School Immunization Requirements Research Articles

Moving the Needle: A Qualitative Exploration of the School Nurses' Experience with Virginia's Human Papillomavirus Mandate.

In all US localities, students provide proof of compliance with vaccination requirements to attend school. Despite benefits, vaccine legislation remains contentious. The human papillomavirus (HPV) vaccine is recommended for adolescents and prevents cancer, but its inclusion in school immunization requirements is challenged. Virginia was the first state to mandate HPV vaccination. HPV is the only required vaccine in VA that allows caregivers to elect out. School nurses are trusted members of communities and enforce vaccine compliance. This study aims to understand Virginia school nurses' practice in implementing the HPV vaccine mandate through the exploration of their subjective experiences. Semi-structured interviews were conducted. Thematic analysis using the socioecological model guided data analysis. Factors that influence nursing practice were identified at all socioecological model levels The data from this study is intended to provide an understanding of school nursing practice so that interventions to improve HPV vaccination rates can be developed.

Data-Driven Assessment of Nonmedical Vaccination Exemption Can Guide Public Health Response.

Kindergarten immunization requirements are an important inflection point to ensure children are fully vaccinated before they begin school, but some parents choose to obtain an exemption from school immunization requirements. All states have medical exemptions, and 47 states also offer nonmedical (philosophical and/or religious) ones, with considerable variation in the process to obtain the exemption.1 Eleven states mandate some type of education, ranging from online modules to in-person meetings, before receiving a nonmedical exemption (NME).2Nationally, the proportion of kindergartners with an NME has increased from 1.4% for the 2011–2012 school year to 2.6% for the 2019–2020 school year, whereas medical exemptions have remained at 0.2%.3 Clusters of high exemption rates can lead to outbreaks of vaccine-preventable diseases.4In this issue of Pediatrics, Masters et al5 assess the impact of a 2014 change in Michigan’s administrative rules6 to require parents to attend a vaccine education session at a local health department to obtain an NME. Masters et al5 analyzed school-level data on kindergarten vaccination requirements for 4 years before and after implementation of the new rules (2011–2014, 2015–2018) to calculate medical, philosophical, and religious exemption rates. They mapped school-level exemption rates to the district level and used the local indicators of spatial association to identify school districts with clusters of high exemption rates.Before the administrative rules change, Michigan parents could obtain an exemption at their child’s school, a situation ripe for “convenience exemptions,” in which it was easier for parents to get an exemption than to get their child up to date with vaccination requirements.2 Masters et al5 noted that from 2014 to 2015, immediately after the change in the administrative rules, NME rates fell by 32% but then increased in the 3 subsequent years. In the context of increasing NME rates nationwide,3 these findings suggest that the new NME policy successfully minimized exemptions of convenience but, given reports that few parents changed their decision secondary to the education session at the local health department,7 had minimal impact on exemptions of conviction linked to parental vaccine hesitancy.Overall NME trends mask a marked difference by school type. From 2015 to 2018, public school NME rates increased 25%; although private schools began with a higher NME rate, they had an even slower rate of increase. Over the same period, charter and virtual school NME rates increased ≥80%, suggesting a vastly different trajectory for vaccine hesitance in these settings. The study also identified school-level demographic characteristics (white, college educated, affluent) associated with high NME rates in other studies.8A strength of this study is the differentiation between the 3 types of exemptions and the description of the persistence of clustering over multiple years. The multiyear district-level information provided in this study would be useful to public health officials in every state. It would enable them to better understand the nuances of NME patterns so that they could develop partnerships and devise an array of strategies to address exemptions of conviction, specifically around clusters of religious or philosophical exemptions. This type of data also signals early trends, allowing public health officials to proactively address emerging problems, such as the extremely high NME rate in virtual schools, which are gaining in student enrollment.Although focused on NMEs, the study also revealed areas where persistent medical exemption clusters disappeared after the administrative rules change, as well as the appearance of a new medical exemption cluster. These unexpected patterns serve as a reminder that child health providers should be prudent in offering medical exemptions to vaccination.

Political Will, Vaccines, and Community Immunity.

Political Will, Vaccines, and Community Immunity.

Shouting at each other into the void: A linguistic network analysis of vaccine hesitance and support in online discourse regarding California law SB277.

In 2015, California passed Senate Bill 277 and became the third state in the United States to ban all nonmedical exemptions from school immunization requirements, effectively prohibiting religious and personal belief exemptions. This attracted grassroots opposition and considerable debate among vaccine hesitant factions online. This mixed-methods study used quantitative linguistic analysis, semantic network analysis, and content analysis techniques to examine 2424 online documents drawn from newspapers, blogs, health websites, government information pages, web forums, personal websites, Facebook groups, among others. The study examined which words and phrases were used most frequently by vaccine skeptics, vaccine defenders, and more neutral media accounts to illuminate how groups with different attitudes towards vaccination discuss and disseminate information about vaccines and vaccine policy online. We proposed an innovative methodology for examining online discourse surrounding vaccine hesitance, as well as for studying the online dissemination of misinformation about vaccines. Our findings highlighted discrepancies in the narratives between what vaccine supporters believe causes vaccine skepticism and the issues that vaccine skeptics actually discuss within their own digital spaces. For example, in these exchanges, the importance of parental rights overshadowed that of children's rights; supporters of vaccines brought up autism in more distinct documents than skeptics do; distrust of government regulators and researchers seemed to unite vaccine skeptics and defenders; and politicians, doctors, and even celebrities often served as proxies in heated exchanges about factual evidence, believability, and the importance of expertise in public discourse.

Exploring California’s new law eliminating personal belief exemptions to childhood vaccines and vaccine decision-making among homeschooling mothers in California

BackgroundCalifornia’s Senate Bill 277 (SB-277) law eliminated the personal belief exemption to school immunization requirements. A potential consequence may be that parents choose homeschooling to avoid immunization. Vaccine attitudes and behaviors have not been well studied among the home-schooling population. This study explored the effect of SB-277 and vaccine decision-making among California home schoolers. MethodsPurposive and snowball sampling were used recruit home-schooling parents through home-schooling Facebook groups based on home school type in high-exemption regions in California for in-depth interviews. Participants had to have a child in a legalized form of homeschooling in California in grades kindergarten-twelfth grade. ResultsTwenty-four mothers were interviewed. Participants were categorized based on self-reported vaccine attitudes and behavior into three groups: Confident and Accepting, Hesitant and Accepting, and Skeptical and Refusing. All reported the belief that SB-277 is an infringement on parental rights but was not currently impacting them. Confident and Accepting mothers (n = 10) generally believed vaccinations were safe, effective, and posed a lower risk than vaccine preventable disease (VPD). Hesitant and Accepting mothers (n = 5) expressed varying confidence levels in the belief that vaccinations were safe and effective, were not confident in the belief that vaccination posed lower risks than VPD risk, and risk perception affected vaccine decision-making. Skeptical and Refusing mothers (n = 9) generally believed that vaccinations were unsafe and ineffective, refused select vaccines, believed that vaccination posed a more serious risk than VPD risks, and belief of vaccine harm was a salient factor in vaccine decision-making. ConclusionHome-schooling mothers were concerned about SB-277 but did not report that it was directly impacting their children, their vaccine decisions, or reason to home school. Vaccine attitudes and beliefs among homeschooling mothers broadly fell into categories similar to parents of non-home-schooled children. Future quantitative studies should measure vaccine hesitancy and refusal prevalence and potential confounders.

Licensure, Approval, and Uptake of Vaccines in the United States.

Immunization is one of the most effective public and private preventive health interventions, resulting in significant reductions in vaccine-preventable diseases and in substantial cost savings to the US healthcare system. Vaccine licensure, development of recommendations for use, and implementation of those recommendations leading to uptake, community protection, and effect on disease burden represent a complex system that requires collaboration in the areas of basic science, public health, vaccine delivery, outcome monitoring, and public perception. The Advisory Committee on Immunization Practices (ACIP) sets standards for immunization delivery for both public and private vaccine providers, and state immunization programs can use these ACIP recommendations to develop school immunization requirements.

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.

Parental attitudes and perceptions associated with childhood vaccine exemptions in high-exemption schools.

Previous work demonstrates that individuals who obtain exemptions from school immunization requirements are geographically clustered, making regional differences in vaccination coverage a significant concern. Even where exemption levels are high, there are still parents that vaccinate. School-level assessments have determined that exemptors are more likely to attend wealthier schools with fewer minorities. Few studies have assessed divergent opinions within the context of a higher-exemption community to examine subtle differences in opinion surrounding vaccinations. Therefore, the objective of this work was to assess attitudes and perceptions towards vaccinations and compare them for exemptors and non-exemptors. We administered surveys to parents in high-exemption (>10%) elementary schools in Arizona during the 2012–13 school year. A total of 404 surveys were completed by parents among schools in Maricopa (n = 7) and Yavapai (n = 2) counties. Of these, 35% (n = 141) were exemptors and 65% (n = 261) were non-exemptors. Exemptors were more likely than non-exemptors to be concerned about serious side-effects (p<0.001). They were more likely to report knowing someone who had been diagnosed with a vaccine-preventable disease (p<0.001) but less likely to report that this had been a serious illness in that person (p<0.001) and they believed it is better for a child to develop immunity through illness than vaccination (p<0.001). They were less likely to trust physicians (p<0.001) and information about vaccines (p<0.001) and were more likely to obtain their health care from a naturopath (p<0.001). In summary, exemptors in these Arizona schools do not appear to be exempting their children from vaccinations due to convenience, as has been hypothesized in other settings. Based on the divergent views within high-exemption schools and reported distrust of the medical establishment, target interventions for high-exemption schools are discussed. Additionally, given the lack of effective non-policy based interventions to-date, the negligible declines in personal belief exemption rates, and vaccine preventable disease rate increases in Arizona, especially in high-exemption areas, legislative action in Arizona may also warrant further investigation.

Immunization Mandates, Vaccination Coverage, and Exemption Rates in the United States.

BackgroundVaccination coverage among children entering kindergarten in the United States is high, but interstate variations exist. The relationship between state immunization laws and vaccination coverage has not been fully assessed. We evaluated associations of state laws on both measles, mumps, and rubella (MMR) and diphtheria, tetanus, and pertussis (DTaP) vaccination coverage and exemptions to school immunization requirements.MethodsWe conducted a retrospective, longitudinal analysis of the effect of state immunization laws on vaccination coverage and exemptions among US kindergarteners from SY 2008 to SY 2014. The primary outcome measures were state-level kindergarten entry vaccination coverage rates for 2-dose MMR and 4-dose DTaP vaccines. Secondary outcome measures included rates of state-level exemptions (ie, medical, religious, philosophical) to school immunization requirements.ResultsWe found that state policies that refer to Advisory Committee on Immunization Practices recommendations were associated with 3.5% and 2.8% increases in MMR and DTaP vaccination rates. Health Department–led parental education was associated with 5.1% and 4.5% increases in vaccination rates. Permission of religious and philosophical exemptions was associated with 2.3% and 1.9% decreases in MMR and DTaP coverage, respectively, and a 1.5% increase in both total exemptions and nonmedical exemptions, respectively.ConclusionsWe found higher vaccination coverage and lower nonmedical exemption rates for MMR and DTaP vaccines in states adopting Advisory Committee on Immunization Practices guidelines for school entry. Adherence to these best practices was a successful strategy to increase vaccination coverage and reduce vaccination exemptions.

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.

An Evidence-Based Project Demonstrating Increased School Immunization Compliance Following a School Nurse-Initiated Vaccine Compliance Strategy.

During the 2012-2013 school year, only 66% of students at a Northern Indiana High School were in compliance with school immunization requirements. We report here successful implementation of evidence-based, time, and cost-effective methods aimed at increasing school immunization compliance. A three-stage strategy initiated by the school nurse was employed. In the first stage, letters were sent home with students, indicating the lack of compliance with school immunization laws. The next stage involved a second letter sent home with the student which contained immunization information from the Indiana State Department of Health, appointment information, and a copy of the student's immunization record. In the final stage, letters were sent home via e-mail and phone calls were used for follow-up. At each stage, students and parents were given an explanation of exclusion and a date when exclusion would apply. Postintervention, vaccine compliance was 99.6%, exceeding both national and state averages.

Co-Opting Discrimination to Augment Privilege: Misuse of Claims of Discrimination by Anti-Vaccine Activists

In their efforts to fight against tightening of school immunization requirements anti-vaccine activists have repeatedly claimed that such tightening discriminates against, or even segregates, intentionally non-vaccinated children. They have drawn on language and imagery created in response to racial discrimination against minority groups. This essay explains why such claims are legally incorrect - and pragmatically inappropriate. First, unvaccinated children are meaningfully different from the vaccinated. Second, not vaccinating is a choice, and not an immutable characteristic. Treating non-vaccinating parents differently is closer to different treatment of those who drink and drive than to different treatment of racial minorities. Finally, the use of the discrimination language is troubling here. Most parents that do not vaccinate (though not all) belong to privileged groups. Vaccine refusal is much more common among white, middle class people. Using the language created to protect disadvantaged minorities from oppression in this context is incorrect and jarring.

Decoupling Vaccine Laws

When a parent decides not to vaccinate, that parent is deciding to leave the child at risk of preventable disease - a much larger risk than the small risk of vaccine injury. Arguably, the law has some tools to protect the child from that decision, including family law court decisions, injunctions in cases of high risk, and tort or criminal liability if a child is harmed.This short essay explains that exemptions from school immunization requirements do not prevent the law from protecting a child against parental decisions not to vaccinate her, or compensating a child harmed by non-vaccinating. School immunization requirements, however, may be a barrier to criminal liability for non-vaccinating.

Vaccine hesitancy: Causes, consequences, and a call to action

Vaccine hesitancy reflects concerns about the decision to vaccinate oneself or one's children. There is a broad range of factors contributing to vaccine hesitancy, including the compulsory nature of vaccines, their coincidental temporal relationships to adverse health outcomes, unfamiliarity with vaccine-preventable diseases, and lack of trust in corporations and public health agencies. Although vaccination is a norm in the U.S. and the majority of parents vaccinate their children, many do so amid concerns. The proportion of parents claiming non-medical exemptions to school immunization requirements has been increasing over the past decade. Vaccine refusal has been associated with outbreaks of invasive Haemophilus influenzae type b disease, varicella, pneumococcal disease, measles, and pertussis, resulting in the unnecessary suffering of young children and waste of limited public health resources. Vaccine hesitancy is an extremely important issue that needs to be addressed because effective control of vaccine-preventable diseases generally requires indefinite maintenance of extremely high rates of timely vaccination. The multifactorial and complex causes of vaccine hesitancy require a broad range of approaches on the individual, provider, health system, and national levels. These include standardized measurement tools to quantify and locate clustering of vaccine hesitancy and better understand issues of trust; rapid, independent, and transparent review of an enhanced and appropriately funded vaccine safety system; adequate reimbursement for vaccine risk communication in doctors' offices; and individually tailored messages for parents who have vaccine concerns, especially first-time pregnant women. The potential of vaccines to prevent illness and save lives has never been greater. Yet, that potential is directly dependent on parental acceptance of vaccines, which requires confidence in vaccines, healthcare providers who recommend and administer vaccines, and the systems to make sure vaccines are safe.

Vaccine Hesitancy: Causes, Consequences, and a Call to Action.

Vaccine hesitancy reflects concerns about the decision to vaccinate oneself or one's children. There is a broad range of factors contributing to vaccine hesitancy, including the compulsory nature of vaccines, their coincidental temporal relationships to adverse health outcomes, unfamiliarity with vaccine-preventable diseases, and lack of trust in corporations and public health agencies. Although vaccination is a norm in the U.S. and the majority of parents vaccinate their children, many do so amid concerns. The proportion of parents claiming non-medical exemptions to school immunization requirements has been increasing over the past decade. Vaccine refusal has been associated with outbreaks of invasive Haemophilus influenzae type b disease, varicella, pneumococcal disease, measles, and pertussis, resulting in the unnecessary suffering of young children and waste of limited public health resources. Vaccine hesitancy is an extremely important issue that needs to be addressed because effective control of vaccine-preventable diseases generally requires indefinite maintenance of extremely high rates of timely vaccination. The multifactorial and complex causes of vaccine hesitancy require a broad range of approaches on the individual, provider, health system, and national levels. These include standardized measurement tools to quantify and locate clustering of vaccine hesitancy and better understand issues of trust; rapid, independent, and transparent review of an enhanced and appropriately funded vaccine safety system; adequate reimbursement for vaccine risk communication in doctors' offices; and individually tailored messages for parents who have vaccine concerns, especially first-time pregnant women. The potential of vaccines to prevent illness and save lives has never been greater. Yet, that potential is directly dependent on parental acceptance of vaccines, which requires confidence in vaccines, healthcare providers who recommend and administer vaccines, and the systems to make sure vaccines are safe.

Vaccines, School Mandates, and California's Right to Education

California recently enacted Senate Bill 277, which abolishes the personal-beliefs exemption to school immunization requirements. One possible challenge to the law’s constitutionality is that it impermissibly limits the right to education. This Essay rebuts such positions. California’s jurisprudence regarding access to education applies to protected categories; it does not limit the ability of the state to impose health and safety regulations such as immunization requirements. Moreover, the requirement would withstand even strict scrutiny, if applied, because disease prevention in the school context is a compelling interest and there is no alternative that is as effective. Finally, the law actually protects the right of access to education for those whose parents do not have the luxury of choice, such as immune-compromised children, while still reasonably preserving parental choice overall.

Measles in our time: the US experience.

Measles in our time: the US experience.

Variation in exemptions to school immunization requirements among New York State private and public schools

Background and objectivesSchool immunization requirements have ensured high vaccination rates and have helped to control vaccine-preventable diseases. However, vaccine exemptions have increased in the last decade. This study compared New York State private versus public schools with respect to medical and religious exemption rates. MethodsThis retrospective study utilizes New York State Department of Health Immunization Survey data from the 2003 through 2012 academic years. Schools were categorized as private or public, the former further categorized by religious affiliation. Rates of medical and religious vaccine exemptions were compared by school category. ResultsFrom 2003 to 2012, religious exemptions increased in private and public schools from 0.63% to 1.35% and 0.17% to 0.29% (Spearman's R: 0.89 and 0.81), respectively. Among private schools, increases in religious exemption rates during the study period were observed in Catholic/Eastern Orthodox, Protestant/Other Christian, Jewish, and secular schools (Spearman's R=0.66, 0.99, 0.89, and 0.93), respectively. Exemption rate ratios in private schools compared to public schools were 1.39 (95% CI 1.15–1.68) for medical and 3.94 (95% CI: 3.20–4.86) for religious exemptions. Among private school students, all school types except for Catholic/Eastern Orthodox and Episcopal affiliates were more likely to report religious exemptions compared to children in public schools. ConclusionsMedical and religious exemption rates increased over time and higher rates were observed among New York State private schools compared to public schools. Low exemption rates are critical to minimize disease outbreaks in the schools and their community.

Nonmedical exemptions from school immunization requirements: a systematic review.

We summarized studies describing the prevalence of, trends in, and correlates of nonmedical exemptions from school vaccination mandates and the association of these policies with the incidence of vaccine-preventable disease. We searched 4 electronic databases for empirical studies published from 1997 to 2013 to capture exemption dynamics and qualitatively abstracted and synthesized the results. Findings from 42 studies suggest that exemption rates are increasing and occur in clusters; most exemptors questioned vaccine safety, although some exempted out of convenience. Easier state-level exemption procedures increase exemption rates and both individual and community disease risk. State laws influence exemption rates, but policy implementation, exemptors' vaccination status, and underlying mechanisms of geographical clustering need to be examined further to tailor specific interventions.

The Complexity of the Resurgence of Childhood Vaccine-Preventable Diseases in the United States

Vaccines have saved the lives of innumerable children from infectious diseases. In the United States, state mandates for school immunization requirements and federal funding have enabled high immunization coverage and have resulted in historic low levels of many infectious diseases. However, in recent years, there have been widespread outbreaks of a number of vaccine-preventable infectious diseases, including measles, mumps, and pertussis. Reasons for these resurgences vary and are complex. They include decreases in vaccination rates, waning immunity, changes in the vaccine, and changes in the pathogen.