CE programs either already meet activity requirements, which they will be required to proactively report, or may qualify for a medical frailty exemption. Consequently, the outcomes of CE programs will depend on states' processes for addressing health-related, socioeconomic, and administrative barriers to participating in and reporting CE activities and identifying medical frailty.

Elimination of Nonmedical Immunization Exemptions in California and School-Entry Vaccine Status.

California implemented Senate Bill 277 (SB277) in 2016, becoming the first state in nearly 30 years to eliminate nonmedical exemptions from immunization requirements for schoolchildren. Our objectives were to determine (1) the impacts of SB277 on the percentage of kindergarteners entering school not up-to-date on vaccinations and (2) if geographic patterns of vaccine refusal persisted after the implementation of the new law. At the state level, we analyzed the magnitude and composition of the population of kindergarteners not up-to-date on vaccinations before and after the implementation of SB277. We assessed correlations between previous geographic patterns of nonmedical exemptions and patterns of the remaining entry mechanisms for kindergarteners not up-to-date after the law's implementation. In the first year after SB277 was implemented, the percentage of kindergartners entering school not up-to-date on vaccinations decreased from 7.15% to 4.42%. The conditional entrance rate fell from 4.43% to 1.91%, accounting for much of this decrease. Other entry mechanisms for students not up-to-date, including medical exemptions and exemptions for independent study or homeschooled students, largely replaced the decrease in the personal belief exemption rate from 2.37% to 0.56%. In the second year, the percentage of kindergartners not up-to-date increased by 0.45%, despite additional reductions in conditional entrants and personal belief exemptions. The correlational analysis revealed that previous geographic patterns of vaccine refusal persisted after the law's implementation. Although the percentage of incoming kindergarteners up-to-date on vaccinations in California increased after the implementation of SB277, we found evidence for a replacement effect.

How to Prepare for Expert Testimony on the Safety of Vaccination.

The Centers for Disease Control and Prevention has recently announced that vaccine coverage in American children has begun to decline as more parents seek medical, religious, and so-called philosophical exemptions. The proportion of unvaccinated American children has now reached 1.3%.1 This was a depressing announcement but not surprising in view of the increase in antivaccinationism, or as it is euphemistically called, “vaccine hesitancy.” One of the reasons for the decline in vaccination became clear to me in January 2018, when I was asked to do a pro bono deposition in a case in which a father who wanted his daughter vaccinated before entering kindergarten was suing his divorced wife, who opposes vaccination. I accepted because I viewed it as a public service, and I thought I merely had to testify about the benefits of vaccination and its overall safety. However, when I arrived at the conference room where the deposition was to be conducted, I found 2 lawyers representing the mother. I later learned that 1 of the lawyers was a partner at a New York City law firm that specializes in vaccine injury and antivaccination suits. The firm represents those opposed to mandatory vaccination. As an example, it opposed a regulation in New York that would allow a child … Address correspondence to Stanley A. Plotkin, MD, Department of Pediatrics, University of Pennsylvania, Vaxconsult, 4650 Wismer Rd, Doylestown, PA 18902. E-mail: stanley.plotkin{at}vaxconsult.com

Immunisation coverage annual report, 2015

This 9th annual immunisation coverage report shows data for 2015 derived from the Australian Childhood Immunisation Register and the National Human Papillomavirus (HPV) Vaccination Program Register. This report includes coverage data for ‘fully immunised’ and by individual vaccines at standard age milestones and timeliness of receipt at earlier ages according to Indigenous status. Overall, ‘fully immunised’ coverage has been mostly stable at the 12- and 24-month age milestones since late 2003, but at 60 months of age, coverage reached its highest ever level of 93% during 2015. As in previous years, coverage for ‘fully immunised’ at 12 and 24 months of age among Indigenous children was 3.4% and 3.3% lower than for non-Indigenous children overall, respectively. In 2015, 77.8% of Australian females aged 15 years had 3 documented doses of HPV vaccine (jurisdictional range 68.0–85.6%), and 86.2% had at least one dose, compared to 73.4% and 82.7%, respectively, in 2014. The differential of on-time vaccination between Indigenous and non-Indigenous children in 2015 diminished progressively from 18.4% for vaccines due at 12 months to 15.7% for those due at 24 months of age. In 2015, the proportion of children whose parents had registered an objection to vaccination was 1.2% at the national level, with large regional variations. This was a marked decrease from 1.8% in 2014 and the lowest rate of registered vaccination objection nationally since 2007 when it was 1.1%. Medical contraindication exemptions for Australia were more than double in 2015 compared with the previous year (635 to 1,401).

Neighbourhood influence on the fourth dose of diphtheria-tetanus-pertussis vaccination.

Using 542,159 vaccination records from children born between April 1, 2007, and March 31, 2012, in the Michigan Care Improvement Registry and data from the American Community Survey, we determine if neighbourhood-level characteristics at the Census tract level and block level are associated with low uptake of the fourth dose of diphtheria-tetanus-acellular pertussis vaccine (DTaP4). This study was a cross-sectional study. We used exploratory factor analysis to determine important socio-economic factors at the Census block level and tract level. We then used generalised estimating equations to test the relationship between block- and tract-level socio-economic factors and DTaP4 uptake. DTaP4 coverage was 88.6% (95% confidence interval [CI]: 88.4%-88.7%) in Michigan. At the Census tract level, two factors surfaced as important for DTaP4 vaccination: 'affluence' (Cronbach's alpha=0.88) and 'socio-economic disadvantage' (Cronbach's alpha=0.89). At the Census block level, one factor was important: 'affluence' (Cronbach's alpha=0.90). Affluence may relate to knowledge about medical exemptions and antivaccination sentiment, while socio-economic disadvantage may indicate limited access to healthcare resources. Children in high-affluence tracts had 1.08% lower vaccination coverage (95% CI: -1.62% to -0.55%) than children in low affluence tracts. Children in low socio-economic disadvantage tracts had 2.92% higher coverage than children in high socio-economic disadvantage tracts (95% CI: 2.58%-3.26%). This study articulates the need to further understand the contribution of neighbourhood-level characteristics, from both affluent and socioeconomically disadvantaged areas to low vaccination rates. Developing a better understanding of these social environmental factors will help determine useful community-level interventions to improve vaccination rates and reduce disease burden.

Vaccines Should Not Be a Sticking Point

Vaccines Should Not Be a Sticking Point

California's Senate Bill 277: Local Health Jurisdictions' Experiences With the Elimination of Nonmedical Vaccine Exemptions.

Objectives. To understand the experiences of local health jurisdictions with Senate Bill 277 (SB277), the California law that eliminated nonmedical vaccine exemptions for public- and private-school entry.Methods. We conducted semistructured telephone interviews with health officers and local health department (LHD) staff in California between August and September 2017.Results. Two overall themes emerged: (1) vague legislative and regulatory language led to variation in the interpretation and implementation of SB277, and (2) lack of centralized review of medical exemptions allowed medical exemptions that are not consistent with valid contraindications for immunizations to be accepted. Variation in the interpretation and implementation was commonly reported with provisions related to individualized education programs and special education, and independent study programs and homeschooling. Without a centralized review of medical exemption requests, respondents reported variation in the interpretation of which specialties of physicians can write medical exemptions, which conditions constitute a valid contraindication for immunization, and the process for reporting a questionable or suspicious medical exemption.Conclusions. The regulatory language within SB277 led to variation in how the law was interpreted and implemented within and across LHD jurisdictions and school districts.

Experiences With Medical Exemptions After a Change in Vaccine Exemption Policy in California.

We conducted semistructured telephone interviews between August 2017 and September 2017 with health officers and immunization staff from local health jurisdictions in California. Interviews were recorded, transcribed, and analyzed for key themes. We conducted 34 interviews with 40 health officers and immunization staff representing 35 of the 61 local health jurisdictions in California. Four main themes emerged related to experiences with medical exemptions: (1) the role of stakeholders, (2) reviewing medical exemptions received by schools, (3) medical exemptions that were perceived as problematic, and (4) frustration and concern over medical exemptions. Generally, local health jurisdictions described a narrow role in providing support and technical assistance to schools. Only 5 jurisdictions actively tracked medical exemptions received by schools, with 1 jurisdiction facing a lawsuit as a result. Examples were provided of medical exemptions that listed family history of allergies and autoimmune diseases as contraindications for immunization and of physicians charging steep fees for medical exemptions. Participants also reported concerns about the increase in medical exemptions after the implementation of SB277. Participants reported many challenges and concerns with medical exemptions under SB277. Without additional legal changes, including a standardized review of medical exemptions, some physicians may continue to write medical exemptions for vaccine-hesitant parents, potentially limiting the long-term impact of SB277.

Vaccine Medical Exemptions Are a Delegated Public Health Authority.

* Abbreviations: ME — : medical exemption SB277 — : Senate Bill 277 Vaccines are safe, >1000 times safer than the diseases they prevent. Protection from vaccines extends beyond individuals when vaccination rates are high enough to confer community immunity. However, vaccine risks may be too high for a few people, for example, those with a known severe allergy to a vaccine. Public health and medical experts have identified contraindications and precautions for each vaccine based on data from extensive postapproval monitoring that reveal actual or theoretical risk.1 Some conditions are so uncommon that despite years of administration of millions of vaccine doses, it is still unclear whether the condition is truly associated with the vaccine; but out of an abundance of caution, those conditions may be listed as a vaccine precaution. The passage of Senate Bill 277 (SB277) in 2015 abolished all nonmedical exemptions in California. SB277 proved to be a great success, with sharp increases in vaccination rates seen in kindergarteners entering school. For the 2014–2015 school year, when the Disneyland measles outbreak occurred and SB277 was introduced and passed into law, the statewide kindergarten full-vaccination rate was only 90.4%,2 below the 94% needed for community immunity to measles. After the passage of SB277, the kindergarten full-vaccination rate for the 2015–2016 school year rose to 92.6%,2 which has … Address correspondence to Richard J. Pan, MD, MPH, State Capitol, Room 5114, Sacramento, CA 95814. E-mail: richard.pan{at}sen.ca.gov

The Results of a Three-Year Pneumococcal Vaccination of Children in Russia

Background.After inclusion of pneumococcal vaccination in the National Vaccination Schedule, it is very important to evaluate the efficacy of routine immunisation of the child population for more than 3 years. The obtained results provide opportunity to analyse the problems in achieving the goal, determine their causes, and suggest the ways of overcoming. Our aim was to study the results of a three-year period of pneumococcal vaccination of children.Methods.The quality of immunoprophylaxis of pneumococcal infection in the territory of the Russian Federation were assessed by analysing the coverage of vaccination and timeliness of its conduct after the inclusion of pneumococcal vaccine in the National Vaccination Schedule. The actual epidemiological efficacy of pneumococcal vaccination was assessed based on morbidity and mortality due to community-acquired pneumonia, incidence of acute otitis media among children. By questioning parents (n = 352) who applied to the Federal State Autonomous Institution of the Russian Federation Ministry of Health ‘National Medical Research Centre for Children’s Health, the timeliness of pneumococcal vaccination for infants was established.Results.In most regions, a high level of pneumococcal vaccination coverage was reached (87% of children). Despite the fact that the majority of children (73%) were vaccinated untimely. In particular, the results of a questionnaire survey conducted in the Moscow vaccination centre indicate insufficient awareness of parents for the need to vaccinate infants against pneumococcal infection by primary care professionals and, as a consequence, a low level of timely initiated vaccine introduction (40.1%). The introduction of routine prophylactic pneumococcal vaccination in Russia resulted in a 35% reduction in the death rate of children from community-acquired pneumonia, led to a decrease in the incidence of acute otitis media.Conclusion.The introduction of routine prophylactic vaccination of children against Streptococcus pneumoniae helps to reduce morbidity and mortality from pneumococcal infections. The surveillance system for community-acquired pneumonia requires further improvement. It is advisable to conduct an additional analysis on the reasons for refusals and medical exemptions to vaccination. It is important to increase the professional level of paediatricians in prophylactic vaccination.

Is physician dismissal of vaccine refusers an acceptable practice in Canada? A 2018 overview.

Despite robust evidence that routine immunization is effective and safe, some parents refuse some or all vaccines for their children. In 2007, concern that Canadian paediatricians and family physicians might be considering dismissal of vaccine refusers from their practices prompted an ethical, legal, and public health analysis which concluded that dismissal was professionally problematic. We now reassess this important issue in the Canadian context updating ethical, legal, and public health considerations highlighting changes since 2007. In light of the recent strengthening of Ontario's school immunization requirements that include stiffer steps to qualify for a medical, conscience, or religious belief exemption, physicians and health care workers may be under more pressure from vaccine refusers in their practice leading some to contemplate dismissal or even consider no longer offering immunizations at all in their practice. Given the challenges that vaccine refusers may present, we offer an overview for managing vaccine refusal by parents/patients in a medical practice.

Overcoming ‘Anti-Vaccination Scepticism’: Seeking a Solution to the Situation

Background. The problem of distrust of immunization is widespread not only in Russia but also all over the world. Many parents refuse to vaccinate their child reasoning that the vaccines can harm their health, the immune system may not cope with the body burden; and some doctors themselves discourage parents from vaccination. Our aim was to assess the attitude of doctors and parents towards vaccination whose children are vaccinated completely or partially; to study the most frequent reasons for refusals of vaccination by parents. Methods. We used the questionnaires for parents (n = 114) who brought their children for vaccination for the first time or repeatedly; and the questionnaires for students of 4–6 courses and interns of medical universities (n = 336) who expressed their sentiments towards vaccination and demonstrated the knowledge of the national and regional immunization schedules. AstonGroup also conducted studies among physicians of different specialties (n = 307) on the most frequent reasons for refusals of vaccination. Results. In most cases, the parents’ attitude towards vaccination was positive. One in three patient representatives considered that he was fully acquainted with immunization issues, and more than half wanted to be vaccinated only within the national immunization schedule. In almost 100% of cases, parents had trust in information about vaccination received from a doctor. The results of the AstonGroup survey showed that the most frequent medical exemptions were given by neurologists, immunologists, and surgeons. And the parents themselves, who brought their children to see doctors, reasoned their refusals of vaccination with fear of complications and also considered vaccination to be harmful and useless. The doctors participating in the survey offered methods for influencing the parents, namely: providing them with accessible information about vaccinations included in the national immunization schedule as well as about the experience of using vaccines, including other countries. Discussion. The survey revealed insufficient knowledge of the national immunization schedule among students as well as cautious attitude towards vaccination issues and the trust in vaccination myths among legally authorized representatives of patients. Conclusion. The effective measures to combat ‘anti-vaccination scepticism’ are lectures for parents; personal, social and health education at pediatric sites as well as continuing medical education.

Litigating Alternative Facts: School Mandates in the Courts

In June 2015, California's governor signed into law SB277, which removed the personal belief exemption to school immunization requirements, making medical exemptions the only valid way to send an unvaccinated child in the affected categories to school. Naturally, vaccine-hesitant parents opposed the legislation. After their efforts failed in the legislature, they turned to the courts, raising arguments old and new. To date, the five lawsuits opponents filed against the new law failed. This Article explains why courts in the United States, which consistently upheld school immunization requirements, are correct to do so. These requirements are supported by strong policy reasons, since they dramatically reduce the risk of outbreaks of potentially deadly diseases, and fit with our basic principles of state police power, reasonable limits on individual rights, and protecting children. They are also supported by over a hundred years of jurisprudence. Using the opponents' arguments to identify the strongest claims against SB277, the Article explains why those arguments - including claims based in the First Amendment, in parental rights, and in the right to education - cannot stand.

A Basic Question: Are Patients with Chronic Obstructive Pulmonary Disease Aware of Their Disease?

Increased awareness and understanding of chronic obstructive pulmonary disease (COPD) is important for its management, but there are limited data regarding the basic knowledge among patients with COPD. This study aimed to evaluate the basic information and knowledge of patients who were specifically provided with a medical exemption certificate for COPD. This cross-sectional, observational, single-center study was conducted at an outpatient clinic of our hospital and included 201 consecutive ambulatory patients who visited the outpatient clinic between January 01, 2015 and June 30, 2015. Data regarding sex, age, educational level, symptoms, smoking history, years since diagnosis, years since obtaining the exemption certificate, and COPD GOLD (Global Initiative for Chronic Obstructive Lung Disease-GOLD) stage were obtained. A questionnaire comprising 15 questions was used. The question regarding the organ primarily affected by COPD was correctly answered as "lung" by 145 (72%) of patients. In addition, 152 (76%) patients declared that they knew the localization of the affected organ; only 44 (22%) patients correctly located the organ on an image. Only seven (3.5% of the total) patients could correctly write "chronic obstructive pulmonary disease." The lack of awareness among patients with COPD emphasizes the lack in the field of patient education. Simple questionnaires can be used to determine and also to improve the awareness and basic knowledge among patients with chronic diseases.

The Importance of Improving Incentives and Employment Opportunities for Farm Households in Poland

Poland is experiencing the first stages of a period where its active labour force will decline steadily over time. This has raised important concerns with how well labour markets in Poland function, especially those in rural areas where there are still large numbers of households on small farms that have only limited engagement with formal work, and whose farm income is too low to provide an acceptable family income. The result is a high level of rural under-employment that imposes a growing burden on the economy and society, both in terms of unproductive labour and in high transfer payments to these families. There is a clear understanding that reducing the number of small full-time family farms in Poland is desirable as a way to: improve household incomes, address the need for more workers in other sectors, and further enhance the competitiveness of farming. Achieving this goal has been problematic, largely because to date there have been few incentives for these farm families to alter their behaviour. Simply put, the vast majority of small farm households do not perceive that they would be better off by engaging in formal employment. This largely reflects limited job opportunities in rural areas and a significant skill mismatch in local labour markets. But, it also reflects the continued existence of a variety of Polish policies that provide considerable financial benefits to these farm households, including a highly subsidized medical and retirement plan and exemption from income taxes, that significantly reduce the incentive to change behaviour. With a shrinking work force the cost of holding these potential workers in their current situation will only increase over time, but changing these longstanding policies remains a major challenge for the government.

Medical Vaccination Exemptions on the Rise in California

In 2015, California became the third state (joining West Virginia and Mississippi) to eliminate personal belief exemptions (PBEs) for vaccination