Nonmedical exemptions from school immunization requirements: a systematic review

Barriers and facilitators to vaccination in Latin America: a thematic synthesis of qualitative studies

Vaccines are often undervalued or underused for a variety of reasons, and vaccine hesitancy is a global challenge that threatens vaccine acceptance and the goals of immunization programs. This review aimed to describe the barriers and facilitators to vaccination in Latin America. The study design was a systematic review and thematic synthesis of qualitative studies reporting on the knowledge or attitudes of adults, parents of children at vaccination age, adolescents and health professionals towards vaccination in Latin America. The databases searched were PubMed, CENTRAL, Scopus, LILACS, SciELO, and CINAHL. A total of 56 studies were included. Facilitators included vaccination being recognized as an effective strategy for preventing infectious diseases and as a requirement for access to social assistance programs, schooling or employment. Recommendations from health professionals and positive experiences with health services were also identified as facilitators. The main barriers were lack of information or counseling, structural problems such as shortages of vaccines and limited hours of operation, the inability to afford over-the-counter vaccines or transportation to health facilities, certain religious beliefs, misconceptions and safety concerns. Qualitative research can contribute to understanding perceptions and decision-making about vaccination and to designing policies and interventions to increase coverage.

Underimmunization of very low birth weight infants at discharge from the neonatal intensive care unit

OBJECTIVE

To quantify immunization status among premature infants discharged from neonatal intensive care units (NICUs), and identify risk factors for underimmunization.

STUDY DESIGN

We performed a cohort study of infants <33 weeks gestation discharged home between 2011 and 2020 from 241 NICUs. Using multivariable logistic regression, we examined the association between risk factors and underimmunization at discharge, defined as <1 dose of 5 vaccine types when discharged at 60-119 days of age and <2 doses when discharged at 120-179 days of age.

RESULTS

Of 30,766 infants discharged at 60-119 days of age, 14% were underimmunized. Among 4358 infants discharged at 120-179 days of age, 53% were underimmunized. For infants discharged at 60-119 days of age, ventilator support within 30 days of discharge was associated with underimmunization. Having a surgical procedure was associated with underimmunization in both groups.

CONCLUSION

A large proportion of premature infants discharged from the NICU are underimmunized.

Flu vaccinations: College campus not making the grade. A study of influenza vaccination at an urban public university

Objective: Even healthy college students are vulnerable to severe complications associated with seasonal influenza (flu). Despite national directives to increase influenza vaccination compliance, college campuses remain woefully below national goals. This study aimed to identify factors correlated with the decision to voluntarily receive an influenza vaccine. Additionally, students' reasons for non-vaccination were also examined. Participants: 1021 undergraduate students across four professional schools. Methods: A representative cross-sectional survey was conducted at a public, urban university. Results: The survey measured self-reported influenza vaccination: an overall influenza vaccination rate of 38% was identified. Student characteristics associated with increased influenza vaccination included students' enrollment in academic health disciplines; being female; human papillomavirus (HPV) vaccination; and no marijuana use in the last month. Barriers to influenza vaccination included contraindications, mistrust issues, and personal reasons. Conclusion: Universities that can identify facilitators and barriers to voluntary influenza vaccination can assist with program initiatives to improve influenza vaccination compliance rates.

Assessing the country-level involvement of nurses in COVID-19 vaccination campaigns: A qualitative study

BACKGROUND

As each country individually manages the COVID-19 pandemic, mass vaccination campaigns have varied considerably. Implementation campaigns often depend on nurses; however, nurses are not consistently involved in higher-level planning, prioritization, and policy development decisions. This study aimed to examine the involvement and engagement of nurses in country-level COVID-19 mass vaccination policies and practices in 10 Office of Economic Cooperation and Development countries, identify barriers and factors to enhancing the engagement of nurses in the evidence-informed mass vaccination decision-making processes, and suggest areas for improvement.

METHODS

A qualitative study using in-depth semi-structured interviews was conducted as a follow-up study to an International Council of Nurses survey. The study sample included a purposeful sample of 14 country-representative nurses from 10 Office of Economic Cooperation and Development countries. Interview questions focused on each country's overall COVID-19 vaccination campaign and policies, participants' perspectives regarding the involvement of nurses in the planning, design, and implementation of the mass vaccination program observed outcomes, and the impact of nursing on the outcomes. Interviews were recorded, transcribed, translated where necessary, coded, and thematically analyzed.

RESULTS

Main areas of involvement identified by participants were membership in advising and decision-making committees, operationalization planning, implementation and coordination processes, education efforts, and nurses' interactions with the media. Seven themes emerged among perceived facilitators of nursing involvement: existing systems and infrastructure, nursing profession-related skills and competencies, communication and messaging, multidisciplinary and interagency work, recognition and visibility of nurses and nursing, trust in nurses, and nursing pride. Meanwhile, perceived barriers included lack of a voice, recognition and appreciation for nursing, workforce-related challenges, decentralization of responsibility and authority, supply and access issues, downstream effects of the pandemic, and non-COVID-related nursing barriers. Three main themes emerged among suggestions made by participants for improved involvement of nursing: culture change within nursing and healthcare, opportunities and momentum to build upon, and perceptions of responsible parties.

CONCLUSIONS

Nurses play a central role in providing health services but are inconsistently included in the policy, planning, and decision-making processes. Findings highlighted the critical importance of nursing leadership roles and expanded roles for nurses. Nursing should be represented by high-level leaders as part of multidisciplinary decision-making groups, educational initiatives for involvement in health policy should be implemented in nursing schools and continuing education, and advocacy and inclusion efforts should utilize bottom-up and top-down approaches concurrently.

Religious Doctrine and Attitudes Toward Vaccination in Jewish Law

Individual and herd immunity against communicable diseases requires high rates of timely and complete vaccination, particularly in closely knit communities, densely populated areas, and places with high influx of potentially infected individuals. Recent outbreaks of COVID-19 and, previously, measles in religious Jewish communities of New York, as well as the rise of vaccine hesitancy in faith communities, call for the examination of Jewish attitudes toward vaccination. In this article, we examine religious doctrine and guidance on vaccination in Orthodox (including Modern Orthodox, Chabad-Lubavich, and Ultra-Orthodox), Conservative, and Reform denominations of Judaism and apply these principles to vaccinations against measles, human papillomavirus (HPV), and COVID-19. We found that the leaders and scholars in these three major denominations of Judaism are uniform in their strong support, often to the point of mandate, for the principles of vaccination. Support for vaccination is deeply rooted in the Torah, Jewish law, and contemporary rulings of poskim (Jewish legal scholars). These principles are applied by each denomination in strong support of measles and COVID-19 vaccination, though there is less certainty in their support of vaccination against HPV.

Sometimes Your Heart Says 'I Don't Know': Insights From Parents of Undervaccinated Children

STUDY OBJECTIVE

To explore drivers of suboptimal vaccination rates by understanding why parents without strong antivaccine beliefs do not fully vaccinate their children.

METHODS

Four focus groups were conducted in Washington state with 41 parents of children aged 24 to 48 months who delayed, declined, or missed some but not all vaccines. During the focus groups, parents were asked about reasons their child was undervaccinated, information that might address their concerns, and additional support they needed. Transcripts were analyzed using template analysis with deductive and inductive codes.

RESULTS

Focus groups identified multiple reasons for parents deciding to delay or decline vaccines for their children, including issues of individualism and control. The groups emphasized the impact of personal circumstances, such as changes in insurance, on whether children were vaccinated. Our data also shed light on the reasons that parents do vaccinate their children, including school vaccination requirements, negative experiences with vaccine-preventable diseases, and a family tradition of vaccinating. Focus group participants offered suggestions for improving vaccine communication with parents such as having more parent/patient-friendly vaccine information, providing forums to discuss their concerns, and offering vaccination information in advance of well-child appointments.

CONCLUSIONS

To achieve the full benefit of vaccines on individual and community health, we need better ways to address vaccine hesitancy and decrease barriers. We suggest that many hesitant parents would benefit from more dialog with health care providers about vaccines, more approachable educational materials, and enforcement of existing policies requiring vaccines in schools and childcare facilities.

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

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

The Long-Term Success of Mandatory Vaccination Laws After Implementing the First Vaccination Campaign in 19th Century Rural Finland

In high-income countries, childhood infections are on the rise, a phenomenon attributed in part to persistent hesitancy toward vaccines. To combat vaccine hesitancy, several countries recently made vaccinating children mandatory, but the effect of such vaccination laws on vaccination coverage remains debated, and the long-term consequences are unknown. Here we quantified the consequences of vaccination laws on vaccination coverage, monitoring for a period of 63 years (1837-1899) rural Finland's first vaccination campaign against the highly lethal childhood infection smallpox. We found that annual vaccination campaigns were focused on children up to 1 year old and that their vaccination coverage was low and declined over time until the implementation of the vaccination law, which stopped the declining trend and was associated with an abrupt coverage increase, of 20%, to cover >80% of all children. Our results indicate that vaccination laws can have a long-term beneficial effect of increasing the vaccination coverage and will help public health practitioners to make informed decisions on how to act against vaccine hesitancy and optimize the impact of vaccination programs.

Towards Eliminating Nonmedical Vaccination Exemptions Among School-Age Children

The increase in childhood vaccine hesitancy and corresponding use of nonmedical exemptions to abstain from vaccination has deleteriously impacted the public's health. This has many in the field calling for widespread elimination of nonmedical school-entry exemptions, as has been done in six states to date: West Virginia, Mississippi, California, New York, Maine, and Connecticut. By eliminating nonmedical exemptions, vaccination rates can be improved, with the corresponding decline in vaccine-preventable disease incidence. Yet the path towards widespread adoption of these policies presents legislative and judicial implications which evolve with the changing political landscape. In this this article, we discuss legislative actions concerning the expansion of exemptions, whether the widespread elimination of nonmedical exemptions would be effective from a practical and legal end, and how the COVID-19 pandemic has influenced such legislation, with specific focus on Delaware.

The association between state-based provisional attendance periods and adolescent middle school-entry vaccination coverage

The rise of vaccine-preventable disease outbreaks calls for a deeper understanding of the impact of policy on school-entry vaccine compliance. Provisional attendance policies vary by state but permit under-vaccinated students a limited period to attend school while receiving their immunizations. The primary objective of this study was to clarify the relationship between annual immunization coverage and state provisional policies for a single-dose of school-entry-required adolescent vaccinations: tetanus, diphtheria, pertussis (Tdap), meningococcal conjugate (MCV4), and human papillomavirus (HPV). From June 22, 2020 to August 20, 2020, the Immunization Action Coalition and state-level Department of Health (DOH) webpages were reviewed with email confirmation with a DOH representative to determine provisional period policy. Vaccination coverage for Tdap, MCV4, and HPV were obtained from the Center for Disease Control's National Immunization Survey. Overall, 49 states and D.C. legally mandate exclusion of vaccine noncompliant adolescents, and the majority of jurisdictions assign responsibility for exclusion to local school officials (84%). Complete provisional period data was obtained for 46/51 jurisdictions. The effect of provisional period length categorized as 0 days (18 jurisdictions, 35.3%), 1 to 30 days (18 jurisdictions, 35.3%), 31+ days (10 jurisdictions, 19.6%), and "unclear" (5 jurisdictions with incomplete data, 9.8%) had no significant association with annual adolescent vaccination coverage for Tdap (p = 0.82), MCV4 (p = 0.08), and HPV (p = 0.76). Provisional policies may not increase vaccination coverage as anticipated. Unintended consequences, such as increased nonmedical exemptions and increased demands on clinical providers, are additional factors to consider.

Evaluating Michigan's Administrative Rule Change on Nonmedical Vaccine Exemptions

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A qualitative study of the views of healthcare professionals on providing vaccines information to patients

Background Healthcare professionals (HCPs) such as pharmacists, general practitioners and practice nurses are a trusted source of vaccines information for patients in primary care. Global regulators have highlighted the key role of HCPs in fostering confidence in COVID-19 vaccines. Objective This study aims to gain insight into the views and experiences of HCPs on providing vaccines information to patients. Setting Primary care general practice surgeries and community pharmacies in Ireland. Methods Qualitative, semi-structured interviews were conducted with 14 HCPs (five General practitioners [GPs], four practice nurses and five community pharmacists) identified through purposive and convenience sampling. The interviews were analysed by inductive thematic analysis. Main outcome measure Participants’ views and experiences of providing vaccines information to patients. Results Five key themes were identified: roles and responsibilities, perception of risk, perception of the public, building a relationship, and emotion. HCPs were motivated by duty and care for their patients. They respected patient autonomy and were driven by their concern for public health. HCPs were influenced by their perception of risk and their perceptions of the public. HCPs practiced patient-centred care by providing tailored vaccines information. They favoured an approach of providing patients with information and support to make their own decision. The topic was emotive; HCPs empathised with patients but were also frustrated by their perceived inability to change some patients’ views. Conclusion The provision of vaccines information by HCPs to patients is multifactorial with participants mindful of patient autonomy and the HCP role to support vaccinations as a public health priority. Participants suggested that education and support on vaccines communication would enable them to support the vaccines uptake in their practice.

Parental attitudes towards mandatory vaccination; a systematic review

Uptake of childhood vaccines is decreasing. While mandatory vaccination schemes can increase vaccine uptake rates, they can also cause backlash among some parents. We conducted a systematic review investigating parental beliefs about vaccine mandates and factors associated with support for mandatory vaccination schemes. We searched Embase, Ovid MEDLINE, Global Health, APA PsycINFO and Web of Science from inception to 17th September 2020. Seventeen studies (five qualitative, twelve quantitative) were eligible for inclusion. We synthesised results of qualitative and quantitative studies separately. As quantitative studies were heterogeneous in the mandatory vaccination schemes and associated factors investigated, there was no scope to conduct a meta-analysis. Instead, data were narratively synthesised, considering risk of bias ratings. Qualitative data were synthesised using meta-ethnography, synthesising themes reported across studies included. Quantitative studies reported that support for mandatory vaccination schemes was reasonably high (73% to 88%). However, due to heterogeneity, there was little evidence for any factors being consistently associated with support for mandatory vaccination. Qualitative studies gave an insight into how parents perceive mandatory vaccination. Studies found that parents perceived mandatory vaccination schemes as an infringement of their rights, and particularly disliked schemes offering financial incentives for vaccination. Nevertheless, some parents felt that schemes limiting access to schooling of unvaccinated children gave them "peace of mind." Results should be taken with caution due to the purposive use of non-representative samples. Before deciding to mandate vaccination, it is important to understand the impact it could have on parental beliefs and attitudes about vaccination.

I'm a mother, therefore I question": Parents' legitimation sources of and hesitancy towards early childhood vaccination

This study was conducted with mothers living in Ankara and registered in the year 2019 with the Immunization Services Unit of the Provincial Directorate of Health as cases of vaccine refusal. This qualitative study used semi-structured interviews to understand how mothers decide about child vaccination and the attitudes, perceptions, and beliefs underlying these decisions. A total of 23 interviews were conducted by two of the authors between March and September 2019. Each of the 23 participants had at least one child aged five years or younger and were living in Ankara. The study shows that mothers with vaccine hesitancy constitute a heterogeneous group whose members have differing levels of hesitation and concern about the vaccination of their children. It is also observed that the most important factor that affects their decisions is related to trust.

Geophilosophical exemption to mandatory vaccination

This correspondence introduces the ethics behind a specific exemption to mandatory vaccination. Public health acknowledges medical and non-medical reasons for vaccination exemption. Geophilosophical ones, which the author coined, can provide an option to remote populations with low density and are seeking more choices in confronting the dilemma of being vaccinated.

Vaccination ethics

Vaccination decisions and policies present tensions between individual rights and the moral duty to contribute to harm prevention. This article focuses on ethical issues around vaccination behaviour and policies. It will not cover ethical issues around vaccination research.

SOURCES OF DATA

Literature on ethics of vaccination decisions and policies.

AREAS OF AGREEMENT

Individuals have a moral responsibility to vaccinate, at least against certain infectious diseases in certain circumstances.

AREAS OF CONTROVERSY

Some argue that non-coercive measures are ethically preferable unless there are situations of emergency. Others hold that coercive measures are ethically justified even in absence of emergencies.

GROWING POINTS

Conscientious objection to vaccination is becoming a major area of discussion.

AREAS TIMELY FOR DEVELOPING RESEARCH

The relationship between individual, collective and institutional responsibilities to contribute to the public good of herd immunity will be a major point of discussion, particularly with regard to the COVID-19 vaccine.

In Their Own Words: Resources Needed by School Nurses to Facilitate Student Immunization Compliance

BACKGROUND

All 50 states have school-entry immunization requirements, and many also allow exemptions based on medical and non-medical reasons. School nurses are responsible for managing student immunization compliance based on state policies, but lack standardized resources and guidance.

METHODS

Pennsylvania school nurses (N = 21) participated in semi-structured interviews regarding their strategies for communication and management of student immunization information, along with resources needed for practice improvement. Data were analyzed using descriptive content analysis.

RESULTS

Nurses reported similarities in timelines used for communication of immunization requirements, but differences in mechanisms used to secure and manage immunization records. Nurses reported a need for clarity regarding exclusions and exemption policy implementation and requested standardized resources and guidance for navigating immunization compliance.

CONCLUSIONS

A need exists for standardized processes that support immunization compliance. Furthermore, nurses highlighted a need for additional training and enhanced networks to develop creative strategies for promoting immunization uptake among families.

The geographic distribution of un-immunized children in Ontario, Canada: Hotspot detection using Bayesian spatial analysis

BACKGROUND

In Ontario, Canada, little is currently known about the extent to which un-immunized children may cluster geographically. Our objectives were to: describe the geographic distribution of fully un-immunized children; identify geographic clusters (hotspots) of un-immunized children; and to characterize the contribution of spatial effects and covariates on hotspots, where found.

METHODS

Our analytic cohort consisted of Ontario students aged 7-17 years in the 2016-2017 school year. We defined students as un-immunized if they had zero doses of any vaccine and a non-medical exemption recorded in Ontario's registry. We calculated unadjusted proportions of un-immunized students by Census Subdivision (CSD) and then used a sequential approach to identify hotspots starting first with hotspot identification at the CSD level and then probed identified hotspots further by Dissemination Area (DA) and including covariates. Hotspots were identified using the Besag-York-Mollie Bayesian spatial model and were defined as areas with >95% probability of having two times the proportion of un-immunized students, relative to the province overall.

RESULTS

We identified 15,208 (0.94%) un-immunized children within our cohort consisting of more than 1.61 million students. Unadjusted proportions of un-immunized students varied greatly by geography, ranging from 0% to 21.5% by CSD. We identified 16 hotspot CSDs which clustered in five distinct areas, all of which were located in southern Ontario. The contribution of covariates and spatial effects on the risk of having un-immunized students varied greatly across hotspot areas.

CONCLUSIONS

Although the provincial proportion (0.94%) of un-immunized students is small, geographical clustering of such students is evident in Ontario and in some areas presents an important risk for future outbreaks. Further qualitative work within these hotspot areas would be a helpful next step to better characterize the factors associated with vaccine refusal in these communities.

Contribution of Social Determinant of Health Factors to Rural-Urban Preventive Care Differences Among Medicaid Enrollees

OBJECTIVE

1) Assess whether rural-urban disparities are present in pediatric preventive health care utilization; and 2) use regression decomposition to measure the contribution of social determinants of health (SDH) to those disparities.

METHODS

With an Ohio Medicaid population served by a pediatric Accountable Care Organization, Partners For Kids, between 2017 and 2019, we used regression decomposition (a nonlinear multivariate regression decomposition model) to analyze the contribution of patient, provider, and SDH factors to the rural-urban well-child visit gap among children in Ohio.

RESULTS

Among the 453,519 eligible Medicaid enrollees, 61.2% of urban children received a well-child visit. Well-child visit receipt among children from large rural cities/towns and small/isolated towns was 58.2% and 55.5%, respectively. Comparing large rural towns to urban centers, 55.8% of the 3.0 percentage-point difference was explained by patient, provider, and community-level SDH factors. In comparing small/isolated town to urban centers, 89.8% of the 5.7 percentage-point difference was explained by these characteristics. Of provider characteristics, pediatrician providers were associated with increased well visit receipt. Of the SDH factors, unemployment and education contributed the most to the explained difference in large rural towns while unemployment, education, and food deserts contributed significantly to the small/isolated town difference.

CONCLUSIONS

The receipt of pediatric preventive care is slightly lower in rural communities. While modest, the largest part of the rural-urban preventive care gap can be explained by differences in provider type, poverty, unemployment, and education levels. More could be done to improve pediatric preventive care in all communities.

Eliminating Religious and Philosophical Exemptions: The Next Step in Ontario's Campaign against Vaccine Hesitancy

Ontario families are required to provide up-to-date vaccination records as children begin schooling. Exemptions are allowed on both medical and nonmedical (religious or philosophical) grounds. In a recent report, Toronto Public Health (2019) called for an end to nonmedical exemptions - a proposal some allege infringes the Canadian Charter of Rights and Freedoms right to freedom of religion and conscience. This paper explores whether and to what extent vaccine refusal is protected under the Charter and argues that the elimination of nonmedical exemptions can be justified under Section 1 of the Charter. The issue of mandatory vaccination may take on special urgency in the coming months and years, if and when a vaccine is found for COVID-19.

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.

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.

A Select Bibliography of Actions to Promote Vaccine Literacy: A Resource for Health Communication

In this bibliography, the researchers provide an introduction to the available evidence base of actions to promote vaccine literacy. The research team organized interventions to create a tool that can inform health communicators and practitioners seeking a resource focused on strategy and implementation design for actions that support vaccine literacy. This scoping bibliography is honed specifically to respond to the urgency of the current pandemic, when supporting and increasing vaccine literacy offers promise for achieving the critically needed high levels of vaccination. Over the course of the coming months and year, this bibliography will be a dynamic and "living" document hosted and maintained on vaccineliteracy.com.

Vaccine Policy in the United States

In an era when the success of the US vaccination policies to date is threatened by vaccine hesitancy, it is important for clinicians to have a working understanding of how vaccines are developed and recommended for use in the United States and how federal and state governments are coordinated to ensure a safe and effective vaccine supply. This article discusses the federal agencies involved in vaccine development and recommendation, other organizations involved in vaccine policy, and the role of vaccine-related public health law in promoting universal vaccination.

Higher education associated with better national tetanus vaccination coverage: A population-based assessment

Vaccination coverage among United States (U.S.) adults for tetanus continues to be lower than the national goals. Education has demonstrated a positive impact on vaccination coverage. However, recently there have been outbreaks of vaccine preventable conditions in areas with high college completion rates. This study assessed the relationship between education and tetanus vaccination. Data from the 2016 Behavioral Risk Factor Surveillance System (BRFSS), a self-reported annual survey for non-institutionalized adults in the US from the Centers for Disease Control, was analyzed in 2019. The outcome was up-to-date tetanus vaccination if received within the last 10 years. Education was categorized into 1) grade 11 or less, 2) grade 12/GED, 3) college 1-3 years, and 4) college 4 or more years. Bivariate analyses and multivariable logistic regression were conducted on the analytic sample (n = 417,473) using Stata 15, accounting for weighting and the complex survey design. In 2016, 59.9% of U.S. adults had up-to-date tetanus vaccination. Higher education level was associated with increased odds of up-to-date tetanus vaccination. The highest odds were for those with 4 or more years of college education [aOR = 1.31; 95% (CI: 1.26-1.35)]. Female sex, Black (non-Hispanic), unemployed, not being married, not having insurance or a personal health care provider, and above 45 years of age had lower odds of up-to-date tetanus vaccination. Targeted community specific vaccination education programs for those without tertiary education may help enhance the knowledge and thus the overall vaccination status in the U.S.

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.

Vaccine exemption requirements and parental vaccine attitudes: an online experiment

Increases in vaccine hesitancy and vaccine-preventable disease outbreaks have focused attention on state laws governing school-entry vaccine mandates and the allowable exemptions (medical and nonmedical) from those mandates. There is substantial variation in the type of exemptions available in each state, and states with more rigorous or burdensome exemption requirements generally have lower exemption rates. States have little evidence, however, about how vaccine-hesitant parents respond to different requirements. Despite recent efforts to formulate "model legislation" templates for states to follow, policy evidence about optimal exemption regimes is limited to observational studies in states that have changed exemption laws. We conducted two online experiments to explore how parental attitudes and intentions responded to different school-entry vaccine mandate exemption requirements. We randomly assigned online participants to one of four hypothetical vaccine exemption application scenarios: parental signature only, a checklist of vaccines for which an exemption is requested, a lengthy (10-30+ min) video-based vaccine education module, and a requirement to write a statement justifying the exemption. Among parents with high vaccine hesitancy, a required vaccine education module led to significant decreases in vaccine hesitancy, while checklist and justification requirements increased vaccine hesitancy slightly. Among parents with low vaccine hesitancy, we observed a potential backfire effect when parents were required to write a justification statement. Our findings warrant replication in a larger, fully-powered trial to accelerate knowledge about how parents across the vaccine hesitancy spectrum respond to exemption regimes.

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.

Propagandizing anti-vaccination: Analysis of Vaccines Revealed documentary series

Politically charged health propaganda films may have public health ramifications through decreased vaccination uptake, especially with expansive dissemination potential on social media. The nine-episode documentary series Vaccines Revealed, touted as foremost truth within the largest anti-vaccination closed Facebook group, advocates for non-medical childhood vaccination exemptions - a policy actively opposed by the American Academy of Pediatrics. This series is recommended specifically to parents who are on the fence about whether or not to vaccinate their children as well as new, first-time, and expectant mothers. Fourteen 'expert' panelists included: six M.D,'s who reportedly prefer natural approaches for everything from chiropractic to cardiology practice, a vaccine injury attorney, two professors, one psychiatrist, the founder of natural search engine Greenmedinfo.com, a nationally-recognized clinical research expert on the HPV vaccine, the president of the National Vaccine Information Center, and three parents of vaccine-injured children. Additionally, voiceover clips from an epidemiologist and former senior scientist at the CDC were played throughout the series as evidence of governmental conspiracy. Inclusion of these testimonies, particularly from white coat doctors, led to a perception of high source credibility. Qualitative analysis of this documentary series revealed five overarching themes: (perceived) solidified science, collusion and conspiracy, canary in the coal mine, fear appeals, and the morality and necessity of individual choice. As opposed to formulating a priori theoretical assumptions, grounded theory allowed an integrative theoretical explanation to emerge from the data. Researchers expanded cognitive dissonance, parasocial interaction, and social identification theories and described how viewers of Vaccines Revealed could come to align their views on vaccinations with those of the panelists featured in the videos.

The Role of Pharmacists in Addressing Vaccine Hesitancy and the Measles Outbreak

Vaccine hesitancy has been identified as a top threat to global health by the World Health Organization. The current measles outbreak in the United States places even greater emphasis on the relevance of this topic. Vaccination is one of the most cost-effective methods to avoid preventable disease and associated complications. Safety concerns and lack of education commonly contribute to vaccination refusals. By providing patients evidence-based facts and education, pharmacists have the opportunity to address common misconceptions influencing the antivaccination movement and prevent future outbreaks of vaccine-preventable diseases.

Moving Childhood Immunizations Out of the Public Health Setting: Effects on Immunization Rates

County health departments typically bear responsibility for implementing immunization programs. In 2011, the Florida state legislature made significant reductions in state health department funding, and responsibility for routine childhood immunizations in some counties was shifted to local federally qualified health centers. This study was conducted to assess the impact of these administrative changes on childhood immunization rates in one county. A secondary analysis of data in the state immunization registry was conducted to assess changes and patterns in childhood immunization rates within the local health department, federally qualified health centers, and private pediatric practices. These changes were compared in the 3-year period before, during, and after the change. Results revealed that there was no net negative change in the vaccination rates of 0- to 7-year-old children in the county. There was a shift in the proportion of vaccinations administered by each health care delivery setting. The majority of immunizations were administered in private pediatric practices. When state funding for the local public health department ceased, other delivery settings covered the immunizations previously provided in the public health sector.

Nudging Immunity: The Case for Vaccinating Children in School and Day Care by Default

Many parents are hesitant about, or face motivational barriers to, vaccinating their children. In this paper, we propose a type of vaccination policy that could be implemented either in addition to coercive vaccination or as an alternative to it in order to increase paediatric vaccination uptake in a non-coercive way. We propose the use of vaccination nudges that exploit the very same decision biases that often undermine vaccination uptake. In particular, we propose a policy under which children would be vaccinated at school or day-care by default, without requiring parental authorization, but with parents retaining the right to opt their children out of vaccination. We show that such a policy is (1) likely to be effective, at least in cases in which non-vaccination is due to practical obstacles, rather than to strong beliefs about vaccines, (2) ethically acceptable and less controversial than some alternatives because it is not coercive and affects individual autonomy only in a morally unproblematic way, and (3) likely to receive support from the UK public, on the basis of original empirical research we have conducted on the lay public.

Image of the new vaccination obligation through the media

INTRODUCTION

Vaccination campaigns always go hand by hand with controversies about their safety and usefulness. The widespread perception of vaccines as dangerous induces a decrease in the population immunization coverage, which led The French Ministry of Health to add 8 new mandatory vaccines to the 3 existing ones. The objective of this study is to analyze the information conveyed by the media and received by the French population about this new legislation.

METHOD

The newspaper articles and television and radio programs were selected from the media with the highest audience rate from January 2016 to May 2018. They were analyzed according to the grounded theory, up to data saturation, with double coding.

RESULTS

The qualitative analysis included 38 written press articles, 18 radio programs and 18 television programs. After coding, several themes emerged. Discussions about the usefulness of vaccination, trust in vaccines, vaccination coverage, and the cost of measure were controversial in the media. Questions about ethics were also mentioned. The description of anti-vaccines by journalists and some doctors conveyed a negative image while reminding their strong mobilization through social media. The law and its implementation details were frequently reminded across the different media.

DISCUSSION-CONCLUSION

Traditional media give opposing views on immunization obligations. Vaccination is supported by a majority of doctors. Parents share their fears and concerns about vaccination and its adverse effects. An effort regarding public communication seems necessary in order to reassure the population. The study of other media, such as the Internet, could help to deepen this study.

Effects of California Assembly Bill 2109 in Low Vaccination Rate Counties: Are We Looking at the Right Variables?

OBJECTIVES

California Assembly Bill 2109 (AB2109) was passed in 2012 and restricted the obtainment of personal belief exemptions (PBEs) for vaccination requirements for school-aged children. This study examined changes in up-to-date (UTD) vaccination rates, PBEs, and conditionally accepted students (CASs) at 3 time points. The study also examined the association of PBEs and CASs on county and school immunization rates.

DESIGN

This study utilized 6 academic years of immunization data from all kindergartens in California from 2010-2011 to 2015-2016. The years were selected to include data 2 years prior to the introduction of the bill, 2 years prior to implementation, and 2 years after the new legislation went into effect in 2014. Data were analyzed for changes in variables over time at the state, county, and school levels. A Pearson correlation was performed to assess the association between CAS, PBE, and not-UTD rates in low- and high-UTD counties.

RESULTS

Counties with the highest percentage of unimmunized students have significantly higher mean CAS rates than PBE rates (P < .01 for all years). CASs were found to be more highly correlated with students not-UTD with immunizations than PBEs in all years studied (P < .01 for all years) and with far greater effect size in low-UTD counties (<90% UTD rate). There was a small rise in PBEs and a small reduction in UTD rates after AB2109 was signed but a fall in PBE and CAS rates and a rise in UTD rates postimplementation.

CONCLUSION

Many California counties have high levels of CASs at the time of kindergarten entry. The extent to which schools require CASs to complete required vaccinations is not known, which could contribute to the pool of undervaccinated students in California. Public health officials should be vigilant to ensure that schools follow up and enforce the completion of vaccines for conditionally admitted students. This study has policy implications due to the fact that it has been revealed that there is a large undervaccinated population remaining relatively unaccounted for in California despite recent efforts.

Vaccination, Risks, and Freedom: The Seat Belt Analogy

We argue that, from the point of view public health ethics, vaccination is significantly analogous to seat belt use in motor vehicles and that coercive vaccination policies are ethically justified for the same reasons why coercive seat belt laws are ethically justified. We start by taking seriously the small risk of vaccines' side effects and the fact that such risks might need to be coercively imposed on individuals. If millions of individuals are vaccinated, even a very small risk of serious side effects implies that, statistically, at some point side effects will occur. Imposing such risks raises issues about individual freedom to decide what risks to take on oneself or on one's children and about attribution of responsibility in case of adverse side effects. Seat belt requirements raise many of the same ethical issues as vaccination requirements, and seat belt laws initially encountered some opposition from the public that is very similar to some of the current opposition to vaccine mandates. The analogy suggests that the risks of vaccines do not constitute strong enough reasons against coercive vaccination policies and that the same reasons that justify compulsory seat belt use-a measure now widely accepted and endorsed-also justify coercive vaccination policies.

Extension of French vaccination mandates: from the recommendation of the Steering Committee of the Citizen Consultation on Vaccination to the law

On 4 December 2017, French parliamentarians passed a law extending the vaccination mandates for children up to 2 years of age from three vaccinations (against diphtheria, tetanus and poliomyelitis) to 11 by adding vaccinations against pertussis, Haemophilus influenza b (Hib), hepatitis B, pneumococcal diseases, meningococcal C diseases, measles, mumps and rubella. This vote follows a recommendation made by the Steering Committee of the Citizen Consultation on Vaccination that took place in 2016. The law applies to all children born after 1 January 2018. Parents who do not fulfil the mandate will not be fined but non-vaccinated children will not be admitted to any collective child services such as nurseries or schools. No exemption other than for medical reasons will be considered. Here we describe the historical background of this evolution and its main epidemiological, sociological and policy drivers. They mainly refer to insufficient vaccine coverage, persistence of a preventable burden for some diseases and growing vaccine hesitancy in the French population. We also discuss some of the challenges and conditions of success.

Assessing National Public Health Law to Prevent Infectious Disease Outbreaks: Immunization Law as a Basis for Global Health Security

Immunization plays a crucial role in global health security, preventing public health emergencies of international concern and protecting individuals from infectious disease outbreaks, yet these critical public health benefits are dependent on immunization law. Where public health law has become central to preventing, detecting, and responding to infectious disease, public health law reform is seen as necessary to implement the Global Health Security Agenda (GHSA). This article examines national immunization laws as a basis to implement the GHSA and promote the public's health, analyzing the scope and content of these laws to prevent infectious disease across Sub-Saharan Africa. Undertaking policy surveillance of national immunization laws in 20 Sub-Saharan African countries, this study: (1) developed a legal framework to map the legal attributes relevant to immunization; (2) created an assessment tool to determine the presence of these attributes under national immunization law; and (3) applied this assessment tool to code national legal landscapes. An analysis of these coded laws highlights legal attributes that govern vaccine requirements, supply chains, vaccine administration standards, and medicines quality and manufacturer liability. Based upon this international policy surveillance, it will be crucial to undertake legal epidemiology research across countries, examining the influence of immunization law on vaccination rates and disease outbreaks.

Forecasted Size of Measles Outbreaks Associated With Vaccination Exemptions for Schoolchildren

IMPORTANCE

Vaccine exemptions, which allow unvaccinated children to attend school, have increased by a factor of 28 since 2003 in Texas. Geographic clustering of unvaccinated children facilitates the spread of measles introductions, but the potential size of outbreaks is unclear.

OBJECTIVE

To forecast the range of measles outbreak sizes in each metropolitan area of Texas at 2018 and future reduced school vaccination rates.

DESIGN, SETTING, AND PARTICIPANTS

An agent-based decision analytical model using a synthetic population of Texas, derived from the 2010 US Census, was used to simulate measles transmission in the Texas population. Real schools were represented in the simulations, and the 2018 vaccination rate of each real school was applied to a simulated hypothetical equivalent. Single cases of measles were introduced, daily activities and interactions were modeled for each population member, and the number of infections over the course of 9 months was counted for 1000 simulated runs in each Texas metropolitan area.

INTERVENTIONS

To determine the outcomes of further decreases in vaccination coverage, additional simulations were performed with vaccination rates reduced by 1% to 10% in schools with populations that are currently undervaccinated.

MAIN OUTCOMES AND MEASURES

Expected distributions of outbreak sizes in each metropolitan area of Texas at 2018 and reduced vaccination rates.

RESULTS

At 2018 vaccination rates, the median number of cases in large metropolitan areas was typically small, ranging from 1 to 3 cases, which is consistent with outbreaks in Texas 2006 to 2017. However, the upper limit of the distribution of plausible outbreaks (the 95th percentile, associated with 1 in 20 measles introductions) exceeded 400 cases in both the Austin and Dallas metropolitan areas, similar to the largest US outbreaks since measles was eliminated in 2000. Decreases in vaccination rates in schools with undervaccinated populations in 2018 were associated with exponential increases in the potential size of outbreaks: a 5% decrease in vaccination rate was associated with a 40% to 4000% increase in potential outbreak size, depending on the metropolitan area. A mean (SD) of 64% (11%) of cases occurred in students for whom a vaccine had been refused, but a mean (SD) of 36% (11%) occurred in others (ie, bystanders).

CONCLUSIONS AND RELEVANCE

This study suggests that vaccination rates in some Texas schools are currently low enough to allow large measles outbreaks. Further decreases are associated with dramatic increases in the probability of large outbreaks. Limiting vaccine exemptions could be associated with a decrease in the risk of large measles outbreaks.