Nonmedical exemptions from school immunization requirements: a systematic review

Current landscape of nonmedical vaccination exemptions in the United States: impact of policy changes

INTRODUCTION

In the United States, high childhood vaccination coverage has reduced the morbidity and mortality due to vaccine-preventable diseases. The success of vaccination programs in achieving this high coverage is due, in part, to vaccination mandates for school entry. All states have such mandates, but there is heterogeneity across the states in the allowance of non-medical exemptions (e.g. religious or personal belief exemptions) to these mandates.

AREAS COVERED

We examine historical trends in non-medical exemption prevalence in the US, discuss recent state-level policy changes that may impact non-medical exemption prevalence, and review recent studies on the association between non-medical exemptions and infectious disease outbreaks.

EXPERT COMMENTARY

State-level implementation of mandates, and related allowances for medical and non-medical exemptions, varies greatly across the United States. Non-medical exemption rates have increased over the last two decades, with an increased risk of disease outbreaks in clusters of children with non-medical exemptions due to differences in state laws. Recent efforts to address non-medical exemption rates range from incorporating additional administrative requirements for exemptions and disallowance of any non-medical exemptions. Continued monitoring is needed to evaluate the impact of these changes on exemption rates, to develop optimal childhood vaccination policy across the United States.

Trends and Characteristics of Proposed and Enacted State Legislation on Childhood Vaccination Exemption, 2011-2017

Objectives. To examine trends and characteristics of proposed and enacted state legislation that would directly affect states' immunization exemption laws.Methods. We performed content analysis of proposed bills in state legislatures from 2011 to 2017. We classified bills as provaccination or antivaccination.Results. State legislators proposed 175 bills, with the volume increasing over time: 92 (53%) bills expanded access to exemptions, and 83 (47%) limited the ability to exempt. Of the 13 bills signed into law, 12 (92%) limited the ability to exempt. Bills that expanded access to exemptions were more likely to come from Republican legislators and Northeastern and Southern states.Conclusions. Although most proposed legislation would have expanded access to exemptions, bills that limited exemptions were more likely to be enacted into law. Legal barriers to exempt one's children from vaccination persist despite vaccine hesitancy, which is encouraging for public health.Public Health Implications. Most vaccine exemption laws introduced in state legislatures would pose threats to the public's health. There is a need for constituents to engage their elected legislators and advocate provaccination policies.

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.

Exploring reasons for vaccine-hesitancy among higher-SES parents in Perth, Western Australia

ISSUES ADDRESSED

The increasing prevalence among higher-socioeconomic (higher-SES) parents in Perth, Western Australia (WA), to be vaccine-hesitant (VH) is placing herd immunity at risk.

METHODS

Eighteen one-on-one interviews were conducted; (n = 11) parents who earned >$125 000 pa and expressed ever having concerns surrounding vaccination; (n = 7) health care professionals (HCPs), who provided clinical services. Using grounded theory methodology, data were analysed by constant coding and comparison until themes emerged and an explanatory model was developed.

RESULTS

Four main areas leading to vaccine-hesitancy emerged from the data: We are Educated; We Control our Health; Safe from Disease, At Risk from Vaccines; and What We Want. Parents believed themselves capable of making good vaccination decisions based on their higher education levels and self-sourced vaccination information, yet frequently sought reassurance. Healthism concepts were adopted and parents believed lifestyle factors could control for vaccine-preventable diseases (VPD). Risk perception of disease was low and influenced by the remote geographic location of Perth, whilst perceived negative consequences of vaccination were high. A reduced concept of the social responsibility for vaccination and understanding of herd immunity emerged. Parents called for vaccine contents to be listed and requested more information on why vaccination was necessary.

CONCLUSION

Four areas of VH emerged and reflected parents' belief that higher educational and socioeconomic status, previous successes in life and where they live would result in positive health outcomes and reduce the risk of contracting VPDs. SO WHAT?: This study provides new research into the perceptions among higher-SES VH parents who live in Perth, WA. It provides a model that fills a significant gap in information that could be used effectively for future health promotion interventions.

Potential strategies to improve childhood immunization rates in Canada

Immunization rates in Canada are suboptimal. Strategies such as making immunization mandatory for child care or school entry and financial incentives are used in other countries. Additional strategies that could work in the Canadian context include requiring accurate immunization records at school entry, implementing immunization registries at the provincial/territorial level, educating parents and school-aged children about vaccine-preventable diseases and making it more convenient for parents to ensure their children are fully immunized.

A Review of Traditional Vaccine-Preventable Diseases and the Potential Impact on the Otolaryngologist

Introduction  A majority of otolaryngologists have not had direct experience with many vaccine-preventable diseases since the creation of national vaccination programs. Despite the elimination of endemic transmission of some of these diseases in the United States, outbreaks can occur anywhere and still pose a threat to public health around the world. Recent outbreaks and changing trends in exemption rates indicate that it is important for physicians to maintain a working knowledge of how these diseases present and of the recommended treatment guidelines. Objectives  This review will evaluate the current state of vaccination rates, vaccine exemption rates and disease incidence in the United States and in the world. It will also examine the clinical presentation and treatment recommendations of these diseases. Data Synthesis  United States estimated vaccination rates, vaccine exemption rates and vaccine-preventable disease incidences were obtained from data compiled by the Centers for Disease Control and Prevention. World vaccination rates and disease incidences were obtained from the World Health Organization databases, which compile official figures reported by member states. A PubMed literature review provided information on the current state of vaccination exemptions and outbreaks in the United States. Conclusion  Vaccination and vaccine exemption rates continue to put the United States and many areas of the world at risk for outbreaks of vaccine-preventable diseases. Clinical guidelines should be reviewed in the event of a local outbreak.

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.

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.

Examining the spatiotemporal evolution of vaccine refusal: nonmedical exemptions from vaccination in California, 2000-2013

BACKGROUND

Vaccine hesitancy continues to be an issue throughout the United States, as numerous vaccine hesitant parents are choosing to exempt their children from school-entry vaccination requirements for nonmedical reasons, despite the safety and effectiveness of vaccines. We conduct an analysis of how vaccine refusal, measured by the use of nonmedical exemptions (based on personal or religious beliefs) from vaccination (NMEs), evolved across space and over time in California.

METHODS

Using school-entry data from the California Department of Public Health, we examined NMEs for students entering kindergarten in California from 2000 to 2013. We conduct global and local spatial autocorrelation analysis to determine whether NME use became more geographically clustered over the study period and whether the location of local clusters of high use were temporally stable. We conducted a grouping analysis that identified the general temporal trends in NME use over the time period.

RESULTS

The use of NMEs increased from 0.73% of all kindergarteners in 2000 to 3.09% in 2013 and became more geographically clustered over the study period. Local geographic clusters of high use were relatively isolated early in the study period, but expanded in size over time. The grouping analysis showed that regions with high NME use early in the study period were generally few (15% of all US Census tracts) and relatively isolated. Regions that had low initial NME use and moderate to large increases over the study period were located in close proximity to the initial high use regions. The grouping analysis also showed that roughly half of all tracts had 0% or very low NME use throughout the study period.

CONCLUSIONS

We found an observable spatial structure to vaccine refusal and NME use over time, which appeared to be a self-reinforcing process, as well as a spatially diffusive process. Importantly, we found evidence that use of NMEs in the initially isolated regions appeared to stimulate vaccine refusal in geographically proximal regions. Thus, our results suggest that efforts aimed at decreasing future NME use may be most effective if they target regions where NME use is already high, as well as the nearby regions.

Mumps: Resurgence of a once-dormant disease

Mumps is a systemic viral illness, preventable by vaccination, that typically affects children and is characterized by unilateral or bilateral swelling of the parotid glands. Uncommon complications such as orchitis, oophoritis, deafness, pancreatitis, aseptic meningitis, and encephalitis occur more often in adults. Recent outbreaks of the disease appear to be caused by a failure to maintain herd immunity in certain populations, particularly in affluent white communities. This article reviews the clinical manifestations, diagnosis, and potential complications in patients with mumps.

A Qualitative Comparative Analysis of Combined State Health Policies Related to Human Papillomavirus Vaccine Uptake in the United States

OBJECTIVES

To examine how combinations of state policies, rather than single policies, are related to uptake of human papillomavirus (HPV) vaccine.

METHODS

Using publicly available records and the literature, we characterized policies for each US state and Washington, DC, in 2015 (n = 51), including (1) Medicaid expansion, (2) policies permitting HPV vaccination in pharmacies, (3) school-entry requirements, (4) classroom sex education mandates, and (5) parental education mandates. Using qualitative comparative analysis, we identified which existing combinations of these policies were necessary and sufficient for high HPV vaccine initiation among adolescents, with National Immunization Survey-Teen data.

RESULTS

No single policy was necessary or sufficient for high HPV vaccine uptake; however, 1 set of policies had consistently high HPV vaccine uptake: adoption of all policies except parental education mandates (girls: consistency = 1.00, coverage = 0.07; boys: consistency = 0.99, coverage = 0.08).

CONCLUSIONS

We identified a set of polices related to high HPV vaccine uptake. Future studies should examine how these policies and others, individually and in combination, are associated with HPV vaccine uptake. Public Health Implications. This study provides insight into what sets of policies are consistently related to high HPV vaccine uptake.

Sharing knowledge about immunisation (SKAI): An exploration of parents' communication needs to inform development of a clinical communication support intervention

INTRODUCTION

The SKAI (Sharing Knowledge About Immunisation) project aims to develop effective communication tools to support primary health care providers' consultations with parents who may be hesitant about vaccinating their children.

AIM

This study explored parents' communication needs using a qualitative design.

METHODS

Parents of at least one child less than five years old were recruited from two major cities and a regional town known for high prevalence of vaccine objection. Focus groups of parents who held similar vaccination attitudes and intentions were convened to discuss experiences of vaccination consultations and explore their communication needs, including preferences. Draft written communication support tools were used to stimulate discussion and gauge acceptability of the tools.

RESULTS

Important differences in communication needs between group types emerged. The least hesitant parent groups reported feeling reassured upon reading resources designed to address commonly observed concerns about vaccination. As hesitancy of the group members increased, so did their accounts of the volume and detail of information they required. Trust appeared to be related to apparent or perceived transparency. More hesitant groups displayed increased sensitivity and resistance to persuasive language forms.

Variation in Human Papillomavirus Vaccine Uptake and Acceptability Between Female and Male Adolescents and Their Caregivers

HPV vaccination coverage is suboptimal. Previous research largely focused on vaccinating girls. This study aimed to identify factors associated with HPV vaccination among male and female adolescents. We conducted secondary analyses using the National Immunization Survey-Teen. We specified parallel logistic models to examine associations of adolescent, caregiver, and provider characteristics with vaccination status among boys and girls. The primary outcome was HPV vaccination status defined as unvaccinated, initiated, or completed. Additionally, we analyzed caregivers' intent to initiate or complete the three-dose series. The vaccination completion rate was 26 %. Among teens aged 13-17 years, 19 % initiated, but did not complete the vaccine. Additionally, 14 % of males completed the 3-dose series as compared to 38 % of females. Vaccination rates were higher among teens receiving a provider recommendation [girls: adjusted odds ratio (AOR) = 3.33, 95 % confidence interval (CI) (2.44, 4.55); boys: AOR = 10.0, 95 % CI (7.69, 12.5)]. Moreover, provider recommendation was associated with caregivers' intent to initiate vaccination [girls: AOR = 2.32, 95 % CI (1.77, 3.02); boys: AOR = 2.76, 95 % CI (2.22, 3.43)]. Other associations differed by gender. Higher vaccine initiation rates were associated with younger age and residing in the mid-west for girls and racial/ethnic minority and eligibility for the "Vaccine for Children" program for boys. Provider recommendation for vaccination was the strongest predictor for both genders; however, it is insufficient to achieve high coverage rates, especially among boys. Factors associated with HPV vaccination were different for males and females. These findings suggest providers should consider gender bias with regard to HPV vaccination.

Association of moral values with vaccine hesitancy

Clusters of unvaccinated children are particularly susceptible to outbreaks of vaccine-preventable disease ^1,2 . Existing messaging interventions demonstrate short-term success, but some may backfire and worsen vaccine hesitancy ³ . Values-based messages appeal to core morality, which influences the attitudes individuals then have on topics like vaccination ^4-7 . We must understand how underlying morals, not just attitudes, differ by hesitancy type to develop interventions that work with individual values. Here, we show in two correlational studies that harm and fairness foundations are not significantly associated with vaccine hesitancy, but purity and liberty foundations are. We found that medium-hesitancy parents were twice as likely as low-hesitancy parents to highly emphasize purity (adjusted odds ratio: 2.08; 95% confidence interval: 1.27-3.40). High-hesitancy respondents were twice as likely to strongly emphasize purity (adjusted odds ratio: 2.15; 95% confidence interval: 1.39-3.31) and liberty (adjusted odds ratio: 2.19; 95% confidence interval: 1.50-3.21). Our results demonstrate that endorsement of harm and fairness-ideas often emphasized in traditional vaccine-focused messages-are not predictive of vaccine hesitancy. This, combined with significant associations of purity and liberty with hesitancy, indicates a need for inclusion of broader themes in vaccine discussions. These findings have the potential for application to other health decisions and communications as well.

Vaccine exemptions and the kindergarten vaccination coverage gap

BACKGROUND

Vaccination requirements for kindergarten entry vary by state, but all states require 2 doses of measles containing vaccine (MCV) at kindergarten entry.

OBJECTIVE

To assess (i) national MCV vaccination coverage for children who had attended kindergarten; (ii) the extent to which undervaccination after kindergarten entry is attributable to parents' requests for an exemption; (iii) the extent to which undervaccinated children had missed opportunities to be administered missing vaccine doses among children whose parent did not request an exemption; and (iv) the vaccination coverage gap between the "highest achievable" MCV coverage and actual MCV coverage among children who had attended kindergarten.

METHODS

A national survey of 1465 parents of 5-7year-old children was conducted during October 2013 through March 2014. Vaccination coverage estimates are based provider-reported vaccination histories. Children have a "missed opportunity" for MCV if they were not up-to-date and if there were dates on which other vaccines were administered but not MCV. The "highest achievable" MCV vaccination coverage rate is 100% minus the sum of the percentages of (i) undervaccinated children with parents who requested an exemption; and (ii) undervaccinated children with parents who did not request an exemption and whose vaccination statuses were assessed during a kindergarten grace period or period when they were provisionally enrolled in kindergarten.

RESULTS

Among all children undervaccinated for MCV, 2.7% were attributable to having a parent who requested an exemption. Among children who were undervaccinated for MCV and whose parent did not request an exemption, 41.6% had a missed opportunity for MCV. The highest achievable MCV coverage was 98.6%, actual MCV coverage was 90.9%, and the kindergarten vaccination gap was 7.7%.

CONCLUSION

Vaccination coverage may be increased by schools fully implementing state kindergarten vaccination laws, and by providers assessing children's vaccination status at every clinic visit, and administering missed vaccine doses.

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

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.

Measles in the United States since the Millennium: Perils and Progress in the Postelimination Era

This article describes measles and measles vaccination, along with the challenges, successes, and progress in the postelimination era.

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.

Parental Vaccine Acceptance: A Logistic Regression Model Using Previsit Decisions

This study explores how parents' intentions regarding vaccination prior to their children's visit were associated with actual vaccine acceptance. A convenience sample of parents accompanying 6-week-old to 17-year-old children completed a written survey at 2 pediatric practices. Using hierarchical logistic regression, for hospital-based participants (n = 216), vaccine refusal history ( P < .01) and vaccine decision made before the visit ( P < .05) explained 87% of vaccine refusals. In community-based participants (n = 100), vaccine refusal history ( P < .01) explained 81% of refusals. Over 1 in 5 parents changed their minds about vaccination during the visit. Thirty parents who were previous vaccine refusers accepted current vaccines, and 37 who had intended not to vaccinate choose vaccination. Twenty-nine parents without a refusal history declined vaccines, and 32 who did not intend to refuse before the visit declined vaccination. Future research should identify key factors to nudge parent decision making in favor of vaccination.

Variation in Human Papillomavirus Vaccine Uptake and Acceptability Between Female and Male Adolescents and Their Caregivers

HPV vaccination coverage is suboptimal. Previous research largely focused on vaccinating girls. This study aimed to identify factors associated with HPV vaccination among male and female adolescents. We conducted secondary analyses using the National Immunization Survey-Teen. We specified parallel logistic models to examine associations of adolescent, caregiver, and provider characteristics with vaccination status among boys and girls. The primary outcome was HPV vaccination status defined as unvaccinated, initiated, or completed. Additionally, we analyzed caregivers' intent to initiate or complete the three-dose series. The vaccination completion rate was 26 %. Among teens aged 13-17 years, 19 % initiated, but did not complete the vaccine. Additionally, 14 % of males completed the 3-dose series as compared to 38 % of females. Vaccination rates were higher among teens receiving a provider recommendation [girls: adjusted odds ratio (AOR) = 3.33, 95 % confidence interval (CI) (2.44, 4.55); boys: AOR = 10.0, 95 % CI (7.69, 12.5)]. Moreover, provider recommendation was associated with caregivers' intent to initiate vaccination [girls: AOR = 2.32, 95 % CI (1.77, 3.02); boys: AOR = 2.76, 95 % CI (2.22, 3.43)]. Other associations differed by gender. Higher vaccine initiation rates were associated with younger age and residing in the mid-west for girls and racial/ethnic minority and eligibility for the "Vaccine for Children" program for boys. Provider recommendation for vaccination was the strongest predictor for both genders; however, it is insufficient to achieve high coverage rates, especially among boys. Factors associated with HPV vaccination were different for males and females. These findings suggest providers should consider gender bias with regard to HPV vaccination.

Public attitudes toward child undervaccination: A randomized experiment on evaluations, stigmatizing orientations, and support for policies

Child undervaccination is a complex public health problem and a contentious social and political issue. Efforts to increase vaccination coverage require understanding how the public evaluates different reasons for child undervaccination, which may influence attitudes, stigmatizing behaviors, and support for vaccination policies. We conducted a vignette experiment with a United States national online sample (n = 1469) to investigate how and why different undervaccination actions shape evaluations (blame, anger, sympathy, differentness, credibility, dangerousness), stigmatizing orientations (social distance, discrimination), and support for particular policies (e.g., research funding, belief exemptions, fines). Each participant was randomly assigned to read one of four vignettes that described a mother who either refused vaccines, delayed vaccines, encountered social barriers to obtaining vaccines, or was up-to-date on vaccines for her child. Compared to the up-to-date condition, each undervaccination action predicted significantly more negative evaluations and stigmatizing orientations. Vaccine refusal was the most negatively appraised. Differences in social distance and discrimination were explained by negative evaluations about the parent. These evaluations and orientations predicted support for a range of policies. Negative parental evaluations were associated with increased support for more severe policies. We discuss the implications of these findings for addressing undervaccination and informing health scholarship on stigma.

Assessment of the Status of Measles Elimination in the United States, 2001-2014

We assessed the status of measles elimination in the United States using outbreak notification data. Measles transmissibility was assessed by estimation of the reproduction number, R, the average number of secondary cases per infection, using 4 methods; elimination requires maintaining R at <1. Method 1 estimates R as 1 minus the proportion of cases that are imported. Methods 2 and 3 estimate R by fitting a model of the spread of infection to data on the sizes and generations of chains of transmission, respectively. Method 4 assesses transmissibility before public health interventions, by estimating R for the case with the earliest symptom onset in each cluster (R_index). During 2001–2014, R and R_index estimates obtained using methods 1–4 were 0.72 (95% confidence interval (CI): 0.68, 0.76), 0.66 (95% CI: 0.62, 0.70), 0.45 (95% CI: 0.40, 0.49), and 0.63 (95% CI: 0.57, 0.69), respectively. Year-to-year variability in the values of R and R_index and an increase in transmissibility in recent years were noted with all methods. Elimination of endemic measles transmission is maintained in the United States. A suggested increase in measles transmissibility since elimination warrants continued monitoring and emphasizes the importance of high measles vaccination coverage throughout the population.

Complementary and Alternative Medicine and Influenza Vaccine Uptake in US Children

BACKGROUND

Complementary and alternative medicine (CAM) is increasingly used in the United States. Although CAM is mostly used in conjunction with conventional medicine, some CAM practitioners recommend against vaccination, and children who saw naturopathic physicians or chiropractors were less likely to receive vaccines and more likely to get vaccine-preventable diseases. Nothing is known about how child CAM usage affects influenza vaccination.

METHODS

This nationally representative study analyzed ∼9000 children from the Child Complementary and Alternative Medicine File of the 2012 National Health Interview Survey. Adjusting for health services use factors, it examined influenza vaccination odds by ever using major CAM domains: (1) alternative medical systems (AMS; eg, acupuncture); (2) biologically-based therapies, excluding multivitamins/multiminerals (eg, herbal supplements); (3) multivitamins/multiminerals; (4) manipulative and body-based therapies (MBBT; eg, chiropractic manipulation); and (5) mind-body therapies (eg, yoga).

RESULTS

Influenza vaccination uptake was lower among children ever (versus never) using AMS (33% vs 43%; P = .008) or MBBT (35% vs 43%; P = .002) but higher by using multivitamins/multiminerals (45% vs 39%; P < .001). In multivariate analyses, multivitamin/multimineral use lost significance, but children ever (versus never) using any AMS or MBBT had lower uptake (respective odds ratios: 0.61 [95% confidence interval: 0.44-0.85]; and 0.74 [0.58-0.94]).

CONCLUSIONS

Children who have ever used certain CAM domains that may require contact with vaccine-hesitant CAM practitioners are vulnerable to lower annual uptake of influenza vaccination. Opportunity exists for US public health, policy, and medical professionals to improve child health by better engaging parents of children using particular domains of CAM and CAM practitioners advising them.

A spatiotemporal analysis of non-medical exemptions from vaccination: California schools before and after SB277

Childhood vaccination programs are considered one of the most beneficial public health programs in modern history. In the United States, the increasing use of non-medical exemptions (NMEs) from school entry vaccination requirements has garnered attention and scrutiny in the popular press, academic literature, and policy forums. In 2016, California law SB277 goes into effect, eliminating the NME option for students attending the state's public and private schools. Whereas SB277 is a strong move to increase vaccination coverage within California's schools, the new law contains an important caveat - students already having a valid NME (obtained prior to the 2016 school year) are "grandfathered" in until their next grade checkpoint (seventh grade). Although no new students will enter the California school system with a NME after 2016, the law's grandfather clause will allow NMEs to persist within the state school system until 2022. This analysis demonstrates how the past "build up" of students with pre-SB277 NMEs and the law's grandfather clause will act in combination to affect NME rates across the state after the implementation of SB277. We construct spatially explicit, yearly models of all students (K-12) enrolled in the California school system from 2011 to 2022. Our analysis finds that, although all regions of the state will eventually reach an NME rate of 0% by 2022, SB277's effect will be highly spatially and temporally variable. Some school districts will continue to experience elevated NME rates and increased risk of disease outbreak for years after SB277 is implemented. Our analysis highlights the potential spatially variant consequences of SB277's grandfather clause, providing important information for other states considering similar policy initiatives.

Countering Vaccine Hesitancy

Immunizations have led to a significant decrease in rates of vaccine-preventable diseases and have made a significant impact on the health of children. However, some parents express concerns about vaccine safety and the necessity of vaccines. The concerns of parents range from hesitancy about some immunizations to refusal of all vaccines. This clinical report provides information about addressing parental concerns about vaccination.

Parents' Support for School-Entry Requirements for Human Papillomavirus Vaccination: A National Study

BACKGROUND

The number of states proposing school-entry requirements for human papillomavirus (HPV) vaccination has increased over the last decade. However, data are currently limited regarding parents' support of such laws. We sought to obtain the first national estimates of parents' support of HPV vaccination school-entry requirements.

METHODS

A national sample of 1,501 parents of 11- to 17-year-old children completed a web-based survey between November 2014 and January 2015. Analyses used multivariable logistic regression to assess correlates of support for school-entry requirements for HPV vaccination.

RESULTS

Overall, 21% of parents agreed that laws requiring HPV vaccination for school attendance "are a good idea," and 54% disagreed. If school-entry requirements included opt-out provisions, agreement increased to 57%, and only 21% disagreed. Parents more often agreed with requirements without opt-out provisions if they were Hispanic [OR = 1.53; 95% confidence interval (CI), 1.05-2.22], believed HPV vaccine was as or more important than other adolescent vaccines (OR = 2.76; 95% CI, 1.98-3.83), or believed HPV vaccine was effective for preventing cervical cancer (OR = 2.55; 95% CI, 1.93-3.37). Parents less often agreed if they resided in Midwest states or believed that HPV vaccine was being pushed to make money for drug companies (both P < 0.05).

CONCLUSION

Opt-out provisions almost tripled parents' support for HPV vaccine school-entry requirements. Our findings suggest that race/ethnicity, attitudes about HPV vaccine, and region of residence may influence support for requirements without opt-out provisions.

IMPACT

Opt-out provisions greatly increase parent support of school-entry requirements for HPV vaccination but may make them ineffective. Cancer Epidemiol Biomarkers Prev; 25(9); 1317-25. ©2016 AACR.

Adolescent Vaccination Strategies: Interventions to Increase Coverage

While vaccines have decreased the burden of disease, many adolescents still remain under-immunized, particularly for human papillomavirus (HPV) and influenza. We review the most current data regarding adolescent immunizations in the United States and discuss proven strategies that work for increasing vaccination rates. Strategies that have been shown to improve rates include provider feedback, immunization information systems (or registries), and enhanced access outside of provider offices, such as school-based immunization programs. Overall, practices may want to consider multimodal quality improvement approaches to enhance practice vaccination rates. The public health and cost benefits of immunizing adolescents are well known, yet recent measles outbreaks in the United States have highlighted issues with state immunization laws and vaccine refusals. Providers should be clear in their advice regarding vaccines and use effective reminder strategies as parents commonly cite not having enough information or knowledge that a vaccine was needed for their adolescent. Additional research is needed regarding adolescent consent for vaccines, as well as adolescent and parental refusal, in order to design systems that will help inform families and allow for widespread vaccine availability.

Varicella immunization requirements for US colleges: 2014-2015 academic year

OBJECTIVE

To obtain information on varicella prematriculation requirements in US colleges for undergraduate students during the 2014-2015 academic year.

PARTICIPANTS

Health care professionals and member schools of the American College Health Association (ACHA).

METHODS

An electronic survey was sent to ACHA members regarding school characteristics and whether schools had policies in place requiring that students show proof of 2 doses of varicella vaccination for school attendance.

RESULTS

Only 27% (101/370) of schools had a varicella prematriculation requirement for undergraduate students. Only 68% of schools always enforced this requirement. Private schools, 4-year schools, northeastern schools, those with <5,000 students, and schools located in a state with a 2-dose varicella vaccine mandate were significantly more likely to have a varicella prematriculation requirement.

CONCLUSIONS

A small proportion of US colleges have a varicella prematriculation requirement for varicella immunity. College vaccination requirements are an important tool for controlling varicella in these settings.

Risk is for the rich? Childhood vaccination resistance and a Culture of Health

Childhood vaccination resistance has given rise to outbreaks of diseases, which had been virtually eliminated in the developed world. A parent's decision to forego vaccination for their child is a private choice that can have collective outcomes. This article takes a two-pronged approach to unraveling the puzzle of perceiving vaccines as dangerous in view of evidence that testifies to their effectiveness and relative safety. First, it draws on fifty-seven years of newspaper articles on vaccines to outline the public narratives. Second, it uses school-level data from New York and California to explore how these public narratives shape a geography of vaccination rates. We have two main findings. First, we find that while risk has always been a feature of vaccine narratives, the perception that the risks of vaccines out-weigh the benefits has grown. By the millennium, some began to view medical treatments as sources of risk rather than cure. Second, our geography of childhood vaccination reveals two distinct vaccine worlds. Affluence governs one world. Poverty governs the other. The geographic locales where vaccination rates are low enable us to contrast the difference between imagining risk, the prerogative of the affluent, and being at risk, the fate of the poor. Vaccination resistance speaks directly to a Culture of Health as it poses questions about the collective perception of risk and its relation to social inequality and solidarity.

Immunization in the United States: Recommendations, Barriers, and Measures to Improve Compliance: Part 1: Childhood Vaccinations

Childhood vaccination is one of the most effective public health strategies to control and prevent disease, but some parents decline or delay vaccinating their children. A variety of measures have been suggested to overcome vaccine noncompliance.

Hurdles to herd immunity: Distrust of government and vaccine refusal in the US, 2002-2003

High rates of nonmedical exemptions (NMEs) from required childhood vaccinations have contributed to outbreaks of vaccine-preventable diseases, such as measles and pertussis. Understanding the parental decision to obtain an NME could help health professionals and public health programs improve vaccination rates in areas with high vaccine refusal. Using a 2002-2003 multi-state survey of parents of school age children (​n=2445), this study found that parental distrust of the government and of healthcare providers is a significant factor related to a number of vaccine-related beliefs and behaviors. The odds that parents who distrust the government have seen a complementary/alternative medicine (CAM) provider were 2.11 times greater than those of parents who trust the government (70.1% vs 52.6%; OR, 2.11; 95% CI, 1.59-2.84; P<0.01). Parents who distrust the government had increased odds of trusting vaccine information from CAM providers compared to trusting parents (57.9% vs 46.3%; OR, 1.53; 95% CI, 1.16-2.01; P<0.01). Parents who distrust the government also had increased odds of distrusting vaccine information acquired at their healthcare providers' offices (12.6% vs 4.7%; OR, 2.64; 95% CI, 1.64-4.24; P<0.01). Distrustful parents had increased odds of thinking government sources of information about vaccines were unreliable, categorizing the CDC, the Food and Drug Administration (FDA), or local and state health departments as poor or very poor sources (distrust government vs trust government: 25.2% vs 11.7%; OR, 2.39; 95% CI, 1.70-3.36; P<0.01; distrust healthcare providers vs trust healthcare providers: 24.4% vs 11.4%; OR, 2.44; 95% CI, 1.75-3.38; P<0.01). These findings indicate that distrustful parent populations may need to be reached through modalities outside of traditional government and healthcare provider communications. Research into new and more effective techniques for delivering pro-vaccine messages is warranted.

What is herd immunity, and how does it relate to pediatric vaccination uptake? US parent perspectives

In light of current concern over pediatric immunization rates, 53 US parents with at least one child kindergarten age or younger were surveyed and interviewed regarding vaccine decision making. Data were collected in 2014 in San Diego, California. Herd immunity was not a salient issue: only six (11.3%) referenced the term or concept spontaneously; others had to be prompted. Parents familiar with herd immunity (70%) variously saw it as not just unnecessary but unproven, illogical, unrealistic, and unreliable. For instance, parents questioned its attainability because many adults do not immunize themselves. Some understood the concept negatively, as an instance of "herd mentality." Further, having knowledge of herd immunity that public health experts would deem 'correct' did not lead to full vaccination. Implications of findings for understanding how the public makes use of scientific information, the potential role of public health messaging regarding altruism and 'free-riding,' and assumptions that vaccine-cautious parents would willfully take advantage of herd immunity are explored in relation to parent role expectations and American individualism.

Pediatric Care Provider Density and Personal Belief Exemptions From Vaccine Requirements in California Kindergartens

OBJECTIVES

To understand contextual associations between medical care providers-pediatricians, family medical practitioners, and alternative medicine practitioners-and personal belief exemptions (PBEs) from mandated school entry vaccinations.

METHODS

Data on kindergarten PBEs from the California Department of Public Health were analyzed for 2010, 2011, and 2012, with each school sorted into Primary Care Service Areas (PCSAs). Provider data from federal sources and state records of alternative medicine providers, alongside controls for school factors, were used to estimate panel models.

RESULTS

Each 10% increase in the relative proportion of pediatricians in a given PCSA was associated with a statistically significant 11% decrease in PBE prevalence. The same increase in the proportion of family medical practitioners was associated with a 3.5% relative increase. Access to alternative medicine practitioners was also associated with a significantly higher PBE prevalence.

CONCLUSIONS

Medical provider contexts are associated with PBEs, reflecting a combination of contextual effects and self-selection of families into schools and PCSAs that share their preferences. The geographic distribution of child primary care services may be a key factor in a school's health risk associated with lack of immunization or underimmunization.

Information Curation among Vaccine Cautious Parents: Web 2.0, Pinterest Thinking, and Pediatric Vaccination Choice

To learn about pediatric vaccine decision-making, we surveyed and interviewed US parents with at least one child kindergarten age or younger (N = 53). Through an anthropologically informed content analysis, we found that fully vaccinating parents (n = 33) mostly saw vaccination as routine. In contrast, selective and nonvaccinating parents (n = 20) exhibited the type of self-informed engagement that the health care system recommends. Selective vaccinators also expressed multiple, sometimes contradictory positions on vaccination that were keyed to individual children's biologies, child size, environmental hazards, specific diseases, and discrete vaccines. Rather than logical progressions, viewpoints were presented as assembled collections, reflecting contemporary information filtering and curation practices and the prevalence of collectively experienced and constructed digital "hive" narratives. Findings confirm the need for a noncategorical approach to intervention that accommodates the fluid, polyvalent nature of vaccine reasoning and the curatorial view selectively vaccinating parents take toward information while honoring their efforts at engaged healthcare consumption.

Ethics and Childhood Vaccination Policy in the United States

Childhood immunization involves a balance between parents' autonomy in deciding whether to immunize their children and the benefits to public health from mandating vaccines. Ethical concerns about pediatric vaccination span several public health domains, including those of policymakers, clinicians, and other professionals. In light of ongoing developments and debates, we discuss several key ethical issues concerning childhood immunization in the United States and describe how they affect policy development and clinical practice. We focus on ethical considerations pertaining to herd immunity as a community good, vaccine communication, dismissal of vaccine-refusing families from practice, and vaccine mandates. Clinicians and policymakers need to consider the nature and timing of vaccine-related discussions and invoke deliberative approaches to policy-making.

Use of Fees to Discourage Nonmedical Exemptions to School Immunization Laws in US States

Recent outbreaks of vaccine-preventable diseases in the United States have renewed public discourse about state vaccine mandates for children entering schools. With acknowledgment of the challenge of eliminating religious and philosophical exemptions in most states, some have proposed instead to impose additional administrative burdens for parents seeking such exemptions. We review the use of taxes, fines, and fees as financial disincentives in public health. We argue that adding processing fees to a comprehensive set of administrative requirements for obtaining exemptions will avoid the use of taxpayer funding for exemption processing and will help tilt the balance of convenience in favor of vaccination.

Affluence as a predictor of vaccine refusal and underimmunization in California private kindergartens

BACKGROUND

Non-medical vaccine exemption rates in California private schools far exceed those of public schools, but little is known about specific factors which may be associated with high exemption rates in private schools.

METHODS

The percent of personal-belief exemptions (PBEs) among California public and private kindergartens were computed for 2000-2001 to 2014-2015 academic years. For the 2014-2015 academic year, a random sample of private schools was selected to investigate associations between kindergarten characteristics (tuition amount, religious affiliation) and vaccine profile (non-medical vaccine exemptions, vaccine coverage).

RESULTS

The proportion of private kindergartens reporting 5% or more children with PBEs increased from 9% (2000-2001) to 34% (2013-2014), followed by a small decrease in 2014-2015 (31%). Overall, 93.7% (565/605) of kindergartens sampled in 2014-2015 had data available. Very high PBE levels (>20%) were seen among secular and non-Catholic, Christian kindergartens but not Roman Catholic, Jewish or Islamic kindergartens. However, the majority of schools at all tuition levels had fewer than 5% of children with a PBE. Kindergartens with an annual tuition of $10,000 or more were over twice as likely to have 20% or more children with PBEs than kindergartens with a lower tuition (p<.01). Additionally, the conditional admission proportions for kindergartens with tuitions of $10,000 or more were 39% compared to 22% for less expensive kindergartens (p<.01). Only about half of all private kindergartens had 95% coverage of the MMR (49%) and pertussis-containing vaccines (51%).

CONCLUSIONS

School-entry vaccination requirements are critical to preventing outbreaks of vaccine preventable diseases in the US. Nonmedical exemptions increased between the 2000-2001 and 2014-2015 academic years and appear to be associated with affluence, raising social justice concerns.

Sociodemographic Predictors of Vaccination Exemptions on the Basis of Personal Belief in California

OBJECTIVES

We examined the variability in the percentage of students with personal belief exemptions (PBEs) from mandatory vaccinations in California schools and communities according to income, education, race, and school characteristics.

METHODS

We used spatial lag models to analyze 2007-2013 PBE data from the California Department of Public Health. The analyses included school- and regional-level models, and separately examined the percentage of students with exemptions in 2013 and the change in percentages over time.

RESULTS

The percentage of students with PBEs doubled from 2007 to 2013, from 1.54% to 3.06%. Across all models, higher median household income and higher percentage of White race in the population, but not educational attainment, significantly predicted higher percentages of students with PBEs in 2013. Higher income, White population, and private school type significantly predicted greater increases in exemptions from 2007 to 2013, whereas higher educational attainment was associated with smaller increases.

CONCLUSIONS

Personal belief exemptions are more common in areas with a higher percentage of White race and higher income.

Addressing Parental Vaccination Questions in the School Setting: An Integrative Literature Review

School nurses work in a unique environment with key opportunities to address parental concerns and questions regarding their child's health. A common concern for parents during school enrollment is childhood vaccination safety and efficacy. As public health leaders, school nurses are well respected among parents, therefore school nurses are in a prime position to educate parents and promote childhood vaccinations while also dispelling common vaccination myths. The purpose of this integrative literature review is to synthesize evidence-based answers to common parental questions regarding childhood vaccinations.

Vaccination uptake by vaccine-hesitant parents attending a specialist immunization clinic in Australia

Vaccine hesitancy (VH) is an issue of global concern. The quality of communication between healthcare providers and parents can influence parental immunization acceptance. We aimed to describe immunization uptake following specialist immunization clinic (SIC) consultation for Australian children of VH parents as a cohort, and according to pre-clinic parental position on immunization. At a single tertiary pediatric SIC (RCH, Melbourne) a retrospective descriptive study classified VH families according to 3 proposed parental positions on immunization at initial clinic attendance. Immunization status at follow up was ascertained via the Australian Children's Immunization Register and National HPV Program Register and compared between groups. Of the VH cohort, 13/38 (34%) families were classified as hesitant, 21 (55%) as late/selective vaccinators and 4 (11%) as vaccine refusers. Mean follow up post-SIC attendance was 14.5 months. For the overall VH cohort, the majority chose selective immunization (42%) following SIC consultation. When analyzed by pre-clinic parental position on immunization, there was a trend for hesitant families to proceed with full immunization, selective families to continue selective immunization and refusing families to remain unimmunised (p < 0.0001). The most commonly omitted vaccines were hepatitis B (66%) and Haemophilus influenzae type B (55%), followed by the meningococcal C conjugate vaccine (53%) and measles, mumps and rubella vaccine (53%). Immunization outcome appears to correlate with pre-clinic parental position on immunization for the majority of families attending a SIC in Australia, with selective immunization the most common outcome. Tailored communication approaches based on parental position on immunization may optimise clinic resources and engagement of families, but require prospective research evaluation.