Personal Belief Exemptions Research Articles

Personal Belief Exemptions to Vaccination in California: A Spatial Analysis.

School vaccination rates in California have fallen as more parents opt for personal belief exemptions (PBEs) for their children. Our goals were to (1) spatially analyze PBE patterns over time, (2) determine correlates of PBEs, and (3) examine their spatial overlap with personal medical exemptions (PMEs). PBE and PME data for California kindergarten classes from the 2001/2002 to 2013/2014 school years were matched to the locations of schools. Nonspatial clustering algorithms were implemented to group 5147 schools according to their trends in PBE percentages among kindergartners. Cluster assignments were mapped and hotspot analysis was performed to find areas in California where schools sharing trends in PBEs over time were colocated. Schools were further associated both with school-level data on minority enrollment and free and reduced price lunch participation and with charter/private and rural/urban status. Spatial regression was implemented to determine which school-level variables were correlated with PBE rates in the 2013/2014 school year. Distinct spatial patterns are observed in California when PBE cluster assignments are mapped. Results indicate that schools belonging to the "high PBE" cluster are spatially buffered from those in "low PBE" areas by "medium PBE" schools. Further, PBE rates are positively associated with the percentage of white students, charter status, and private schools. Hotspots of high PBE schools are in some cases colocated with schools that have elevated PME rates, prompting concern that herd immunity is diminished for school populations where students have no choice but to remain unvaccinated.

Personal Belief Exemptions and Vaccination Rates in California

The risk for vaccine-preventable diseases increases when immunization rates decline. Most states allow parents claiming personal belief exemptions

Vaccination policies among health professional schools: evidence of immunity and allowance of vaccination exemptions.

OBJECTIVE To characterize health professional schools by their vaccination policies for acceptable forms of evidence of immunity and exemptions permitted. METHODS Data were collected between September 2011 and April 2012 using an Internet-based survey e-mailed to selected types of accredited health professional programs. Schools were identified through accrediting associations for each type of health professional program. Analysis was limited to schools requiring ≥1 vaccine recommended by the Advisory Committee on Immunization Practices (ACIP): measles, mumps, rubella, hepatitis B, varicella, pertussis, and influenza. Weighted bivariate frequencies were generated using SAS 9.3. RESULTS Of 2,775 schools surveyed, 75% (n=2,077) responded; of responding schools, 93% (1947) required ≥1 ACIP-recommended vaccination. The proportion of schools accepting ≥1 non-ACIP-recommended form of evidence of immunity varied by vaccine: 42% for pertussis, 37% for influenza, 30% for rubella, 22% for hepatitis B, 18% for varicella, and 9% for measles and mumps. Among schools with ≥1 vaccination requirement, medical exemptions were permitted for ≥1 vaccine by 75% of schools; 54% permitted religious exemptions; 35% permitted personal belief exemptions; 58% permitted any nonmedical exemption. CONCLUSIONS Many schools accept non-ACIP-recommended forms of evidence of immunity which could lead some students to believe they are protected from vaccine preventable diseases when they may be susceptible. Additional efforts are needed to better educate school officials about current ACIP recommendations for acceptable forms of evidence of immunity so school policies can be revised as needed.

United States Private Schools Have Higher Rates of Exemptions to School Immunization Requirements than Public Schools

To compare medical, religious, and personal belief immunization exemption rates between private and public schools in US. Exemption rates were calculated using the Centers for Disease Control and Prevention School Immunization Assessment Surveys for the 2009-2010 school year excluding states with incomplete survey data. Standardized exemption rates weighted on enrollments in public and private schools were calculated. Differences in exemption rates between public and private schools were tested using Wilcoxon signed rank test. The overall state exemption rate was higher in US private than public schools, 4.25% (SD 4.27) vs 1.91% (1.67), P = .0001 and private schools had higher exemption rates for all types of exemptions; medical 0.58% (0.71) vs 0.34% (0.34) respectively (P = .0004), religious 2.09% (3.14) vs 0.83% (1.05) respectively (P = .0001), and personal belief 6.10% (4.12) vs 2.79% (1.57), respectively (P = .006). Overall exemption rates were significantly higher in states that allowed personal belief exemptions. Exemption rates were significantly higher in US private than in public schools. Children attending private schools may be at higher risk of vaccine-preventable diseases than public school children.

Legislative Challenges to School Immunization Mandates, 2009-2012

School immunization mandates, implemented through state-level legislation, have played an important role in maintaining high immunization coverage in the United States. Immunization mandates permit exemptions that vary from state to state in terms of type of exemption (eg, religious, personal belief, medical), and administrative ease of obtaining these exemptions. Certain types of exemptions (especially personal belief exemptions) and the ease of obtaining them are predictive of high rates of vaccine exemptions and increased disease risk among exemptors themselves and in the communities in which they reside.1,2 Legislation has been proposed in recent years to modify exemptions to school immunization requirements. We analyzed such legislation at the state level.

Personal Belief Exemptions From School Vaccination Requirements

Despite the impact vaccination has had on the control and prevention of many infectious diseases, some parents choose not to vaccinate their children. Although there is no federal law requiring vaccination of children in the United States, all states require evidence of vaccination against at least some diseases as a condition of school entry. Which vaccines are required; how many doses are required; whether entry requirements apply to child care, kindergarten, or middle school; and whether exemptions from vaccine requirements will be allowed all differ by state. All but two states allow some kind of personal belief exemption from school vaccination requirements. This article reviews the history of school vaccination requirements and exemptions, the legal status of state vaccination laws and exemptions, the impact of school vaccination requirements and personal belief exemptions on vaccination rates and disease incidence, and strategies for maintaining adequate vaccination rates in states that allow personal belief exemptions.

P205 A multifaceted intervention to increase the influenza vaccination rate of healthcare workers without a mandatory policy in Japan

Overall annual influenza vaccination rate has slowly increased among health care workers but still remains below the national goal of 90%.To compare hospitals that mandate annual health care worker (HCW) influenza vaccination with and without consequences for noncompliance, a 34-item survey was mailed to an infection control professional in 964 hospitals across the United States in 4 waves. Respondents were grouped by presence of a hospital policy that required annual influenza vaccination of HCWs with and without consequences for noncompliance. Combined with hospital characteristics from the American Hospital Association, data were analyzed using χ2 or Fisher exact tests for categorical variables and t tests for continuous variables.One hundred fifty hospitals required influenza vaccination, 84 with consequences (wear a mask, termination, education, restriction from patient care duties, unpaid leave) and 66 without consequences for noncompliance. Hospitals whose mandates have consequences for noncompliance included a broader range of personnel, were less likely to allow personal belief exemptions, or to require formal declination. The change in vaccination rates in hospitals with mandates with consequences (19.5%) was nearly double that of the hospitals with mandates without consequences (11%; P = .002). Presence of a state law regulating HCW influenza vaccination was associated with an increase in rates for mandates with consequences nearly 3 times the increase for mandates without consequences.Hospital mandates for HCW influenza vaccination with consequences for noncompliance are associated with larger increases in HCW influenza vaccination rates than mandates without such consequences.

Nonmedical exemptions to immunization requirements in California: A 16-year longitudinal analysis of trends and associated community factors

BackgroundRates of nonmedical exemptions to kindergarten-entry immunization requirements have increased over the past 2 decades, especially in states that permit philosophical exemptions and/or have easier administrative policies for obtaining nonmedical exemptions. We evaluated trends in school personal belief exemption rates over the period 1994–2009 in California, and associated school and community characteristics. MethodsWe used data on personal belief exemptions from 6392 public and private elementary schools from the California Department of Public Health, as well as census tract and school demographic data. Generalized estimating equations were used to model annual mean increases in personal belief exemption rates, and to identify school and community characteristics associated with personal belief exemption rates. ResultsOver the study period, the average school personal belief exemption rate increased from 0.6% in 1994 to 2.3% in 2009, an average of 9.2% (95% CI: 8.8–9.6%) per year. The average personal belief exemption rate among private schools over the entire study period was 1.77 (95% CI: 1.55–2.01) times that among public schools. The annual rate of increase was slightly higher among private schools (10.1%, 95% CI: 9.1–11.1%) than among public schools (8.8%, 95% CI: 8.4–9.2%). Schools located within census tracts classified as rural had 1.66 (95% CI: 1.26–2.08) times higher personal belief exemption rates than schools located within urban census tracts. Exemption rates were also associated with race, population density, education, and income. ConclusionsThis study confirms concerns about increasing rates of nonmedical exemptions to kindergarten vaccine requirements within the state of California, using data collected over a 16-year period.

Impact of hospital policies on health care workers’ influenza vaccination rates

Overall annual influenza vaccination rate has slowly increased among health care workers but still remains below the national goal of 90%. To compare hospitals that mandate annual health care worker (HCW) influenza vaccination with and without consequences for noncompliance, a 34-item survey was mailed to an infection control professional in 964 hospitals across the United States in 4 waves. Respondents were grouped by presence of a hospital policy that required annual influenza vaccination of HCWs with and without consequences for noncompliance. Combined with hospital characteristics from the American Hospital Association, data were analyzed using χ(2) or Fisher exact tests for categorical variables and t tests for continuous variables. One hundred fifty hospitals required influenza vaccination, 84 with consequences (wear a mask, termination, education, restriction from patient care duties, unpaid leave) and 66 without consequences for noncompliance. Hospitals whose mandates have consequences for noncompliance included a broader range of personnel, were less likely to allow personal belief exemptions, or to require formal declination. The change in vaccination rates in hospitals with mandates with consequences (19.5%) was nearly double that of the hospitals with mandates without consequences (11%; P=.002). Presence of a state law regulating HCW influenza vaccination was associated with an increase in rates for mandates with consequences nearly 3 times the increase for mandates without consequences. Hospital mandates for HCW influenza vaccination with consequences for noncompliance are associated with larger increases in HCW influenza vaccination rates than mandates without such consequences.

Correlates of high vaccination exemption rates among kindergartens

ObjectivesThe present study was designed to characterize Arizona schools with high rates of permanent PBE among kindergartners, and to determine the degree to which they aggregate across the state. MethodsData for permanent personal belief exemptions (PBE) were accessed through the 2010–2011 kindergarten Immunization Data Report (IDR) from the Arizona Department of Health Services (AZDHS), and were linked to the 2009–2010 data from the National Center of Education Statistics (NCES). Incidence rate ratios (IRR) were calculated using negative binomial regression, and hotspots were identified using Getis-Ord Gi*. ResultsSchools with highest proportion of white students compared to the lowest had the highest exemption rates (IRR=14.11; 95% confidence interval [CI], 9.47–21.03); furthermore charter schools and those with low prevalence of free and reduced lunches had significantly higher rates of PBE. Statewide analyses of PBE identified higher rates of permanent PBE in northern vs. southern Arizona, while a more focused examination of the central Arizona region demonstrated a pattern of increased PBE from west to east. ConclusionIn Arizona, the profile of a high PBE school is that of a charter school attended by predominantly white, higher-income students. The local and statewide hotspots serve as a challenge that requires a multi-faceted approach that calls upon all healthcare professionals. It is important that both local and statewide pockets be targeted by local and state officials either to improve vaccination uptake or to employ careful monitoring to identify outbreaks at their onset.

Personal Belief Exemptions for Vaccines: What Is Just?

Parental refusal or delay in vaccination of their children has become a vexing problem for many pediatric health care providers and has led to communicable disease outbreaks in the United States and Europe. Personal belief exemptions allow parents to opt out of having their children receive vaccinations required for school or child care entry. Personal belief exemptions can be based on religious beliefs or political ideology. There are also “self-interest maximizers” who choose for their child to benefit from herd immunity without incurring the risks of vaccination.Tension arises when parents, in the interest of preserving their individual freedom to decide what they believe to be best for their children, choose against the common good. Two groups of ethicists have recently weighed in on this issue.1,2Lantos, Jackson, and Harrison argue that personal belief exemptions should not be allowed on the basis that vaccines are very safe and have far fewer risks than the diseases they prevent.1 They assert that vaccination of individual children also has the benefit of promoting herd immunity. These authors affirm that personal belief exemptions put both the individual child and the public at increased risk. They recommend eliminating personal belief exemptions to vaccine mandates when a disease is potentially deadly, occurs during childhood, and there is a safe and effective vaccine.Opel and Diekema agree that vaccines are safe, efficient, protect the individual as well as the community, and that a link exists between exemptors and the transmission of disease.2 They argue, on the basis of both health policy and morality, that a just vaccine policy need not forbid parents from exercising their personal belief exemptions. The authors believe a ban would, perversely, make parents resist even more. Instead, they recommend making personal belief exceptions more difficult to obtain, by adding the additional step of requiring a conference with a child’s physician before an exemption is granted. Opel and Diekema also recommend financial incentives such as a decrease in insurance rates and/or state rebates for receiving vaccines and the removal of financial barriers by establishment of a publicly funded immunization program with no individual out-of-pocket cost.Society recognizes that parents are their children’s principal caretakers, responsible for their well-being, with a wide range of discretion as to what that well-being will include. In most cases, fully informed parents are the best decision-makers for their children. At the same time, parents are morally and legally obligated to observe certain standards in the decisions they make for their children.Must individual freedom be restricted? What is the just decision? The tenets of patient/family-centered care demand substantial and sometimes difficult effort by physicians to engage parents as partners in medical decision-making for their children. Complete and accurate information on the risks and benefits of vaccination to their child and for the community must be provided, with empathetic persuasion, cultural sensitivity, and an effort to reconcile with dissenting parents.The decision to vaccinate or not should not be made by parents in isolation; pediatricians and others providing health care to children must do their best to ensure that it is a fully informed decision. Society ought not supersede the authority of the fit parent. A ban on personal exemptions would be considered coercive by many. Financial incentives could be helpful, although they may not sway the decision of many parents. This is not a cost issue, but a battle fought best by earned trust and relationship, not legal mandates.

The financial impact of a state adopting a personal/philosophical belief exemption policy: Modeling the cost of pertussis disease in infants, children and adolescents

State school immunization exemption policies help reduce the risk of individual and community disease. Assessing the costs of vaccine preventable disease associated with a state adding a philosophical/personal belief school exemption policy is useful for making future policy decisions. Two formulas were developed to estimate the infant, child and adolescent hospitalization and non-medical costs of pertussis disease that are associated with adding a philosophical/personal belief school exemption policy. The parameter estimates were obtained from peer reviewed literature and the Centers for Disease Control and Prevention. The state of Iowa was used as an example in order to demonstrate how the formulas can be applied. The annual projected impact of pertussis disease in Iowa is $273,365 without a philosophical/personal belief exemption policy and an average of $410,047 (range of $281,566–$582,267) with adding a personal belief exemption policy. We project that adding a philosophical/personal belief exemption will cost 50% more dollars annually.

Exposure of California Kindergartners to Students With Personal Belief Exemptions From Mandated School Entry Vaccinations

Personal belief exemptions (PBEs) from mandated school entry vaccinations have increased in California over the past decade. Infectious disease outbreaks in the state may be associated with the aggregation of intentionally unvaccinated children within schools. We sought to quantify the exposure of California kindergartners to children with PBEs at school. We used cross-sectional California Department of Public Health data on 3 kindergarten cohorts to define and calculate multiple measures of exposure to children with exemptions, including interaction and aggregation indices, for the state as a whole (2008-2010) and by county (2010). In 2010, the PBE rate in California was 2.3 per 100 students, and the school PBE rate for the average kindergartner with a PBE was 15.6 per 100. More than 7000 kindergartners in California attend schools with PBE rates greater than 20 per 100, including 2700 kindergartners with PBEs. Exposure measures vary considerably across counties. Our results suggest increasing levels of exposure among kindergarten students in California to other kindergartners with PBEs. Our data provide a concrete set of metrics through which public health and education officials can identify high-risk areas as targets for policy and programmatic interventions.

Risk factors associated with parents claiming personal-belief exemptions to school immunization requirements: Community and other influences on more skeptical parents in Oregon, 2006

With vaccine-preventable diseases at record lows, few studies investigate rising parent-claimed exemptions to school immunization requirements. After finding exemption clusters in Oregon, we hypothesized that exemption risk factors may vary among communities. We surveyed parents to identify risk factors for exemptions and evaluated risk factor differences among communities with differing exemption rates. Retrospective cohort study, multi-staged, population-proportionate sampling. Parents of 2004-05 Oregon elementary school children (N=2900). Parent-reported exemption status. The response rate was 55%. Compared to vaccinators, exemptors were significantly more likely to have: strong vaccine concerns (weighted adjusted odds ratio (aOR)=15.3, 95% CI 6.4-36.7); "vaccine-hesitant" concerns (aOR=2.3; 95% CI 1.0-5.0); >1 childbirth(s) at a non-hospital, alternative setting (aOR=3.6; 95% CI 1.6-8.0); distrust of local doctors (aOR=2.7; 95% CI 1.0-7.5); reported chiropractic healthcare for their youngest school-age child (aOR=3.9; 95% CI 1.8-8.5); and reported knowledge of someone with a vaccine-hurt child (aOR=1.8; 95% CI 0.9-3.4). Exemptors were less likely to have "pro-vaccine" beliefs (aOR=0.2; 95% CI 0.0-0.6) and less likely to report relying on print materials (aOR=0.4; 95% CI 0.2-0.8). The strengths of association differed significantly for those with strong vaccine concerns and those reporting knowledge of someone with a vaccine-hurt child, depending on residence in exemption-rate areas, e.g., exemptors in medium-rate areas were more likely to have strong vaccine concerns (aOR=13.5; 95% CI 5.4-34.0) than those in high-rate areas (aOR=9.7; 95% CI 3.7-25.4). Vaccine beliefs were important risk factors. That differing community-level exemption use modified the effects of several individual-level factors suggests that communities also influence parent decisions. Therefore, understanding community contexts and norms may be important when designing interventions.

Finding the Proper Balance between Freedom and Justice: Why We Should Not Eliminate Personal Belief Exemptions to Vaccine Mandates

Lantos and colleagues (this issue) propose to eliminate personal belief exemptions from school vaccine mandates, particularly for those vaccines that target deadly contagious childhood disease. They argue that not doing so would be unjust. In this counterpoint, we argue that, for reasons grounded in both health policy and morality, a just vaccine policy need not prohibit parents from claiming personal belief exemptions.

Why We Should Eliminate Personal Belief Exemptions to Vaccine Mandates

We argue that personal belief exemptions to the mandate for childhood immunizations should not be allowed. Parents who choose not to immunize their children put both their own children and other children at risk. Other children are at risk because unimmunized children go to school or day care when they are contagious but asymptomatic, exposing many more children to potentially dangerous infections. The risks to children from disease are much higher than the risks of vaccines. There are, of course, some bona fide reasons why children should not be immunized. Some children have known allergies or other medical contraindications to certain immunizations. Immunization refusals based on parental beliefs, however, do not fall into this category. In those cases, children are denied the protection of immunizations without any medical or scientific justification. By eliminating personal belief exemptions to those childhood vaccines associated with contagious diseases that have high rates of childhood mortality, we would better protect children and would more fairly spread the burdens of this important public health program.

Measles in the United States during the Postelimination Era

Measles affected entire birth cohorts in the prevaccine era but was declared eliminated in the United States in 2000 because of a successful measles vaccination program. We reviewed US surveillance data on confirmed measles cases reported to the Centers for Disease Control and Prevention and data on national measles-mumps-rubella (MMR) vaccination coverage during postelimination years 2001-2008. During 2001-2008, a total of 557 confirmed cases of measles (annual median no. of cases, 56) and 38 outbreaks (annual median no. of outbreaks, 4) were reported in the United States; 232 (42%) of the cases were imported from 44 countries, including European countries. Among case-patients who were US residents, the highest incidences of measles were among infants 6-11 months of age and children 12-15 months of age (3.5 and 2.6 cases/1 million person-years, respectively). From 2001 through 2008, national 1-dose MMR vaccine coverage among children 19-35 months of age ranged from 91% to 93%. From 2001 through 2008, a total of 285 US-resident case-patients (65%) were considered to have preventable measles (ie, the patients were eligible for vaccination but unvaccinated). During 2004-2008, a total of 68% of vaccine-eligible US-resident case-patients claimed exemptions for personal beliefs. The United States maintained measles elimination from 2001 through 2008 because of sustained high vaccination coverage. Challenges to maintaining elimination include large outbreaks of measles in highly traveled developed countries, frequent international travel, and clusters of US residents who remain unvaccinated because of personal belief exemptions.

Nonmedical Exemptions to School Immunization Requirements

School immunization requirements have played a major role in controlling vaccine-preventable diseases in the United States. Most states offer nonmedical exemptions to school requirements (religious or personal belief). Exemptors are at increased risk of acquiring and transmitting disease. The role of exemption policies may be especially important for pertussis, which is endemic in the United States. To determine if (1) the rates of nonmedical exemptions differ and have been increasing in states that offer only religious vs personal belief exemptions; (2) the rates of nonmedical exemptions differ and have been increasing in states that have easy vs medium and easy vs difficult processes for obtaining exemptions; and (3) pertussis incidence is associated with policies of granting personal belief exemptions, ease of obtaining exemptions, and acceptance of parental signature as sufficient proof of compliance with school immunization requirements. We analyzed 1991 through 2004 state-level rates of nonmedical exemptions at school entry and 1986 through 2004 pertussis incidence data for individuals aged 18 years or younger. State-level exemption rates and pertussis incidence. From 2001 through 2004, states that permitted personal belief exemptions had higher nonmedical exemption rates than states that offered only religious exemptions, and states that easily granted exemptions had higher nonmedical exemption rates in 2002 through 2003 compared with states with medium and difficult exemption processes. The mean exemption rate increased an average of 6% per year, from 0.99% in 1991 to 2.54% in 2004, among states that offered personal belief exemptions. In states that easily granted exemptions, the rate increased 5% per year, from 1.26% in 1991 to 2.51% in 2004. No statistically significant change was seen in states that offered only religious exemptions or that had medium and difficult exemption processes. In multivariate analyses adjusting for demographics, easier granting of exemptions (incidence rate ratio = 1.53; 95% confidence interval, 1.10-2.14) and availability of personal belief exemptions (incidence rate ratio = 1.48; 95% confidence interval, 1.03-2.13) were associated with increased pertussis incidence. Permitting personal belief exemptions and easily granting exemptions are associated with higher and increasing nonmedical US exemption rates. State policies granting personal belief exemptions and states that easily grant exemptions are associated with increased pertussis incidence. States should examine their exemption policies to ensure control of pertussis and other vaccine-preventable diseases.