Exemptions to school immunization requirements: the role of school-level requirements, policies, and procedures

Coverage with Selected Vaccines and Exemption Rates Among Children in Kindergarten - United States, 2023-24 School Year

In the United States, states and local jurisdictions set vaccination requirements for school attendance, conditions and procedures for exemptions from these requirements, grace periods for submitting documentation, and provisional enrollment for students who need more time to be vaccinated. States annually report data to CDC on the number of children in kindergarten who meet, are exempt from, or are in the process of meeting requirements. Data reported by 49 states and the District of Columbia (DC) for the 2023-24 school year were used for national- and state-level estimates of the following measures: complete vaccination with required doses of measles, mumps, and rubella vaccine (MMR), diphtheria, tetanus, and acellular pertussis vaccine (DTaP), poliovirus vaccine (polio), and varicella vaccine (VAR); exemptions from vaccination; and school attendance while meeting requirements. The 2023-24 kindergarten class became age-eligible to complete most state-required vaccinations during the COVID-19 pandemic, after schools had returned to routine in-person learning. Compared with approximated national coverage levels across all reported vaccines for the 2019-20 (95%) and 2022-23 (93%) school years, coverage dropped below 93% for the 2023-24 school year, ranging from 92.3% for DTaP to 92.7% for MMR. Exemptions increased to 3.3%, compared with those during the 2022-23 (3.0%) and 2021-22 school years (2.6%). Coverage with MMR, DTaP, polio, and VAR decreased in 35, 32, 33, and 36 jurisdictions, respectively, compared with the 2022-23 school year. Exemptions increased in 41 jurisdictions, with 14 reporting that >5% of kindergartners had an exemption from one or more vaccine. Efforts by health departments, schools, and providers are needed to ensure that students begin school fully vaccinated.

Spatial distribution and determinants of childhood vaccination refusal in the United States

Parental refusal and delay of childhood vaccination has increased in recent years in the United States. This phenomenon challenges maintenance of herd immunity and increases the risk of outbreaks of vaccine-preventable diseases. We examine US county-level vaccine refusal for patients under five years of age collected during the period 2012-2015 from an administrative healthcare dataset. We model these data with a Bayesian zero-inflated negative binomial regression model to capture social and political processes that are associated with vaccine refusal, as well as factors that affect our measurement of vaccine refusal. Our work highlights fine-scale socio-demographic characteristics associated with vaccine refusal nationally, finds that spatial clustering in refusal can be explained by such factors, and has the potential to aid in the development of targeted public health strategies for optimizing vaccine uptake.

The Impact of Australian Childhood Vaccination Mandates on Immunization Specialists and Their Interactions With Families

BACKGROUND

Recent global outbreaks of vaccine-preventable diseases, both before and since the coronavirus disease 2019 pandemic, have led to the introduction or strengthening of vaccine mandate policies to target vaccine refusal. Globally, there is wide variation in how governments and jurisdictions implement and enforce mandatory vaccination as well as the financial and educational consequences to those who fail to comply. We explored the impact of mandate vaccination policies on Australian Immunization Specialists who work in Specialist Immunization Clinics (SIC) for approving vaccine exemptions outside of the mandated criteria. In particular, their interactions with patients and families.

METHODS

A national, prospective, mixed methods, survey-based study conducted with members of the Australian Adverse Event Following Immunisation Clinical Assessment Network between February 2020 and June 2020.

RESULTS

Sixteen Immunization physicians and nurse practitioner specialists working in a SIC completed the survey. All sixteen respondents had been requested by parents to provide a Medical Exemptions at least once. 88% of respondents felt pressure to provide an exemption that was not medically justified according to legislation. Seventy-five percent of SIC consultants felt that the "No Jab" policies created a moderate or extreme amount of stress to both themselves and parents. All respondents reported experiencing hostility from parents with three respondents having received threats of violence.

CONCLUSIONS

Mandatory vaccination policies are associated with increased vaccination coverage but can result in widened financial and social inequity, and may harm families' relationships with health care providers. Countries considering the implementation of vaccination mandates should use the least restrictive health policies to ensure a balance between the public health and individual benefit whilst minimizing burdens on health care professionals, children and their parents.

Content analysis of digital media coverage of the human papillomavirus vaccine school-entry requirement policy in Puerto Rico

Background

In August 2018, Puerto Rico (PR) became the 4th state or territory in the United States to adopt a human papillomavirus (HPV) vaccine school-entry requirement, for students 11–12 years old. Evidence suggests that the content of media coverage may impact people’s perception of HPV vaccine and their willingness to vaccinate. This study aimed to analyze the content of digital news coverage related to the implementation of the policy in PR.

Methods

A content review was conducted of digital media published from January 2017 through December 2018. The content reviewed was carried out in two steps: 1) creating a matrix to summarize each article’s content about the policy and 2) qualitative analysis using a grounded theory approach.

Results

The search resulted in 34 articles obtained from 17 online local and international news outlets that reported the policy's implementation. Analyses showed that 61% of the news articles did not mention the number of required doses, and 79% discussed the new policy concerning cancer prevention. In 2017, news coverage focused mostly on describing the policy, while 2018 coverage focused on controversies surrounding the implementation. Neutral emergent codes included: 1) Description of the policy; 2) Information about HPV related cancers; and 3) General information about HPV vaccine. Negative emergent codes included: 1) infringement to patient and parental autonomy; 2) Hesitancy from the political sector, and 3) Hesitancy from groups and coalitions. Positive content included: 1) knowledge and acceptance of HPV vaccine for cancer prevention; 2) importance of education and protective sexual behaviors; and 3) new vaccination law proposal.

Conclusions

Most of the media coverage in PR was neutral and included limited information related to the vaccine, HPV, and HPV-related cancers. Neutral and negative themes could influence public concerns regarding the new policy, as well as HPV vaccination rates in PR.

In the Wake of a Pandemic: Revisiting School Approaches to Nonmedical Exemptions to Mandatory Vaccination in the US

Mandatory school vaccination policies with exclusion of unvaccinated students can be a powerful tool in ensuring high vaccination rates. Some parents may object to mandatory vaccination policies, claiming exemptions based on medical, religious, or philosophical reasons. Individual schools, school systems, or local or regional governments have different policies with respect to whether, and what kind of, exemptions may be allowed. In the setting of the current pandemic, questions regarding the acceptability of exemptions have resurfaced, as schools and local governments struggle with how to safely return children to school. Anticipating that school attendance will be facilitated by the development of a vaccine, school systems will face decisions about whether to mandate vaccination and whether to permit exemptions. The American Academy of Pediatrics promulgates policy favoring the elimination of nonmedical exemptions generally in schools. This discussion considers whether schools should eliminate nonmedical exemptions to vaccination as proposed in the American Academy of Pediatrics policy, ultimately concluding that broad elimination of exemptions is not justified and advocating a more nuanced approach that encourages school attendance while promoting vaccination and broader public health goals.

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.

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.

NAVIN MARK. Childhood Vaccination Mandates: Scope, Sanctions, Severity, Selectivity, and Salience

Policy Points We offer the first systematic conceptual framework for analyzing the operation of mandatory vaccination policies. Our multicomponent framework facilitates synthesis judgments on single issues of pressing concern to policymakers, in particular, how mandatory vaccination policies motivate people to vaccinate. We consider the impact of each component of our framework on persons who remain unvaccinated for different reasons, including complacency, social disadvantage, and more or less committed forms of refusal.

CONTEXT

In response to outbreaks of vaccine-preventable disease and increasing rates of vaccine refusal, some political communities have recently implemented coercive childhood immunization programs, or they have made existing childhood immunization programs more coercive. Many other political communities possess coercive vaccination policies, and others are considering developing them. Scholars and policymakers generally refer to coercive immunization policies as "vaccine mandates." However, mandatory vaccination is not a unitary concept. Rather, coercive childhood immunization policies are complex, context-specific instruments. Their legally and morally significant features often differ, and they are imposed by political communities in varying circumstances and upon diverse populations.

METHODS

In this paper, we introduce a taxonomy for classifying real-world and theoretical mandatory childhood vaccination policies, according to their scope (which vaccines to require), sanctions and severity (which kind of penalty to impose on vaccine refusers, and how much of that penalty to impose), and selectivity (how to enforce or exempt people from vaccine mandates).

FINDINGS

A full understanding of the operation of a vaccine mandate policy (real or potential) requires attention to the separate components of that policy. However, we can synthesize information about a policy's scope, sanctions, severity, and selectivity to identify a further attribute-salience-which identifies the magnitude of the burdens the state imposes on those who are not vaccinated.

CONCLUSION

Our taxonomy provides a framework for forensic examination of current and potential mandatory vaccination policies, by focusing attention on those features of vaccine mandates that are most relevant for comparative judgments.

Quality management principles and school quality

Purpose

The purpose of this paper is to test the relationship of process approach (PA), customer focus approach (CFA) and school quality with the moderation of professional certification of school principal to fill the gap of quality management practices in private schools.

Design/methodology/approach

Study applied quantitative design with the sample of 401 principals of private schools. Questionnaires were adapted from different studies, and pilot study was carried out. Confirmatory factor analysis was done along with structural equation modeling.

Findings

Results indicate that the process approach has a significant effect on functional quality and academic quality of schools. Customer focus approach medicates the relationship of process approach and functional quality. The study found no evidence of the relationship of moderation of professional certification of school principal with process approach, functional quality and academic quality.

Practical implications

Study contributed through the generation of new dimensions of school quality, putting professional degree of school principal as a moderator and by providing basis to understand the implementation of quality management system in schools. The outcomes of study will guide school managers to implement the process management approach to improve the school quality.

Originality/value

Originality of the study is defined in three ways; first, it is first study that examines the relationship of process approach, customer focus approach and school quality with the moderation of professional certification of principal. Second, it chooses “single” schools that have not been subject of any quantitative research exclusively. Third, it is a first attempt to examine the working of private schools in Pakistan with respect to quality management principles.

Association of Presence of a School Nurse With Increased Sixth-Grade Immunization Rates in Low-Income Arizona Schools in 2014-2015

School nurses often play large roles in implementation of school vaccination requirements aimed at controlling the spread of communicable disease. We analyzed the association between the presence of a school nurse and school-level vaccination rates in Arizona. Using school-level data from Arizona sixth-grade schools (n = 749), we regressed average sixth-grade school-level immunization rates on presence of a school nurse (registered nurse [RN] or licensed practical nurse [LPN]) and school-level socioeconomic status (SES), controlling for other school- and district-level characteristics. Schools with a nurse had higher overall vaccination rates than those without a nurse (96.1% vs. 95.0%, p < .01). For schools in the lowest SES quartile, the presence of a school nurse was associated with approximately 2 percentage point higher immunization rates. These findings add to the growing literature that defines the impact of school nurses on student health status and outcomes, emphasizing the value of school nurses, especially in lower SES schools.

Experiences With Medical Exemptions After a Change in Vaccine Exemption Policy in California

: media-1vid110.1542/5804909532001PEDS-VA_2018-1051Video Abstract OBJECTIVES: In 2015, California passed Senate Bill 227 (SB277), eliminating nonmedical vaccine exemptions for school entry. Our objective for this study was to describe the experiences of health officers and immunization staff addressing medical exemption requests under SB277.

METHODS

We conducted semistructured telephone interviews between August 2017 and September 2017 with health officers and immunization staff from local health jurisdictions in California. Interviews were recorded, transcribed, and analyzed for key themes.

RESULTS

We conducted 34 interviews with 40 health officers and immunization staff representing 35 of the 61 local health jurisdictions in California. Four main themes emerged related to experiences with medical exemptions: (1) the role of stakeholders, (2) reviewing medical exemptions received by schools, (3) medical exemptions that were perceived as problematic, and (4) frustration and concern over medical exemptions. Generally, local health jurisdictions described a narrow role in providing support and technical assistance to schools. Only 5 jurisdictions actively tracked medical exemptions received by schools, with 1 jurisdiction facing a lawsuit as a result. Examples were provided of medical exemptions that listed family history of allergies and autoimmune diseases as contraindications for immunization and of physicians charging steep fees for medical exemptions. Participants also reported concerns about the increase in medical exemptions after the implementation of SB277.

CONCLUSIONS

Participants reported many challenges and concerns with medical exemptions under SB277. Without additional legal changes, including a standardized review of medical exemptions, some physicians may continue to write medical exemptions for vaccine-hesitant parents, potentially limiting the long-term impact of SB277.

Some state vaccination laws contribute to greater exemption rates and disease outbreaks in the United States

Health officials attest that immunizations are among the most successful interventions in public health. However, there remains a substantial unvaccinated population in the United States. We analyzed how state-level vaccination exemption laws affect immunization rates and the incidence of preventable disease. We measured the association between each component of state kindergarten vaccination exemption laws and state vaccination exemption rates from 2002 to 2012, using the Centers for Disease Control and Prevention's annual school assessment reports. We found that policies such as requiring health department approval of nonmedical exemptions, requiring a physician to sign an exemption application, and having criminal or civil punishments for noncompliance with immunization requirements had a significant effect in reducing vaccine exemptions. Our exemption law effectiveness index identified eighteen states with the most effective laws and nine states with the least effective ones. The most effective states had lower incidences of pertussis, compared to other states. For policy makers interested in decreasing the number of vaccine exemptions in their state, our findings are of particular interest.

Trends in Personal Belief Exemption Rates Among Alternative Private Schools: Waldorf, Montessori, and Holistic Kindergartens in California, 2000-2014

OBJECTIVES

To evaluate trends in rates of personal belief exemptions (PBEs) to immunization requirements for private kindergartens in California that practice alternative educational methods.

METHODS

We used California Department of Public Health data on kindergarten PBE rates from 2000 to 2014 to compare annual average increases in PBE rates between schools.

RESULTS

Alternative schools had an average PBE rate of 8.7%, compared with 2.1% among public schools. Waldorf schools had the highest average PBE rate of 45.1%, which was 19 times higher than in public schools (incidence rate ratio = 19.1; 95% confidence interval = 16.4, 22.2). Montessori and holistic schools had the highest average annual increases in PBE rates, slightly higher than Waldorf schools (Montessori: 8.8%; holistic: 7.1%; Waldorf: 3.6%).

CONCLUSIONS

Waldorf schools had exceptionally high average PBE rates, and Montessori and holistic schools had higher annual increases in PBE rates. Children in these schools may be at higher risk for spreading vaccine-preventable diseases if trends are not reversed.

Increasing Immunization Compliance by Reducing Provisional Admittance

Students in Vermont with incomplete or undocumented immunization status are provisionally admitted to schools and historically had a calendar year to resolve their immunization status. The process of resolving these students’ immunization status was challenging for school nurses. We conducted a school-based quality improvement effort to increase student compliance with Vermont immunization regulations using a collaborative learning approach with public health school liaisons and school nurses from public schools to reduce provisional admittance in 2011–2012. Strategies included using a tracking system, accessing the immunization registry, promoting immunization importance, tracking immunization plans, and working with medical homes to update records. Participating school nurses observed decreases in the number of provisionally admitted students, although this reduction was not significantly different than matched comparison schools. We also found the number of provisionally admitted students fluctuated throughout the year and resolving the immunization status of New Americans and exchange students required special attention. Our approach supports the coordinated school health model and demonstrates the critical role school nurses play in improving population health outcomes.

Characterization of Heterogeneity in Childhood Immunization Coverage in Central Florida Using Immunization Registry Data

Despite high vaccine coverage in the United States in general, and in the State of Florida specifically, some children miss scheduled vaccines due to health system failures or vaccine refusal by their parents. Recent experiences with outbreaks in the United States suggest that geographic clustering of un(der)vaccinated populations represent a threat to the elimination status of some vaccine-preventable diseases. Immunization registries continue to expand and play an important role in efforts to track vaccine coverage and use. Using nearly 700,000 de-identified immunization records from the Florida Department of Health immunization information system (Florida SHOTS™) for children born during 2003-2014, we explored heterogeneity and potential clustering of un(der)vaccinated children in six counties in central Florida-Brevard, Lake, Orange, Oseola, Polk, and Seminole-that represent a high-risk area for importation due to family tourist attractions in the area. By zip code, we mapped the population density, the percent of children with religious exemptions, the percent of children on track or overdue for each vaccine series without and with exemptions, and the numbers of children with no recorded dose of each vaccine. Overall, we found some heterogeneity in coverage among the counties and zip codes, but relatively consistent and high coverage. We found that some children with an exemption in the system received the vaccines we analyzed, but exemption represents a clear risk factor for un(der)immunization. We identified many challenges associated with using immunization registry data for spatial analysis and potential opportunities to improve registries to better support future analyses.

Role of the School Nurse in Providing School Health Services

The American Academy of Pediatrics recognizes the important role school nurses play in promoting the optimal biopsychosocial health and well-being of school-aged children in the school setting. Although the concept of a school nurse has existed for more than a century, uniformity among states and school districts regarding the role of a registered professional nurse in schools and the laws governing it are lacking. By understanding the benefits, roles, and responsibilities of school nurses working as a team with the school physician, as well as their contributions to school-aged children, pediatricians can collaborate with, support, and promote school nurses in their own communities, thus improving the health, wellness, and safety of children and adolescents.

Affluence as a predictor of vaccine refusal and underimmunization in California private kindergartens

BACKGROUND

Non-medical vaccine exemption rates in California private schools far exceed those of public schools, but little is known about specific factors which may be associated with high exemption rates in private schools.

METHODS

The percent of personal-belief exemptions (PBEs) among California public and private kindergartens were computed for 2000-2001 to 2014-2015 academic years. For the 2014-2015 academic year, a random sample of private schools was selected to investigate associations between kindergarten characteristics (tuition amount, religious affiliation) and vaccine profile (non-medical vaccine exemptions, vaccine coverage).

RESULTS

The proportion of private kindergartens reporting 5% or more children with PBEs increased from 9% (2000-2001) to 34% (2013-2014), followed by a small decrease in 2014-2015 (31%). Overall, 93.7% (565/605) of kindergartens sampled in 2014-2015 had data available. Very high PBE levels (>20%) were seen among secular and non-Catholic, Christian kindergartens but not Roman Catholic, Jewish or Islamic kindergartens. However, the majority of schools at all tuition levels had fewer than 5% of children with a PBE. Kindergartens with an annual tuition of $10,000 or more were over twice as likely to have 20% or more children with PBEs than kindergartens with a lower tuition (p<.01). Additionally, the conditional admission proportions for kindergartens with tuitions of $10,000 or more were 39% compared to 22% for less expensive kindergartens (p<.01). Only about half of all private kindergartens had 95% coverage of the MMR (49%) and pertussis-containing vaccines (51%).

CONCLUSIONS

School-entry vaccination requirements are critical to preventing outbreaks of vaccine preventable diseases in the US. Nonmedical exemptions increased between the 2000-2001 and 2014-2015 academic years and appear to be associated with affluence, raising social justice concerns.

Sociodemographic Predictors of Vaccination Exemptions on the Basis of Personal Belief in California

OBJECTIVES

We examined the variability in the percentage of students with personal belief exemptions (PBEs) from mandatory vaccinations in California schools and communities according to income, education, race, and school characteristics.

METHODS

We used spatial lag models to analyze 2007-2013 PBE data from the California Department of Public Health. The analyses included school- and regional-level models, and separately examined the percentage of students with exemptions in 2013 and the change in percentages over time.

RESULTS

The percentage of students with PBEs doubled from 2007 to 2013, from 1.54% to 3.06%. Across all models, higher median household income and higher percentage of White race in the population, but not educational attainment, significantly predicted higher percentages of students with PBEs in 2013. Higher income, White population, and private school type significantly predicted greater increases in exemptions from 2007 to 2013, whereas higher educational attainment was associated with smaller increases.

CONCLUSIONS

Personal belief exemptions are more common in areas with a higher percentage of White race and higher income.

Power and persuasion in the vaccine debates: an analysis of political efforts and outcomes in the United States, 1998-2012

CONTEXT

This article examines trends in state-level childhood vaccine policies in the United States from 1998 to 2012 and explains the trajectories for both vaccine-critical and proimmunization legislative efforts. Successful mobilization by vaccine critics during the height of the autism and thimerosal scares (roughly 1998 to 2003) yielded a few state-level expansions for the most permissive type of exemption from vaccine mandates for public school attendance, those based on personal beliefs. Vaccine-critical positions, however, have largely become discredited. How has vaccine critics' ability to advance preferred policies and prevent the passage of unfavorable legislation changed over time?

METHODS

We created a unique data set of childhood vaccine bills (n = 636), introduced from 1998 to 2012 across the 50 state legislatures, and coded them by type of effort (exemption, mandate, mercury ban, and information policies) and outcome. We then mapped out the trends in vaccine policies over time. In order to contextualize the trends we identified, we also reviewed numerous primary sources and conducted interviews with stakeholders.

FINDINGS

In general, we found that vaccine critics' legislative success has begun to wane. In only 20 bills in our data set were vaccine critics able to change policy in their preferred direction via the legislative process. Only 5 of those wins were significant (such as obtaining a new philosophical exemption to vaccine mandates), and the last of these was in 2007. Critics were more successful at preventing passage of proimmunization legislation, such as mandates for the human papillomavirus (HPV) vaccine.

CONCLUSIONS

Recent legislation in California, Oregon, and Washington that tightened philosophical exemptions by means of informational requirements suggests that vaccine politics may be entering another phase, one in which immunization supporters may be able to counter increasing opt-out rates, particularly in states with recent outbreaks and politicians favoring science-based policies.

Nonmedical exemptions from school immunization requirements: a systematic review

We summarized studies describing the prevalence of, trends in, and correlates of nonmedical exemptions from school vaccination mandates and the association of these policies with the incidence of vaccine-preventable disease. We searched 4 electronic databases for empirical studies published from 1997 to 2013 to capture exemption dynamics and qualitatively abstracted and synthesized the results. Findings from 42 studies suggest that exemption rates are increasing and occur in clusters; most exemptors questioned vaccine safety, although some exempted out of convenience. Easier state-level exemption procedures increase exemption rates and both individual and community disease risk. State laws influence exemption rates, but policy implementation, exemptors' vaccination status, and underlying mechanisms of geographical clustering need to be examined further to tailor specific interventions.

Frequency and erroneous usage of temporary medical exemptions and knowledge of immunization guidelines among some Miami-Dade County Florida providers

OBJECTIVE

We assessed knowledge and practices regarding immunization guidelines and the Florida Certificate of Immunization (DH-680) based on FL-DOH and CDC recommendations, to identify the cause of the increasing number of erroneously issued temporary medical exemptions (TME) among selected health care providers in Miami-Dade County Florida.

METHODOLOGY

After reviewing immunization certificates from all public schools, a list of physicians who improperly issued 3 or more TMEs, defined as one given to a child who was up to date for their kindergarten and seventh grade requirements, was compiled. The DOH-Miami-Dade developed educational materials and questionnaires, and conducted face-to-face interviews and interventions during site visits to these providers (n=134). Data was analyzed using SAS 9.2.

RESULTS

Of the 104 questionnaires completed, 4 (3.85%) had correct answers to all 10 vaccine knowledge and practice related questions, while 10 (9.62%) had 7 or more incorrect answers. Frequently missed questions included: the required doses of varicella vaccine for seventh grade students entering the 2011-12 school year (86, 82.7%) and the proper scenario for issuing a TME (57, 54.8%).

CONCLUSIONS

In order to eliminate the improper use of TMEs, long-term efforts are needed to provide immunization-related educational materials and trainings to the medical community regarding vaccinations. These findings also suggest a need for enhanced explanation in multiple languages on the current Florida Immunization Certificate. Due to enhanced surveillance and education, the number of TMEs for kindergarten and seventh grade students was reduced by 12% and 4.9%, respectively, during the 2011 and 2012 school year.

United States private schools have higher rates of exemptions to school immunization requirements than public schools

OBJECTIVE

To compare medical, religious, and personal belief immunization exemption rates between private and public schools in US.

STUDY DESIGN

Exemption rates were calculated using the Centers for Disease Control and Prevention School Immunization Assessment Surveys for the 2009-2010 school year excluding states with incomplete survey data. Standardized exemption rates weighted on enrollments in public and private schools were calculated. Differences in exemption rates between public and private schools were tested using Wilcoxon signed rank test.

RESULTS

The overall state exemption rate was higher in US private than public schools, 4.25% (SD 4.27) vs 1.91% (1.67), P = .0001 and private schools had higher exemption rates for all types of exemptions; medical 0.58% (0.71) vs 0.34% (0.34) respectively (P = .0004), religious 2.09% (3.14) vs 0.83% (1.05) respectively (P = .0001), and personal belief 6.10% (4.12) vs 2.79% (1.57), respectively (P = .006). Overall exemption rates were significantly higher in states that allowed personal belief exemptions.

CONCLUSIONS

Exemption rates were significantly higher in US private than in public schools. Children attending private schools may be at higher risk of vaccine-preventable diseases than public school children.

Ready or not? School preparedness for California's new personal beliefs exemption law

OBJECTIVE

This paper describes elementary school officials' awareness of and preparedness for the implementation of California's new exemption law that went into effect on January 1, 2014. The new law prescribes stricter requirements for claiming a personal beliefs exemption from mandated school-entry immunizations.

METHOD

We used cross-sectional data collected from a stratified random sample of 315 schools with low, middle, and high rates of personal beliefs exemptions. We described schools' awareness and specific knowledge of the new legislation and tested for differences across school types. We additionally tested for associations between outcome variables and school and respondent characteristics using ordered logit and negative binomial regression. Finally, we described schools' plans and needs for implementing the new legislation.

RESULTS

Elementary school staff reported an overall low level of awareness and knowledge about the new legislation and could identify few of its features. We observed, however, that across the exemption-level strata, respondents from high-PBE schools reported significantly higher awareness, knowledge and feature identification compared to respondents from low-PBE schools. Multivariate analyses revealed only one significant association with awareness, knowledge and identification: respondent role. Support staff roles were associated with lower odds of having high self-rated awareness or knowledge compared to health workers, as well as with a reduced log count of features identified. Though most school officials were able to identify a communication plan, schools were still in need of resources and support for successful implementation, in particular, the need for information on the new law.

CONCLUSION

Schools need additional information and support from state and local agencies in order to successfully implement and enforce California's new school immunization law. In particular, our results suggest the need to ensure information on the new law reaches all levels of school staff.

Rising rates of vaccine exemptions: problems with current policy and more promising remedies

Parents of school-age children are increasingly claiming nonmedical exemptions to refuse vaccinations required for school entry. The resultant unvaccinated pockets in many areas of the country have been linked with outbreaks of vaccine-preventable diseases. Many states are now focused on reducing rates of nonmedical exemptions by making exemption processes more restrictive or burdensome for the exemptor. These strategies, however, pose ethical problems and may ultimately be inadequate. A shift to strategies that raise the financial liabilities of exemptors may lead to better success and prove ethically more sound. Potential areas of reform include tax law, health insurance, and private school funding programs. We advocate an approach that combines this type of incentive with more effective vaccination education.

Assessment of Vaccine Exemptions Among Wyoming School Children, 2009 and 2011

During 2010–2011, varicella vaccination was an added requirement for school entrance in Wyoming. Vaccination exemption rates were compared during the 2009–2010 and 2011–2012 school years, and impacts of implementing a new childhood vaccine requirement were evaluated. All public schools, grades K–12, were required to report vaccination status of enrolled children for the 2009–2010 and 2011–2012 school years to the Wyoming Department of Health. Exemption data were analyzed by exemption category, vaccine, county, grade, and rurality. The proportion of children exempt for ≥1 vaccine increased from 1.2% (1,035/87,398) during the 2009–2010 school year to 1.9% (1,678/89,476) during 2011–2012. In 2011, exemptions were lowest (1.5%) in urban areas and highest (2.6%) in the most rural areas, and varicella vaccine exemptions represented 67.1% (294/438) of single vaccination exemptions. Implementation of a new vaccination requirement for school admission led to an increased exemption rate across Wyoming.

Parent and provider perspectives on immunization: are providers overestimating parental concerns?

OBJECTIVES

Data are limited on whether providers understand parental attitudes to recommended childhood immunizations. We determined parental attitudes and assessed how accurately providers estimated parental opinions.

METHODS

Survey of parents and providers (pediatricians, nurses, medical assistants) in randomly selected practices in Houston, Texas. Surveys assessed demographics, perceptions of immunization importance, safety and efficacy, and acceptability of vaccine delivery. Providers estimated parental responses.

RESULTS

401 parents (82% mothers, 12% fathers, 6% other) and 105 providers participated. Parents thought vaccines were important for health (median score 9.5; 0=not important, 10=extremely important) but also were concerned regarding vaccine safety and side effects (8.9 on 0-10 scale). 309 (77%) agreed that vaccines effectively prevent disease. Route of administration mattered to 147 (37%), who preferred injection (9.0) over oral (7.3) or intranasal (4.8) routes. Although parents would prefer three or fewer injections per visit, preventing more diseases (189 [47.6%]) was more important than number of injections (167 [42.3%]) when deciding the number of vaccines allowed per visit. White parents rated vaccines less important in preventing some illnesses than did non-white (P≤0.006 for meningitis, hepatitis, HPV, influenza and rotavirus) and rated number of injections per visit more important than number of diseases prevented (51.6% white versus 34.2% non-white; P 0.002). Providers underestimated parental attitudes toward vaccine importance (particularly influenza and HPV), and overestimated the proportion of parents who thought route of administration mattered (63%) and that number of injections per visit was the most important factor (76%) around parental vaccine decisions (P<0.001 for parent-provider mismatch).

CONCLUSIONS

Most surveyed parents believe vaccines are important for child health and rate disease prevention higher than number of injections entailed. Providers underestimate the importance of some vaccines to parents and overestimate parental concerns regarding route of administration. Future research should focus on how this mismatch impacts parental vaccine decisions.

Nonmedical vaccine exemptions and pertussis in California, 2010

BACKGROUND

In 2010, 9120 cases of pertussis were reported in California, more than any year since 1947. Although this resurgence has been widely attributed to waning immunity of the acellular vaccine, the role of vaccine refusal has not been explored in the published literature. Many factors likely contributed to the outbreak, including the cyclical nature of pertussis, improved diagnosis, and waning immunity; however, it is important to understand if clustering of unvaccinated individuals also played a role.

METHODS

We analyzed nonmedical exemptions (NMEs) for children entering kindergarten from 2005 through 2010 and pertussis cases with onset in 2010 in California to determine if NMEs increased in that period, if children obtaining NMEs clustered spatially, if pertussis cases clustered spatially and temporally, and if there was statistically significant overlap between clusters of NMEs and cases.

RESULTS

Kulldorff's scan statistics identified 39 statistically significant clusters of high NME rates and 2 statistically significant clusters of pertussis cases in this time period. Census tracts within an exemptions cluster were 2.5 times more likely to be in a pertussis cluster (odds ratio = 2.47, 95% confidence interval: 2.22-2.75). More cases occurred within as compared with outside exemptions clusters (incident rate ratios = 1.20, 95% confidence interval: 1.10-1.30). The association remained significant after adjustment for demographic factors. NMEs clustered spatially and were associated with clusters of pertussis cases.

CONCLUSIONS

Our data suggest clustering of NMEs may have been 1 of several factors in the 2010 California pertussis resurgence.

A systematic review of interventions for reducing parental vaccine refusal and vaccine hesitancy

Unvaccinated individuals pose a public health threat to communities. Research has identified many factors associated with parental vaccine refusal and hesitancy toward childhood and adolescent immunizations. However, data on the effectiveness of interventions to address parental refusal are limited. We conducted a systematic review of four online databases to identify interventional studies. We used criteria recommended by the WHO's Strategic Advisory Group of Experts on immunization (SAGE) for the quality assessment of studies. Intervention categories and outcomes were evaluated for each body of evidence and confidence in overall estimates of effect was determined. There is limited evidence to guide implementation of effective strategies to deal with the emerging threat of parental vaccine refusal. There is a need for appropriately designed, executed and evaluated intervention studies to address this gap in knowledge.

Nonmedical exemptions to immunization requirements in California: a 16-year longitudinal analysis of trends and associated community factors

BACKGROUND

Rates of nonmedical exemptions to kindergarten-entry immunization requirements have increased over the past 2 decades, especially in states that permit philosophical exemptions and/or have easier administrative policies for obtaining nonmedical exemptions. We evaluated trends in school personal belief exemption rates over the period 1994-2009 in California, and associated school and community characteristics.

METHODS

We used data on personal belief exemptions from 6392 public and private elementary schools from the California Department of Public Health, as well as census tract and school demographic data. Generalized estimating equations were used to model annual mean increases in personal belief exemption rates, and to identify school and community characteristics associated with personal belief exemption rates.

RESULTS

Over the study period, the average school personal belief exemption rate increased from 0.6% in 1994 to 2.3% in 2009, an average of 9.2% (95% CI: 8.8-9.6%) per year. The average personal belief exemption rate among private schools over the entire study period was 1.77 (95% CI: 1.55-2.01) times that among public schools. The annual rate of increase was slightly higher among private schools (10.1%, 95% CI: 9.1-11.1%) than among public schools (8.8%, 95% CI: 8.4-9.2%). Schools located within census tracts classified as rural had 1.66 (95% CI: 1.26-2.08) times higher personal belief exemption rates than schools located within urban census tracts. Exemption rates were also associated with race, population density, education, and income.

CONCLUSIONS

This study confirms concerns about increasing rates of nonmedical exemptions to kindergarten vaccine requirements within the state of California, using data collected over a 16-year period.

Common perceptions of parents requesting personal exemption from vaccination

School nurses, as vaccination advocates, need to be aware of parents' common concerns regarding vaccines, so the nurse can develop strategies to communicate with parents. The purpose of this cross-sectional, descriptive study was to identify common reasons parents in Utah seek exempting rather than vaccinating their children. Data were collected from a convenience sample of 801 parents responding to a 16-item questionnaire about why they exempted their children from receiving vaccinations. The most commonly reported reason for seeking a personal exemption included vaccines conflicting with philosophical beliefs. Parents exempting from one vaccine most commonly exempted the hepatitis series. Most parents communicated their vaccine concerns with their health care provider prior to seeking exemption. The majority of exempting parents did not use the Internet when researching vaccines even though they had Internet access. Considering the common vaccine-related perceptions of parents may be helpful when developing strategies to overcome these barriers to vaccination.

Parent attitudes about school requirements for human papillomavirus vaccine in high-risk communities of Los Angeles, California

BACKGROUND

Human papillomavirus (HPV) immunization requirements for school entry could increase HPV vaccine uptake but are controversial. This study assessed parents' attitudes about HPV immunization requirements.

METHODS

During October 2007 to June 2008, we conducted telephone surveys with 484 parents of girls attending middle/high schools serving communities in Los Angeles County with elevated cervical cancer rates.

RESULTS

Parents were mostly Hispanic (81%) or African American (15%); 71% responded in Spanish. Many parents did not know if HPV vaccine works well (42%) or is unsafe (41%). Overall, 59% of parents agreed that laws requiring HPV vaccination for school attendance "are a good idea." In multivariable analysis, African Americans and Hispanics responding in English were less likely than Hispanics responding in Spanish to agree (aOR 0.1, 95% CI: 0.1-0.3; aOR 0.4, 95% CI: 0.2-0.8, respectively). Parents were less likely to agree with these laws if they did not believe the vaccine works well (aOR 0.2, 95% CI: 0.1-0.5) but more likely to agree if they believed the vaccine is not "too new for laws like these" (aOR 4.5, 95% CI: 2.6-8.0). Agreement with laws increased to 92% when including agreement that "these laws are okay only if parents can opt out."

CONCLUSIONS

In this at-risk community, more than half of the parents agreed with HPV immunization requirements generally, and the vast majority agreed when including opt-out provisions.

IMPACT

Support for HPV vaccine requirements may depend on race/ethnicity and inclusion of opt-out provisions. Information about vaccine efficacy and safety may increase support and reduce uncertainty about HPV vaccine in high-risk populations.

NASN position statement: caseload assignments

It is the position of the National Association of School Nurses (NASN) that schools should employ professionally prepared Registered Nurses, to conduct and supervise school health programs which address the variety of health problems experienced by school children. NASN recommends a formula-based approach with minimum ratios of nurses-to-students depending on the needs of the student populations as follows: 1:750 for students in the general population, 1:225 in the student populations requiring daily professional school nursing services or interventions, 1:125 in student populations with complex health care needs, and 1:1 may be necessary for individual students who require daily and continuous professional nursing services. Other factors that should be considered in the formula-based approach are number of students on free or reduced lunch, number of students with a medical home, and average number of emergency services per year.

Compulsory school-entry vaccination laws and exemptions: who is opting out in ontario and why does it matter?

School-entry vaccination regulations are a policy instrument that has been widely used in some jurisdictions as a mechanism to ensure high immunization coverage rates. Exemptions to school-entry vaccination, which can be allowed on medical or non-medical grounds, present a number of ethical and policy challenges. In this paper, we consider the situation in Canada, where school-entry vaccination laws are rare. We present newly available aggregate-level registry data from Ontario comparing the use of medical and non-medical immunization exemptions to school-entry vaccination and the implications for population health.

Measles outbreak in a highly vaccinated population, San Diego, 2008: role of the intentionally undervaccinated

OBJECTIVE

In January 2008, an intentionally unvaccinated 7-year-old boy who was unknowingly infected with measles returned from Switzerland, resulting in the largest outbreak in San Diego, California, since 1991. We investigated the outbreak with the objective of understanding the effect of intentional undervaccination on measles transmission and its potential threat to measles elimination.

METHODS

We mapped vaccination-refusal rates according to school and school district, analyzed measles-transmission patterns, used discussion groups and network surveys to examine beliefs of parents who decline vaccination, and evaluated containment costs.

RESULTS

The importation resulted in 839 exposed persons, 11 additional cases (all in unvaccinated children), and the hospitalization of an infant too young to be vaccinated. Two-dose vaccination coverage of 95%, absence of vaccine failure, and a vigorous outbreak response halted spread beyond the third generation, at a net public-sector cost of $10 376 per case. Although 75% of the cases were of persons who were intentionally unvaccinated, 48 children too young to be vaccinated were quarantined, at an average family cost of $775 per child. Substantial rates of intentional undervaccination occurred in public charter and private schools, as well as public schools in upper-socioeconomic areas. Vaccine refusal clustered geographically and the overall rate seemed to be rising. In discussion groups and survey responses, the majority of parents who declined vaccination for their children were concerned with vaccine adverse events.

CONCLUSIONS

Despite high community vaccination coverage, measles outbreaks can occur among clusters of intentionally undervaccinated children, at major cost to public health agencies, medical systems, and families. Rising rates of intentional undervaccination can undermine measles elimination.

Vaccine refusal, mandatory immunization, and the risks of vaccine-preventable diseases

Vaccines are among the most effective prevention tools available to clinicians. However, the success of an immunization program depends on high rates of acceptance and coverage. There is evidence of an increase in vaccine refusal in the United States and of geographic clustering of refusals that results in outbreaks. Children with exemptions from school immunization requirements (a measure of vaccine refusal) are at increased risk for measles and pertussis and can infect others who are too young to be vaccinated, cannot be vaccinated for medical reasons, or were vaccinated but did not have a sufficient immunologic response. Clinicians can play a crucial role in parental decision making. Health care providers are cited as the most frequent source of immunization information by parents, including parents of unvaccinated children. Although some clinicians have discontinued or have considered discontinuing their provider relationship with patients who refuse vaccines, the American Academy of Pediatrics Committee on Bioethics advises against this and recommends that clinicians address vaccine refusal by respectfully listening to parental concerns and discussing the risks of nonvaccination.

Geographic clustering of nonmedical exemptions to school immunization requirements and associations with geographic clustering of pertussis

School immunization requirements are important in controlling vaccine-preventable diseases in the United States. Forty-eight states offer nonmedical exemptions to school immunization requirements. Children with exemptions are at increased risk of contracting and transmitting vaccine-preventable diseases. The clustering of nonmedical exemptions can affect community risk of vaccine-preventable diseases. The authors evaluated spatial clustering of nonmedical exemptions in Michigan and geographic overlap between exemptions clusters and clusters of reported pertussis cases. Kulldorf's scan statistic identified 23 statistically significant census tract clusters for exemption rates and 6 significant census tract clusters for reported pertussis cases between 1993 and 2004. The time frames for significant space-time pertussis clusters were August 1993-September 1993, August 1994-February 1995, May 1998-June 1998, April 2002, May 2003-July 2003, and June 2004-November 2004. Census tracts in exemptions clusters were more likely to be in pertussis clusters (odds ratio = 3.0, 95% confidence interval: 2.5, 3.6). The overlap of exemptions clusters and pertussis clusters remained significant after adjustment for population density, proportion of racial/ethnic minorities, proportion of children aged 5 years or younger, percentage of persons below the poverty level, and average family size (odds ratio = 2.7, 95% confidence interval: 2.2, 3.3). Geographic pockets of vaccine exemptors pose a risk to the whole community. In addition to monitoring state-level exemption rates, health authorities should be mindful of within-state heterogeneity.

Vaccinating adolescents in high-risk settings: lessons learned from experiences with hepatitis B vaccine

Meeting the health needs of adolescents who live in high-risk settings such as homeless shelters, migrant camps, juvenile detention centers, prisons, and other types of residential facilities presents many challenges. Although there is no doubt that adolescents in many high-risk settings are at increased risk for hepatitis B and human papillomavirus, acute medical and psychological problems may consume all of the provider's time and resources. Potential health threats such as vaccine-preventable diseases must necessarily be given lower priority. Lack of vaccination expertise, supplies, and access to records further complicate delivery of vaccines. Since the 1990s, a number of approaches have been used to deliver hepatitis B vaccine to adolescents in many high-risk settings. Close collaboration among state and federal programs, local health departments, and community-based organizations has been necessary to introduce and sustain the delivery of vaccines to these young people. Medicaid, Statute 317 of the Public Health Service Act, the Vaccines for Children program, and State Children's Health Insurance Program have been used to finance vaccinations for adolescents 18 years or younger, and the expanded Medicaid option in the Foster Care Independence Act of 1999 has been used for adolescents older than 18 years of age. A number of states allow adolescents under age 18 to consent to their own hepatitis B vaccination under laws passed to allow treatment of sexually transmitted infections without parental consent. In this article, we present the experiences of several model programs that developed successful hepatitis B vaccination programs in venues that serve adolescents at risk, the important role of state laws and state agencies in funding immunization and other preventive health services for adolescents in high-risk situations, and discuss barriers and means to resolve them.

College and university compliance with a required meningococcal vaccination law

OBJECTIVE

Maryland became the first state to pass a vaccination law requiring college and university students living on campus to obtain a meningococcal vaccination or to sign a waiver refusing vaccination because college students are at increased risk for disease. The authors sought to identify how Maryland colleges addressed the law and determine whether schools were in full compliance.

PARTICIPANTS

The authors surveyed 32 college/university administrators via a self-administered questionnaire.

METHODS

The authors calculated vaccination and waiver rates and assessed compliance with the law overall and with specific law components.

RESULTS

Among 28 participating schools, annual vaccination rates and waiver rates among students during 2000-2004 ranged from 66%-76% and 12%-17%, respectively. Two (7%) schools were compliant with all components of the law.

CONCLUSIONS

Mandatory vaccination laws do not ensure compliance at the college and university level. Mandatory reporting, increased education, and collaboration between colleges and universities and public health agencies are needed.

Impact of addition of philosophical exemptions on childhood immunization rates

BACKGROUND

Although incidence of vaccine-preventable diseases has decreased, states' school immunization requirements are increasingly challenged. Subsequent to a federal court ruling affecting religious immunization exemptions to school requirements, new legislation made philosophical immunization exemptions available in Arkansas in 2003-2004. This retrospective study conducted in 2006 describes the impact of philosophical exemption legislation in Arkansas.

METHODS

Arkansas Division of Health data on immunization exemptions granted were linked to Department of Education data for all school attendees (grades K through 12) during 2 school years before the legislation (2001-2002 and 2002-2003 [Years 1 and 2, respectively]) and 2 years after philosophical exemptions were available (2003-2004 and 2004-2005 [Years 3 and 4, respectively]). Changes in numbers, types, and geographic distribution of exemptions granted are described.

RESULTS

The total number of exemptions granted increased by 23% (529 to 651) from Year 1 to 2; by 17% (total 764) from Year 2 to 3 after philosophical exemptions were allowed; and by another 50% from Year 3 to 4 (total 1145). Nonmedical exemptions accounted for 79% of exemptions granted in Years 1 and 2, 92% in Year 3, and 95% in Year 4. Importantly, nonmedical exemptions clustered geographically, suggesting concentrated risks for vaccine-preventable diseases in Arkansas communities.

CONCLUSIONS

Legislation allowing philosophical exemptions from school immunization requirements was linked to increased numbers of parents claiming nonmedical exemptions, potentially causing an increase in risk for vaccine-preventable diseases. Continued education and dialogue are needed to explore the balance between individual rights and the public's health.

Compulsory vaccination and conscientious or philosophical exemptions: past, present, and future

Compulsory vaccination has contributed to the success of immunisation programmes in the USA and Australia, yet the benefits from compulsory vaccination are not universally recognised. Some people--experts and the public alike--believe that the benefits of compulsory vaccination are outweighed by the associated ethical problems. A review of vaccination legislation in the UK, Australia, and the USA raises four main points. First, compulsory vaccination may be effective in preventing disease outbreaks, reaching and sustaining high immunisation coverage rates, and expediting the introduction of new vaccines. Second, to be effective, compulsory programmes must have a reliable supply of safe and effective vaccines and most people must be willing to be vaccinated. Third, allowance of exemptions to compulsory vaccination may limit public backlash. Finally, compulsory vaccination may increase the burden on governments to ensure the safety of vaccines. Nevertheless, although compulsory immunisation can be very effective, it might not be acceptable in some countries where high coverage has been achieved through other approaches or efforts, such as in Sweden, Norway, Denmark, the Netherlands, and the UK. These factors should be considered when compulsory vaccinations are being introduced or immunisation laws refined. Lessons learned from compulsory vaccination could be useful to other public-health programmes.

Public health and the politics of school immunization requirements

Compulsory vaccination has contributed to the enormous success of US immunization programs. Movements to introduce broad "philosophical/personal beliefs" exemptions administered without adequate public health oversight threaten this success. Health professionals and child welfare advocates must address these developments in order to maintain the effectiveness of the nation's mandatory school vaccination programs. We review recent events regarding mandatory immunization in Arkansas and discuss a proposed nonmedical exemption designed to allow constitutionally permissible, reasonable, health-oriented administrative control over exemptions. The proposal may be useful in political environments that preclude the use of only medical exemptions. Our observations may assist states whose current nonmedical exemption provisions are constitutionally suspect as well as states lacking legally appropriate administrative controls on existing, broad non-medical exemptions.