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Morrison M, Castro LA, Ancel Meyers L. Conscientious vaccination exemptions in kindergarten to eighth-grade children across Texas schools from 2012 to 2018: A regression analysis. PLoS Med 2020; 17:e1003049. [PMID: 32155142 PMCID: PMC7064178 DOI: 10.1371/journal.pmed.1003049] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Accepted: 01/31/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND As conscientious vaccination exemption (CVE) percentages rise across the United States, so does the risk and occurrence of outbreaks of vaccine-preventable diseases such as measles. In the state of Texas, the median CVE percentage across school systems more than doubled between 2012 and 2018. During this period, the proportion of schools surpassing a CVE percentage of 3% rose from 2% to 6% for public schools, 20% to 26% for private schools, and 17% to 22% for charter schools. The aim of this study was to investigate this phenomenon at a fine scale. METHODS AND FINDINGS Here, we use beta regression models to study the socioeconomic and geographic drivers of CVE trends in Texas. Using annual counts of CVEs at the school system level from the 2012-2013 to the 2017-2018 school year, we identified county-level predictors of median CVE percentage among public, private, and charter schools, the proportion of schools below a high-risk threshold for vaccination coverage, and five-year trends in CVEs. Since the 2012-2013 school year, CVE percentages have increased in 41 out of 46 counties in the top 10 metropolitan areas of Texas. We find that 77.6% of the variation in CVE percentages across metropolitan counties is explained by median income, the proportion of the population that holds a bachelor's degree, the proportion of the population that self-reports as ethnically white, the proportion of the population that is English speaking, and the proportion of the population that is under the age of five years old. Across the 10 top metropolitan areas in Texas, counties vary considerably in the proportion of school systems reporting CVE percentages above 3%. Sixty-six percent of that variation is explained by the proportion of the population that holds a bachelor's degree and the proportion of the population affiliated with a religious congregation. Three of the largest metropolitan areas-Austin, Dallas-Fort Worth, and Houston-are potential vaccination exemption "hotspots," with over 13% of local school systems above this risk threshold. The major limitations of this study are inconsistent school-system-level CVE reporting during the study period and a lack of geographic and socioeconomic data for individual private schools. CONCLUSIONS In this study, we have identified high-risk communities that are typically obscured in county-level risk assessments and found that public schools, like private schools, are exhibiting predictable increases in vaccination exemption percentages. As public health agencies confront the reemerging threat of measles and other vaccine-preventable diseases, findings such as ours can guide targeted interventions and surveillance within schools, cities, counties, and sociodemographic subgroups.
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Affiliation(s)
- Maike Morrison
- Department of Integrative Biology, The University of Texas at Austin, Austin, Texas, United States of America
| | - Lauren A. Castro
- Department of Integrative Biology, The University of Texas at Austin, Austin, Texas, United States of America
- Analytics, Intelligence, and Technology Division, Los Alamos National Laboratory, Los Alamos, New Mexico, United States of America
| | - Lauren Ancel Meyers
- Department of Integrative Biology, The University of Texas at Austin, Austin, Texas, United States of America
- The Santa Fe Institute, Santa Fe, New Mexico, United States of America
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Delamater PL, Pingali SC, Buttenheim AM, Salmon DA, Klein NP, Omer SB. Elimination of Nonmedical Immunization Exemptions in California and School-Entry Vaccine Status. Pediatrics 2019; 143:e20183301. [PMID: 31113831 PMCID: PMC6564056 DOI: 10.1542/peds.2018-3301] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/13/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES California implemented Senate Bill 277 (SB277) in 2016, becoming the first state in nearly 30 years to eliminate nonmedical exemptions from immunization requirements for schoolchildren. Our objectives were to determine (1) the impacts of SB277 on the percentage of kindergarteners entering school not up-to-date on vaccinations and (2) if geographic patterns of vaccine refusal persisted after the implementation of the new law. METHODS At the state level, we analyzed the magnitude and composition of the population of kindergarteners not up-to-date on vaccinations before and after the implementation of SB277. We assessed correlations between previous geographic patterns of nonmedical exemptions and patterns of the remaining entry mechanisms for kindergarteners not up-to-date after the law's implementation. RESULTS In the first year after SB277 was implemented, the percentage of kindergartners entering school not up-to-date on vaccinations decreased from 7.15% to 4.42%. The conditional entrance rate fell from 4.43% to 1.91%, accounting for much of this decrease. Other entry mechanisms for students not up-to-date, including medical exemptions and exemptions for independent study or homeschooled students, largely replaced the decrease in the personal belief exemption rate from 2.37% to 0.56%. In the second year, the percentage of kindergartners not up-to-date increased by 0.45%, despite additional reductions in conditional entrants and personal belief exemptions. The correlational analysis revealed that previous geographic patterns of vaccine refusal persisted after the law's implementation. CONCLUSIONS Although the percentage of incoming kindergarteners up-to-date on vaccinations in California increased after the implementation of SB277, we found evidence for a replacement effect.
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Affiliation(s)
- Paul L Delamater
- Department of Geography and Carolina Population Center, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Departments of
| | | | - Alison M Buttenheim
- Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Daniel A Salmon
- Department of International Health, Johns Hopkins University, Baltimore, Maryland; and
| | - Nicola P Klein
- Kaiser Permanente Vaccine Study Center, Oakland, California
| | - Saad B Omer
- Global Health, Emory University, Atlanta, Georgia
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Cadena J, Falcone D, Marathe A, Vullikanti A. Discovery of under immunized spatial clusters using network scan statistics. BMC Med Inform Decis Mak 2019; 19:28. [PMID: 30717725 PMCID: PMC6360755 DOI: 10.1186/s12911-018-0706-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Accepted: 11/01/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Clusters of under-vaccinated children are emerging in a number of states in the United States due to rising rates of vaccine hesitancy and refusal. As the measles outbreaks in California and other states in 2015 and in Minnesota in 2017 showed, such clusters can pose a significant public health risk. Prior methods have used publicly-available school immunization data for analysis (except for a few, which use private healthcare patient records). School immunization data has limited demographic information-as a result, such analyses are not able to provide demographic characteristics of significant clusters. Further, the resolution of the clusters identified by prior methods is limited since they are typically restricted to disks or well-rounded shapes. METHODS We use realistic population models for Minnesota (MN) and Washington (WA) state, which provide a model of activities for all individuals in the population. We combine this with school level immunization data for these two states, to estimate vaccine coverage at the level of census block groups. A scan statistic method defined on networks is used for finding significant clusters of under-immunized block groups, without any restrictions on shape. Further we provide the demographic characteristics of these clusters. RESULTS We find 2 significant under-vaccinated clusters in MN and 3 in WA. These are very irregular in shape, in contrast to the circular disks reported in prior work, which rely on the SatScan approach. Some of the clusters found by our method are not contained in those computed using SatScan, a state-of-the-art software tool used in similar studies in other states. CONCLUSIONS The emergence of under-immunized clusters is a growing concern for public health agencies because they can act as reservoirs of infection and increase the risk of infection into the wider population. Higher resolution clusters computed using our network based approach and population models provide new insights on the structure and characteristics of such clusters and enable targeted interventions.
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Affiliation(s)
- Jose Cadena
- Lawrence Livermore National Laboratory, 7000 East Ave, Livermore, CA 94550 USA
| | | | - Achla Marathe
- Biocomplexity Institute & Initiative, University of Virginia, 995 Research Park Boulevard, Charlottesville, VA 22911 USA
- Department of Public Health Science, University of Virginia, School of Medicine, Charlottesville, VA 22911 USA
| | - Anil Vullikanti
- Biocomplexity Institute & Initiative, University of Virginia, 995 Research Park Boulevard, Charlottesville, VA 22911 USA
- Department of Computer Science, University of Virginia, Charlottesville, VA 22911 USA
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Delamater PL, Leslie TF, Yang YT. Examining the spatiotemporal evolution of vaccine refusal: nonmedical exemptions from vaccination in California, 2000-2013. BMC Public Health 2018; 18:458. [PMID: 29688861 PMCID: PMC5913803 DOI: 10.1186/s12889-018-5368-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Accepted: 03/22/2018] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Paul L Delamater
- Department of Geography, Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Timothy F Leslie
- Department of Geography and Geoinformation Science, George Mason University, Fairfax, VA, USA
| | - Y Tony Yang
- Department of Health Administration and Policy, George Mason University, Fairfax, VA, USA
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Leslie TF, Delamater PL, Yang YT. It could have been much worse: The Minnesota measles outbreak of 2017. Vaccine 2018; 36:1808-1810. [PMID: 29496348 PMCID: PMC6626669 DOI: 10.1016/j.vaccine.2018.02.086] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Revised: 02/19/2018] [Accepted: 02/20/2018] [Indexed: 12/18/2022]
Abstract
In 2017, Minnesota battled its largest measles outbreak in nearly 30 years, with 79 cases, most of them Somali-American children. In this study, we gathered vaccination and enrollment data for incoming kindergarteners in Minnesota over fall 2012-2016 from the Minnesota Department of Health. We also gathered the number of measles cases by county in 2017. We found that MMR coverage has substantial variation across districts and district types. The minimum MMR coverage is 58.3% and the maximum is 100%. Private schools, which represent approximately six percent of Minnesota's kindergarten enrollment, have a substantially lower coverage rate, with an overall coverage of 83.00%. The 2017 outbreak was relatively isolated. However, the MMR coverage data suggests that other communities could have been at risk given their geographic proximity to the outbreak and modest coverage rates.
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Affiliation(s)
- Timothy F Leslie
- Department of Geography and Geoinformation Science, George Mason University, Fairfax, VA, USA.
| | - Paul L Delamater
- Department of Geography, University of North Carolina, Chapel Hill, NC, USA
| | - Y Tony Yang
- Department of Health Administration and Policy, George Mason University, Fairfax, VA, USA
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Leslie TF, Street EJ, Delamater PL, Yang YT, Jacobsen KH. Variation in Vaccination Data Available at School Entry Across the United States. Am J Public Health 2016; 106:2180-2182. [PMID: 27736214 PMCID: PMC5105002 DOI: 10.2105/ajph.2016.303455] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/20/2016] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To compile substate-level data on US school-age children's vaccination rates. METHODS For states that did not have suitable data online, in 2015 we submitted information requests to the state health department and followed up with the state's Freedom of Information Act when necessary. RESULTS The accessibility, scale, and types of vaccination data varied considerably. Whereas 26 states provided data online, 14 released data only after a Freedom of Information Act request. School or school-district data were available for 24 states, 19 at the county level, 2 at the health department level, and 6 provided no substate-level data. CONCLUSIONS Effective vaccination policy requires a robust understanding of vaccination behavior. Some states make it difficult to access data or provide low-resolution data of limited value for identifying vaccination behavior.
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Affiliation(s)
- Timothy F Leslie
- Timothy F. Leslie and Paul L. Delamater are with the Department of Geography and Geoinformation Science, George Mason University, Fairfax, VA. Erica J. Street and Kathryn H. Jacobsen are with the Department of Global and Community Health, George Mason University. Y. Tony Yang is with the Department of Health Administration and Policy, George Mason University
| | - Erica J Street
- Timothy F. Leslie and Paul L. Delamater are with the Department of Geography and Geoinformation Science, George Mason University, Fairfax, VA. Erica J. Street and Kathryn H. Jacobsen are with the Department of Global and Community Health, George Mason University. Y. Tony Yang is with the Department of Health Administration and Policy, George Mason University
| | - Paul L Delamater
- Timothy F. Leslie and Paul L. Delamater are with the Department of Geography and Geoinformation Science, George Mason University, Fairfax, VA. Erica J. Street and Kathryn H. Jacobsen are with the Department of Global and Community Health, George Mason University. Y. Tony Yang is with the Department of Health Administration and Policy, George Mason University
| | - Y Tony Yang
- Timothy F. Leslie and Paul L. Delamater are with the Department of Geography and Geoinformation Science, George Mason University, Fairfax, VA. Erica J. Street and Kathryn H. Jacobsen are with the Department of Global and Community Health, George Mason University. Y. Tony Yang is with the Department of Health Administration and Policy, George Mason University
| | - Kathryn H Jacobsen
- Timothy F. Leslie and Paul L. Delamater are with the Department of Geography and Geoinformation Science, George Mason University, Fairfax, VA. Erica J. Street and Kathryn H. Jacobsen are with the Department of Global and Community Health, George Mason University. Y. Tony Yang is with the Department of Health Administration and Policy, George Mason University
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Delamater PL, Leslie TF, Yang YT. A spatiotemporal analysis of non-medical exemptions from vaccination: California schools before and after SB277. Soc Sci Med 2016; 168:230-238. [PMID: 27567288 PMCID: PMC6626670 DOI: 10.1016/j.socscimed.2016.08.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 07/01/2016] [Accepted: 08/06/2016] [Indexed: 11/23/2022]
Abstract
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.
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Affiliation(s)
| | | | - Y Tony Yang
- Department of Health Administration and Policy, George Mason University, USA
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