Elimination of Nonmedical Immunization Exemptions in California and School-Entry Vaccine Status

The implementation of a new measles vaccine mandate in Germany: A qualitative study in local health departments

BACKGROUND

Measles is a highly contagious disease with the potential for severe complications. Despite the availability of effective vaccines, there have been recurrent measles outbreaks in Germany over the past decades. In response, a new measles vaccine mandate was introduced on March 1, 2020, aimed at closing vaccination gaps in high-risk populations. This study evaluates the mandate's implementation, identifies operational challenges, assesses the impact of the Coronavirus disease 2019 pandemic, and investigates expert attitudes towards the new policy.

METHODS

Semi-structured expert interviews were conducted with staff members of 16 different local health departments in Germany. The interviews, carried out in April and May 2021, were electronically recorded, transcribed verbatim, and analyzed using the Framework method.

RESULTS

The implementation of the measles vaccine mandate in local health departments varied substantially. Challenges in implementing the mandate primarily arose from uncertainties regarding procedural specifics, such as handling fraudulent medical certificates and imposing sanctions, leading to a call from many interviewees for uniform guidelines to ensure coherent implementation. At the time the measles vaccine mandate came into force, managing the Coronavirus disease 2019 pandemic was a priority in most local health departments, often delaying the implementation of the mandate. Despite the difficulties encountered, most experts considered the mandate to be an effective step towards measles elimination.

CONCLUSIONS

The measles vaccine mandate has imposed a new responsibility on staff in German local health departments, which is associated with implementation challenges such as procedural uncertainties and vaccine hesitancy, but also the Coronavirus disease 2019 pandemic as a contextual impediment. Significant differences in the implementation approach underscore the need for harmonization to enhance implementation efficiency and public acceptance of the mandate. Despite the mandate's potential to increase vaccination rates, our findings advocate for a comprehensive approach, incorporating public education, accessible vaccination, and measures to address social disparities.

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 Vaccine Coverage and Medical Exemption Uptake After the New York State Repeal of Nonmedical Vaccination Exemptions

Importance

Although New York State (NYS) recently adopted legislation eliminating nonmedical vaccination exemption options from school-entry requirements, the implications of the law for school vaccine coverage and medical vaccine exemption uptake have not been examined.

Objective

To evaluate the implications of the repeal of school-entry nonmedical vaccination exemptions for vaccine coverage and medical exemption uptake at NYS schools outside of New York City (NYC).

Design, Setting, and Participants

This cohort study had an interrupted time-series design and used generalized estimating equation models to examine longitudinal school immunization compliance data from the 2012 to 2013 through 2021 to 2022 school years. The cohort comprised NYS public and nonpublic schools, excluding NYC schools, with any students enrolled in kindergarten to 12th grade. Eligible schools had enrollment and immunization data before and after the implementation of the Senate Bill 2994A legislation. Data analyses were conducted in July 2023.

Exposure

Senate Bill 2994A was passed in June 2019, eliminating school-entry nonmedical vaccination exemptions. Since compliance with the law was evaluated for most students during the next school year, the 2019 to 2020 school year was considered to be the law's effective date.

Main Outcomes and Measures

The primary outcomes were school vaccine coverage (defined as the percentage of students at each school who completed grade-appropriate requirements for all required vaccines) and medical exemption uptake (defined as the percentage of students at each school who received a medical exemption).

Results

Among the 3821 eligible schools, 3632 (95.1%) were included in the analysis, representing 2794 (96.9% of eligible) public schools and 838 (89.2% of eligible) nonpublic schools. The implementation of Senate Bill 2994A was associated with absolute increases in mean vaccine coverage of 5.5% (95% CI, 4.5%-6.6%) among nonpublic schools and 0.9% (95% CI, 0.7%-1.1%) among public schools, with additional annual increases in vaccine coverage observed through the 2021 to 2022 school year. The law's implementation was also associated with a 0.1% (95% CI, 0.0%-0.1%) mean absolute decrease in medical vaccination exemption uptake at both public and nonpublic schools, and small but significant mean annual decreases in medical vaccination exemptions (0.02%; 95% CI, 0.01%-0.03%) through the end of the study period.

Conclusions and Relevance

Results of this cohort study suggested that repeal of school-entry nonmedical vaccination exemptions was associated with increased vaccine coverage at NYS schools outside of NYC. Coverage gains were not replaced by increases in medical vaccination exemptions.

A survey of college students' knowledge and attitudes regarding vaccination practices

Objective: The prevalence of illnesses related to VPDs is higher among older adults and college students experience them despite decades of vaccine availability. The Centers for Disease Control and Prevention and American College Health Association (ACHA) emphasizes that all students should provide vaccine proof or receive immunizations prior to class registration. Methods: Using the KAP model, this study investigates the perceptions of first-generation university students regarding campus vaccine requirements. Data were collected using the Web-based survey software Qualtrics regarding students' vaccine knowledge and attitudes. Results: Of the 1,327 responses, the majority were female (74.23%), Hispanic (56.67%), and ages 18-25 years (35.57%). Participants were familiar with the function of vaccines (96.64%) and believed that vaccines prevent contagious diseases (92.70%). These responses were significantly associated with vaccination compliance however, 18.48% of students were not in full compliance. There were significant differences in vaccination compliance across academic standing, age, and race. Conclusion: Implications for public health practices on university campuses are discussed.

Provisional Entrants, Exemptions, and Kindergarteners Up-to-Date on Vaccination Before and After a Regulatory Change in Pennsylvania, 2015-2019

OBJECTIVES

Before the 2017-2018 school year, Pennsylvania shortened the grace period for provisional entrants-kindergarteners who are not up-to-date on vaccination and do not have medical or nonmedical exemption-from 8 months to 5 days. We analyzed the impact of this change on school-entry vaccination status.

METHODS

Using data from the Pennsylvania Department of Health for school years 2015-2016 through 2018-2019, we examined state-level trends in Pennsylvania kindergarteners' vaccination status, including the percentage who were up-to-date on each required vaccine, provisionally enrolled, medically exempted from vaccination, and nonmedically exempted from vaccination. Using the Spearman correlation coefficient, we assessed associations at the school level among changes in kindergarteners' vaccination status after the grace period was shortened.

RESULTS

From 2016-2017 to 2017-2018, the provisional entrance rate of kindergarteners in Pennsylvania decreased substantially after the change in the grace period (from 8.1% to 2.2%), the medical exemption rate remained stable, and the nonmedical exemption rate increased slightly (from 1.8% to 2.5%). The percentage of kindergarteners up-to-date on required vaccines increased or remained stable across the study period except for polio, which decreased from 97.9% in 2015-2016 to 96.2% in 2018-2019. The change in provisional entrance rate was negatively associated with change in kindergarteners up-to-date on required vaccines (ρ range, -0.30 to -0.70) but not with change in medical or nonmedical exemptions (ρ range, -0.01 to -0.08).

CONCLUSIONS

Efforts to reduce provisional entrants may increase the percentage of kindergarteners up-to-date on vaccinations at school entry without a corresponding increase in exemptions.

Assessing vaccine hesitancy and support for vaccination requirements for pets and potential Spillovers from humans

BACKGROUND

Growing vaccination hesitancy is well-document among humans. However, we know very little about vaccination hesitancy for pets as well as whether the two phenomena are interconnected. Moreover, support for pet vaccination requirements also remain underassessed.

METHODS

We fielded a large, national survey (N = 3,958) on August 18 and August 19, 2023, to assess U.S. public opinion about the vaccination status of dogs (rabies, canine parvovirus, canine distemper, canine influenza, and Lyme disease) and cats (rabies, feline panleukopenia (parvo), feline herpesvirus-1, feline chlamydia, and feline Bordetella) in the United States. We also queried respondents about their support for vaccination requirements for the 10 diseases.

RESULTS

We find that the vast majority of cats and dogs are vaccinated. However, a substantial minority of pets is not, particularly for cats and for non-core vaccines. We find that attitudinal measures of human and pet vaccine hesitancy are closely related to each other. Moreover, they are strong predictors of vaccine behavior. Measures of vaccine hesitancy are also strong predictors of support for vaccination mandates. Common measures used to assess human vaccine hesitancy showed inconsistent effects. However, pet vaccinations appear to be less politically polarizing.

CONCLUSION

The high correlation between pet and human measures raises the stake for public health efforts to improve attitudes about vaccines and vaccination rates across the board. Strong support for vaccination requirements should encourage policymakers to explore policy change. Moreover, veterinarians and their associations should consider expanding the number of core vaccinations.

U.S. public support and opposition to vaccination mandates in K-12 education in light of the COVID-19 pandemic

BACKGROUND

Vaccination mandates have long been an effective tool in increasing vaccination rates and reducing the potential for disease outbreaks. In the wake of COVID-19, opposition to mandates in the K-12 setting has garnered more attention, and policymakers opposed to them have become more active. This study sought to assess whether these efforts are supported by the U.S. public.

METHODS

We fielded a large, national survey (N = 16,461) from January to April of 2022 to assess U.S. public opinion about seven specific vaccination mandates (diphtheria, tetanus, & pertussis (DTaP); polio; chickenpox; measles, mumps, and rubella (MMR); hepatitis; human papillomavirus (HPV); and COVID-19) in K-12 educational settings.

RESULTS

We found that Americans are overwhelmingly supportive of all vaccination mandates with support ranging from a high 90 percent of respondents for DTaP, polio, chickenpox, and MMR to a low of 68 percent for COVID-19. Individuals who deemed vaccines safe and important, those with trust in the National Institutes of Health and the Food and Drug Administration, urban residents, and ethnic and racial minorities tended to be consistently more supportive. Perceptions about vaccine effectiveness were positively associated with mandate support in most cases, as was trust in medical doctors. Respondents who believed that vaccines cause autism, those with better health and more trust in religious leaders tended to be consistently more opposed. Women were generally more supportive of mandates except for HPV and COVID-19. Ideology and partisanship affected opinion for COVID-19 as did trust in the Centers for Disease Control and Prevention. We found no effects for income or education.

CONCLUSION

Vaccination mandates in K-12 have broad support among the American public, even in more controversial cases such as HPV and COVID-19. Vocal opposition and growing interest by policymakers to limit or undo vaccination mandates are not supported by the broader public.

Students Provisionally Enrolled Due to Vaccination Requirements: Variation in State Laws and Rates

This research examined the laws and regulations surrounding provisional enrollment in schools across the United States. Provisional enrollment refers to children who have started, but not completed, their required vaccinations and are allowed to attend school while completing their vaccinations. We found that nearly all states have laws regarding provisional enrollment, with 5 essential components to compare the laws including vaccine- and dose-specific requirements, type of personnel permitted to authorize, length of time that the children have to become up to date on their vaccinations (grace period), follow-up procedures, and consequences for noncompliance. In addition, we found that the percentage of provisionally enrolled kindergarteners varied greatly from state to state, with some states having less than 1% of provisionally enrolled kindergarteners and others having more than 8% between school years 2015-2016 and 2020-2021. We suggest that reducing the number of provisional entrants could be an alternative intervention to increase vaccination coverage.

Kindergarten Vaccination Status in California After Changes to Medical Exemption Policy

This study evaluates changes in medical exemptions and geographic distribution of kindergarteners in California not up to date on vaccination after changes to state legislation.

What Causes the Discrepancy in SARS-CoV-2 Vaccine Between Parental Hesitancy for Themselves and for Their Children During Lockdown Period?

BACKGROUND

Parents are usually the decision-makers for vaccinations of children. Therefore, it is important to understand parental beliefs and attitudes toward severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccine for themselves and their children when it was approved for children age 3-17.

METHOD

A cross-sectional survey based on an anonymous online questionnaire for parents was conducted in seven provinces of China, and demographic information, vaccination history, parental decision motives, and health belief model toward themselves and their children were collected, respectively.

RESULTS

The overall parental hesitancy rate toward themselves was 20.30%, and that toward their children was 7.80%. More parental concerns on disease severity (odd ratio [OR] = 1.11, 95% confidence interval [CI]: 1.01-1.61) and susceptibility (OR = 1.29, 95% CI: 1.01-1.63) of children could be the causes of discrepancy in hesitancy for themselves and for their children. Parents who hesitated to vaccinate themselves might also be hesitated to vaccinate their children (β = 0.077, P < 0.001).

CONCLUSION

Threat perception may lead to inconsistencies in parental vaccination decisions toward themselves and toward their children. Correcting misinformation and strengthening education about COVID-19 are of great significance in addressing vaccine hesitancy among parents and children.

State Policy Removing the Personal Belief Exemption for Measles, Mumps, and Rubella (MMR) School Immunization Requirement, Washington State, 2014-2022

Objectives. To assess the impact of Washington State's 2019 Engrossed House Bill (EHB) 1638-which removed measles, mumps, and rubella (MMR) personal belief exemptions-on MMR vaccine series completion and exemption rates in K-12 students. Methods. We used interrupted time-series analyses to examine changes in MMR vaccine series completion rates before and after EHB 1638 was passed and the χ2 test for differences in exemption rates. Results. EHB 1638 implementation was associated with a 5.4% relative increase in kindergarten MMR vaccine series completion rates (95% confidence interval = 3.8%, 7.1%; P ≤ .001), and results were similar with Oregon as a control state (no change observed in Oregon; P = .68). MMR exemptions overall decreased 41% (from 3.1% in 2018-2019 to 1.8% in 2019-2020; P ≤ .001), and religious exemptions increased 367% (from 0.3% to 1.4%; P ≤ .001). Conclusions. EHB 1638 was associated with an increase in MMR vaccine series completion rates and a decrease in any MMR exemption. However, effects were partially offset by an increase in religious exemption rates. Public Health Implications. Removal of personal belief exemptions for the MMR immunization requirement only may be an effective approach to increase MMR vaccine coverage rates statewide and among underimmunized communities. (Am J Public Health. 2023;113(7):795-804. https://doi.org/10.2105/AJPH.2023.307285).

Donor selection for adoptive cell therapy with CD45RA- memory T cells for patients with coronavirus disease 2019, and dexamethasone and interleukin-15 effects on the phenotype, proliferation and interferon gamma release

BACKGROUND AIMS

We have previously demonstrated the safety and feasibility of adoptive cell therapy with CD45RA- memory T cells containing severe acute respiratory syndrome coronavirus 2-specific T cells for patients with coronavirus disease 2019 from an unvaccinated donor who was chosen based on human leukocyte antigen compatibility and cellular response. In this study, we examined the durability of cellular and humoral immunity within CD45RA- memory T cells and the effect of dexamethasone, the current standard of care treatment, and interleukin-15, a cytokine critically involved in T-cell maintenance and survival.

METHODS

We performed a longitudinal analysis from previously severe acute respiratory syndrome coronavirus 2-infected and infection-naïve individuals covering 21 months from infection and 10 months after full vaccination with the BNT162b2 Pfizer/BioNTech vaccine.

RESULTS

We observed that cellular responses are maintained over time. Humoral responses increased after vaccination but were gradually lost. In addition, dexamethasone did not alter cell functionality or proliferation of CD45RA- T cells, and interleukin-15 increased the memory T-cell activation state, regulatory T cell expression, and interferon gamma release.

CONCLUSIONS

Our results suggest that the best donors for adoptive cell therapy would be recovered individuals and 2 months after vaccination, although further studies with larger cohorts would be needed to confirm this finding. Dexamethasone did not affect the characteristics of the memory T cells at a concentration used in the clinical practice and IL-15 showed a positive effect on SARS-CoV-2-specific CD45RA- T cells.

Convergence on Coercion: Functional and Political Pressures as Drivers of Global Childhood Vaccine Mandates

BACKGROUND

Vaccine hesitancy is a global problem with diverse local policy responses, from voluntaristic to coercive. Between 2015 and 2017, California, Australia, France, and Italy increased the coerciveness of their childhood vaccine regimes. Despite this apparent convergence, there is little evidence of imposition, policy learning, or diffusion - the drivers that are usually discussed in scholarly literature on policy convergence. The fact that the four governments were oriented across the political spectrum, with quite different political and institutional systems, further indicates an empirical puzzle.

METHODS

To better understand the drivers of enhanced vaccine mandates, a crucial issue during the coronavirus disease 2019 (COVID-19) global rollout, this article engages with four case studies assembled from qualitative analysis of semi-structured in-country interviews and document analysis between November 2018 and November 2020. Key informants had specific expert knowledge or played a role in the introduction or implementation of the new policies. Interview transcripts were coded inductively and deductively, augmented with extensive analysis of legal, policy, academic and media documents.

RESULTS

The case analysis identifies two key and interacting elements in government decisions to tighten vaccine mandates: functional and political pressures. Policy-makers in Italy and France were primarily driven by functional challenges, with their vaccination governance systems under threat from reduced population compliance. California and Australia did not face systemic threats to the functioning of their systems, but activists utilised local opportunities to heighten political pressure on decision makers.

CONCLUSION

In four recent cases of high-income jurisdictions making childhood vaccination policies more coercive, vaccine hesitancy alone could not explain why the policies arose in these jurisdictions and not others, while path dependency alone could not explain why some jurisdictions with mandates made them more coercive. Explanation lies in restrictive mandates being attractive for governments, whether they face systemic functional problems in vaccine governance, or political pressures generated by media and activists. Mandates can be framed as targeting whole populations or localised groups of refusers, and implemented without onerous costs or policy complexity.

COVID-19 vaccine Mandates: An Australian attitudinal study

BACKGROUND

The rollout of vaccines against COVID-19 is prompting governments and the private sector to adopt mandates. However, there has been little conceptual analysis of the types of mandates available, nor empirical analysis of how the public thinks about different mandates and why. Our conceptual study examines available instruments, how they have been implemented pre-COVID, and their use for COVID-19 globally. Then, our qualitative study reports the acceptability of such measures in Western Australia, which has experienced very limited community transmission, posing an interesting scenario for vaccine acceptance and acceptability of measures to enforce it.

METHOD

Our conceptual study developed categories of mandates from extant work, news reports, and legislative interventions globally. Then, our empirical study asked 44 West Australians about their attitudes towards potential mandatory policies, with data analysed using NVivo 12.

RESULTS

Our novel studies contribute richness and depth to emerging literature on the types and varying acceptability of vaccine requirements. Participants demonstrated tensions and confusion about whether instruments were incentives or punishments, and many supported strong consequences for non-vaccination even if they ostensibly opposed mandates. Those attached to restrictions for disease prevention were most popular. There were similar degrees of support for mandates imposed by employers or businesses, with participants showing little concern for potential issues of accountability linked to public health decisions delegated to the private sector. Participants mostly supported tightly regulated medical exemptions granted by specialists, with little interest in religious or personal belief exemptions.

CONCLUSION

Our participants are used to being governed by vaccine mandates, and now by rigorous lockdown and travel restrictions that have ensured limited local COVID-19 disease and transmission. These factors appear influential in their general openness to COVID-19 vaccine mandates, especially when linked explicitly to the prevention of disease in high-risk settings.

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.

Vaccine mandates on childcare entry without conscientious objection exemptions: A quasi-experimental panel study

OBJECTIVES

Examine the effect of No Jab No Play policies, which linked vaccine status to childcare service entry without allowing for personal belief exemptions, on immunisation coverage.

STUDY DESIGN

Immunisation coverage rates from the Australian Immunisation Register were linked to regional level covariates from the Australian Bureau of Statistics between January 2016 and December 2019. Differential timings of policy rollouts across states were used to assess changes in coverage with the implementation of policies with generalised linear models. Quantile regression and subgroup analysis were also conducted to explore the variation in policy responses.

RESULTS

Baseline mean vaccination rates in 2016 were 93.4% for one-year-olds, 91.2% for two-year-olds and 93.2% for five-year-olds. Increases in coverage post-policy were significant but small, at around 1% across age groups, with larger increases in two and five-year-olds. Accounting for aggregate time trends and regional characteristics, implementation of the policies was associated with improved full immunisation coverage rates for age one (post-year 1: 0.15% [95 %CI-0.23; 0.52]; post-year 2: 0.56% [95 %CI 0.05; 1.07]), age two (post-year 1: 0.49 [95 %CI: 0.00; 0.97]; post-year 2: 1.15% [95 %CI: 0.53; 1.77], and age five (post-year 1: 0.38% [95 %CI 0.08; 0.67]; post-year 2: 0.71% [95 %CI 0.25; 1.16]. The policy effect was dispersed and insignificant at the lowest quantiles of the distribution of immunisation coverage, and smaller and insignificant in the highest socioeconomic areas.

CONCLUSION

Findings suggest that No Jab No Play policies had a small positive impact on immunisation coverage. This policy effect varied according to prior distribution of coverage and socio-economic status. Childcare access equity and unresponsiveness in high socioeconomic areas remain concerns.

Evaluation of Trends in Homeschooling Rates After Elimination of Nonmedical Exemptions to Childhood Immunizations in California, 2012-2020

INTRODUCTION

In 2015, California passed Senate Bill No. 277 (SB 277) and became the first state in more than 30 years to eliminate nonmedical exemptions to mandatory childhood immunizations for school entry. One concern that emerged was that the law created an incentive for parents to remove children from brick-and-mortar schools to bypass the immunization requirements.

OBJECTIVE

To assess the trends in homeschooling rates after the elimination of nonmedical exemptions to the requirement of childhood immunizations for school entry.

DESIGN, SETTING, AND PARTICIPANTS

This preintervention-postintervention cross-sectional study calculated homeschooling rates as the number of students in kindergarten through grade 8 (K-8) enrolled through each of California's 3 homeschooling mechanisms (independent study program, private school affidavit, and private school satellite program) divided by all K-8 students enrolled in the same academic year. Data on homeschooling rates were obtained from the California Department of Education. Interrupted time series analyses were conducted using a linear regression model in which the outcome variable was the percentage of students enrolled in a homeschool program before and after SB 277. Data were collected and analyzed from October 3, 2012, to October 2, 2019.

INTERVENTION

Passage of SB 277, which eliminated nonmedical exemptions to childhood immunizations for school entry.

MAIN OUTCOMES AND MEASURES

Homeschooling rates for K-8 students.

RESULTS

Among the students included in the analysis, the homeschooling enrollment for K-8 students in California increased from 35 122 students (0.8%) during the 2012-2013 school year to 86 574 students (1.9%) during the 2019-2020 school year; however, the implementation of SB 277 was not associated with an increase in the percentage of students enrolled in homeschooling programs in California beyond the secular trend. The increase in homeschooling was greatest for the lower grade levels: kindergarten homeschooling enrollment increased from 2068 students (0.4%) in the 2012-2013 school year to 10 553 students (1.9%) in the 2019-2020 school year, whereas the grade 8 homeschool enrollment rate increased from 5146 students (1.0%) in the 2012-2013 school year to 10 485 students (2.0%) in the 2019-2020 school year. Independent study programs accounted for 20 149 students (45.3%) of homeschooling enrollment, private school affidavits accounted for 19 333 students (43.5%), and private school satellite programs accounted for 4935 students (11.1%) during the 2015-2016 school year.

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that legislative action to limit nonmedical exemptions for compulsory vaccination for school entry is not associated with removal of students from classroom-based instruction in brick-and-mortar institutions.

Spatial Clustering of Vaccine Exemptions on the Risk of a Measles Outbreak

OBJECTIVES

Areas of increased school-entry vaccination exemptions play a key role in epidemics of vaccine-preventable diseases in the United States. California eliminated nonmedical exemptions in 2016, which increased overall vaccine coverage but also rates of medical exemptions. We examine how spatial clustering of exemptions contributed to measles outbreak potential pre- and postpolicy change.

METHODS

We modeled measles transmission in an empirically calibrated hypothetical population of youth aged 0 to 17 years in California and compared outbreak sizes under the observed spatial clustering of exemptions in schools pre- and postpolicy change with counterfactual scenarios of no postpolicy change increase in medical exemptions, no clustering of exemptions, and lower population immunization levels.

RESULTS

The elimination of nonmedical exemptions significantly reduced both average and maximal outbreak sizes, although increases in medical exemptions resulted in more than twice as many infections, on average, than if medical exemptions were maintained at prepolicy change levels. Spatial clustering of nonmedical exemptions provided some initial protection against random introduction of measles infections; however, it ultimately allowed outbreaks with thousands more infections than when exemptions were randomly distributed. The large-scale outbreaks produced by exemption clusters could not be reproduced when exemptions were distributed randomly until population vaccination was lowered by >6 percentage points.

CONCLUSIONS

Despite the high overall vaccinate rate, the spatial clustering of exemptions in schools was sufficient to threaten local herd immunity and reduce protection from measles outbreaks. Policies strengthening vaccine requirements may be less effective if alternative forms of exemptions (eg, medical) are concentrated in existing low-immunization areas.

Stigmatized for standing up for my child: A qualitative study of non-vaccinating parents in Australia

BACKGROUND

Vaccine refusal is highly polarizing in Australia, producing a challenging social landscape for non-vaccinating parents. We sought to understand the lived experience of non-vaccinating parents in contemporary Australia.

METHODS

We recruited a national sample of non-vaccinating parents of children <18 yrs, advertising on national radio, in playgrounds in low vaccination areas, and using snowballing. Grounded Theory methodology guided data collection (via semi-structured interviews). Inductive analysis identified stigmatization as a central concept; stigma theory was adopted as an analytical lens.

RESULTS

Twenty-one parents from regional and urban locations in five states were interviewed. Parent's described experiences point to systematic stigmatization which can be characterized using Link & Phelan's five-step process. Parents experienced (1) labelling and (2) stereotyping, with many not identifying with the "anti-vaxxers" portrayed in the media and describing frustration at being labelled as such, believing they were defending their child from harm. Participants described (3) social "othering", leading to relationship loss and social isolation, and (4) status loss and discrimination, feeling "brushed off" as incompetent parents and discriminated against by medical professionals and other parents. Finally, (5) legislative changes exerted power over their circumstances, rendering them unable to provide their children with the same financial and educational opportunities as vaccinated children, often increasing their steadfastness in refusing vaccination.

CONCLUSION

Non-vaccinating Australian parents feel stigmatized for defending their child from perceived risk of harm, reporting a range of social and psychological effects, as well as financial effects from policies which disadvantaged their children through differential financial treatment, and diminished early childhood educational opportunities. While it might be argued that social stigma and exclusionary policies directed a small minority for the greater good are justified, other more nuanced approaches based on better understandings of vaccine rejection could achieve comparable public health outcomes without the detrimental effect on unvaccinated families.

Using a Harm Reduction Model to Reduce Barriers to Vaccine Administration

Vaccination is a strategic public health measure designed to reduce the adverse effects of many infectious diseases. Although national recommendations exist for vaccine administration across the life span, immunization rates are affected by barriers to vaccine access and hesitancy in vaccine acceptance. Midwives and women's health clinicians are optimally poised to assess their client's vaccination status and provide vaccinations during clinical encounters. In order to address client concerns about vaccine safety and administration, each clinician is expected to be knowledgeable about vaccine benefits, recommendations, side effects, and potential adverse reactions. Socioeconomic factors, social policies, and historic and continued experiences related to racism have been identified as barriers to ready access to vaccinations and vaccine acceptance. Midwives can act as leaders within their practice sites and communities through participation in projects that reduce barriers to vaccine access and uptake. Community vaccine outreach programs and relationship-based care can increase vaccine uptake through improved health literacy and associated behavioral changes including greater vaccine acceptance. This article focuses on identifying barriers to vaccine uptake and describing harm reduction measures designed to improve uptake of vaccines. A variety of leadership activities are discussed that can improve clinicians' understanding of their role in optimizing vaccination.

School-level perceptions and enforcement of the elimination of nonmedical exemptions to vaccination in California

In 2015, California passed Senate Bill 277 eliminating all nonmedical exemptions to school vaccinations. We aimed to explore school-level modes of SB277 enforcement, characterize vaccination knowledge, attitudes, and beliefs of school officials, and identify whether school vaccination policies are associated with medical exemptions being granted. Surveys were mailed to a stratified random sample of 1,450 schools in California. School personnel (n = 752) reported their medical training, vaccination beliefs, enforcement of vaccination policies, and school rates of medical exemptions. Multiple logistic regression was used to assess whether school policies are associated with the likelihood of medical exemption requests being granted. Nurses were more likely than non-nurses to hold beliefs recognizing the importance of vaccination. A school where the survey respondent was a nurse was more likely to have granted a medical exemption request compared to a school where the respondent was not a nurse (OR 2.11, 95% CI 1.34-3.36). The training of school officials and school-level practices may impact the enforcement of medical exemptions. Equipping school officials as competent sources of vaccine information for concerned parents will be valuable in improving parental vaccine uptake.

Charting mandatory childhood vaccination policies worldwide

Mandatory childhood vaccination is becoming an increasingly important policy intervention for governments trying to address low vaccination rates. Mandates require vaccination for a certain purpose, most commonly related to school entry for children. However, the discussion surrounding the extent and impact of mandatory vaccination programmes for babies and children have largely been limited to high-income countries. While many recent publications discuss the issue, they have not been inclusive of low- and middle-income countries. This paper thus presents a comprehensive and updatable database of mandatory childhood vaccination policies worldwide, covering 149 countries. The list indicates whether a country has a mandatory vaccination policy and the strictness of the mandate on a scale ranging across three levels of mandatory, mandatory for school entry or recommended. It draws on extensive desk-based research analysing a variety of sources, supplemented by consultations with experts from various health authorities. The paper provides an overview of the state of mandatory childhood vaccination across different World Health Organization (WHO) regions and with country case studies, setting out the general trends and issues, and engages with a discussion about why, how, and where mandatory vaccination is put in place. Our findings show in-country variation in vaccination policy and a variation between vaccination in policy compared to in practice. We observe, particularly for high-income countries, that the occurrence of recent outbreaks is a major factor for the introduction of mandatory vaccination. Also, many low- and middle- income countries have resorted to mandatory vaccination policies because of a lack of other policy options yet still have lower than targeted vaccination rates due to problems with vaccine supply, delivery, and access. Offering comparisons between countries will provide a useful tool for government decision-makers considering the merits of mandatory vaccination.

Measles (Rubeola): A Case Of Vaccine Hesitancy And Pregnancy

Measles (rubeola) is a highly contagious virus. Vaccination has nearly eradicated measles in the United States, yet sporadic outbreaks persist. Although the live-attenuated measles, mumps, rubella vaccine has not been found to cause fetal harm, pregnancy is considered a contraindication for the vaccine and contracting measles during pregnancy can have serious sequelae. Furthermore, lifelong immunity conferred by childhood vaccination is questionable as the vaccine's protection may wane during the childbearing years. Reluctance to vaccinate, or vaccine hesitancy, may leave a proportion of people of childbearing age unprotected. It is unlikely that many clinicians providing preconception, primary, and perinatal care have had occasion to diagnose measles. Susceptibility to infection combined with clinician inexperience may contribute to missed opportunities to halt the spread of this highly contagious, preventable illness. A case of parents' religion-based vaccine hesitancy complicating the pregnancy of their adult daughter is presented. Guidelines for screening for immunity, identifying measles in the clinical setting, and protocols for mitigating spread are reviewed.

Removing conscientious objection: The impact of 'No Jab No Pay' and 'No Jab No Play' vaccine policies in Australia

Vaccine refusal and hesitancy pose a significant public health threat to communities. Public health authorities have been developing a range of strategies to improve childhood vaccination coverage. This study examines the effect of removing conscientious objection on immunisation coverage for one, two and five year olds in Australia. Conscientious objection was removed from immunisation requirement exemptions for receipt of family assistance payments (national No Jab No Pay) and enrolment in childcare (state No Jab No Play). The impact of these national and state-level policies is evaluated using quarterly coverage data from the Australian Immunisation Register linked with regional data from the Australian Bureau of Statistics at the statistical area level between 2014 and 2018. Results suggest that there have been overall improvements in coverage associated with No Jab No Pay, and states that implemented additional No Jab No Play and tightened documentation requirement policies tended to show more significant increases. However, policy responses were heterogeneous. The improvement in coverage was largest in areas with greater socioeconomic disadvantage, lower median income, more benefit dependency, and higher pre-policy baseline coverage. Overall, while immunisation coverage has increased post removal of conscientious objection, the policies have disproportionally affected lower income families whereas socioeconomically advantaged areas with lower baseline coverage were less responsive. More effective strategies require investigation of differential policy effects on vaccine hesitancy, refusal and access barriers, and diagnosis of causes for unresponsiveness and under-vaccination in areas with persistently low coverage, to better address areas with persistent non-compliance with accordant interventions.

Joining the herd? U.S. public opinion and vaccination requirements across educational settings during the COVID-19 pandemic

With effective and safe COVID-19 vaccines beginning to be distributed across the United States, questions about who should receive the vaccine first have been the focus of public discussions. Yet, over the long-term, questions about the order of distribution will be displaced by questions about how to achieve high levels of vaccination rates. Historically, absent incentives or mandates, Americans have shown ambivalence, if not general antipathy, towards vaccinations, and vaccination rates have generally been low for many vaccines. There is evidence that vaccination requirements across educational settings are an effective policy instrument to increase vaccination rates. We administered a large national survey to assess American's attitudes towards vaccination requirements across three educational settings (daycare, K-12 schools, and universities) in general and for COVID-19 specifically. Partisanship, gender, race, rurality, and perceptions about the appropriate role schools should play in providing health services are substantive predictors of public opinion. While Americans generally support vaccination mandates across all three settings for both types of requirements, support is consistently and significantly lower for COVID19 requirements. The effect of partisanship is accentuated for COVID-19 requirements as compared to general requirements. Drop off in support between general and COVID-19 specific requirements are driven by partisanship, gender, political knowledge, rurality, and having children in the household. Nonetheless, mandates are supported by a majority of Americans. Assessing Americans' opinions of vaccination requirements in educational settings offers an important opportunity to explore the potential of mandates as policy instrument in the government's arsenal against COVID-19 and guide public policy on the issues.

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

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.

Parental vaccine attitudes, beliefs, and practices: initial evidence in California after a vaccine policy change

Senate Bill 277 (SB277) eliminated nonmedical exemptions for school-entry vaccines in California, but the impact of parental vaccine knowledge, attitudes, and beliefs on vaccine decision-making has not been extensively examined within the post-SB277 context. This study generates preliminary understanding and discussion of the vaccination knowledge, attitudes, and beliefs among a pilot population of parents of kindergarten students in California after the implementation of SB277. School officials administered a cross-sectional survey to parents of kindergarten children in California from April to July 2019. Parents reported their perceptions of diseases and vaccines, key immunization beliefs, and confidence in different sources of vaccine information. Most parents (92%) had fully vaccinated their children post-SB277 and generally perceived vaccines to be safe and effective, but about 44% reported they were hesitant about childhood vaccines. The majority of parents (87%) rated vaccine information from their doctor as highly credible. This pilot group of kindergarten parents was generally supportive of vaccination and had fully vaccinated their children, but most parents still harbored concerns and misconceptions about vaccines and about public health authorities. This indicates a disconnect between parental vaccine compliance and confidence, and suggests that educational interventions could impact parental vaccine behavior and decision-making.

The landscape of childhood vaccine exemptions in the United States

Once-eliminated vaccine-preventable childhood diseases, such as measles, are resurging across the United States. Understanding the spatio-temporal trends in vaccine exemptions is crucial to targeting public health intervention to increase vaccine uptake and anticipating vulnerable populations as cases surge. However, prior available data on childhood disease vaccination is either at too rough a spatial scale for this spatially-heterogeneous issue, or is only available for small geographic regions, making general conclusions infeasible. Here, we have collated school vaccine exemption data across the United States and provide it at the county-level for all years included. We demonstrate the fine-scale spatial heterogeneity in vaccine exemption levels, and show that many counties may fall below the herd immunity threshold. We also show that vaccine exemptions increase over time in most states, and non-medical exemptions are highly prevalent where allowed. Our dataset also highlights the need for greater data sharing and standardized reporting across the United States.

Global assessment of national mandatory vaccination policies and consequences of non-compliance

BACKGROUND

Declining vaccination coverage and increasing hesitancy is a worldwide concern. Many countries have implemented mandatory vaccination policies to promote vaccination. However, mandatory vaccination policies differ significantly by country. Beyond case studies, no comprehensive study has compared these policies or the penalties for non-compliance on a global scale.

METHODS

We conducted extensive keyword, policy, and literature searches to identify mandatory national vaccination policies globally and develop a comprehensive database. A mandatory national vaccination policy was defined as a policy from a national authority that requires individuals to receive at least one vaccination based on age or to access a service. Two reviewers independently evaluated evidence for a mandate and whether non-compliance penalties were incorporated. We categorized penalties into four types, based on the nature of the penalty. These penalties impact an individual's financial, parental rights, educational (i.e., child's school entry and access), and liberty status. We rated the severity within each category.

RESULTS

Of 193 countries investigated, 54% (n = 105) had evidence of a nationwide mandate as of December 2018. The frequency, types, and severity of penalties varied widely across all regions. We found that 59% (n = 62) of countries with national mandates defined at least one penalty for non-compliance with a vaccine mandate. Among those, educational penalties (i.e., limiting a child's entry or ongoing access to school) were the most common (69%; n = 43), with most countries with educational penalties refusing school enrollment until vaccination requirements are met (81%; n = 35).

CONCLUSION

We undertook a comprehensive assessment of national mandatory vaccination policies and identified a diversity of penalties in place to promote compliance. Our results highlight the need to critically evaluate the implementation of non-compliance penalties in order to determine their effectiveness and to define best practices for sustaining high vaccination uptake worldwide.

The role of epidemiology in informing United States childhood immunization policy and practice

One of the ten greatest public health achievements is childhood vaccination because of its impact on controlling and eliminating vaccine-preventable diseases (VPDs). Evidence-based immunization policies and practices are responsible for this success and are supported by epidemiology that has generated scientific evidence for informing policy and practice. The purpose of this report is to highlight the role of epidemiology in the development of immunization policy and successful intervention in public health practice that has resulted in a measurable public health impact: the control and elimination of VPDs in the United States. Examples in which epidemiology informed immunization policy were collected from a literature review and consultation with experts who have been working in this field for the past 30 years. Epidemiologic examples (e.g., thimerosal-containing vaccines and the alleged association between the measles, mumps, and rubella (MMR) vaccine and autism) are presented to describe challenges that epidemiologists have addressed. Finally, we describe ongoing challenges to the nation's ability to sustain high vaccination coverage, particularly with concerns about vaccine safety and effectiveness, increasing use of religious and philosophical belief exemptions to vaccination, and vaccine hesitancy. Learning from past and current experiences may help epidemiologists anticipate and address current and future challenges to respond to emerging infectious diseases, such as COVID-19, with new vaccines and enhance the public health impact of immunization programs for years to come.

Parental Hesitancy About Routine Childhood and Influenza Vaccinations: A National Survey

BACKGROUND AND OBJECTIVES

The World Health Organization has designated vaccine hesitancy as 1 of the 10 leading threats to global health, yet there is limited current national data on prevalence of hesitancy among US parents. Among a nationally representative sample of US parents, we aimed to (1) assess and compare prevalence of hesitancy and factors driving hesitancy for routine childhood and influenza vaccination and (2) examine associations between sociodemographic characteristics and hesitancy for routine childhood or influenza vaccination.

METHODS

In February 2019, we surveyed families with children using the largest online panel generating representative US samples. After weighting, we assessed hesitancy using a modified 5-point Vaccine Hesitancy Scale and labeled parents as hesitant if they scored >3.

RESULTS

A total of 2176 of 4445 parents sampled completed the survey (response rate 49%). Hesitancy prevalence was 6.1% for routine childhood and 25.8% for influenza vaccines; 12% strongly and 27% somewhat agreed they had concerns about serious side effects of both routine childhood and influenza vaccines. A total of 70% strongly agreed that routine childhood vaccines are effective versus 26% for influenza vaccine (P < .001). In multivariable models, an educational level lower than a bachelor's degree and household income <400% of the federal poverty level predicted hesitancy about both routine childhood and influenza vaccines.

CONCLUSIONS

Almost 1 in 15 US parents are hesitant about routine childhood vaccines, whereas >1 in 4 are hesitant about influenza vaccine. Furthermore, 1 in 8 parents are concerned about vaccine safety for both routine childhood and influenza vaccines, and only 1 in 4 believe influenza vaccine is effective. Vaccine hesitancy, particularly for influenza vaccine, is prevalent in the United States.

Getting Personal: How Childhood Vaccination Policies Shape the Landscape of Vaccine Exemptions

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.

Homeschooling parents in California: Attitudes, beliefs and behaviors associated with child's vaccination status

BACKGROUND

Senate Bill 277 (SB277) banned nonmedical exemptions from school-entry vaccination requirements for children attending classroom-based schools in California, but excluded homeschooled children from vaccination requirements. Thus, it was hypothesized that more parents would choose to homeschool to avoid vaccination requirements in response to SB277. There is limited literature on the vaccine attitudes, beliefs, and behaviors among the homeschooling population in the US, despite an overall increase in homeschooling nationwide and documented vaccine-preventable disease outbreaks within the homeschooled child population.

METHODS

Between November 2018 and January 2019, we conducted a cross-sectional online survey among homeschooling parents with at least one child in grades K-8 who is currently enrolled in one of the legally-acceptable mechanisms to homeschool in California: (1) home-based private school satellite program (PSP), or (2) public or charter independent study program (ISP) with no classroom-based instruction.

RESULTS

Among 140 homeschooling parents from 8 schools in California, 71% reported that their youngest child in grade K-8 was up-to-date on immunizations at kindergarten-entry and 56% reported that they made the decision to homeschool their child after the implementation of SB277. Compared to homeschooling parents whose child was up-to-date at kindergarten entry, homeschooling parents whose child was not up-to-date at kindergarten entry reported higher concerns over vaccine safety and effectiveness, more frequently cited immunization mandates as a reason to homeschool, and were more likely to report having considered moving out of California due to immunization mandates.

CONCLUSION

There was variation in vaccine attitudes and beliefs within the homeschooling population in this sample. Immunization mandates were a factor in the decision to homeschool for some parents in this sample, supporting the hypothesis that vaccine-hesitant parents considered homeschooling as a way to avoid immunization mandates such as SB277. Future studies should explore the complexities around vaccine attitudes, beliefs and behaviors among homeschooling populations.

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.

Evidence-based strategies to increase vaccination uptake: a review

PURPOSE OF REVIEW

To summarize evidence-based strategies for improving pediatric immunization rates including physician behaviors, clinic and public health processes, community-based and parent-focused interventions, and legal and policy approaches RECENT FINDINGS: Studies continue to show the effectiveness of audit and feedback, provider reminders, standing orders, and reminder/recall to increase immunization rates. Provider communication strategies may improve immunization rates including use of a presumptive approach and motivational interviewing. Centralized reminder/recall (using a state Immunization Information System) is more effective and cost-effective compared to a practice-based approach. Recent work shows the success of text messages for reminder/recall for vaccination. Web-based interventions, including informational vaccine websites with interactive social media components, have shown effectiveness at increasing uptake of pediatric and maternal immunizations. Vaccination requirements for school attendance continue to be effective policy interventions for increasing pediatric and adolescent vaccination rates. Allowance for and ease of obtaining exemptions to vaccine requirements are associated with increased exemption rates.

SUMMARY

Strategies to increase vaccination rates include interventions that directly impact physician behavior, clinic and public health processes, patient behaviors, and policy. Combining multiple strategies to work across different settings and addressing different barriers may offer the best approach to optimize immunization coverage.

Mandatory vaccination for infants and children: the Italian experience

Maintaining high vaccination coverage is important in order to protect the individual and the community. Mandatory vaccination is an option in case of declining coverage. Widely used in the USA, it is considered a rather controversial issue in Europe. In Italy, after a decrease of vaccination coverage for the hexavalent and the MPR vaccine under the optimal threshold, a new law, which extended the number of mandatory vaccines from 4 to 10 and reinforced coercive measures, was introduced in July 2017. After 2 years, vaccination coverage increased for all mandatory vaccines and for the other two recommended vaccines (anti-pneumococcal and anti-meningococcal C). Although it is not possible to disentangle the role of other factors contributing to the positive outcome, consistently with the results of studies conducted in the USA, vaccine mandates appeared to be successful in increasing vaccination coverage in Italy. The long-term sustainability of the effect of mandatory vaccination and the potential negative drawbacks of the coercive measures need to be evaluated to generate scientific evidence in public health.

Religious Vaccine Exemptions in Kindergartners: 2011-2018

BACKGROUND

Forty-five states permit religious exemptions to school immunization laws; 15 allow personal belief exemptions. Updated religious exemption estimates are lacking, and it is unclear if personal belief exemption availability impacts religious exemption rates. We aimed to (1) update religious exemption trends in kindergartners, (2) compare states' proportions of kindergartners with religious exemptions by personal belief exemption availability, and (3) describe whether the proportion of kindergartners with religious exemptions changed in Vermont after it eliminated personal belief exemptions in 2016.

METHODS

We analyzed Centers for Disease Control and Prevention data on exemptions for children entering kindergarten from 2011 to 2018, including 295 state-years in our final analysis. Using a quasi-binomial regression analysis, we compared mean proportions of kindergartners with religious exemptions in states allowing both nonmedical exemptions against states with religious exemptions only, adjusting for policy strength and school year.

RESULTS

States with religious and personal belief exemptions were one-fourth as likely to have kindergartners with religious exemptions as states with religious exemptions only (risk ratio 0.25; 95% confidence interval 0.16-0.38). After Vermont's policy change, the mean proportion of kindergartners with a religious exemption increased from 0.5% to 3.7%. States were significantly more likely to have kindergartners with religious exemptions during the 2017-2018 school year compared with the 2011-2012 school year (P = .04).

CONCLUSIONS

Religious exemption rates appear to be associated with personal belief exemption availability, may be subject to a replacement effect on personal belief exemption elimination, and are increasing. Researchers and policy makers should confirm findings with individual-level studies and reconsider the purpose and nature of religious exemption laws.

The 2016 California policy to eliminate nonmedical vaccine exemptions and changes in vaccine coverage: An empirical policy analysis

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.

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.

8 months to 5 days: what happened when Pennsylvania changed the vaccination regulations for provisional enrollment?

In March 2017, the Pennsylvania Department of Health reduced the time allowed to demonstrate compliance with school-entry vaccination requirements from eight months to five days. We describe changes in provisional enrollment, vaccine exemptions, and vaccine coverage rates before and after the new regulation. Across Pennsylvania, provisional enrollment decreased from 11.1% in 2016/17 to 2.5% in 2017/18 (77% relative decrease). Personal belief exemptions continued a modest upward trend, similar to previous years, and medical exemptions remained steady. Among kindergartners, coverage with ≥ 2 doses of MMR vaccine and 2 doses of Varicella vaccine increased; similar increases were seen for the MCV and Tdap vaccines among 7th graders. However, improvements in coverage and reductions in provisional enrollment were not consistent across counties. Provisional enrollment in Philadelphia County during the 2017/18 school year (10.4%) did not substantially decrease. The statewide reduction in provisional enrollment suggests that the new regulations accomplished the goal of increasing the proportion of students who are up-to-date on required vaccines at the beginning of the school year without a significant increase in vaccine exemptions. However, the persistence of high provisional enrollment in some counties points to additional barriers to this goal in some schools and regions.

Vaccination Coverage with Selected Vaccines and Exemption Rates Among Children in Kindergarten - United States, 2018-19 School Year

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.