Health consequences of religious and philosophical exemptions from immunization laws: individual and societal risk of measles

The media-driven risk society, the anti-vaccination movement and risk of autismo

Marked changes have been seen in the epidemiological profile of infectious diseases among middle-class families in industrialized countries due to beliefs related to the risks of vaccination. These beliefs are proliferating globally due to internet sites, blogs and the influence of celebrities in the mass communication media. Due to the complexity of a cultural phenomenon of this nature, contemporary concepts aligned to the idea of reflexivity in the risk society are analyzed. The concept of a receptive media-driven society in which the announcement of danger and protection in mutual reference and contradiction are also assessed. The frequent emergence of tensions derived from cycles of utterances and baseless comments construed as symbolic "biovalues" are discussed. The persistent effect of threatening biotechnological and fraudulent utterances has influenced virtual networks for almost three decades, supporting the debate about the connection between autism and vaccines. The conclusion reached is that the processes of production of significance interconnect at various levels in which representations circulate that support communication and group identity based on historical and cultural references.

"Mommy Blogs" and the Vaccination Exemption Narrative: Results From A Machine-Learning Approach for Story Aggregation on Parenting Social Media Sites

Background

Social media offer an unprecedented opportunity to explore how people talk about health care at a very large scale. Numerous studies have shown the importance of websites with user forums for people seeking information related to health. Parents turn to some of these sites, colloquially referred to as “mommy blogs,” to share concerns about children’s health care, including vaccination. Although substantial work has considered the role of social media, particularly Twitter, in discussions of vaccination and other health care–related issues, there has been little work on describing the underlying structure of these discussions and the role of persuasive storytelling, particularly on sites with no limits on post length. Understanding the role of persuasive storytelling at Internet scale provides useful insight into how people discuss vaccinations, including exemption-seeking behavior, which has been tied to a recent diminution of herd immunity in some communities.

Objective

To develop an automated and scalable machine-learning method for story aggregation on social media sites dedicated to discussions of parenting. We wanted to discover the aggregate narrative frameworks to which individuals, through their exchange of experiences and commentary, contribute over time in a particular topic domain. We also wanted to characterize temporal trends in these narrative frameworks on the sites over the study period.

Methods

To ensure that our data capture long-term discussions and not short-term reactions to recent events, we developed a dataset of 1.99 million posts contributed by 40,056 users and viewed 20.12 million times indexed from 2 parenting sites over a period of 105 months. Using probabilistic methods, we determined the topics of discussion on these parenting sites. We developed a generative statistical-mechanical narrative model to automatically extract the underlying stories and story fragments from millions of posts. We aggregated the stories into an overarching narrative framework graph. In our model, stories were represented as network graphs with actants as nodes and their various relationships as edges. We estimated the latent stories circulating on these sites by modeling the posts as a sampling of the hidden narrative framework graph. Temporal trends were examined based on monthly user-poststatistics.

Results

We discovered that discussions of exemption from vaccination requirements are highly represented. We found a strong narrative framework related to exemption seeking and a culture of distrust of government and medical institutions. Various posts reinforced part of the narrative framework graph in which parents, medical professionals, and religious institutions emerged as key nodes, and exemption seeking emerged as an important edge. In the aggregate story, parents used religion or belief to acquire exemptions to protect their children from vaccines that are required by schools or government institutions, but (allegedly) cause adverse reactions such as autism, pain, compromised immunity, and even death. Although parents joined and left the discussion forums over time, discussions and stories about exemptions were persistent and robust to these membership changes.

Conclusions

Analyzing parent forums about health care using an automated analytic approach, such as the one presented here, allows the detection of widespread narrative frameworks that structure and inform discussions. In most vaccination stories from the sites we analyzed, it is taken for granted that vaccines and not vaccine preventable diseases (VPDs) pose a threat to children. Because vaccines are seen as a threat, parents focus on sharing successful strategies for avoiding them, with exemption being the foremost among these strategies. When new parents join such sites, they may be exposed to this endemic narrative framework in the threads they read and to which they contribute, which may influence their health care decision making.

Vaccination against yellow fever in French Guiana: The impact of educational level, negative beliefs and attitude towards vaccination

OBJECTIVE

Analyze the impact of educational level, negative beliefs and negative attitudes on the yellow fever vaccination coverage (YFVC).

METHODOLOGY

This analytical study involved a sample of 2763 people from 866 households. Educational status was described in six levels: No level (Respondent had never attended school), level-1 (respondent left before intermediate school), level-2 (Respondent attended intermediate school), level-3 (respondent attended high school), level-4 (Respondent attended university), Other level (When the level could not be determined). The Attitude towards vaccination was described in terms of person's availability to recommend vaccination to third. The relationships were analyzed by multivariate mixed logistic regression.

RESULTS

Among the 2763 peoples, 2039 (73.8%) were vaccinated against yellow fever. People who left high school with or without the French baccalaureate were more likely to be vaccinated against YF than people without any diploma (OR = 1.4; p < 0.05). The probability of being vaccinated among people with negative attitudes was reduced by 40% (OR = 0.6; p < 0.05).

CONCLUSION

Low level of education, negative beliefs and negative attitudes have significant impacts on YFVC. Negatives beliefs and attitudes result often from a major lack of information about the benefits of vaccination. This deficit is exacerbated in persons with low educational level.

Changes in childhood immunization decisions in the United States: Results from 2012 & 2014 National Parental Surveys

OBJECTIVE

Understanding the current status of parents' vaccine decision making is crucial to inform public policy. We sought to assess changes in vaccine decisions among parents of young children.

METHODS

We conducted a web-based national poll of parents of children <7years in 2012 and 2014. Participants reported vaccine decisions for their youngest child. We calculated survey-weighted population estimates of overall immunizations decisions, and delay/refusal rates for specific vaccines.

RESULTS

In 2012, 89.2% (95% CI, 87.3-90.8%) reported accepting or planning to accept all recommended non-influenza childhood vaccines, 5.5% (4.5-6.6%) reported intentionally delaying one or more, and 5.4% (4.1-6.9%) reported refusing one or more vaccines. In 2014, the acceptance, delay, and refusal rates were 90.8% (89.3-92.1%), 5.6% (4.6-6.9%), and 3.6% (2.8-4.5%), respectively. Between 2012 and 2014, intentional vaccine refusal decreased slightly among parents of older children (2-6years) but not younger children (0-1years). The proportion of parents working to catch up on all vaccines increased while those refusing some but not all vaccines decreased. The South experienced a significant increase in estimated acceptance (90.1-94.1%) and a significant decrease in intentional ongoing refusal (5.0-2.1%). Vaccine delay increased in the Northeast (3.2-8.8%).

CONCLUSIONS

Nationally, acceptance and ongoing intentional delay of recommended non-influenza childhood vaccines were stable. These findings suggest that more effort is warranted to counter persistent vaccine hesitancy, particularly at the local level. Longitudinal monitoring of immunization attitudes is also warranted to evaluate temporal shifts over time and geographically.

Vaccine Delays, Refusals, and Patient Dismissals: A Survey of Pediatricians

BACKGROUND

Parental noncompliance with the American Academy of Pediatrics and Centers for Disease Control and Prevention immunization schedule is an increasing public health concern. We examined the frequency of requests for vaccine delays and refusals and the impact on US pediatricians' behavior.

METHODS

Using national American Academy of Pediatrics Periodic Surveys from 2006 and 2013, we describe pediatrician perceptions of prevalence of (1) vaccine refusals and delays, (2) parental reasons for refusals and/or delays, and (3) physician dismissals. Questions about vaccine delays were asked only in 2013. We examined the frequency, reasons for, and management of both vaccine refusals and delays by using bivariate and multivariable analyses, which were controlled for practice characteristics, demographics, and survey year.

RESULTS

The proportion of pediatricians reporting parental vaccine refusals increased from 74.5% in 2006 to 87.0% in 2013 (P < .001). Pediatricians perceive that parents are increasingly refusing vaccinations because parents believe they are unnecessary (63.4% in 2006 vs 73.1% in 2013; P = .002). A total of 75.0% of pediatricians reported that parents delay vaccines because of concern about discomfort, and 72.5% indicated that they delay because of concern for immune system burden. In 2006, 6.1% of pediatricians reported "always" dismissing patients for continued vaccine refusal, and by 2013 that percentage increased to 11.7% (P = .004).

CONCLUSIONS

Pediatricians reported increased vaccine refusal between 2006 and 2013. They perceive that vaccine-refusing parents increasingly believe that immunizations are unnecessary. Pediatricians continue to provide vaccine education but are also dismissing patients at higher rates.

Estimating the Number of Measles-Susceptible Children and Adolescents in the United States Using Data From the National Immunization Survey-Teen (NIS-Teen)

Despite high measles vaccination rates in the United States, imported measles cases have led to outbreaks in the United States. These outbreaks have not led to sustained measles transmission; however, with each birth cohort of children not fully vaccinated against measles, measles-susceptible individuals accumulate in the population. The total number of measles-susceptible children and adolescents in the United States is unknown. We used age-specific measles vaccination data from the National Immunization Survey-Teen (2008-2013) to estimate the number of measles-susceptible children aged 17 years or younger, accounting for vaccine effectiveness, infant protection from maternal antibodies, and loss of immunity following childhood cancer treatment. Approximately 12.5% of US children and adolescents are susceptible to measles, with the highest levels of susceptibility being observed in children aged 3 years or younger (24.7% are susceptible to measles). In sensitivity analyses, we found that a sustained decrease in measles vaccination coverage from 91.9% (2013 level) to 90.0% (2009 level) would add nearly 1.2 million susceptible children and adolescents (thus making 14.2% of those aged 17 years or younger susceptible to measles). This reemphasizes the need for high measles vaccination coverage to support population-level immunity and prevent reestablishment of indigenous measles transmission in the United States.

Hurdles to herd immunity: Distrust of government and vaccine refusal in the US, 2002-2003

High rates of nonmedical exemptions (NMEs) from required childhood vaccinations have contributed to outbreaks of vaccine-preventable diseases, such as measles and pertussis. Understanding the parental decision to obtain an NME could help health professionals and public health programs improve vaccination rates in areas with high vaccine refusal. Using a 2002-2003 multi-state survey of parents of school age children (​n=2445), this study found that parental distrust of the government and of healthcare providers is a significant factor related to a number of vaccine-related beliefs and behaviors. The odds that parents who distrust the government have seen a complementary/alternative medicine (CAM) provider were 2.11 times greater than those of parents who trust the government (70.1% vs 52.6%; OR, 2.11; 95% CI, 1.59-2.84; P<0.01). Parents who distrust the government had increased odds of trusting vaccine information from CAM providers compared to trusting parents (57.9% vs 46.3%; OR, 1.53; 95% CI, 1.16-2.01; P<0.01). Parents who distrust the government also had increased odds of distrusting vaccine information acquired at their healthcare providers' offices (12.6% vs 4.7%; OR, 2.64; 95% CI, 1.64-4.24; P<0.01). Distrustful parents had increased odds of thinking government sources of information about vaccines were unreliable, categorizing the CDC, the Food and Drug Administration (FDA), or local and state health departments as poor or very poor sources (distrust government vs trust government: 25.2% vs 11.7%; OR, 2.39; 95% CI, 1.70-3.36; P<0.01; distrust healthcare providers vs trust healthcare providers: 24.4% vs 11.4%; OR, 2.44; 95% CI, 1.75-3.38; P<0.01). These findings indicate that distrustful parent populations may need to be reached through modalities outside of traditional government and healthcare provider communications. Research into new and more effective techniques for delivering pro-vaccine messages is warranted.

Contributions and challenges for worldwide vaccine safety: The Global Advisory Committee on Vaccine Safety at 15 years

In 1999, the Global Advisory Committee on Vaccine Safety (GACVS) was established by the World Health Organization (WHO) to provide independent scientific advice on issues relating to the safety of vaccines and immunization. Fifteen years onward, we conducted a multi-faceted review to evaluate the impact, reach and challenges facing GACVS, including the role GACVS plays in informing global, regional and WHO member state vaccine policy. The methods included measures of organizational structure, citation impact, themes approached, and a discussion by previous and current members to evaluate past, present and future challenges. Given the increasing range of data sources and the deployment of many new vaccines, the Committee is facing the complex task of identifying the best available evidence for recommendations on vaccine safety. To help meet the increased demand for public transparency in decision making, GACVS-structured methodology for evidence-based decisions is evolving. GACVS also promotes best practices and capacity building for timely and accurate risk assessment; risk communications; outreach to help countries maintain and, if needed, rebuild public trust in vaccines; and advocacy for bridging the major gaps in vaccine safety capacity globally.

Association Between Vaccine Refusal and Vaccine-Preventable Diseases in the United States: A Review of Measles and Pertussis

IMPORTANCE

Parents hesitant to vaccinate their children may delay routine immunizations or seek exemptions from state vaccine mandates. Recent outbreaks of vaccine-preventable diseases in the United States have drawn attention to this phenomenon. Improved understanding of the association between vaccine refusal and the epidemiology of these diseases is needed.

OBJECTIVE

To review the published literature to evaluate the association between vaccine delay, refusal, or exemption and the epidemiology of measles and pertussis, 2 vaccine-preventable diseases with recent US outbreaks.

EVIDENCE REVIEW

Search of PubMed through November 30, 2015, for reports of US measles outbreaks that have occurred since measles was declared eliminated in the United States (after January 1, 2000), endemic and epidemic pertussis since the lowest point in US pertussis incidence (after January 1, 1977), and for studies that assessed disease risk in the context of vaccine delay or exemption.

FINDINGS

We identified 18 published measles studies (9 annual summaries and 9 outbreak reports), which described 1416 measles cases (individual age range, 2 weeks-84 years; 178 cases younger than 12 months) and more than half (56.8%) had no history of measles vaccination. Of the 970 measles cases with detailed vaccination data, 574 cases were unvaccinated despite being vaccine eligible and 405 (70.6%) of these had nonmedical exemptions (eg, exemptions for religious or philosophical reasons, as opposed to medical contraindications; 41.8% of total). Among 32 reports of pertussis outbreaks, which included 10,609 individuals for whom vaccination status was reported (age range, 10 days-87 years), the 5 largest statewide epidemics had substantial proportions (range, 24%-45%) of unvaccinated or undervaccinated individuals. However, several pertussis outbreaks also occurred in highly vaccinated populations, indicating waning immunity. Nine reports (describing 12 outbreaks) provided detailed vaccination data on unimmunized cases; among 8 of these outbreaks from 59% through 93% of unvaccinated individuals were intentionally unvaccinated.

CONCLUSIONS AND RELEVANCE

A substantial proportion of the US measles cases in the era after elimination were intentionally unvaccinated. The phenomenon of vaccine refusal was associated with an increased risk for measles among people who refuse vaccines and among fully vaccinated individuals. Although pertussis resurgence has been attributed to waning immunity and other factors, vaccine refusal was still associated with an increased risk for pertussis in some populations.

Vaccine Hesitancy: Causes, Consequences, and a Call to Action

Vaccine hesitancy reflects concerns about the decision to vaccinate oneself or one's children. There is a broad range of factors contributing to vaccine hesitancy, including the compulsory nature of vaccines, their coincidental temporal relationships to adverse health outcomes, unfamiliarity with vaccine-preventable diseases, and lack of trust in corporations and public health agencies. Although vaccination is a norm in the U.S. and the majority of parents vaccinate their children, many do so amid concerns. The proportion of parents claiming non-medical exemptions to school immunization requirements has been increasing over the past decade. Vaccine refusal has been associated with outbreaks of invasive Haemophilus influenzae type b disease, varicella, pneumococcal disease, measles, and pertussis, resulting in the unnecessary suffering of young children and waste of limited public health resources. Vaccine hesitancy is an extremely important issue that needs to be addressed because effective control of vaccine-preventable diseases generally requires indefinite maintenance of extremely high rates of timely vaccination. The multifactorial and complex causes of vaccine hesitancy require a broad range of approaches on the individual, provider, health system, and national levels. These include standardized measurement tools to quantify and locate clustering of vaccine hesitancy and better understand issues of trust; rapid, independent, and transparent review of an enhanced and appropriately funded vaccine safety system; adequate reimbursement for vaccine risk communication in doctors' offices; and individually tailored messages for parents who have vaccine concerns, especially first-time pregnant women. The potential of vaccines to prevent illness and save lives has never been greater. Yet, that potential is directly dependent on parental acceptance of vaccines, which requires confidence in vaccines, healthcare providers who recommend and administer vaccines, and the systems to make sure vaccines are safe.

The Reemergence of Measles

Measles, or rubeola, is a highly infectious, acute viral illness of childhood that is considered eliminated in the USA but has reemerged in the past few years. Globally, an estimated 20 million cases of measles continue to occur, and it remains a leading cause of death among young children. It is rare in the USA and other first world countries, but numerous outbreaks have occurred in the USA recently, due to a combination of factors including poor vaccine coverage and importation of cases among travelers returning from endemic areas. The diagnosis of measles is usually made clinically, when an individual presents with a constellation of symptoms including cough, coryza, conjunctivitis, high fever, and an erythematous maculopapular rash in a cephalocaudal distribution. Complications are common and include otitis media, pneumonia, encephalitis, and rarely death. A measles vaccine is available in two doses and provides excellent protection against the disease. Despite this, vaccination coverage, especially among young adults, remains poor. Given its resurgence in the USA and other countries, interventions are urgently needed to address low vaccination rates and vaccine hesitancy. Measles awareness should also be a priority among young clinicians, who may have never seen a case or are not familiar with the disease.

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.

MMR vaccination status of children exempted from school-entry immunization mandates

BACKGROUND

Child immunizations are one of the most successful public health interventions of the past century. Still, parental vaccine hesitancy is widespread and increasing. One manifestation of this are rising rates of nonmedical or "personal beliefs" exemptions (PBEs) from school-entry immunization mandates. Exemptions have been shown to be associated with increased risk of disease outbreak, but the strength of this association depends critically on the true vaccination status of exempted children, which has not been assessed.

OBJECTIVE

To estimate the true measles-mumps-rubella (MMR) vaccination status of children with PBEs.

METHODS

We use administrative data collected by the California Department of Public Health in 2009 and imputation to estimate the MMR vaccination status of children with PBEs under varying scenarios.

RESULTS

Results from 2009 surveillance data indicate MMR1/MMR2 coverage of 18-47% among children with PBEs at typical schools and 11-34% among children with PBEs at schools with high PBE rates. Imputation scenarios point to much higher coverage (64-92% for MMR1 and 25-58% for MMR2 at typical schools; 49-90% for MMR1 and 16-63% for MMR2 at high PBE schools) but still below levels needed to maintain herd immunity against measles.

CONCLUSIONS

These coverage estimates suggest that prior analyses of the relative risk of measles associated with vaccine refusal underestimate that risk by an order of magnitude of 2-10 times.

Personal Belief Exemptions to Vaccination in California: A Spatial Analysis

BACKGROUND

School vaccination rates in California have fallen as more parents opt for personal belief exemptions (PBEs) for their children. Our goals were to (1) spatially analyze PBE patterns over time, (2) determine correlates of PBEs, and (3) examine their spatial overlap with personal medical exemptions (PMEs).

METHODS

PBE and PME data for California kindergarten classes from the 2001/2002 to 2013/2014 school years were matched to the locations of schools. Nonspatial clustering algorithms were implemented to group 5147 schools according to their trends in PBE percentages among kindergartners. Cluster assignments were mapped and hotspot analysis was performed to find areas in California where schools sharing trends in PBEs over time were colocated. Schools were further associated both with school-level data on minority enrollment and free and reduced price lunch participation and with charter/private and rural/urban status. Spatial regression was implemented to determine which school-level variables were correlated with PBE rates in the 2013/2014 school year.

RESULTS

Distinct spatial patterns are observed in California when PBE cluster assignments are mapped. Results indicate that schools belonging to the "high PBE" cluster are spatially buffered from those in "low PBE" areas by "medium PBE" schools. Further, PBE rates are positively associated with the percentage of white students, charter status, and private schools.

CONCLUSIONS

Hotspots of high PBE schools are in some cases colocated with schools that have elevated PME rates, prompting concern that herd immunity is diminished for school populations where students have no choice but to remain unvaccinated.

Geographic clusters in underimmunization and vaccine refusal

BACKGROUND AND OBJECTIVE

Parental refusal and delay of childhood vaccines has increased in recent years and is believed to cluster in some communities. Such clusters could pose public health risks and barriers to achieving immunization quality benchmarks. Our aims were to (1) describe geographic clusters of underimmunization and vaccine refusal, (2) compare clusters of underimmunization with different vaccines, and (3) evaluate whether vaccine refusal clusters may pose barriers to achieving high immunization rates.

METHODS

We analyzed electronic health records among children born between 2000 and 2011 with membership in Kaiser Permanente Northern California. The study population included 154,424 children in 13 counties with continuous membership from birth to 36 months of age. We used spatial scan statistics to identify clusters of underimmunization (having missed 1 or more vaccines by 36 months of age) and vaccine refusal (based on International Classification of Diseases, Ninth Revision, Clinical Modification codes).

RESULTS

We identified 5 statistically significant clusters of underimmunization among children who turned 36 months old during 2010-2012. The underimmunization rate within clusters ranged from 18% to 23%, and the rate outside them was 11%. Children in the most statistically significant cluster had 1.58 (P < .001) times the rate of underimmunization as others. Underimmunization with measles, mumps, rubella vaccine and varicella vaccines clustered in similar geographic areas. Vaccine refusal also clustered, with rates of 5.5% to 13.5% within clusters, compared with 2.6% outside them.

CONCLUSIONS

Underimmunization and vaccine refusal cluster geographically. Spatial scan statistics may be a useful tool to identify locations with challenges to achieving high immunization rates, which deserve focused intervention.

Vaccinating my way--use of alternative vaccination schedules in New York State

OBJECTIVE

To identify children vaccinated following an alternative vaccine schedule using immunization information system data and determine the impact of alternative schedule use on vaccine coverage.

STUDY DESIGN

Children born in New York State, outside New York City, between January 1, 2009 and August 14, 2011 were assessed for vaccination patterns consistent with use of an alternative schedule. Children who by 9 months of age had at least 3 vaccination visits recorded in the statewide mandatory immunization information system after 41 days of age were classified as either attempting to conform to the Centers for Disease Control and Prevention published recommended vaccination schedule or an alternative schedule. The number of vaccination visits and up-to-date status at age 9 months were compared between groups.

RESULTS

Of the 222 628 children studied, the proportion of children following an alternative schedule was 25%. These children were significantly less likely to be up-to-date at age 9 months (15%) compared with those conforming to the routine schedule (90%, P < .05). Children following an alternative schedule on average had about 2 extra vaccine visits compared with children following a routine schedule (P < .05).

CONCLUSIONS

Almost 1 in 4 children in this study appear to be intentionally deviating from the routine schedule. Intentional deviation leads to poor vaccination coverage leaving children vulnerable to infection and increasing the potential for vaccine-preventable disease outbreaks.

Saving Human Lives: What Complexity Science and Information Systems can Contribute

We discuss models and data of crowd disasters, crime, terrorism, war and disease spreading to show that conventional recipes, such as deterrence strategies, are often not effective and sufficient to contain them. Many common approaches do not provide a good picture of the actual system behavior, because they neglect feedback loops, instabilities and cascade effects. The complex and often counter-intuitive behavior of social systems and their macro-level collective dynamics can be better understood by means of complexity science. We highlight that a suitable system design and management can help to stop undesirable cascade effects and to enable favorable kinds of self-organization in the system. In such a way, complexity science can help to save human lives.

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.

Exempting schoolchildren from immunizations: states with few barriers had highest rates of nonmedical exemptions

Rates of nonmedical exemptions from school immunizations are increasing and have been associated with resurfacing clusters of vaccine-preventable diseases, such as measles. Historically, state-level school immunization policies successfully suppressed such diseases. We examined state immunization exemption regulations across the United States. We assessed procedures for exempting schoolchildren and whether exemption rates were associated with the complexity of the procedures. We also analyzed legal definitions of religious objections and state legislatures' recent modifications to exemption policies. We found that states with simpler immunization exemption procedures had nonmedical exemption rates that were more than twice as high as those in states with more-complex procedures. We also found that the stringency of legal definitions of religious exemptions was not associated with exemption procedure complexity. Finally, we found that although there were more attempts by state legislatures to broaden exemptions than to tighten them in 2011-13, only bills tightening exemptions passed. Policy makers seeking to control exemption rates to achieve public health goals should consider tightening nonmedical exemption procedures and should add vaccine education components to the procedures by either mandating or encouraging yearly educational sessions in schools for parents reluctant to have their children vaccinated.

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.

Knowledge and risk perception of measles and factors associated with vaccination decisions in subjects consulting university affiliated public hospitals in Lyon, France, after measles infection

In 2011, a large number of European countries faced measles outbreaks, France accounting for more than half of the reported cases. The Rhône-Alpes region, located in south-east France, was one of the most affected provinces, with an incidence rate of 97.9 cases per 100 000 inhabitants. We conducted a retrospective survey of adults and parents of children consulting university affiliated public hospitals because of measles infections between January 1, 2010 and September 2012 in Lyon, France. Our main objectives were to evaluate (1) the level of study population knowledge of measles, (2) vaccination practices, and (3) changes in opinion with regard to measles vaccination after disease onset. Overall, 73.64% of patients were not vaccinated or partially vaccinated. The main reason for non-vaccination in children was inappropriate age while among non-vaccinated adults, 29.3% could not give any reason. In total, 29.1% of the responding parents and 24.2% of adult cases were opposed to vaccination "in principle." A large number of patients did not recognize measles as a serious illness and were unaware of its complications. Among parents of infected children, knowledge of transmission mode (odds ratio [OR] = 5.9; 95% confidence interval [95% CI]: 1.64-21.26), perceived severity of measles (OR = 1.5; 95% CI: 1.06-2.13), and absence of hepatitis B vaccination (OR = 0.17; 95% CI: 0.04-0.65) were independently associated with a more positive opinion about measles vaccination after disease onset. In adult patients, low education level (OR = 3.39; 95% CI: 1.03-11.11) and lack of knowledge of sequelae (OR = 10.19; 95% CI: 1.14-91.31) were linked with a more positive opinion. Individuals affected by vaccine-preventable diseases are interesting populations to study disease impact on vaccine perception.

Freedom of conscience and health care in the United States of america: the conflict between public health and religious liberty in the patient protection and affordable care act

The recent confirmation of the constitutionality of the Obama administration's Patient Protection and Affordable Care Act (PPACA) by the US Supreme Court has brought to the fore long-standing debates over individual liberty and religious freedom. Advocates of personal liberty are often critical, particularly in the USA, of public health measures which they deem to be overly restrictive of personal choice. In addition to the alleged restrictions of individual freedom of choice when it comes to the question of whether or not to purchase health insurance, opponents to the PPACA also argue that certain requirements of the Act violate the right to freedom of conscience by mandating support for services deemed immoral by religious groups. These issues continue the long running debate surrounding the demands of religious groups for special consideration in the realm of health care provision. In this paper I examine the requirements of the PPACA, and the impacts that religious, and other ideological, exemptions can have on public health, and argue that the exemptions provided for by the PPACA do not in fact impose unreasonable restrictions on religious freedom, but rather concede too much and in so doing endanger public health and some important individual liberties.

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.

A longitudinal analysis of the effect of nonmedical exemption law and vaccine uptake on vaccine-targeted disease rates

OBJECTIVES

We assessed how nonmedical exemption (NME) laws and annual uptake of vaccines required for school or daycare entry affect annual incidence rates for 5 vaccine-targeted diseases: pertussis, measles, mumps, Haemophilus influenzae type B, and hepatitis B.

METHODS

We employed longitudinal mixed-effects models to examine 2001-2008 vaccine-targeted disease data obtained from the National Notifiable Disease Surveillance System. Key explanatory variables were state-level vaccine-specific uptake rates from the National Immunization Survey and a state NME law restrictiveness level.

RESULTS

NME law restrictiveness and vaccine uptake were not associated with disease incidence rate for hepatitis B, Haemophilus influenzae type B, measles, or mumps. Pertussis incidence rate, however, was negatively associated with NME law restrictiveness (b = -0.20; P = .03) and diphtheria-pertussis-tetanus vaccine uptake (b = -0.01; P = .05).

CONCLUSIONS

State NME laws and vaccine uptake rates did not appear to influence lower-incidence diseases but may influence reported disease rates for higher-incidence diseases. If all states increased their NME law restrictiveness by 1 level and diphtheria-pertussis-tetanus uptake by 1%, national annual pertussis cases could decrease by 1.14% (171 cases) and 0.04% (5 cases), respectively.

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.

Epidemiology of vaccine hesitancy in the United States

Vaccines are among the most effective public health interventions against infectious diseases. However, there is evidence in the United States for parents either delaying or refusing recommended childhood vaccination. Exemptions to school immunization laws and use of alternative schedule from those recommended by the Advisory Committee on Immunization Practices and the American Academy of Pediatrics cannot only increase the risk of children contracting vaccine-preventable diseases but also increases the risk of infecting others who are either too young to be vaccinated, cannot be vaccinated for medical reasons or did not develop a sufficient immunological response to the vaccine. Healthcare providers are cited as the most influential source by parents on vaccine decision-making. Vaccine hesitancy needs to be addressed by healthcare providers and the scientific community by listening to the parental concerns and discussing risks associated with either delaying or refusing vaccines.

HPV vaccine decision-making and acceptance: does religion play a role?

We conducted a web-based survey among 476 white, Black, and Hispanic parents or caregivers with daughter(s) between the ages of 9-17 to better understand how religion influences HPV vaccine acceptance. Catholic parents were more likely than nonaffiliated parents to have already vaccinated their daughters (vs. being undecided) (OR = 3.26, 95% CI = 1.06, 10.06). Parents with frequent attendance at religious services were more likely than parents who do not attend services to have decided against vaccination (vs. being undecided) (OR = 2.92, 95% CI = 1.25, 6.84). Directions for research and implications for interventions are addressed.

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.

How parents make decisions about their children's vaccinations

BACKGROUND

Continued parental acceptance of childhood vaccination is essential for the maintenance of herd immunity and disease prevention. As such, understanding parents' decision-making in relation to their children's vaccinations is vitally important.

OBJECTIVE

This qualitative study sought to develop an understanding of the general process parents go through when making decisions about their children's vaccinations.

METHODS

Interviews were conducted with U.S.-born parents living in King County, Washington who had children ≤18 months of age. These interviews were recorded and transcribed verbatim.

RESULTS

Through the application of grounded theory, a general decision-making process was identified. Stages in this process included: awareness, assessing and choosing, followed by either stasis or ongoing assessment. The greatest variation occurred during the assessing stage, which involved parents examining vaccination-related issues to make subsequent decisions. This research suggests that three general assessment groups exist: acceptors, who rely primarily on general social norms to make their vaccination decisions; reliers, who rely primarily on other people for information and advice; and searchers, who seek for information on their own, primarily from published sources.

CONCLUSIONS

These results imply that one-size-fits-all approaches to vaccination interventions are inappropriate. Instead, this research suggests that interventions must be targeted to parents based on how they assess vaccination.

Association of vaccine-related attitudes and beliefs between parents and health care providers

OBJECTIVES

Health care providers influence parental vaccination decisions. Over 90% of parents report receiving vaccine information from their child's health care provider. The majority of parents of vaccinated children and children exempt from school immunization requirements report their child's primary provider is a good source for vaccine information. The role of health care providers in influencing parents who refuse vaccines has not been fully explored. The objective of the study was to determine the association between vaccine-related attitudes and beliefs of health care providers and parents.

METHODS

We surveyed parents and primary care providers of vaccinated and unvaccinated school age children in four states in 2002-2003 and 2005. We measured key immunization beliefs including perceived risks and benefits of vaccination. Odds ratios for associations between parental and provider responses were calculated using logistic regression.

RESULTS

Surveys were completed by 1367 parents (56.1% response rate) and 551 providers (84.3% response rate). Parents with high confidence in vaccine safety were more likely to have providers with similar beliefs, however viewpoints regarding disease susceptibility and severity and vaccine efficacy were not associated. Parents whose providers believed that children get more immunizations than are good for them had 4.6 higher odds of holding that same belief compared to parents whose providers did not have that belief.

CONCLUSIONS

The beliefs of children's health care providers and parents, including those regarding vaccine safety, are similar. Provider beliefs may contribute to parental decisions to accept, delay or forgo vaccinations. Parents may selectively choose providers who have similar beliefs to their own.

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.

Religious exemptions for immunization and risk of pertussis in New York State, 2000-2011

OBJECTIVE

The objective of this study was to describe rates of religious vaccination exemptions over time and the association with pertussis in New York State (NYS).

METHODS

Religious vaccination exemptions reported via school surveys of the NYS Department of Health from 2000 through 2011 were reviewed by county, and the changes were assessed against incidence rates of pertussis among children reported to the NYS Department of Health Communicable Disease Electronic Surveillance System.

RESULTS

The overall annual state mean prevalence (± SD) of religious exemptions for ≥1 vaccines in 2000-2011 was 0.4% ± 0.08% and increased significantly from 0.23% in 2000 to 0.45% in 2011 (P = .001). The prevalence of religious exemptions varied greatly among counties and increased by >100% in 34 counties during the study period. Counties with mean exemption prevalence rates of ≥1% reported a higher incidence of pertussis, 33 per 100 000 than counties with lower exemption rates, 20 per 100 000, P < .001. In addition, the risk of pertussis among vaccinated children living in counties with high exemption rate increased with increase of exemption rate among exempted children (P = .008).

CONCLUSIONS

The prevalence of religious exemptions varies among NYS counties and increased during the past decade. Counties with higher exemption rates had higher rates of reported pertussis among exempted and vaccinated children when compared with the low-exemption counties. More studies are needed to characterize differences in the process of obtaining exemptions among NYS schools, and education is needed regarding the risks to the community of individuals opting out from recommended vaccinations.

Communication and mass vaccination strategies after pertussis outbreak in rural Amish communities-Illinois, 2009-2010

PURPOSE

During January 2010, 2 infants from an Amish community in east-central Illinois were hospitalized with pertussis. The local health department (LDH) intervened to control disease transmission, identify contributing factors, and determine best communications methods to improve vaccination coverage.

METHODS

A retrospective cohort study was conducted using public health surveillance data to determine the extent of the outbreak; the standard Centers for Disease Control and Prevention and Council of State and Territorial Epidemiologists case definition for pertussis was used. The standardized Illinois Department of Public Health pertussis patient interview form was used to collect demographic, symptom, vaccination history, and treatment history information. To control disease transmission, LDH staff worked with the Amish community to promote a vaccination campaign during February 6-April 30, 2010.

FINDINGS

Forty-seven cases were identified, with onsets during December 2009-March 2010. Median age was 7 (interquartile range 1-12) years. Nineteen (40%) patients were male; 39 (83%) were aged <18 years; 37 (79%) had not received any pertussis-containing vaccine. Presenting symptoms did not differ substantially between vaccinated and unvaccinated patients. Duration of cough was longer among unvaccinated than vaccinated patients (32 vs. 15.5 days, P = .002). Compared with vaccinated patients, proportionately more unvaccinated patients reported secondary household transmission (30% vs. 72%; P = .012). Through enhanced vaccination campaigns, 251 (∼10%) Amish community members were administered 254 pertussis-containing vaccines.

CONCLUSIONS

Targeted health communication and outreach resulted in a successful vaccine campaign and long-running monthly vaccination clinic. Amish do not universally reject vaccines, and their practices regarding vaccination are not static.

What the world's religions teach, applied to vaccines and immune globulins

For millennia, humans have sought and found purpose, solace, values, understanding, and fellowship in religious practices. Buddhist nuns performed variolation against smallpox over 1000 years ago. Since Jenner developed vaccination against smallpox in 1796, some people have objected to and declined vaccination, citing various religious reasons. This paper reviews the scriptural, canonical basis for such interpretations, as well as passages that support immunization. Populous faith traditions are considered, including Hinduism, Buddhism, Jainism, Judaism, Christianity, and Islam. Subjects of concern such as blood components, pharmaceutical excipients of porcine or bovine origin, rubella strain RA 27/3, and cell-culture media with remote fetal origins are evaluated against the religious concerns identified. The review identified more than 60 reports or evaluations of vaccine-preventable infectious-disease outbreaks that occurred within religious communities or that spread from them to broader communities. In multiple cases, ostensibly religious reasons to decline immunization actually reflected concerns about vaccine safety or personal beliefs among a social network of people organized around a faith community, rather than theologically based objections per se. Themes favoring vaccine acceptance included transformation of vaccine excipients from their starting material, extensive dilution of components of concern, the medicinal purpose of immunization (in contrast to diet), and lack of alternatives. Other important features included imperatives to preserve health and duty to community (e.g., parent to child, among neighbors). Concern that 'the body is a temple not to be defiled' is contrasted with other teaching and quality-control requirements in manufacturing vaccines and immune globulins. Health professionals who counsel hesitant patients or parents can ask about the basis for concern and how the individual applies religious understanding to decision-making about medical products, explain facts about content and processes, and suggest further dialog with informed religious leaders. Key considerations for observant believers for each populous religion are described.

The financial impact of a state adopting a personal/philosophical belief exemption policy: modeling the cost of pertussis disease in infants, children and adolescents

State school immunization exemption policies help reduce the risk of individual and community disease. Assessing the costs of vaccine preventable disease associated with a state adding a philosophical/personal belief school exemption policy is useful for making future policy decisions. Two formulas were developed to estimate the infant, child and adolescent hospitalization and non-medical costs of pertussis disease that are associated with adding a philosophical/personal belief school exemption policy. The parameter estimates were obtained from peer reviewed literature and the Centers for Disease Control and Prevention. The state of Iowa was used as an example in order to demonstrate how the formulas can be applied. The annual projected impact of pertussis disease in Iowa is $273,365 without a philosophical/personal belief exemption policy and an average of $410,047 (range of $281,566-$582,267) with adding a personal belief exemption policy. We project that adding a philosophical/personal belief exemption will cost 50% more dollars annually.

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.

The prevalence and genotype of human papillomavirus on cervical samples from an Irish female population with external genital warts

The aim of this study was to determine the cervical genotype profile of females who presented to an STI Clinic with external genital warts (EGW); and to determine the potential vaccine coverage prior to the uptake of the HPV vaccines. Sixty-one cervical scrapings were taken from females aged 18-35 y who had external genital warts or a history of external genital warts. The resulting 50 samples that were positive for HPV-DNA were subjected to genotype identification. Forty-six of these samples had detectable genotypes by LIPA analysis and most (78%, 36/46) had multiple low risk (LR) and high risk (HR) genotypes on the cervix. Twenty-five of these samples (54%) had more than 1 HR genotype. Of the 36 patients who had any HR genotypes, 18 (50%) were identified to have the most oncogenic HPV genotypes, namely 16 and 18. Three of these samples had both 16 and 18 on the cervix. The presence of multiple HR genotypes on the majority of cervical samples from a self-referred population of females with EGW is presented. This study is of importance since persistent HR-HPV is the necessary risk factor in the development of precancerous and cancerous lesions of the cervix. Gardisil, the quadrivalent HPV vaccine would have been useful in the prevention of 28% (13/46) of these infections.