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Armario P, Gómez-Choco M, García-Sánchez SM, Ruilope LM, Williams B, de la Sierra A. Clinic and ambulatory blood pressures, blood pressure phenotypes and mortality in patients with a previous stroke. Hypertens Res 2024:10.1038/s41440-024-01760-1. [PMID: 38918531 DOI: 10.1038/s41440-024-01760-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 05/09/2024] [Accepted: 05/28/2024] [Indexed: 06/27/2024]
Abstract
There is scarce evidence of the role of clinic and ambulatory BP indices, as well as blood pressure phenotypes in the prognosis of stroke survivors. We aimed to evaluate the association between ambulatory BP indices and mortality in patients with a previous stroke. Our study was an observational cohort study from individuals included in the Spanish Ambulatory Blood Pressure Registry from March 2004 to December 2014. The Cox model was used to estimate associations between usual clinic and ambulatory BP and mortality, adjusted for confounders and additionally for alternative measures of BP. Two thousand one hundred and eighty-three patients with a previous stroke were included. During a median of 9.2 years, 632 (28.9%) patients died: 236 (10.8%) from cardiovascular causes. In the confounder-adjusted model, clinic systolic BP was not associated with the risk of all-cause or cardiovascular mortality. In contrast, systolic BP indices obtained through ABPM (24 h, day and night) were all associated with all-cause and cardiovascular death. In the simultaneous adjustment of daytime and night-time systolic BP, only night-time systolic BP remained significantly associated with all-cause and cardiovascular death: HR 1.35 (95% CI 01.21-1.51) and 1.44 (1.20-1.72), respectively. For diastolic BP, only night-time BP was associated with all-cause and cardiovascular mortality: HR 1.32 (1.18-1.48) and 1.57 (1.31-1.88), respectively. According to the circadian pattern, a riser pattern was associated with all-cause and cardiovascular mortality: HR 1.49 (1.18-1.87) and 1.70 (1.14-2.52), respectively. In conclusion, in patients who have suffered a stroke, night-time BP is the BP estimate most closely associated with all-cause and cardiovascular mortality.
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Affiliation(s)
- Pedro Armario
- Department of Internal Medicine, Cardiovascular Risk Area, Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí, University of Barcelona, Barceloncoa, Spain.
| | - Manuel Gómez-Choco
- Department of Neurology, Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí, University of Barcelona, Barcelona, Spain
| | - Sonia M García-Sánchez
- Department of Neurology, Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí, University of Barcelona, Barcelona, Spain
| | - Luis M Ruilope
- Hypertension Unit and Cardiorenal Translational Laboratory, Hospital 12 de Octubre, Madrid, Spain
| | - Bryan Williams
- University College London (UK) Institute of Cardiovascular Science and National Institute for Health Research (NIHR) UCL Hospitals Biomedical Research Centre, London, UK
| | - Alejandro de la Sierra
- Hypertension Unit. Department of Internal Medicine. Hospital Mutua Terrassa. University of Barcelona, Terrassa, Spain
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2
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Greyson D, Goh G. Education components of school vaccine mandates: An environmental scan. Vaccine 2023; 41:7089-7095. [PMID: 37923695 DOI: 10.1016/j.vaccine.2023.09.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 09/26/2023] [Accepted: 09/27/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND School vaccine mandates (SVMs) are population health interventions that require monitoring and communicating about vaccination of school-aged children, with an aim of controlling infectious disease outbreaks. While 43 % of World Health Organization member states report having some sort of SVM, their details vary. A newer element of some SVMs is an "education component" requiring compulsory information, education, or counseling of parents/guardians who decline to vaccinate their children for non-medical reasons. METHODS This environmental scan sought, mapped, and synthesized evidence on the existence, format, and impacts of education components of SVMs in 18 affluent Organization for Economic Co-operation and Development comparator countries. FINDINGS We found current SVMs in nine of the 18 comparator countries, but education components to those SVMs only in Canada (n = 2) and the U.S. (n = 9), where such policies were made at the provincial/state level. The earliest was implemented in 2011 and most recent has not yet been implemented. Education components were used as requirements for obtaining non-medical exemptions from SVMs, and involved either an informational paper to be read and signed, a counseling or information session from a health professional (public health worker or licensed provider such as family doctor), or an online module to be completed. Peer-reviewed research on in-person sessions suggests association with at least short-term increased vaccine uptake and reduction of non-medical exemptions. Available data on online module education components suggests similar impacts, but research to date is limited. CONCLUSION SVMs with educational components are uncommon but have been increasing since 2011. The details of these education components vary, although topics covered in online modules are relatively consistent. Evidence to date suggests at least short-term reduction in non-medical exemptions associated with implementation of SVM education components, but additional research is required to follow-up and confirm, especially as regards online education modules.
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Affiliation(s)
- Devon Greyson
- School of Population and Public Health, University of British Columbia, Vancouver, Canada; Vaccine Evaluation Center, British Columbia Children's Hospital Research Institute, Vancouver, Canada.
| | - Gerry Goh
- School of Population and Public Health, University of British Columbia, Vancouver, Canada; School of Information, University of British Columbia, Vancouver, Canada
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Yu L, Qiao J, Ming WK, Wu Y. Megastudies: A New Approach to Reducing Vaccine Hesitation Worldwide. Vaccines (Basel) 2023; 11:vaccines11010133. [PMID: 36679978 PMCID: PMC9865671 DOI: 10.3390/vaccines11010133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 12/29/2022] [Accepted: 12/30/2022] [Indexed: 01/09/2023] Open
Abstract
Vaccine hesitancy is a considerable obstacle to achieving vaccine protection worldwide. There needs to be more evidence-based research for interventions for vaccine hesitancy. Existing effectiveness evaluations are limited to one particular hypothesis, and no studies have compared the effectiveness of different interventions. A megastudy takes a large-scale, multi-intervention, uniform participant and the same evaluation criteria approach to evaluate many interventions simultaneously and find the most effective ones. Therefore, megastudies can help us find the most effective interventions for vaccine hesitancy. Additionally, considering the complex causes of vaccine hesitancy, we design interventions that involve social factors in megastudies. Lastly, quality control and justice are critical issues for megastudies in the future.
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Affiliation(s)
- Lian Yu
- Health Care System Reform and Development Institute, School of Public Health, Xi’an Jiaotong University, Xi’an 710061, China
| | - Jiaqi Qiao
- Jinhe Center for Economic Research, Xi’an Jiaotong University, Xi’an 710061, China
| | - Wai-Kit Ming
- Department of Infectious Diseases and Public Health, Jockey Club College of Veterinary Medicine and Life Sciences, City University of Hong Kong, Hong Kong 999077, China
- Correspondence: (W.-K.M.); (Y.W.); Tel.: +85-234-426-956 (W.-K.M.); +861-881-016-9630 (Y.W.)
| | - Yibo Wu
- School of Public Health, Peking University, Beijing 100191, China
- Correspondence: (W.-K.M.); (Y.W.); Tel.: +85-234-426-956 (W.-K.M.); +861-881-016-9630 (Y.W.)
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4
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Affiliation(s)
- H Cody Meissner
- From the Department of Pediatrics, Tufts Children's Hospital, Tufts Medical Center, Boston
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Masters NB, Delamater PL, Boulton ML, Zelner J. Measuring Multiple Dimensions and Indices of Nonvaccination Clustering in Michigan, 2008-2018. Am J Epidemiol 2021; 190:1113-1121. [PMID: 33305789 DOI: 10.1093/aje/kwaa264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 11/23/2020] [Accepted: 12/07/2020] [Indexed: 11/15/2022] Open
Abstract
Michigan experienced a significant measles outbreak in 2019 amidst rising rates of nonmedical vaccine exemptions (NMEs) and low vaccination coverage compared with the rest of the United States. There is a critical need to better understand the landscape of nonvaccination in Michigan to assess the risk of vaccine-preventable disease outbreaks in the state, yet there is no agreed-upon best practice for characterizing spatial clustering of nonvaccination, and numerous clustering metrics are available in the statistical, geographical, and epidemiologic literature. We used school-level data to characterize the spatiotemporal landscape of vaccine exemptions in Michigan for the period 2008-2018 using Moran's I, the isolation index, the modified aggregation index, and the Theil index at 4 spatial scales. We also used nonvaccination thresholds of 5%, 10%, and 20% to assess the bias incurred when aggregating vaccination data. We found that aggregating school-level data to levels commonly used for public reporting can lead to large biases in identifying the number and location of at-risk students and that different clustering metrics yielded variable interpretations of the nonvaccination landscape in Michigan. This study shows the importance of choosing clustering metrics with their mechanistic interpretations in mind, be it large- or fine-scale heterogeneity or between- and within-group contributions to spatial variation.
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Völker S, Hammerschmidt R, Spura A. [Geographic analyses as a foundation for evidence-based public health interventions: the example identification and typology of risk clusters for mumps, measles, and rubella]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2021; 64:600-609. [PMID: 33891131 PMCID: PMC8087606 DOI: 10.1007/s00103-021-03318-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 03/17/2021] [Indexed: 10/25/2022]
Abstract
BACKGROUND Ideally, health services and interventions to improve immunization rates should be tailored to local target populations, such as spatial clusters. However, to date, little attention has been paid to spatial clusters of underimmunization and have instead been typified based on small-scale data. AIM Using the example of vaccination against measles, mumps, and rubella (MMR) in children, the present study aims to (1) identify the spatial distribution of insufficient MMR vaccination in Westphalia-Lippe on a small scale, (2) identify specific, spatial risk clusters with insufficient vaccination protection, and (3) describe spatial-neighborhood influencing factors of the different risk clusters as starting points for public health interventions. MATERIAL AND METHODS Account data from the Kassenärztliche Vereinigung Westfalen-Lippe (KVWL) were used as a basis. Birth cohorts 2013-2016 of children with statutory health insurance were formed and aggregated at postcode level (n = 410). Statistically significant, spatially compact clusters and relative risks (RRs) of underimmunization were identified. Local risk models were estimated in binary logistic regressions based on spatial-neighborhood variables. RESULTS AND DISCUSSION Two significant clusters of underimmunization were identified for each of the vaccination rates "at least one MMR vaccination" and "both MMR vaccinations." Significant risk factors for low immunization rates included age structure, socioeconomic variables, population density, medical coverage, and value attitude. The proposed methodology is suitable for describing spatial variations in vaccination behavior based on identified typologies for targeted evidence-based interventions.
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Affiliation(s)
- Sebastian Völker
- Stabsbereich Unternehmensentwicklung, Kassenärztliche Vereinigung Westfalen-Lippe (KVWL), Robert-Schimrigk-Str. 4-6, 44141, Dortmund, Deutschland.
- Zentrum für Public Health und Versorgungsforschung, Masterstudiengang Public Health, Paracelsus Medical University, Salzburg, Österreich.
| | - Reinhard Hammerschmidt
- Stabsbereich Unternehmensentwicklung, Kassenärztliche Vereinigung Westfalen-Lippe (KVWL), Robert-Schimrigk-Str. 4-6, 44141, Dortmund, Deutschland
| | - Anke Spura
- Referat 2-24 Fortbildung, Qualifizierung, Hochschulkooperation, Bundeszentrale für gesundheitliche Aufklärung (BZgA), Köln, Deutschland
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Attwell K, Betsch C, Dubé E, Sivelä J, Gagneur A, Suggs LS, Picot V, Thomson A. Increasing vaccine acceptance using evidence-based approaches and policies: Insights from research on behavioural and social determinants presented at the 7th Annual Vaccine Acceptance Meeting. Int J Infect Dis 2021; 105:188-193. [PMID: 33578012 DOI: 10.1016/j.ijid.2021.02.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 01/25/2021] [Accepted: 02/03/2021] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND In 2019, the World Health Organization (WHO) flagged vaccine hesitancy as one of the top 10 threats to global health. The drivers of and barriers to under-vaccination include logistics (access to and awareness of affordable vaccines), as well as a complex mix of psychological, social, political, and cultural factors. INCREASING VACCINE UPTAKE There is a need for effective strategies to increase vaccine uptake in various settings, based on the best available evidence. Fortunately, the field of vaccine acceptance research is growing rapidly with the development, implementation, and evaluation of diverse measurement tools, as well as interventions to address the challenging range of drivers of and barriers to vaccine acceptance. ANNUAL VACCINE ACCEPTANCE MEETINGS Since 2011, the Mérieux Foundation has hosted Annual Vaccine Acceptance Meetings in Annecy, France that have fostered an informal community of practice on vaccination confidence and vaccine uptake. Mutual learning and sharing of knowledge has resulted directly in multiple initiatives and research projects. This article reports the discussions from the 7th Annual Vaccine Acceptance Meeting held September 23-25, 2019. During this meeting, participants discussed emergent vaccine acceptance challenges and evidence-informed ways of addressing them in a programme that included sessions on vaccine mandates, vaccine acceptance and demand, training on vaccine acceptance, and frameworks for resilience of vaccination programmes.
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Affiliation(s)
- Katie Attwell
- School of Social Science, University of Western Australia, 35 Stirling Highway, Crawley, WA, 6009, Australia; Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, Perth Children's Hospital, 15 Hospital Ave, Nedlands, WA, 6009, Australia.
| | - Cornelia Betsch
- University of Erfurt, Nordhäuser Str. 63, 99089, Erfurt, Germany.
| | - Eve Dubé
- Centre de Recherche du CHU de Québec-Université Laval, 2400 D'Estimauville, Quebec, QC, G1E 7G9, Canada.
| | - Jonas Sivelä
- Infectious Disease Control and Vaccinations, Finnish Institute for Health and Welfare (THL), Mannerheimintie 166, Helsinki, Finland.
| | - Arnaud Gagneur
- Department of Pediatrics, Faculty of Medicine and Health Sciences, Université de Sherbrooke, 3001 12e Avenue Nord, Sherbrooke, Quebec, J1H 5N4, Canada.
| | - L Suzanne Suggs
- BeCHANGE Research Group, Institute of Public Health, Faculty of Communication Sciences, Università della Svizzera Italiana, via G. Buffi 13, Lugano, Switzerland; Swiss School of Public Health (SSPH+), Zurich, Switzerland; Institute for Global Health Innovation, Imperial College London, London, UK.
| | - Valentina Picot
- Scientific Conferences and Public Health Initiatives, Fondation Mérieux, 17 Rue Bourgelat, 69002, Lyon, France.
| | - Angus Thomson
- Sanofi Pasteur, 14 Espace Henry Vallee, 69007, Lyon, France.
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8
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Fine-scale spatial clustering of measles nonvaccination that increases outbreak potential is obscured by aggregated reporting data. Proc Natl Acad Sci U S A 2020; 117:28506-28514. [PMID: 33106403 DOI: 10.1073/pnas.2011529117] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
The United States experienced historically high numbers of measles cases in 2019, despite achieving national measles vaccination rates above the World Health Organization recommendation of 95% coverage with two doses. Since the COVID-19 pandemic began, resulting in suspension of many clinical preventive services, pediatric vaccination rates in the United States have fallen precipitously, dramatically increasing risk of measles resurgence. Previous research has shown that measles outbreaks in high-coverage contexts are driven by spatial clustering of nonvaccination, which decreases local immunity below the herd immunity threshold. However, little is known about how to best conduct surveillance and target interventions to detect and address these high-risk areas, and most vaccination data are reported at the state-level-a resolution too coarse to detect community-level clustering of nonvaccination characteristic of recent outbreaks. In this paper, we perform a series of computational experiments to assess the impact of clustered nonvaccination on outbreak potential and magnitude of bias in predicting disease risk posed by measuring vaccination rates at coarse spatial scales. We find that, when nonvaccination is locally clustered, reporting aggregate data at the state- or county-level can result in substantial underestimates of outbreak risk. The COVID-19 pandemic has shone a bright light on the weaknesses in US infectious disease surveillance and a broader gap in our understanding of how to best use detailed spatial data to interrupt and control infectious disease transmission. Our research clearly outlines that finer-scale vaccination data should be collected to prevent a return to endemic measles transmission in the United States.
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9
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Abstract
A significant minority of patients and parents are vaccine hesitant, defined as having the desire to delay or defer immunizations despite easy access to vaccines. Vaccine hesitancy exists along a spectrum, from patients who are concerned but willing to accept the recommended vaccine schedule to those who wish to use a delayed schedule to those who refuse vaccines altogether. A strong recommendation in favor of a vaccine is the most important reason a patient or parent accepts the immunization. Structural changes, such as removing personal and religious exemptions for vaccines required for attending school, are effective tools in increasing vaccination rates.
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Affiliation(s)
- Jamie Loehr
- Cayuga Family Medicine, 302 West Seneca Street, Ithaca, NY 14850, USA.
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10
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Mellerson JL, Street E, Knighton C, Calhoun K, Seither R, Underwood JM. Centers for Disease Control and Prevention's School Vaccination Assessment: Collaboration With US State, Local, and Territorial Immunization Programs, 2012-2018. Am J Public Health 2020; 110:1092-1097. [PMID: 32437281 DOI: 10.2105/ajph.2020.305643] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Objectives. To describe the ongoing collaboration of the Centers for Disease Control and Prevention's (CDC's) school vaccination assessment with state, local, and territorial immunization programs to provide data to monitor school entry vaccination.Methods. Departments of health and education partner to collect data from public school, private school, and homeschooled kindergartners in the 50 US states, the District of Columbia, 2 cities, and the US territories. Immunization programs submit vaccination coverage and exemption data to the CDC, and the CDC reports these data annually via multiple sources.Results. Among the 50 states and the District of Columbia, the number of programs using a census for vaccination coverage data increased from 39 to 41 during the school years 2012-2013 to 2017-2018 (which for most states was August or September through May or June), and the number using a census to collect exemption data increased from 40 to 46. The number of states that reported sharing their local-level vaccination coverage data online increased from 11 in 2012-2013 to 31 in 2017-2018.Conclusions. Coverage data can be used to address undervaccination among kindergartners to work with communities and schools that are susceptible to vaccine-preventable diseases. As more states publish local-level data online, access to improved data provides the public more valuable information.
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Affiliation(s)
- Jenelle L Mellerson
- All authors are with the Centers for Disease Control and Prevention (CDC), Atlanta, GA. Jenelle L. Mellerson is also with Certified Technical Experts, Montgomery, AL. Erica Street is also with the Oak Ridge Institute for Science and Education, Oak Ridge, TN. Kayla Calhoun is also with CyberData Technologies, Herndon, VA
| | - Erica Street
- All authors are with the Centers for Disease Control and Prevention (CDC), Atlanta, GA. Jenelle L. Mellerson is also with Certified Technical Experts, Montgomery, AL. Erica Street is also with the Oak Ridge Institute for Science and Education, Oak Ridge, TN. Kayla Calhoun is also with CyberData Technologies, Herndon, VA
| | - Cynthia Knighton
- All authors are with the Centers for Disease Control and Prevention (CDC), Atlanta, GA. Jenelle L. Mellerson is also with Certified Technical Experts, Montgomery, AL. Erica Street is also with the Oak Ridge Institute for Science and Education, Oak Ridge, TN. Kayla Calhoun is also with CyberData Technologies, Herndon, VA
| | - Kayla Calhoun
- All authors are with the Centers for Disease Control and Prevention (CDC), Atlanta, GA. Jenelle L. Mellerson is also with Certified Technical Experts, Montgomery, AL. Erica Street is also with the Oak Ridge Institute for Science and Education, Oak Ridge, TN. Kayla Calhoun is also with CyberData Technologies, Herndon, VA
| | - Ranee Seither
- All authors are with the Centers for Disease Control and Prevention (CDC), Atlanta, GA. Jenelle L. Mellerson is also with Certified Technical Experts, Montgomery, AL. Erica Street is also with the Oak Ridge Institute for Science and Education, Oak Ridge, TN. Kayla Calhoun is also with CyberData Technologies, Herndon, VA
| | - J Michael Underwood
- All authors are with the Centers for Disease Control and Prevention (CDC), Atlanta, GA. Jenelle L. Mellerson is also with Certified Technical Experts, Montgomery, AL. Erica Street is also with the Oak Ridge Institute for Science and Education, Oak Ridge, TN. Kayla Calhoun is also with CyberData Technologies, Herndon, VA
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Wright AL, Meyer AD, Reay T, Staggs J. Maintaining Places of Social Inclusion: Ebola and the Emergency Department. ADMINISTRATIVE SCIENCE QUARTERLY 2020; 66:0001839220916401. [PMCID: PMC7141156 DOI: 10.1177/0001839220916401] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
We introduce the concept of places of social inclusion—institutions endowed by a society or a community with material resources, meaning, and values at geographic sites where citizens can access services for specific needs—as taken-for-granted, essential, and inherently precarious. Based on our study of an emergency department that was disrupted by the threat of the Ebola virus in 2014, we develop a process model to explain how a place of social inclusion can be maintained by custodians. We show how these custodians—in our fieldsite, doctors and nurses—experience and engage in institutional work to manage different levels of tension between the value of inclusion and the reality of finite resources, as well as tension between inclusion and the desire for safety. We also demonstrate how the interplay of custodians’ emotions is integral to maintaining the place of social inclusion. The primary contribution of our study is to shine light on places of social inclusion as important institutions in democratic society. We also reveal the theoretical and practical importance of places as institutions, deepen understanding of custodians and custodianship as a form of institutional work, and offer new insight into the dynamic processes that connect emotions and institutional work.
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12
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Garnier R, Nedell ER, Omer SB, Bansal S. Getting Personal: How Childhood Vaccination Policies Shape the Landscape of Vaccine Exemptions. Open Forum Infect Dis 2020; 7:ofaa088. [PMID: 32258205 PMCID: PMC7111605 DOI: 10.1093/ofid/ofaa088] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 03/12/2020] [Indexed: 02/02/2023] Open
Abstract
Background State-mandated school entry immunization requirements in the United States play an important role in achieving high vaccine coverage, but variations in vaccine exemption policies result in a patchwork of vaccine coverage across the country. Methods In this study, we evaluate epidemiological effects and spatial variations in nonmedical exemption (NME) rates in the context of vaccine policies. We first analyze the correlation between NME rates and vaccine coverage for 3 significant childhood vaccinations. Furthermore, we assess the effects of policy changes in a subset of states, using a correlative approach at the state level and performing a clustering analysis at the county level. Results We find that higher rates of exemptions are associated with lower vaccination rates of school-aged children in all cases. In a subset of states where exemption policy has recently changed, we show that the effects on statewide NME rates vary widely and that decreases in NMEs can lead to an increase in other types of exemptions. Finally, our clustering analysis in California, Illinois, and Connecticut shows that policy changes affect the spatial distribution of NMEs. Conclusions Our work suggests that vaccination policies have significant impacts on patterns of herd immunity. Our findings can be used to develop evidence-based vaccine legislation.
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Affiliation(s)
- Romain Garnier
- Department of Biology, Georgetown University, Washington, District of Columbia, USA
| | - Emma R Nedell
- Department of Biology, Georgetown University, Washington, District of Columbia, USA
| | - Saad B Omer
- Yale Institute for Global Health, Yale University, New Haven, Conneticut, USA.,Department of Internal Medicine (Infectious Diseases), Yale School of Medicine, Yale University, New Haven, Connecticut, USA.,Department of Epidemiology of Microbial Diseases, Yale School of Public Health, Yale University, New Haven, Connecticut, USA
| | - Shweta Bansal
- Department of Biology, Georgetown University, Washington, District of Columbia, USA
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13
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Abstract
PURPOSE OF REVIEW This review summarizes the current state of school-entry vaccination requirements and related exemption policies in the United States and examines recent changes to these policies. RECENT FINDINGS With recent infectious disease outbreaks in the United States, there has been heightened awareness on unvaccinated individuals, and the state-level policies that allow individuals to be exempted from school-entry vaccination requirements. Between 2015 and 2017, there have been eleven states that have altered their policies regarding school-entry vaccination requirements and related reporting for which no formal evaluations have been published. One policy change during that period, California SB 277, which became law in 2016, reduced the nonmedical exemption and increased the childhood vaccination coverage rate in that state, though with some evidence of exemption replacement through the use of medical exemptions. Through September 2019, five additional state law changes have been enacted. SUMMARY The large number of heterogeneous changes to state-level policies for school-entry vaccination requirements in recent years need rigorous evaluation to identify best practices for balancing public health authority and parental autonomy while seeking to achieve the highest level of infectious disease prevention for children.
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14
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Nyathi S, Karpel HC, Sainani KL, Maldonado Y, Hotez PJ, Bendavid E, Lo NC. The 2016 California policy to eliminate nonmedical vaccine exemptions and changes in vaccine coverage: An empirical policy analysis. PLoS Med 2019; 16:e1002994. [PMID: 31869328 PMCID: PMC6927583 DOI: 10.1371/journal.pmed.1002994] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 11/20/2019] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Vaccine hesitancy, the reluctance or refusal to receive vaccination, is a growing public health problem in the United States and globally. State policies that eliminate nonmedical ("personal belief") exemptions to childhood vaccination requirements are controversial, and their effectiveness to improve vaccination coverage remains unclear given limited rigorous policy analysis. In 2016, a California policy (Senate Bill 277) eliminated nonmedical exemptions from school entry requirements. The objective of this study was to estimate the association between California's 2016 policy and changes in vaccine coverage. METHODS AND FINDINGS We used a quasi-experimental state-level synthetic control analysis and a county-level difference-in-differences analysis to estimate the impact of the 2016 California policy on vaccination coverage and prevalence of exemptions to vaccine requirements (nonmedical and medical). We used publicly available state-level data from the US Centers for Disease Control and Prevention on coverage of measles, mumps, and rubella (MMR) vaccination, nonmedical exemption, and medical exemption in children entering kindergarten. We used county-level data individually requested from state departments of public health on overall vaccine coverage and exemptions. Based on data availability, we included state-level data for 45 states, including California, from 2011 to 2017 and county-level data for 17 states from 2010 to 2017. The prespecified primary study outcome was MMR vaccination in the state analysis and overall vaccine coverage in the county analysis. In the state-level synthetic control analysis, MMR coverage in California increased by 3.3% relative to its synthetic control in the postpolicy period (top 2 of 43 states evaluated in the placebo tests, top 5%), nonmedical exemptions decreased by 2.4% (top 2 of 43 states evaluated in the placebo tests, top 5%), and medical exemptions increased by 0.4% (top 1 of 44 states evaluated in the placebo tests, top 2%). In the county-level analysis, overall vaccination coverage increased by 4.3% (95% confidence interval [CI] 2.9%-5.8%, p < 0.001), nonmedical exemptions decreased by 3.9% (95% CI 2.4%-5.4%, p < 0.001), and medical exemptions increased by 2.4% (95% CI 2.0%-2.9%, p < 0.001). Changes in vaccination coverage across counties after the policy implementation from 2015 to 2017 ranged from -6% to 26%, with larger increases in coverage in counties with lower prepolicy vaccine coverage. Results were robust to alternative model specifications. The limitations of the study were the exclusion of a subset of US states from the analysis and the use of only 2 years of postpolicy data based on data availability. CONCLUSIONS In this study, implementation of the California policy that eliminated nonmedical childhood vaccine exemptions was associated with an estimated increase in vaccination coverage and a reduction in nonmedical exemptions at state and county levels. The observed increase in medical exemptions was offset by the larger reduction in nonmedical exemptions. The largest increases in vaccine coverage were observed in the most "high-risk" counties, meaning those with the lowest prepolicy vaccine coverage. Our findings suggest that government policies removing nonmedical exemptions can be effective at increasing vaccination coverage.
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Affiliation(s)
- Sindiso Nyathi
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, California, United States of America
| | - Hannah C. Karpel
- New York University School of Medicine, New York, New York, United States of America
| | - Kristin L. Sainani
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, California, United States of America
| | - Yvonne Maldonado
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, California, United States of America
- Division of Infectious Diseases, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, United States of America
| | - Peter J. Hotez
- Texas Children's Hospital Center for Vaccine Development, Departments of Pediatrics and Molecular Virology and Microbiology, Baylor College of Medicine, Houston, Texas, United States of America
- Department of Biology, Baylor University, Waco, Texas, United States of America
- Hagler Institute for Advanced Study at Texas A&M University, College Station, Texas, United States of America
- James A. Baker III Institute for Public Policy, Rice University, Houston, Texas, United States of America
| | - Eran Bendavid
- Center for Population Health Sciences, Division of Primary Care and Population Health, Department of Medicine, Stanford University, Stanford, California, United States of America
| | - Nathan C. Lo
- Department of Medicine, University of California, San Francisco, San Francisco, California, United States of America
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Meissner HC. Complexity in Assessing the Benefit vs Risk of Vaccines: Experience With Rotavirus and Dengue Virus Vaccines. JAMA 2019; 322:1861-1862. [PMID: 31621790 DOI: 10.1001/jama.2019.16206] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- H Cody Meissner
- Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts
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Seither R, Loretan C, Driver K, Mellerson JL, Knighton CL, Black CL. Vaccination Coverage with Selected Vaccines and Exemption Rates Among Children in Kindergarten - United States, 2018-19 School Year. MMWR-MORBIDITY AND MORTALITY WEEKLY REPORT 2019; 68:905-912. [PMID: 31622283 PMCID: PMC6802678 DOI: 10.15585/mmwr.mm6841e1] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
State and local school vaccination requirements exist to ensure that students are protected against vaccine-preventable diseases (1). This report summarizes data collected by state and local immunization programs* on vaccination coverage among children in kindergarten in 49 states, exemptions for kindergartners in 50 states, and provisional enrollment and grace period status for kindergartners in 30 states. Nationally, vaccination coverage† was 94.9% for the state-required number of doses of diphtheria and tetanus toxoids, and acellular pertussis vaccine (DTaP); 94.7% for 2 doses of measles, mumps, and rubella vaccine (MMR); and 94.8% for the state-required doses of varicella vaccine. Whereas 2.5% of kindergartners had an exemption from at least one vaccine,§ 2.8% of kindergartners were not up to date for MMR and did not have a vaccine exemption. Nearly all states could achieve the recommended ≥95% MMR coverage if all nonexempt kindergartners were vaccinated in accordance with local and state vaccination policies.
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Hecht H, Hayney MS. Understanding the role of vaccination exemption in the recent measles outbreaks. J Am Pharm Assoc (2003) 2019; 59:753-755. [DOI: 10.1016/j.japh.2019.07.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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