Efficient burdens decrease nonmedical exemption rates: A cross-county comparison of Michigan's vaccination waiver education efforts

Medical exemptions to mandatory vaccinations: The state of play in Australia and a pressure point to watch

Australia's mandatory vaccination policies have historically allowed for non-medical exemptions (NMEs), but this changed in 2016 when the Federal Government discontinued NMEs for childhood vaccination requirements. Australian states introduced further mandatory vaccination policies during the COVID-19 pandemic for a range of occupations including healthcare workers (HCWs). There is global evidence to suggest that medical exemptions (MEs) increase following the discontinuation of NMEs; the new swathe of COVID-19 mandatory vaccination policies likely also placed further pressure on ME systems in many jurisdictions. This paper examines the state of play of mandatory vaccination and ME policies in Australia by outlining the structure and operation of these policies for childhood vaccines, then for COVID-19, with a case study of HCW mandates. Next, the paper explores HCWs' experiences in providing vaccine exemptions to patients (and MEs in particular). Finally, the paper synthesizes existing literature and reflects on the challenges of MEs as a pressure point for people who do not want to vaccinate and for the clinicians who care for them, proposing areas for future research and action.

School staff and immunization governance: Missed opportunities for public health promotion

BACKGROUND

In US states, childhood immunization mandates are enforced for school registration by front-line school staff, usually secretaries. Despite substantial changes to mandate policies in several states and many countries, little attention has been paid to the people who enforce them. This qualitative pilot study aimed to uncover beliefs, attitudes, and practices regarding immunization governance of Michigan school staff.

METHOD

Front-line administrative workers from Michigan schools and district offices were solicited by email. Sixteen were interviewed remotely.

RESULTS

Front-line school staff believed in vaccines, but did not advocate for vaccination while registering children. Instead, they sought low-friction bureaucratic transactions, privileging the collection of data over the promotion of public health goals. This revealed a mismatch between the goals of the front-line staff who enforce vaccine mandates in schools and the goals of the policymakers who created school vaccine mandates.

CONCLUSIONS

This study found low mobilization of front-line enforcers of mandates in public-facing school administration roles, a problem likely to afflict the majority of American states with the 'mandates + exemptions' model of immunization governance. Schools would have stronger incentives to promote vaccination if state funding were better tied to immunization compliance. Front-line staff could better enforce vaccine mandates if they were provided with resources and training about vaccine promotion.

Methods of Current Practice: Qualitative Analysis of Intervention Strategies Utilized by Vaccine Waiver Educators in Michigan

By enacting administrative rule 325.176 (12), Michigan added a vaccine education component as a precondition to granting vaccine waivers to vaccine-hesitant parents wishing to file a nonmedical vaccine exemption for their school-aged child. The purpose of the study was to identify best practices for reaching vaccine-hesitant parents during face-to-face vaccine education sessions conducted by vaccine waiver educators in Michigan. This study utilized qualitative descriptive content analysis of semi-structured phone interviews with vaccine waiver educators from local health departments (LHDs) in Michigan. Participants were vaccine waiver educators who were employed by a local health department in Michigan and had conducted at least 30 vaccine waiver education sessions. Strategies, resources, and techniques identified by educators as beneficial included using and providing information from a variety of sources, compiling their own educational materials, creating a positive experience, holding personalized sessions, and streamlining exemption and vaccination sessions. However, unexpected themes that emerged from the interviews revealed that vaccine waiver educators need additional training in discussing vaccine ingredients with parents, handling religious vaccine exemption requests, and assessing the role of schools. Implementing successful vaccine education interventions targeting vaccine-hesitancy is crucial to public health. Charging LHDs with overseeing vaccine education via a face-to-face discussion is a novel intervention strategy, the effective implementation of which may inform vaccine education intervention nationwide and may even be translated into international contexts and prove useful to current COVID-19 vaccination efforts.

COVID-19 Vaccine Mandates: Attitudes and Effects on Holdouts in a Large Australian University Population

Many governments and institutions mandated COVID-19 vaccines. In late 2021, we sought to ascertain the perspectives of staff and students from The University of Western Australia about the State or the University mandating COVID-19 vaccines. The survey captured vaccination status and intentions along with attitudes towards mandates and potential types of exemptions with 2878 valid responses which were quantitatively analysed and 2727 which were qualitatively analysed. The study found generally high levels of vaccination or intent, and strong support for mandates, underpinned by beliefs that vaccination is a moral duty and that mandates make campus feel safer. These sentiments were not more prevalent amongst individuals with comorbidities; often healthy individuals supported mandates to reduce their risk of transmitting disease to vulnerable family members. Individuals with comorbidities were, however, more supportive of excluding the unvaccinated from campus. Most opponents were unvaccinated, and many indicated that mandate policies would backfire, making them less likely to vaccinate. Despite the strong overall support, 41% of respondents did not want to see non-compliant staff or students lose their positions, and only 35% actively sought this. Institutions or governments introducing mandates should emphasise community concerns about catching COVID-19 and becoming sick or transmitting the disease to vulnerable loved ones.

Evaluating Michigan's Administrative Rule Change on Nonmedical Vaccine Exemptions

OBJECTIVES

Vaccine hesitancy is a growing threat to health in the United States. Facing the fourth highest vaccine exemption rate in the United States in 2014, Michigan changed its state Administrative Rules, effective January 1, 2015, requiring parents to attend an in-person vaccine education session at their local health department before obtaining a nonmedical exemption (NME). In this article, we evaluate the longer-term impact of this policy change on the rate, spatial distribution, and sociodemographic predictors of NMEs in Michigan.

METHODS

Using school-level kindergarten vaccination data from Michigan from 2011 to 2018, we evaluated sociodemographic predictors of NMEs before and after this Administrative Rule change using Bayesian binomial regression. We measured the persistence and location of school district-level geographic clustering using local indicators of spatial association.

RESULTS

Immediately after the rule change, rates of NMEs fell by 32%. However, NME rates rebounded in subsequent years, increasing by 26% by 2018, although income disparities in NME rates decreased after the rule change. Philosophical, religious, and medical vaccine exemptions exhibited distinct geographic patterns across the state, which largely persisted after 2015, illustrating that NME clusters remain a concern despite this rule change.

CONCLUSIONS

Although Michigan's Administrative Rule change caused a short-term decline in NME rates, NME rates have risen dramatically in the following 4 years since the policy was implemented. Michigan's administrative effort to require parental education at the local health department before receiving an exemption did not cause a sustained reduction in the rate or spatial distribution of NMEs.

Financial Interventions to Increase Vaccine Coverage

BACKGROUND

Recent vaccine mandates in Australia, as in other high income settings, have sought to change the behavior of parents, including those who would otherwise access nonmedical exemptions. Since 2014, Australian state governments have introduced and progressively tightened policies restricting the access of unvaccinated children to early education and child care. In 2016, the Federal Government removed financial entitlements and subsidies from nonvaccinating families. We sought to ascertain the impact of these policies on vaccine coverage rates by state, and also to consider their impact on communities with high numbers of registered refusers.

METHODS

Interrupted time series models were fitted by using the Autoregressive Integrated Moving Average framework to test for changes in trend in vaccination rates following implementation of government policies.

RESULTS

Australian vaccine coverage rates were rising before the vaccine mandates and continued to do so subsequently, with no statistically significant changes to coverage rates associated with the interventions. The exception was New South Wales, where vaccine coverage rates were static before the policy intervention, but were increasing at an annual rate of 1.25% after (P < .001). The impact of the policies was indistinguishable between communities with high, medium and low numbers of registered vaccine refusers.

CONCLUSIONS

In our study, we show that childhood vaccine coverage continued on its positive trajectory without any conclusive evidence of impact of mandatory policies. Overseas policymakers looking to increase coverage rates would be well-advised to examine the contribution of pre-existing and parallel nonmandatory interventions employed by Australian governments to the country's enhanced coverage.

Vaccine sentiments and under-vaccination: Attitudes and behaviour around Measles, Mumps, and Rubella vaccine (MMR) in an Australian cohort

OBJECTIVE

The study aimed to examine the consistency in factors associated with attitudes towards vaccination and MMR vaccination status.

METHODS

Using the nationally representative Longitudinal Study of Australian Children matched with the Australian Childhood Immunisation Register, 4,779 children were included from 2004-2005 to 2010-11. Different MMR vaccine dosages and general attitude towards vaccination were modelled individually with multinomial logit regressions, controlling for demographic, socioeconomic, and health related factors of the children and their primary carers.

RESULTS

The group with non-vaccination and negative attitudes was characterised by more siblings and older parents the group with under-vaccination but positive attitudes was characterised by younger parental age; and the group with under-vaccination and neutral attitudes was characterised by less socioeconomically advantaged areas. The presence of parental medical condition(s), being private or public renters, and higher parental education were associated with under-vaccination but not with attitudes towards vaccination, whilst parental religion was associated with attitudes towards vaccination but not reflected in the vaccine uptake.

CONCLUSIONS

Vaccine attitudes were largely consistent with MRR vaccine outcomes. However, there was variation in the associations of factors with vaccine attitudes and uptake. The results have implications for different policy designs that target subgroups with consistent or inconsistent vaccination attitudes and behaviour. Parents with intentional and unintentional under-vaccination are of policy concern and require different policy solutions.

Imperfect Immunization Communication on School District Websites: A Mixed-Methods Review

Schools and school districts are key to U.S. vaccination policies: They communicate immunization enrollment requirements and enforce them during registration. This article presents a mixed-methods study of how Michigan's 537 districts communicate about vaccine mandates through public-facing websites. It reports the results of a qualitative analysis (n = 50) of websites from Southeast Michigan and a quantitative analysis of all (n = 537) Michigan's district websites. School district websites engage in diverse health promotion practices surrounding immunization, from encouraging vaccination to neutral messaging and to encouraging exemptions. Most provide scant immunization information and few promote the importance of immunization for individual and community health. We recommend that school nurses, district staff, and health authorities collaborate to ensure that school district communication promotes immunization and does not promote nonmedical exemptions. This can lead schools to embrace immunization as an essential activity for their own functioning rather than as an unwelcome requirement imposed by outside agents.