Vaccine exemptions and the kindergarten vaccination coverage gap

Evaluating the Accuracy of the Annual Statewide Kindergarten Vaccination Survey Submitted to Public Health Authorities by School Systems, Oklahoma, 2018

Recent trends in vaccine hesitancy have brought to light the importance of using accurate school vaccination data. This study evaluated the accuracy of a pilot statewide kindergarten vaccination survey in Oklahoma. School vaccination and exemption data were collected from November 2017 to April 2018 via the Research Electronic Data Capture system. A multivariable linear regression model was used to evaluate the relationship between students who are up to date for all vaccines comparing school reported and Oklahoma State Department of Health-validated data. Adjusted vaccination data were overestimated by 1.0% among public schools and 3.3% among private schools. These results were validated by a random audit of participating schools finding the school-reported vaccination data to be overestimated by 0.6% compared to true student immunization records on file. Our analysis indicates that school-reported vaccination data are sufficiently valid. Immunization record audits provide confidence in available data, which drives evidence-based decision-making.

COVID-19 vaccination intention and activation among health care system employees: A mixed methods study

BACKGROUND

Achieving high COVID-19 vaccination rates among employees is necessary to prevent outbreaks in health care settings. The goal of the study was to produce actionable and timely evidence about factors underlying the intention and decisions to obtain the COVID-19 vaccine by employees.

METHODS

The study was conducted from December 2020 - May 2021 with employees from a VA health care system in Southeastern US. The study used a convergent mixed methods design comprising two main activities: a cross-sectional survey conducted prior to COVID-19 vaccine distribution, and semi-structured interviews conducted 4-6 months after vaccine distribution. Data were collected about participant characteristics, vaccination intention prior to distribution, vaccination decision post-distribution, determinants of vaccination intention and decision, activating factors, sources of information and intervention needs. Data from the survey and interviews were analyzed separately and integrated narratively in the discussion.

RESULTS

Prior to vaccine distribution, 77% of employees wanted to be vaccinated. Post vaccine distribution, we identified 5 distinct decision-making groups: 1) vaccine believers who actively sought vaccination and included those sometimes described as "immunization advocates", 2) go along to get along (GATGA) individuals who got vaccinated but did not actively seek it, 3) cautious acceptors who got the COVID-19 vaccine after some delay, 4) fence sitters who remained uncertain about getting vaccinated, and 5) vaccine refusers who actively rejected the COVID-19 vaccine. Participants identifying with Black or multiple races were more likely to express hesitancy in their vaccination intention.

CONCLUSION

The findings of our study highlight distinct decision-making profiles associated with COVID-19 vaccination among employees of a VA health care system, and provide tailored recommendations to reduce vaccine hesitancy in this population.

Vaccination-Related Activities at Schools With Kindergartners: Evidence From a School Nurse Survey

Vaccination coverage among children in kindergarten varies across the country and within states. We surveyed a convenience sample of kindergarten school nurses to investigate self-reported vaccination-related activities conducted at schools nationwide. The majority of the 1,435 kindergarten school nurses responding reported that their schools communicate with parents and guardians of undervaccinated students by phone (96%), postal mail (67%), newsletters (61%), and e-mail (59%). Most respondents reported documenting vaccination coverage in electronic systems (85%) and sharing coverage reports with health departments (69%). A total of 41% of school nurses worked with external partners for vaccination efforts, the most common support received from partners being vaccine administration (38%) and providing materials/vaccines (21%). School nurses also reported that 95% of kindergartners were up to date for all vaccines. School-based vaccination-related activities are essential to sustaining high levels of vaccination coverage for the protection of children at schools and in the broader community.

Recent advances in addressing vaccine hesitancy

PURPOSE OF REVIEW

To offer healthcare providers current, evidence-based approaches for addressing vaccine hesitancy to increase vaccine coverage and reduce the frequency of vaccine-preventable disease outbreaks.

RECENT FINDINGS

Vaccine hesitancy is a growing problem with profound societal, economic, and medical consequences. Understanding the complexity of vaccine hesitancy can inform approaches to increasing vaccine uptake on both the individual and population levels. Notably, pediatricians play a critical role in increasing vaccine uptake due to their relationships with families. This doctor-patient relationship establishes trust and allows evidence-based intervention strategies to be effective in the office. Understanding potential solutions outside the office, such as media campaigns and policy changes, also provide insight into vaccine hesitancy and potential directions for future research. While pediatricians' attempts in the clinic to increase coverage remain crucial, vaccine hesitancy remains a formidable public health problem that requires attention on both the micro and macro levels to be addressed successfully.

SUMMARY

Providers have an opportunity to increase both confidence in and uptake of vaccines. Public health interventions would effectively complement strategies in the clinic to increase overall coverage.

Understanding the impact of state vaccination laws on exemption rates

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.

Legislative and administrative actions to increase vaccination coverage in Washington schools

Current outbreaks of vaccine-preventable diseases in the U.S. highlight the consequences of declining levels of vaccination coverage. Attempts to increase coverage by banning or restricting nonmedical exemptions from school-entry vaccination requirements disregard children not up to date on vaccination who already attend school and those who are not up to date for reasons other than vaccine hesitancy. We analyze the potential effects of legislative and administrative options to increase vaccination coverage in Washington schools. We constructed a grade-specific model of the detailed vaccination status for all required vaccines and the MMR vaccine specifically for all children in the state's school system. We used scenario modeling to evaluate the effects of potential legislative and administrative actions on the percent of students up to date on all required vaccines and the MMR vaccine from 2018 to 2030. Our analysis shows that eliminating nonmedical exemptions may not be the optimal solution for reducing disease outbreak risk. Instead, focusing on children not up to date for reasons other than nonmedical exemption could have a larger impact and does not carry the controversy that accompanies attempts to ban or restrict nonmedical exemptions. Further, implementing a one-time catch-up period for all children not up to date would increase coverage promptly. Evidence-based policymaking is an essential component of efforts to reduce the risk of disease outbreaks in U.S. schools, and analysis of potential legislative and administrative actions complement these efforts.

Increasing Vaccination: Putting Psychological Science Into Action

Vaccination is one of the great achievements of the 20th century, yet persistent public-health problems include inadequate, delayed, and unstable vaccination uptake. Psychology offers three general propositions for understanding and intervening to increase uptake where vaccines are available and affordable. The first proposition is that thoughts and feelings can motivate getting vaccinated. Hundreds of studies have shown that risk beliefs and anticipated regret about infectious disease correlate reliably with getting vaccinated; low confidence in vaccine effectiveness and concern about safety correlate reliably with not getting vaccinated. We were surprised to find that few randomized trials have successfully changed what people think and feel about vaccines, and those few that succeeded were minimally effective in increasing uptake. The second proposition is that social processes can motivate getting vaccinated. Substantial research has shown that social norms are associated with vaccination, but few interventions examined whether normative messages increase vaccination uptake. Many experimental studies have relied on hypothetical scenarios to demonstrate that altruism and free riding (i.e., taking advantage of the protection provided by others) can affect intended behavior, but few randomized trials have tested strategies to change social processes to increase vaccination uptake. The third proposition is that interventions can facilitate vaccination directly by leveraging, but not trying to change, what people think and feel. These interventions are by far the most plentiful and effective in the literature. To increase vaccine uptake, these interventions build on existing favorable intentions by facilitating action (through reminders, prompts, and primes) and reducing barriers (through logistics and healthy defaults); these interventions also shape behavior (through incentives, sanctions, and requirements). Although identification of principles for changing thoughts and feelings to motivate vaccination is a work in progress, psychological principles can now inform the design of systems and policies to directly facilitate action.

It could have been much worse: The Minnesota measles outbreak of 2017

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.