Nonmedical Exemptions Research Articles

Measles outbreaks and public attitudes towards vaccine exemptions: some cautions and strategies for addressing vaccine hesitancy

ABSTRACT Today, the United States and countries throughout the world are experiencing measles outbreaks that have sickened thousands of children. From the Disneyland outbreak in 2014 to today, some states have responded with changes in laws on vaccine requirements and exemptions. In this article, we examine the history of vaccine laws, and using our 2015 survey data, explore to what extent the news coverage of the Disneyland outbreak altered parents’ attitudes toward required vaccination and non-medical exemptions. We explore those results in the context of today’s increasing polarized and politicalized battle over vaccine laws, and consider how health care providers and policy makers can work to improve public attitudes about vaccines.

Perspectives on state vaccine education mandate policy and implementation among public health department officials: a qualitative study

ABSTRACT In response to the increase in non-medical vaccine exemptions (NME), many states have adopted education mandates (EM), required vaccine education for parents requesting NMEs for their school-age children, but these EMs vary greatly in implementation. In order to learn about the administrative aspects of each state’s EM, we interviewed fourteen health department officials from nine states with EMs. Interviews were conducted over the phone, transcribed by a professional transcription service, and double-coded using NVivo 12 by two members of the study staff. The coding resulted in 3698 comments overall, 98.5% inter-coder reliability, and a κ statistic of 0.691. We found no consistent format for content delivery, and methods used included in-person dialogs, web-based education, and video modules. Content of the education is not standardized, and education length ranges from 15 to 60 minutes. Four major themes about the EM policies emerged: (1) the use of EMs to eliminate “convenience exemptions;” (2) the importance of health department communication with health-care providers; (3) facilitators and barriers to implementation; and (4) the positive recommendation for other states to adopt EM policies. We concluded that current EM implementation varies greatly, but officials in states which have adopted EMs for parents requesting NMEs for school-entry vaccinations overwhelmingly recommend other states to adopt them as well. Key features of successful programs may include conversations with parents requesting NMEs and strong communication channels with health-care providers. Systematic tracking of vaccine status after exemption requests and education is necessary to quantitatively determine the effectiveness of EM programs.

The Impact of Michigan's Nonmedical Vaccine Exemption Rule Change on Philosophical Exemption Rates.

To examine school factors associated with philosophical exemption rates among kindergarteners in Michigan from 2014, before Michigan's implementation of administrative rule 325.176 (12), to 2015, after the rule change revising the process for receiving nonmedical exemptions from school entry vaccines. The study explored the extent to which the factors-school type, geographical location, and socioeconomics-were associated with philosophical exemptions among kindergarteners before and after the rule change, using negative binomial regression and Spearman's Rho correlation. Philosophical exemptions decreased from 2014 to 2015 for all school types but remained highest among rural private schools. Urban private schools had the second highest exemptions with rates 2.22 times higher than those of urban public schools. Exemption rates among rural charter schools were double those of urban public schools, while rural public schools' rates were 1.22 times higher than those of urban public schools. Free and reduced school lunch eligibility had a strong inverse association with philosophical exemptions for both 2014 and 2015, with higher philosophical exemptions being associated with higher socioeconomic schools. Philosophical exemption rates decreased in the wake of the rule change; however, high philosophical exemptions, post rule change, were still associated with private schools, rural locations, and high socioeconomic status schools.

Parental opinions towards the “No Jab, No Pay” policy in Australia

BackgroundIn 2016, Australia introduced the “No Jab, No Pay” legislation, which removed the option of non-medical exemptions from the vaccination requirements to receive certain family and child care tax benefits. We aimed to gauge parental support for “No Jab, No Pay” and explore how it has impacted parental attitudes towards vaccination, particularly among families that are reliant on the tax benefits linked to vaccination under “No Jab, No Pay”. MethodsAn online survey distributed to parents with children under 5 in Australia assessed parental knowledge and opinions towards childhood vaccination and the “No Jab, No Pay” policy. ResultsA total of 411 parents completed the survey. The majority of parents reported their child was either fully vaccinated or they intended to fully vaccinate. Eighty-two percent of parents were in favour of “No Jab, No Pay.” The belief that vaccine-preventable diseases are a significant risk to unvaccinated children was a predictor of supporting the “No Jab, No Pay” policy (AOR = 5.95, 95% CI = [3.60, 10.94], p < 0.001). Parents that depend on the financial benefits associated with “No Jab, No Pay” and parents that utilize child care services were significantly more likely to reconsider vaccination, if they previously hesitated or objected, because of the policy (AOR = 9.66, 95% CI = [4.98, 18.72], p < 0.001 and AOR = 2.09, 95% CI = [1.04, 4.17], p = 0.04). ConclusionWe found that there is widespread support for “No Jab, No Pay” among parents of young children, but parents that depend on the financial benefits or utilize child care services may be disproportionately affected by the policy. Childhood vaccination coverage in Australia could best be improved by increasing access to vaccination services and by imposing significant administrative barriers to obtaining non-medical exemptions.

Parent psychology and the decision to delay childhood vaccination

ObjectiveThe study of vaccine hesitancy identifies parental decisions to delay childhood vaccinations as an important public health issue, with consequences for immunization rates, the pursuit of nonmedical exemptions in states, and disease outbreaks. While prior work has explored the demographic and social underpinnings of parental decisions to delay childhood vaccinations, little is known about how the psychological dispositions of parents are associated with this choice. We analyze public opinion data to assess the role of psychological factors in reported parental decisions to delay childhood vaccination. RationaleWe anticipate that parents with certain psychological characteristics will be more likely to delay childhood vaccination. Specifically, we explore the roles of conspiratorial thinking, dispositions towards needle sensitivity, and moral purity; expecting that parents with high levels of any of these characteristics will be more likely to delay vaccinating their children. MethodIn an original survey of 4010 American parents weighted to population benchmarks, we asked parents about delay-related vaccination behavior, demographic questions, and several psychological batteries. We then developed a vaccination delay scale and modeled delay as a function of conspiratorial thinking, needle sensitivity, moral purity, and relevant demographic controls. We then re-specified our models to look specifically at the predictors of delaying HPV vaccination, which has a low uptake rate in the United States. ResultsControlling for other common predictors of hesitant behavior, we find that parents with high levels of conspiratorial thinking and needle sensitivity are more likely to report pursuing alternative vaccination schedules. When analyzing the specific decision by parents to delay HPV vaccination, we find that tendencies towards moral purity and, in turn, sexual deviance are also associated with vaccine seeking behavior. ConclusionParental decisions to delay childhood vaccinations are an important public health concern that are associated with conspiratorial thinking and needle sensitivity.

Under-immunization of pediatric transplant recipients: a call to action for the pediatric community.

Vaccine-preventable infections (VPIs) are a common and serious complication following transplantation. One in six pediatric solid organ transplant recipients is hospitalized with a VPI in the first five years following transplant and these hospitalizations result in significant morbidity, mortality, graft injury and cost. Immunizations are a minimally-invasive, cost-effective approach to reducing the incidence of VPIs. Despite published recommendations for transplant candidates to receive all age-appropriate immunizations, under-immunization remains a significant problem, with the majority of transplant recipients not up-to-date on age-appropriate immunizations at the time of transplant. This is extremely concerning as the rate for non-medical vaccine exemptions in the United States (US) is increasing, decreasing the reliability of herd immunity to protect patients undergoing transplant from VPIs. There is an urgent need to better understand barriers to vaccinating this population of high-risk children and to develop effective interventions to overcome these barriers and improve immunization rates. Strengthened national policies requiring complete age-appropriate immunization for non-emergent transplant candidates, along with improved multi-disciplinary immunization practices and tools to facilitate and ensure complete immunization delivery to this high-risk population, are needed to ensure that we do everything possible to prevent infectious complications in pediatric transplant recipients.

Clusters of Nonmedical Exemptions to Vaccination in Illinois K–12 Schools

Vaccination rates in Illinois schools are decreasing as more parents opt for nonmedical exemptions (NMEs). At the local scale, higher levels of exemptions affect herd immunity levels. Few studies have previously conducted or proposed methods to conduct local-scale spatial and temporal cluster pattern analysis. This study used vaccination exemption data from the Illinois School Board of Education’s annual Immunization School Survey for the 2003–2004 and 2013–2014 academic years. The Getis–Ord General G statistic was used to identify cluster detection by individual vaccine at the school level. The Getis–Ord Gi* statistic was used with two different parameter models to identify hot and cold spots. This study found that NMEs are highly clustered. More clusters of high and low NMEs were identified for the 2013–2014 academic year than for 2003–2004. The percentages of schools that were neither hot nor cold averaged 94.0 percent for the 2003–2004 school year and 78.7 percent for the 2013–2014 school year. NME rates in Illinois are rising. The increase in hot and cold spots is evidence that the polarity of vaccination choice is growing. As vaccination exemption rates continue to polarize U.S. society, it is essential for public health efforts to monitor and conduct local-level studies. Key Words: antivaccination, hot spot analysis, medical geography, nonmedical exemption, spatial statistics.

Perspectives of public health nurses on the ethics of mandated vaccine education

BackgroundSince 2015, Michigan has required parents who request nonmedical exemptions (NMEs) from school or daycare immunization mandates to receive education from local public health staff (usually nurses). This is unlike most other US states that have implemented mandatory immunization counseling, which require physicians to document immunization education, or which provide online instruction. PurposeTo attend to the activity and dispositions of the public health staff who provide “waiver education”. MethodThis study reports results of focus group interviews with 39 of Michigan's vaccine waiver educators (37 nurses), conducted during 2016 and 2017, and analyzed in 2018. FindingsFour themes emerged from analysis of the transcripts of these interviews: Participants had (1) complex and nuanced observations and evaluations of parents' judgments and feelings about vaccines and vaccine education; (2) sympathetic attitudes about alternative vaccine schedules; (3) critical and supportive evaluations of institutional policies and the background political context of immunization education; and (4) consistent commitments to respect parents, affirm their values, and protect their rights. DiscussionThese results show that public health nurses are sensitive to the burdens mandatory immunization education places on families, the motivations for parents' requests for nonmedical exemptions, and the values implicated by personal immunization decisions and government immunization policies. In light of the unique training, experiences, and public reputation of nurses, there is good reason for additional investigation into the roles that nurses can play in immunization education and in vaccine mandate policies, more generally.

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.

Characteristics of immunized and un-immunized students, including non-medical exemptions, in Ontario, Canada: 2016–2017 school year

BackgroundOur objectives were: (1) to quantify and describe un-immunized students in Ontario, Canada and assess the extent to which these students have exemptions; and (2) to quantify and describe students with non-medical exemptions (NMEs), including what proportion have up-to-date immunizations. MethodsWe examined Ontario students 7 to 17 years-of-age in the 2016–2017 school year using information within a centralized immunization repository. We identified and described students with different immunization/exemption classifications by age, sex, school type, geography and area-level material deprivation using descriptive and multivariable logistic regression analyses. Finally, we assessed the immunization status of students with NMEs, by antigen. ResultsWe found that students could be recorded as un-immunized with or without an NME, or be immunized with an NME. From a cohort of 1.65 million students, 2.9% of students had zero vaccine doses recorded, and of these 68% had no exemption of any kind. A total of 2.4% of students had an NME. Of these, 39% were un-immunized and 61% had received ≥1 vaccine. Among all students with NMEs, 19–48% had up-to-date immunizations, varying by antigen. Factors associated with increased odds of having a NME and being un-immunized included: attendance at private and ‘other’ schools, rural residence, and geography. Older age and greater area-level deprivation were associated with a reduced odds. ConclusionsOur assessment revealed that Ontario students with NMEs cannot be assumed to be un-immunized and at risk for all vaccine-preventable diseases. Conversely, not all un-immunized students had NMEs suggesting that future studies of un-immunized children in Ontario must consider additional factors beyond NME status alone. Other jurisdictions that use NME data to inform research and surveillance of vaccine hesitancy and risks for VPD outbreaks may wish to undertake a similar assessment to determine how well student NMEs correlate with student immunization status.

Vaccine Education, Reasons for Refusal, and Vaccination Behavior

Little is known about associations between the reasons parents refuse or delay vaccines for their children, their responsiveness to vaccine counseling, and their children's vaccination status at various ages. Since 2015, Michigan has required parents to attend education sessions at local health departments to receive nonmedical exemptions. This requirement provides an opportunity to study otherwise opaque aspects of vaccine refusal. In 2017 and 2018, researchers analyzed a combined data set that included electronic medical records (n=4,098) generated by one Michigan health department during 2015 immunization education sessions, and immunization records from an August 2016 report of the Michigan Care Improvement Registry immunization registry. Analyses employed difference of proportions and ANOVAs to explore group differences in vaccination behaviors after education sessions and on-time vaccination status at various ages. Children whose parents stated a commitment to an alternative schedule at the education session subsequently received a vaccine their parents had refused at a much higher rate (39.2%) than did children whose parents refused for reasons of religion (4.4%), concerns about the risks of vaccines (8.1%), or beliefs that vaccines provide little benefit (10.5%). Different reasons for refusal are associated with different patterns of vaccination behavior. Furthermore, results suggest that education sessions may overcome vaccine refusal in some cases, and that distinct refusal reasons mark real differences in parental motivations regarding vaccination choices. These differences in parental motivations may indicate the existence of different sites for potential pro-vaccination interventions.

The Resurgence of Measles, Mumps, and Pertussis

Although vaccines are one of the greatest scientific innovations to prevent disease and promote well-being, 1 in 10 children is not being vaccinated. This has directly contributed to the rise in vaccine-preventable diseases. Because of the high contagiousness of measles, mumps, and pertussis, innovative efforts are paramount to prevent disease outbreaks in the United States and worldwide. This article reviews measles, mumps, and pertussis; explains the resurgence of these vaccine-preventable diseases; and offers evidence-based solutions for increasing vaccination rates.

Vaccination Data When the Outbreak Happens: A Qualitative Evaluation of Oregon's Rapid Response Tool.

Immunization data are vital to support responses to vaccine-preventable disease outbreaks. The Oregon Immunization Program developed a unique prototype instrument-the Rapid Response Tool (RRT)-that provides population data to local responders within 2 hours of a request. Data outputs include vaccination coverage by age group and zip code; percentages of students with nonmedical exemptions to vaccination requirements, by school; and current, comprehensive lists of local vaccination providers. The RRT was demonstrated to staff at 7 Oregon counties and feedback was solicited via comments and a structured survey. The RRT received strong support. Attendees identified several uses for RRT data, including outbreak response and ongoing intervention efforts, and they pointed to areas for further development. The success of the RRT demonstrations illustrates that a well-populated immunization information system can contribute to preparedness work well beyond current standards. (Disaster Med Public Health Preparedness. 2019;13:682-685).

360 Years of Measles: Limiting Liberty Now for a Healthier Future

The United States Supreme Court has upheld state vaccination mandates as a condition of entry to schools by relying on their police power in protecting public health and safety. Despite this broad authority, many state mandates include exemptions that permit parents to refuse vaccination on behalf of their children for nonmedical reasons, like religious, philosophical, or personal beliefs. A spectrum of these laws currently exists, ranging from California’s ban of all nonmedical claims to Ohio’s extremely permissive grant of exemptions. This article discusses each of these states’ mandates and the relationship between relaxed exemption laws and measles outbreaks using statistical analyses. To curb the spread of this vaccine-preventable disease, states should consider the threat to public health paramount to individual liberty infringement by restricting access to nonmedical exemptions. This approach aligns with a century of case law that has rejected vaccination mandate challenges based on fundamental rights, religious freedom, equal protection, and due process. Now states must act within that authority to safeguard against the persistence of this potentially fatal disease.

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

Immunization Noncompliance: Gauging the Cause, Effect, and Management in the School Setting

Immunization noncompliance is a public health issue. Vaccines have been noted as one of the most effective public health interventions against the spread of infectious disease. However, there is an increase in the number of nonmedical exemptions and vaccine hesitancy. This has been linked to a decrease in the fear of contracting vaccine preventable diseases to public concerns regarding vaccine safety. Research has shown that decreased vaccine coverage lessens the effect of herd immunity placing those who are unvaccinated or unable to be vaccinated at increased risk of contracting vaccine preventable diseases. These factors have led to legislative action with some states implementing stricter exemption laws and stronger enforcement of vaccine mandates. Within the school setting, the school nurse is in a unique position working within both the educational and healthcare domains. The monitoring of immunizations is a key and vital factor in ensuring the health and safety of the school community.

The roles of neighborhood composition and autism prevalence on vaccination exemption pockets: A population-wide study

The number of children entering schools without mandated vaccinations has increased in high-income countries due to the rise of nonmedical exemptions from school vaccination requirements. Herd immunity is threatened when unvaccinated children are concentrated in spatial pockets. Despite the role of vaccine-autism controversy in the current wave of the anti-vaccine movement, we do not know if exemption clusters are associated with local autism rates; it is often assumed that these clusters are merely the result of sociodemographic composition. This study uses data on the number of students with a Personal Belief Exemption reported by schools from 1992 to 2014 and unique data on the locations of children with an autism diagnosis in California to study the correlates of large exemption pockets. Our spatial analysis shows that the prevalence of autism is not associated with the locations of large pockets of vaccination exemptions. Likewise, the spatial distributions of socioeconomic factors and proximity to health care resources have limited roles in explaining these large exemption pockets. Racial/ethnic composition, however, has strong associations with the locations of the large pockets. Our results suggest that community-level interventions are needed to maintain herd immunity as exemption pockets are not merely the result of population composition.

Science in the fight to uphold the rights of children.

The United States is the only major nation to not yet have ratified the United Nations Convention on the Rights of the Child (UNCRC). Recently, there has been an erosion of the rights of children across America, Europe, and elsewhere, but through science, we may have an opportunity to counter some of this alarming trend. In the area of vaccines, the scientific community can raise its voice on the dangers that nonmedical exemptions and delays pose to children at risk for measles, influenza, and other childhood illnesses. Poverty places infants and children at high risk for illness and homelessness. Gun violence and gun-related accidents are killing on average four American children daily, and climate change is promoting global pediatric malnutrition. Increasing international, federal, and state support to seek innovative solutions to these and related issues is a moral imperative.