Nonmedical Vaccine Exemptions Research Articles

Methods of Current Practice: Qualitative Analysis of Intervention Strategies Utilized by Vaccine Waiver Educators in Michigan.

By enacting administrative rule 325.176 (12), Michigan added a vaccine education component as a precondition to granting vaccine waivers to vaccine-hesitant parents wishing to file a nonmedical vaccine exemption for their school-aged child. The purpose of the study was to identify best practices for reaching vaccine-hesitant parents during face-to-face vaccine education sessions conducted by vaccine waiver educators in Michigan. This study utilized qualitative descriptive content analysis of semi-structured phone interviews with vaccine waiver educators from local health departments (LHDs) in Michigan. Participants were vaccine waiver educators who were employed by a local health department in Michigan and had conducted at least 30 vaccine waiver education sessions. Strategies, resources, and techniques identified by educators as beneficial included using and providing information from a variety of sources, compiling their own educational materials, creating a positive experience, holding personalized sessions, and streamlining exemption and vaccination sessions. However, unexpected themes that emerged from the interviews revealed that vaccine waiver educators need additional training in discussing vaccine ingredients with parents, handling religious vaccine exemption requests, and assessing the role of schools. Implementing successful vaccine education interventions targeting vaccine-hesitancy is crucial to public health. Charging LHDs with overseeing vaccine education via a face-to-face discussion is a novel intervention strategy, the effective implementation of which may inform vaccine education intervention nationwide and may even be translated into international contexts and prove useful to current COVID-19 vaccination efforts.

Political Will, Vaccines, and Community Immunity.

Political Will, Vaccines, and Community Immunity.

Measuring Multiple Dimensions and Indices of Nonvaccination Clustering in Michigan, 2008-2018.

Michigan experienced a significant measles outbreak in 2019 amidst rising rates of nonmedical vaccine exemptions (NMEs) and low vaccination coverage compared with the rest of the United States. There is a critical need to better understand the landscape of nonvaccination in Michigan to assess the risk of vaccine-preventable disease outbreaks in the state, yet there is no agreed-upon best practice for characterizing spatial clustering of nonvaccination, and numerous clustering metrics are available in the statistical, geographical, and epidemiologic literature. We used school-level data to characterize the spatiotemporal landscape of vaccine exemptions in Michigan for the period 2008-2018 using Moran's I, the isolation index, the modified aggregation index, and the Theil index at 4 spatial scales. We also used nonvaccination thresholds of 5%, 10%, and 20% to assess the bias incurred when aggregating vaccination data. We found that aggregating school-level data to levels commonly used for public reporting can lead to large biases in identifying the number and location of at-risk students and that different clustering metrics yielded variable interpretations of the nonvaccination landscape in Michigan. This study shows the importance of choosing clustering metrics with their mechanistic interpretations in mind, be it large- or fine-scale heterogeneity or between- and within-group contributions to spatial variation.

Geographic hot spot analysis of vaccine exemption clustering patterns in Michigan from 2008 to 2017

ObjectiveThis study explored vaccine exemption clustering in Michigan and examined whether vaccine exemptions clustered by exemption type (medical, religious, and philosophical). Furthermore, the study investigated whether Michigan’s nonmedical vaccine exemption policy change had an impact on type-specific vaccine exemption clusters following its implementation. MethodsThe study used the ArcGIS optimized hot spot analysis tool to visually examine vaccine exemption clustering by type in Michigan. The study analyzed secondary kindergarten vaccine exemption data from 2301 elementary school buildings in Michigan for years spanning 2008 to 2015 and 2016 to 2017 post policy change. ResultsClustering of vaccine exemptions by type was present both before and after implementation of the policy with fewer statistically significant features and differences regarding the distribution of hot spot clusters following the policy change. ConclusionConsidering the heterogeneity in vaccine exemption hot spot clustering by type can help to inform public health officials to areas/communities at high risk for vaccine preventable disease outbreaks. Such analysis can allow for the implementation of vaccine exemption interventions that are exemption type specific and tailored for a given area, thus maximizing impact and making best use of limited public health resources. This analysis was also able to showcase the impact of Michigan’s nonmedical vaccine exemption policy on vaccine exemption hot spot clusters.

Vaccination policy strategies in Ontario

Vaccination is considered to be one of the greatest public health achievements, contributing to a substantial decline in infectious disease mortality in Canada. However, a growing threat of vaccine hesitancy has led to an upsurge in the prevalence and incidence of vaccine-preventable diseases across the globe, including Canada. Vaccine hesitancy is on the rise in the province of Ontario. Parental vaccine hesitancy, vaccine misconceptions, rising non-medical vaccine exemption rates, and low childhood vaccination coverage has led to a resurgence in vaccine-preventable diseases, especially measles. Given the importance of achieving high vaccine coverage to avoid vaccine-preventable diseases and their dire consequences, vaccine hesitancy is an important issue that needs to be addressed. There is no perfect solution to address vaccine hesitancy. Understanding the complex mix of factors that determine individual and collective vaccination behaviour is vital to designing effective vaccination policies, programs, and targeted interventions. This article critiques current vaccine policy strategies and outlines a policy approach to address parental vaccine hesitancy and prevent future vaccine-preventable disease outbreaks, specifically in Ontario, and more broadly within Canada. Providing support to healthcare providers and primary care physicians; and empowering parents, schools, students, families, and communities in Ontario, will slowly but surely mitigate vaccine hesitancy and enable healthy vaccination behaviours. Healthcare system-based interventions seem to be the most comprehensive approach that requires coordinated efforts and partnerships between community-based organizations and vaccination providers to ensure inclusive and integrated service delivery.

Caring for the Vaccine-Hesitant Family: Evidence-Based Alternatives to Dismissal

Vaccine hesitancy is a growing public health threat. Recent data suggest that only one-half of children in the US are up-to-date for all recommended vaccines by 19-35 months, and more than one-third of children are on alternative or shot-limiting vaccine schedules.1 Measles infected 1282 Americans in 2019—the most cases since 1992—and the US nearly lost its measles elimination status.2 One in 40 kindergartners attends school with a nonmedical vaccine exemption, and many more kindergartners attend school underimmunized without plans to catch up.

The Emergence of Spatial Clustering in Medical Vaccine Exemptions Following California Senate Bill 277, 2015-2018.

Objectives. To understand how the elimination of nonmedical vaccine exemptions through California Senate Bill 277 (SB277) may have resulted in increased spatial clustering of medical exemptions.Methods. We used spatial scan statistics and negative binomial regression models to examine spatial clustering in medical vaccine exemptions in California kindergartens from 2015 to 2018.Results. Spatial clustering of medical exemptions across schools emerged following SB277. Clusters were located in similar geographic areas to previous clusters of nonmedical vaccine exemptions, suggesting a spatial association between high nonmedical exemption prevalence and increasing rates of medical exemptions. Regression results confirmed this positive association at the local level. The sociodemographic characteristics of the neighborhoods in which schools were located explained some, but not all, of the positive spatial associations between exemptions before and after SB277.Conclusions. Elimination of nonmedical vaccine exemptions via SB277 may have prompted some parents to instead seek medical exemptions to required school vaccines. The spatial association of these 2 types of exemptions has implications for maintaining pockets of low vaccine compliance and increased disease transmission.

The 2016 California policy to eliminate nonmedical vaccine exemptions and changes in vaccine coverage: An empirical policy analysis.

Vaccine hesitancy, the reluctance or refusal to receive vaccination, is a growing public health problem in the United States and globally. State policies that eliminate nonmedical ("personal belief") exemptions to childhood vaccination requirements are controversial, and their effectiveness to improve vaccination coverage remains unclear given limited rigorous policy analysis. In 2016, a California policy (Senate Bill 277) eliminated nonmedical exemptions from school entry requirements. The objective of this study was to estimate the association between California's 2016 policy and changes in vaccine coverage. We used a quasi-experimental state-level synthetic control analysis and a county-level difference-in-differences analysis to estimate the impact of the 2016 California policy on vaccination coverage and prevalence of exemptions to vaccine requirements (nonmedical and medical). We used publicly available state-level data from the US Centers for Disease Control and Prevention on coverage of measles, mumps, and rubella (MMR) vaccination, nonmedical exemption, and medical exemption in children entering kindergarten. We used county-level data individually requested from state departments of public health on overall vaccine coverage and exemptions. Based on data availability, we included state-level data for 45 states, including California, from 2011 to 2017 and county-level data for 17 states from 2010 to 2017. The prespecified primary study outcome was MMR vaccination in the state analysis and overall vaccine coverage in the county analysis. In the state-level synthetic control analysis, MMR coverage in California increased by 3.3% relative to its synthetic control in the postpolicy period (top 2 of 43 states evaluated in the placebo tests, top 5%), nonmedical exemptions decreased by 2.4% (top 2 of 43 states evaluated in the placebo tests, top 5%), and medical exemptions increased by 0.4% (top 1 of 44 states evaluated in the placebo tests, top 2%). In the county-level analysis, overall vaccination coverage increased by 4.3% (95% confidence interval [CI] 2.9%-5.8%, p < 0.001), nonmedical exemptions decreased by 3.9% (95% CI 2.4%-5.4%, p < 0.001), and medical exemptions increased by 2.4% (95% CI 2.0%-2.9%, p < 0.001). Changes in vaccination coverage across counties after the policy implementation from 2015 to 2017 ranged from -6% to 26%, with larger increases in coverage in counties with lower prepolicy vaccine coverage. Results were robust to alternative model specifications. The limitations of the study were the exclusion of a subset of US states from the analysis and the use of only 2 years of postpolicy data based on data availability. In this study, implementation of the California policy that eliminated nonmedical childhood vaccine exemptions was associated with an estimated increase in vaccination coverage and a reduction in nonmedical exemptions at state and county levels. The observed increase in medical exemptions was offset by the larger reduction in nonmedical exemptions. The largest increases in vaccine coverage were observed in the most "high-risk" counties, meaning those with the lowest prepolicy vaccine coverage. Our findings suggest that government policies removing nonmedical exemptions can be effective at increasing vaccination coverage.

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.

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.

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.

Conditional admission, religious exemption type, and nonmedical vaccine exemptions in California before and after a state policy change

Recent measles and pertussis outbreaks in the US have focused national attention on state laws governing exemptions from mandatory vaccines for school entry. After several years of increases in nonmedical exemptions in California, the state assembly passed Assembly Bill 2109 in 2012, making nonmedical exemptions more difficult to obtain by requiring parents to obtain a signature from a health care provider. We used data from the California Department of Public Health to describe changes in the overall prevalence of personal belief exemptions and compositional changes in immunization status for the school years 2012–2013 through 2015–2016. Following the implementation of Assembly Bill 2109, the statewide exemption rate declined from 3.1% in 2013 to 2.5% in 2014 and then to 2.3% in 2015, representing a 25% reduction from the 2013 peak. Continued surveillance of exemption rates and vaccine refusal are needed to monitor and protect herd immunity against vaccine-preventable diseases.

Prioritizing Parental Liberty in Non-medical Vaccine Exemption Policies: A Response to Giubilini, Douglas and Savulescu

AbstractIn a recent paper published in this journal, Giubilini, Douglas and Savulescu argue that we have given insufficient weight to the moral importance of fairness in our account of the best policies for non-medical exemptions (NMEs) to childhood immunization requirements. They advocate for a type of policy they call Contribution, according to which parents must contribute to important public health goods before their children can receive NMEs to immunization requirements. In this response, we argue that Giubilini, Douglas and Savulescu give insufficient weight to the moral importance parental liberty in ways that count against their preferred type of NMEs policy and threaten public support for mandatory vaccination laws and public health initiatives generally.

Liberty, Fairness and the ‘Contribution Model’ for Non-medical Vaccine Exemption Policies: A Reply to Navin and Largent

Abstract In a paper recently published in this journal, Navin and Largent argue in favour of a type of policy to regulate non-medical exemptions from childhood vaccination which they call ‘Inconvenience’. This policy makes it burdensome for parents to obtain an exemption to child vaccination, for example, by requiring parents to attend immunization education sessions and to complete an application form to receive a waiver. Navin and Largent argue that this policy is preferable to ‘Eliminationism’, i.e. to policies that do not allow non-medical exemptions, because Inconvenience has been shown to maintain exemption rates low while not harming parents by forcing them to do something that goes against their beliefs. We argue that it is at least doubtful that Inconvenience is ethically preferable to Eliminationism: while the latter disregards the value of liberty, Inconvenience disregards the value of fairness in the distribution of the burdens entailed by the preservation of a public good like herd immunity. We propose a variant of Inconvenience, which we call ‘Contribution’, which we think is preferable to the versions of Inconvenience discussed by Navin and Largent in that it successfully strikes a balance between the values of parents’ liberty, fairness and expected utility.

Geospatial analysis of nonmedical vaccine exemptions and pertussis outbreaks in the United States

Because of increased numbers of recorded pertussis cases in the United States, this study sought to understand the role of nonmedical vaccine exemptions and waning immunity may have had on the resurgence of pertussis in the United States at the community level. We used geospatial scan statistics, SaTScan, version 9.4, to analyze nonmedical vaccine exemptions of children entering kindergarten in 2011 and 2012 and reported pertussis cases in 2012 for children in age groups 5 years and younger and 10 to 14 years. Eight statistically significant clusters of nonmedical vaccine exemptions in kindergarteners and 11 statistically significant clusters of pertussis cases in children and adolescents were identified and geospatially linked. Forty-five percent of the counties in the study had high rates of nonmedical vaccine exemptions. The proportion of kindergarteners with nonmedical vaccine exemptions was 2.8 times larger in the identified exemption clusters. In addition, 31 counties had geographic clusters of high rates of pertussis in children ages 10 to 14 years old, consistent with waning immunity. Our findings are consistent with the view that geographic clusters of nonmedical vaccine exemptions and waning immunity may have been factors contributing to community-level pertussis outbreaks.

Impact of Nonmedical Vaccine Exemption Policies on the Health and Economic Burden of Measles

ObjectiveDespite relatively high national vaccination coverage for measles, geographic vaccination variation exists resulting in clusters of susceptibility. A portion of this geographic variation can be explained by differences in state policies related to nonmedical vaccine exemptions. The objective of this analysis was to determine the magnitude, likelihood, and cost of a measles outbreak under different nonmedical vaccine exemption policies. MethodsAn agent-based transmission model simulated the likelihood and magnitude of a measles outbreak under different nonmedical vaccine exemption policies, previously categorized as easy, medium, or difficult. The model accounted for measles herd immunity, infectiousness of the pathogen, vaccine efficacy, duration of incubation and communicable periods, acquired natural immunity, and the rate of recovery. Public health contact tracing was also modeled. Model outcomes, including the number of secondary cases, hospitalizations, and deaths, were monetized to determine the economic burden of the simulated outbreaks. ResultsA state with easy nonmedical vaccine exemption policies is 140% and 190% more likely to experience a measles outbreak compared with states with medium or difficult policies, respectively. The magnitude of these outbreaks can be reduced by half by strengthening exemption policies. These declines are associated with significant cost reductions to public health, the health care system, and the individual. ConclusionsStrengthening nonmedical vaccine exemption policies is 1 mechanism to increase vaccination coverage to reduce the health and economic effect of a measles outbreak. States exploring options for decreasing their vulnerability to outbreaks of vaccine-preventable diseases should consider more stringent requirements for nonmedical vaccine exemptions.

Is There a Moral Right to Nonmedical Vaccine Exemption?

A recent measles outbreak in the United States was linked to a single source, yet it spanned eighteen jurisdictions and infected 121 people. 1 Forty-seven states currently allow legal exemption from vaccination on religious grounds, eighteen of which also allow it on philosophical grounds. 2 Recent research usually accepts a fundamental right to vaccine exemption and primarily seeks ways to protect herd immunity while also respecting that right, for example, by keeping the exemption available yet harder to procure or by imposing torts for infection-related injury. 3 We argue that when herd immunity is at risk, any moral claim to exemption from vaccination on conscientious, philosophical, or religious grounds is overridden. Our argument rests on an analogy to a series of situations in which a person puts others at risk through philosophically or religiously motivated choices. In these situations, intuitively, there is no claim-right to compromise the safety of others. Similarly, we propose, there is no claim-right to refuse vaccination, regardless of one's conscience, when refusal is sufficiently likely to seriously affect herd immunity and the safety of others. We also address several counterarguments. The lack of a claim-right to exemption when herd immunity is at risk does not mean, however, that it is always prudent for the state to force vaccination, or even that forcing vaccinations must be legal. Alternatives to forced vaccination may prove wiser and more conducive to high vaccination rates.

Childhood Vaccine Exemptions: A Broader Perspective Is Required.

* Abbreviation: LRA — : least-restrictive alternative A selective view of childhood vaccine exemption policy is presented by Opel et al in Pediatrics .1 Their primary premise is that recent attempts to restrict nonmedical vaccine exemptions are scientifically and ethically problematic.1 The authors suggest that rather than working to eliminate all nonmedical exemptions for vaccines, the focus should be on exemptions related to measles, which they see as a unique vaccine-preventable disease. The authors provide information on the highly contagious nature of the measles virus, provide accurate safety and efficacy data about the measles vaccine, and discuss the ethics of the least-restrictive alternative (LRA). They use this information to argue that only measles should be restricted from nonmedical vaccine exemptions. However, we disagree with their interpretations and seek to provide an alternative approach. First, the authors point to the contagiousness of measles as distinctive among infectious diseases. They refer to the high R0 of measles in comparison with other vaccine-preventable infectious diseases. The R0 is defined as the average number of secondary cases produced by a typical infected person in a fully susceptible population.2 The R0 has implications for the spread and control of an infection within a population and provides a basis for understanding the proportion of the population that must be immunized to provide herd or community immunity. Opel et al1 point to the fact that other vaccine-preventable infections have lower R0 than measles, ranging from 4 to 7 as opposed to 12 to 18, although their estimates may be low for some … Address correspondence to Carrie L. Byington, MD, University of Utah Health Sciences Center, 26 South 2000 East, HSEB Suite 5515, Salt Lake City, UT. E-mail: carrie.byington{at}hsc.utah.edu

California Senate Bill 277's Grandfather Clause and Nonmedical Vaccine Exemptions in California, 2015-2022.

California Senate Bill 277's Grandfather Clause and Nonmedical Vaccine Exemptions in California, 2015-2022.