1
|
Greyson D, Goh G. Education components of school vaccine mandates: An environmental scan. Vaccine 2023; 41:7089-7095. [PMID: 37923695 DOI: 10.1016/j.vaccine.2023.09.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 09/26/2023] [Accepted: 09/27/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND School vaccine mandates (SVMs) are population health interventions that require monitoring and communicating about vaccination of school-aged children, with an aim of controlling infectious disease outbreaks. While 43 % of World Health Organization member states report having some sort of SVM, their details vary. A newer element of some SVMs is an "education component" requiring compulsory information, education, or counseling of parents/guardians who decline to vaccinate their children for non-medical reasons. METHODS This environmental scan sought, mapped, and synthesized evidence on the existence, format, and impacts of education components of SVMs in 18 affluent Organization for Economic Co-operation and Development comparator countries. FINDINGS We found current SVMs in nine of the 18 comparator countries, but education components to those SVMs only in Canada (n = 2) and the U.S. (n = 9), where such policies were made at the provincial/state level. The earliest was implemented in 2011 and most recent has not yet been implemented. Education components were used as requirements for obtaining non-medical exemptions from SVMs, and involved either an informational paper to be read and signed, a counseling or information session from a health professional (public health worker or licensed provider such as family doctor), or an online module to be completed. Peer-reviewed research on in-person sessions suggests association with at least short-term increased vaccine uptake and reduction of non-medical exemptions. Available data on online module education components suggests similar impacts, but research to date is limited. CONCLUSION SVMs with educational components are uncommon but have been increasing since 2011. The details of these education components vary, although topics covered in online modules are relatively consistent. Evidence to date suggests at least short-term reduction in non-medical exemptions associated with implementation of SVM education components, but additional research is required to follow-up and confirm, especially as regards online education modules.
Collapse
Affiliation(s)
- Devon Greyson
- School of Population and Public Health, University of British Columbia, Vancouver, Canada; Vaccine Evaluation Center, British Columbia Children's Hospital Research Institute, Vancouver, Canada.
| | - Gerry Goh
- School of Population and Public Health, University of British Columbia, Vancouver, Canada; School of Information, University of British Columbia, Vancouver, Canada
| |
Collapse
|
2
|
School staff as vaccine advocates: Perspectives on vaccine mandates and the student registration process. Vaccine 2023; 41:1169-1175. [PMID: 36631362 DOI: 10.1016/j.vaccine.2022.12.070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 12/08/2022] [Accepted: 12/26/2022] [Indexed: 01/11/2023]
Abstract
Recently, several states in the US have made it more difficult to receive nonmedical exemptions to school vaccine mandates in the hope of better orienting parents towards vaccination. However, little is known about how public-facing school staff implement and enforce mandate policies, including why or how often they steer parents towards nonmedical exemptions. This study focused on Michigan, which has recently added an additional burden for families seeking nonmedical exemptions. We used an anonymous online survey to assess Michigan public-school employees (n = 157) about their knowledge, attitudes, and behaviors regarding Michigan's school enrollment vaccine mandate policy. Our main conclusions are that frontline school staff are generally knowledgeable about vaccines and immunization policy, but are at best ambivalent about their role in immunization governance, believing that other agents should be responsible for ensuring that children are vaccinated. Furthermore, some respondents indicated low vaccine confidence, which was associated with increased ambivalence about, or opposition to, their role in immunization governance. As more jurisdictions within and beyond the US consider introducing or tightening childhood vaccine mandates, it is increasingly important to understand how these policies can be improved by attending to the attitudes and roles of relevant frontline actors.
Collapse
|
3
|
Navin MC, Kozak AT, Attwell K. School staff and immunization governance: Missed opportunities for public health promotion. Vaccine 2022; 40:7433-7439. [PMID: 34579977 DOI: 10.1016/j.vaccine.2021.07.061] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 06/21/2021] [Accepted: 07/20/2021] [Indexed: 01/28/2023]
Abstract
BACKGROUND In US states, childhood immunization mandates are enforced for school registration by front-line school staff, usually secretaries. Despite substantial changes to mandate policies in several states and many countries, little attention has been paid to the people who enforce them. This qualitative pilot study aimed to uncover beliefs, attitudes, and practices regarding immunization governance of Michigan school staff. METHOD Front-line administrative workers from Michigan schools and district offices were solicited by email. Sixteen were interviewed remotely. RESULTS Front-line school staff believed in vaccines, but did not advocate for vaccination while registering children. Instead, they sought low-friction bureaucratic transactions, privileging the collection of data over the promotion of public health goals. This revealed a mismatch between the goals of the front-line staff who enforce vaccine mandates in schools and the goals of the policymakers who created school vaccine mandates. CONCLUSIONS This study found low mobilization of front-line enforcers of mandates in public-facing school administration roles, a problem likely to afflict the majority of American states with the 'mandates + exemptions' model of immunization governance. Schools would have stronger incentives to promote vaccination if state funding were better tied to immunization compliance. Front-line staff could better enforce vaccine mandates if they were provided with resources and training about vaccine promotion.
Collapse
Affiliation(s)
- Mark C Navin
- Department of Philosophy, Oakland University, Mathematics and Science Center, Room 746, 146 Library Drive, Rochester, MI 48309-4479, USA.
| | - Andrea T Kozak
- Department of Psychology, Oakland University, Pryale Hall, Room 210, 654 Pioneer Drive, Rochester, MI 48309-4482, USA.
| | - Katie Attwell
- Political Science and International Relations, University of Western Australia, 35 Stirling Highway, Crawley 6009, Australia.
| |
Collapse
|
4
|
Consolidating a research agenda for vaccine mandates. Vaccine 2022; 40:7353-7359. [PMID: 36396514 PMCID: PMC9662755 DOI: 10.1016/j.vaccine.2022.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 11/04/2022] [Indexed: 11/16/2022]
Abstract
A workshop on mandatory vaccination was pitched to the World Public Health Congress in 2019 and the resultant special issue was pitched to Vaccine in 2020. During this project, the COVID-19 pandemic pushed vaccine policy to the forefront of global public health policy, and the imposition of vaccine mandates prompted a new wave of scholarship in the field. This introductory article employs the heuristic of Lasswell's (1956) policy cycle to synthesise the findings of the articles in the special issue. It considers the temporal lifetime of mandates and highlights findings regarding: the emergence of mandates as a policy option, public support and policy instrument design, what matters in the implementation of mandates, and what we can learn from evaluating them. The second half of the paper categorizes the included papers in terms of what aspects of mandates they study and the methods they employ to do so, in order to formulate a guide for future researchers of vaccine mandates. Scholars study either speculative or existing mandates - research can address several stages of the policy cycle or just one of them, ranging from attitudinal research to implementation studies and impact studies. Historical and contextual studies that take deep dives into a particular mandate are a much needed resource for studying emerging mandates, too, and scoping and framework- building work will undoubtedly be valuable in understanding and appreciating the wealth of knowledge production in this growing field. This special issue can serve as a roadmap for a consolidation of this interdisciplinary research agenda, and provide a helpful resource for decisionmakers at this historical juncture.
Collapse
|
5
|
Teasdale CA, Ratzan S, Stuart Lathan H, Rauh L, Kimball S, El-Mohandes A. Acceptability of COVID-19 vaccine mandates among New York City parents, November 2021. Vaccine 2022; 40:3540-3545. [PMID: 35581098 PMCID: PMC9091158 DOI: 10.1016/j.vaccine.2022.05.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 04/06/2022] [Accepted: 05/04/2022] [Indexed: 01/17/2023]
Abstract
School-based vaccine mandates improve vaccination coverage in children. We conducted a cross-sectional survey of parents in New York City (NYC) in November 2021 to measure acceptability of COVID-19 vaccine mandates for students, and for teachers and school staff. Random address-based sampling was used to recruit parents of children 5-11 years of age. Among 2,506 parents surveyed, 44.3% supported school-based vaccine mandates for students and 69.1% supported mandates for teachers and school staff. Asian parents, male parents, those with higher income, college education, those voting for the 2021 Democratic mayoral candidate and parents from Manhattan were most likely to support vaccine mandates for students. Among all parents, 25.1% said they would not vaccinate their child if required. Our data show only modest support for school-based COVID-19 vaccine mandates for children despite their importance in improving vaccination coverage.
Collapse
Affiliation(s)
- Chloe A. Teasdale
- Department of Epidemiology and Biostatistics, City University of New York (CUNY) Graduate School of Public Health and Health Policy (SPH), New York, NY, United States,Corresponding author at: Department of Epidemiology & Biostatistics, CUNY Graduate School of Public Health & Health Policy, 55 W125th Street, Room 543, New York, NY 10025
| | - Scott Ratzan
- Department of Community Health and Social Sciences, CUNY SPH, New York, NY, United States
| | | | | | | | | |
Collapse
|
6
|
Gromis A, Liu KY. Spatial Clustering of Vaccine Exemptions on the Risk of a Measles Outbreak. Pediatrics 2022; 149:183781. [PMID: 34866158 PMCID: PMC9037455 DOI: 10.1542/peds.2021-050971] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/08/2021] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVES Areas of increased school-entry vaccination exemptions play a key role in epidemics of vaccine-preventable diseases in the United States. California eliminated nonmedical exemptions in 2016, which increased overall vaccine coverage but also rates of medical exemptions. We examine how spatial clustering of exemptions contributed to measles outbreak potential pre- and postpolicy change. METHODS We modeled measles transmission in an empirically calibrated hypothetical population of youth aged 0 to 17 years in California and compared outbreak sizes under the observed spatial clustering of exemptions in schools pre- and postpolicy change with counterfactual scenarios of no postpolicy change increase in medical exemptions, no clustering of exemptions, and lower population immunization levels. RESULTS The elimination of nonmedical exemptions significantly reduced both average and maximal outbreak sizes, although increases in medical exemptions resulted in more than twice as many infections, on average, than if medical exemptions were maintained at prepolicy change levels. Spatial clustering of nonmedical exemptions provided some initial protection against random introduction of measles infections; however, it ultimately allowed outbreaks with thousands more infections than when exemptions were randomly distributed. The large-scale outbreaks produced by exemption clusters could not be reproduced when exemptions were distributed randomly until population vaccination was lowered by >6 percentage points. CONCLUSIONS Despite the high overall vaccinate rate, the spatial clustering of exemptions in schools was sufficient to threaten local herd immunity and reduce protection from measles outbreaks. Policies strengthening vaccine requirements may be less effective if alternative forms of exemptions (eg, medical) are concentrated in existing low-immunization areas.
Collapse
Affiliation(s)
- Ashley Gromis
- Departments of Health Policy and Management,Address correspondence to Ashley Gromis, PhD, Department of Health Policy and Management, University of California, Los Angeles Fielding School of Public Health, 650 Charles Young Dr S, 31-269 CHS Box 951772, Los Angeles, CA 90095. E-mail:
| | - Ka-Yuet Liu
- Sociology,California Center for Population Research, University of California, Los Angeles, California,Center for Brain Science, Riken Institute, Wako, Japan
| |
Collapse
|
7
|
Paquette ET. In the Wake of a Pandemic: Revisiting School Approaches to Nonmedical Exemptions to Mandatory Vaccination in the US. J Pediatr 2021; 231:17-23. [PMID: 33484695 PMCID: PMC7816863 DOI: 10.1016/j.jpeds.2021.01.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 12/23/2020] [Accepted: 01/11/2021] [Indexed: 12/02/2022]
Abstract
Mandatory school vaccination policies with exclusion of unvaccinated students can be a powerful tool in ensuring high vaccination rates. Some parents may object to mandatory vaccination policies, claiming exemptions based on medical, religious, or philosophical reasons. Individual schools, school systems, or local or regional governments have different policies with respect to whether, and what kind of, exemptions may be allowed. In the setting of the current pandemic, questions regarding the acceptability of exemptions have resurfaced, as schools and local governments struggle with how to safely return children to school. Anticipating that school attendance will be facilitated by the development of a vaccine, school systems will face decisions about whether to mandate vaccination and whether to permit exemptions. The American Academy of Pediatrics promulgates policy favoring the elimination of nonmedical exemptions generally in schools. This discussion considers whether schools should eliminate nonmedical exemptions to vaccination as proposed in the American Academy of Pediatrics policy, ultimately concluding that broad elimination of exemptions is not justified and advocating a more nuanced approach that encourages school attendance while promoting vaccination and broader public health goals.
Collapse
Affiliation(s)
- Erin Talati Paquette
- Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Stanley Manne Children's Research Institute; and the Northwestern Pritzker School of Law,∗ Chicago, IL.
| |
Collapse
|
8
|
Hoke AM, Stuckey HL, Keller CM, Lu Z, Hivner EA, Calo WA, Strick JM, Kraschnewski JL. In Their Own Words: Resources Needed by School Nurses to Facilitate Student Immunization Compliance. THE JOURNAL OF SCHOOL HEALTH 2021; 91:218-226. [PMID: 33433022 PMCID: PMC8013341 DOI: 10.1111/josh.12993] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 10/15/2020] [Accepted: 10/24/2020] [Indexed: 06/12/2023]
Abstract
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.
Collapse
Affiliation(s)
- Alicia M. Hoke
- Penn State College of Medicine, 90 Hope DriveHersheyPA17061
| | | | | | - Zhexi Lu
- Penn State College of Medicine, 90 Hope DriveHersheyPA17061
| | | | | | - Janine M. Strick
- Pennsylvania Department of Health, Division of Immunizations, 625 Forster StreetHarrisburgPA17120‐0701
| | | |
Collapse
|
9
|
Vaccine-Preventable Disease Outbreaks. Vaccines (Basel) 2021. [DOI: 10.1007/978-3-030-58414-6_36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
|
10
|
Williams JTB, Hambidge SJ. Effectiveness and Equity of Australian Vaccine Mandates. Pediatrics 2020; 146:peds.2020-024703. [PMID: 33199468 DOI: 10.1542/peds.2020-024703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/12/2020] [Indexed: 11/24/2022] Open
Affiliation(s)
- Joshua T B Williams
- Department of Ambulatory Care Services, Denver Health and Hospital Authority, Denver, Colorado; and .,Department of Pediatrics, School of Medicine, University of Colorado Denver, Aurora, Colorado
| | - Simon J Hambidge
- Department of Ambulatory Care Services, Denver Health and Hospital Authority, Denver, Colorado; and.,Department of Pediatrics, School of Medicine, University of Colorado Denver, Aurora, Colorado
| |
Collapse
|
11
|
The role of epidemiology in informing United States childhood immunization policy and practice. Ann Epidemiol 2020; 62:100-114. [PMID: 33065268 PMCID: PMC7553935 DOI: 10.1016/j.annepidem.2020.09.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 08/17/2020] [Accepted: 09/29/2020] [Indexed: 11/22/2022]
Abstract
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.
Collapse
|
12
|
Buckman C, Liu IC, Cortright L, Tumin D, Syed S. The influence of local political trends on childhood vaccine completion in North Carolina. Soc Sci Med 2020; 260:113187. [DOI: 10.1016/j.socscimed.2020.113187] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 06/11/2020] [Accepted: 06/30/2020] [Indexed: 01/13/2023]
|
13
|
Gromis A, Liu KY. The Emergence of Spatial Clustering in Medical Vaccine Exemptions Following California Senate Bill 277, 2015-2018. Am J Public Health 2020; 110:1084-1091. [PMID: 32437268 DOI: 10.2105/ajph.2020.305607] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Objectives. To understand how the elimination of nonmedical vaccine exemptions through California Senate Bill 277 (SB277) may have resulted in increased spatial clustering of medical exemptions.Methods. We used spatial scan statistics and negative binomial regression models to examine spatial clustering in medical vaccine exemptions in California kindergartens from 2015 to 2018.Results. Spatial clustering of medical exemptions across schools emerged following SB277. Clusters were located in similar geographic areas to previous clusters of nonmedical vaccine exemptions, suggesting a spatial association between high nonmedical exemption prevalence and increasing rates of medical exemptions. Regression results confirmed this positive association at the local level. The sociodemographic characteristics of the neighborhoods in which schools were located explained some, but not all, of the positive spatial associations between exemptions before and after SB277.Conclusions. Elimination of nonmedical vaccine exemptions via SB277 may have prompted some parents to instead seek medical exemptions to required school vaccines. The spatial association of these 2 types of exemptions has implications for maintaining pockets of low vaccine compliance and increased disease transmission.
Collapse
Affiliation(s)
- Ashley Gromis
- Ashley Gromis is with the Department of Sociology, Princeton University, Princeton, NJ. Ka-Yuet Liu is with the Department of Sociology and the California Center for Population Research, University of California, Los Angeles
| | - Ka-Yuet Liu
- Ashley Gromis is with the Department of Sociology, Princeton University, Princeton, NJ. Ka-Yuet Liu is with the Department of Sociology and the California Center for Population Research, University of California, Los Angeles
| |
Collapse
|
14
|
Gandhi CK, Patel J, Zhan X. Trend of influenza vaccine Facebook posts in last 4 years: a content analysis. Am J Infect Control 2020; 48:361-367. [PMID: 32098695 DOI: 10.1016/j.ajic.2020.01.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Revised: 01/05/2020] [Accepted: 01/09/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Decreasing immunization rates may be partly due to antivaccine campaigns and other sources of misinformation available on social media, particularly on Facebook. Given the potential impact of this medium for communicating vaccine-related information, it is important to analyze the trend of information available on Facebook. METHODS We searched Facebook on August 15, 2018 to obtain posts containing relevant health information on influenza vaccine in years 2015-2018. We collected information regarding nature of the post (eg, pro-, antivaccine, and informational), number of shares and likes received, and ease of reading for each post. We evaluated these characteristics by year and type of post in our exploratory analyses. RESULTS The proportion of pro-vaccine posts has increased compared to antivaccine and informational posts since 2016. There was no correlation between ease of reading and popularity of posts. Although the language of antivaccine posts was complex, they were shared and liked more than pro-vaccine posts. The pro-vaccine personal post by a nurse was the most popular in our study (shared over 46,000 times) in 2018. CONCLUSIONS Though the number of pro-vaccine posts increased, antivaccine posts remained more popular. The government agency may use an emotive personal family-oriented message to promote vaccination.
Collapse
|
15
|
Garnier R, Nedell ER, Omer SB, Bansal S. Getting Personal: How Childhood Vaccination Policies Shape the Landscape of Vaccine Exemptions. Open Forum Infect Dis 2020; 7:ofaa088. [PMID: 32258205 PMCID: PMC7111605 DOI: 10.1093/ofid/ofaa088] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 03/12/2020] [Indexed: 02/02/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Romain Garnier
- Department of Biology, Georgetown University, Washington, District of Columbia, USA
| | - Emma R Nedell
- Department of Biology, Georgetown University, Washington, District of Columbia, USA
| | - Saad B Omer
- Yale Institute for Global Health, Yale University, New Haven, Conneticut, USA.,Department of Internal Medicine (Infectious Diseases), Yale School of Medicine, Yale University, New Haven, Connecticut, USA.,Department of Epidemiology of Microbial Diseases, Yale School of Public Health, Yale University, New Haven, Connecticut, USA
| | - Shweta Bansal
- Department of Biology, Georgetown University, Washington, District of Columbia, USA
| |
Collapse
|
16
|
Mello MM. Narrowing Vaccination Exemption Laws: Lessons From California and Beyond. Ann Intern Med 2020; 172:358-359. [PMID: 31683316 DOI: 10.7326/m19-3111] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Michelle M Mello
- Stanford Law School and Stanford University School of Medicine, Stanford, California (M.M.M.)
| |
Collapse
|
17
|
Delamater PL, Buttenheim AM, Klein NP, Mohanty S, Salmon DA, Omer SB. Assessment of Exemptions From Vaccination in California, 2015 to 2027. Ann Intern Med 2020; 172:362-363. [PMID: 31683313 PMCID: PMC7446529 DOI: 10.7326/m19-1933] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Paul L Delamater
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (P.L.D.)
| | - Alison M Buttenheim
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania (A.M.B., S.M.)
| | - Nicola P Klein
- Kaiser Permanente Vaccine Study Center, Oakland, California (N.P.K.)
| | - Salini Mohanty
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania (A.M.B., S.M.)
| | | | - Saad B Omer
- Yale School of Medicine and Yale School of Public Health, New Haven, Connecticut (S.B.O.)
| |
Collapse
|
18
|
Abstract
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.
Collapse
|
19
|
Abstract
PURPOSE OF REVIEW In September 2019, the United States was at risk of losing measles elimination status due to several large-scale outbreaks resulting in more than 1200 confirmed cases across 31 states. This resurgence caps approximately 10 years of increasing incidence, marked by a highly publicized outbreak in 2015 associated with Disneyland when an infected traveler from the Philippines unknowingly spread the virus to susceptible park visitors and the recently ended large outbreak in undervaccinated Orthodox Jewish communities in New York City and Rockland counties. This review highlights current literature elucidating factors associated with current trends in measles epidemiology in the United States, the public health implications of current measles outbreaks and a path forward for addressing challenges contributing to the resurgence of measles in the United States and globally. RECENT FINDINGS AND SUMMARY As the most highly transmissible vaccine preventable disease, measles is especially sensitive to changes in herd immunity, the impact of vaccine refusal and globalization. Results highlight the confluence of these factors in current outbreaks, provide tools to predict outbreak risk, demonstrate the growing impact of misinformation and evaluate the impact of policy approaches for outbreak control and prevention.
Collapse
|
20
|
Nyathi S, Karpel HC, Sainani KL, Maldonado Y, Hotez PJ, Bendavid E, Lo NC. The 2016 California policy to eliminate nonmedical vaccine exemptions and changes in vaccine coverage: An empirical policy analysis. PLoS Med 2019; 16:e1002994. [PMID: 31869328 PMCID: PMC6927583 DOI: 10.1371/journal.pmed.1002994] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 11/20/2019] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Vaccine hesitancy, the reluctance or refusal to receive vaccination, is a growing public health problem in the United States and globally. State policies that eliminate nonmedical ("personal belief") exemptions to childhood vaccination requirements are controversial, and their effectiveness to improve vaccination coverage remains unclear given limited rigorous policy analysis. In 2016, a California policy (Senate Bill 277) eliminated nonmedical exemptions from school entry requirements. The objective of this study was to estimate the association between California's 2016 policy and changes in vaccine coverage. METHODS AND FINDINGS We used a quasi-experimental state-level synthetic control analysis and a county-level difference-in-differences analysis to estimate the impact of the 2016 California policy on vaccination coverage and prevalence of exemptions to vaccine requirements (nonmedical and medical). We used publicly available state-level data from the US Centers for Disease Control and Prevention on coverage of measles, mumps, and rubella (MMR) vaccination, nonmedical exemption, and medical exemption in children entering kindergarten. We used county-level data individually requested from state departments of public health on overall vaccine coverage and exemptions. Based on data availability, we included state-level data for 45 states, including California, from 2011 to 2017 and county-level data for 17 states from 2010 to 2017. The prespecified primary study outcome was MMR vaccination in the state analysis and overall vaccine coverage in the county analysis. In the state-level synthetic control analysis, MMR coverage in California increased by 3.3% relative to its synthetic control in the postpolicy period (top 2 of 43 states evaluated in the placebo tests, top 5%), nonmedical exemptions decreased by 2.4% (top 2 of 43 states evaluated in the placebo tests, top 5%), and medical exemptions increased by 0.4% (top 1 of 44 states evaluated in the placebo tests, top 2%). In the county-level analysis, overall vaccination coverage increased by 4.3% (95% confidence interval [CI] 2.9%-5.8%, p < 0.001), nonmedical exemptions decreased by 3.9% (95% CI 2.4%-5.4%, p < 0.001), and medical exemptions increased by 2.4% (95% CI 2.0%-2.9%, p < 0.001). Changes in vaccination coverage across counties after the policy implementation from 2015 to 2017 ranged from -6% to 26%, with larger increases in coverage in counties with lower prepolicy vaccine coverage. Results were robust to alternative model specifications. The limitations of the study were the exclusion of a subset of US states from the analysis and the use of only 2 years of postpolicy data based on data availability. CONCLUSIONS In this study, implementation of the California policy that eliminated nonmedical childhood vaccine exemptions was associated with an estimated increase in vaccination coverage and a reduction in nonmedical exemptions at state and county levels. The observed increase in medical exemptions was offset by the larger reduction in nonmedical exemptions. The largest increases in vaccine coverage were observed in the most "high-risk" counties, meaning those with the lowest prepolicy vaccine coverage. Our findings suggest that government policies removing nonmedical exemptions can be effective at increasing vaccination coverage.
Collapse
Affiliation(s)
- Sindiso Nyathi
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, California, United States of America
| | - Hannah C. Karpel
- New York University School of Medicine, New York, New York, United States of America
| | - Kristin L. Sainani
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, California, United States of America
| | - Yvonne Maldonado
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, California, United States of America
- Division of Infectious Diseases, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, United States of America
| | - Peter J. Hotez
- Texas Children's Hospital Center for Vaccine Development, Departments of Pediatrics and Molecular Virology and Microbiology, Baylor College of Medicine, Houston, Texas, United States of America
- Department of Biology, Baylor University, Waco, Texas, United States of America
- Hagler Institute for Advanced Study at Texas A&M University, College Station, Texas, United States of America
- James A. Baker III Institute for Public Policy, Rice University, Houston, Texas, United States of America
| | - Eran Bendavid
- Center for Population Health Sciences, Division of Primary Care and Population Health, Department of Medicine, Stanford University, Stanford, California, United States of America
| | - Nathan C. Lo
- Department of Medicine, University of California, San Francisco, San Francisco, California, United States of America
| |
Collapse
|
21
|
Pingali SC, Delamater PL, Buttenheim AM, Salmon DA, Klein NP, Omer SB. Associations of Statewide Legislative and Administrative Interventions With Vaccination Status Among Kindergartners in California. JAMA 2019; 322:49-56. [PMID: 31265099 PMCID: PMC6613302 DOI: 10.1001/jama.2019.7924] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
IMPORTANCE California implemented 3 interventions to increase uptake of vaccines. In 2014, Assembly bill 2109 tightened requirements for obtaining a personal belief exemption. A 2015 campaign provided educational materials to school staff on the proper application of conditional admission for kindergartners who were not up to date on required vaccinations. In 2016, Senate bill 277 eliminated personal belief exemptions. Prior research has not evaluated these 3 interventions together with regard to the vaccination status of students. OBJECTIVE To assess the changes in the yearly rates of kindergartners who were not up to date on required vaccinations who were entering school during the period of the interventions, by focusing on geographic clustering and the potential contacts of these kindergartners. DESIGN, SETTING, AND PARTICIPANTS Observational study that used cross-sectional school-entry data from 2000-2017 to calculate the rates of kindergartners attending California schools who were not up to date on required vaccinations. EXPOSURES Assembly bill 2109, a conditional admission education program, and Senate bill 277. MAIN OUTCOMES AND MEASURES The primary outcome was the yearly rate of kindergartners without up-to-date vaccination status. The secondary outcomes were (1) the modified aggregation index, which was used to assess the potential within-school contacts among kindergartners without up-to-date vaccination status, (2) the number of geographic clusters of schools with rates for kindergartners without up-to-date vaccination status that were higher than the rates for schools located outside the cluster, and (3) the number of schools located inside the geographic clusters. RESULTS In California between 2000 and 2017, 9 323 315 children started attending kindergarten and 721 593 were not up to date on required vaccinations. Prior to the interventions, the statewide rate of kindergartners without up-to-date status for required vaccinations increased from 7.80% during 2000 to 9.84% during 2013 and then decreased after the interventions to 4.87% during 2017. The percentage chance for within-school contact among kindergartners without up-to-date vaccination status decreased from 26.02% during 2014 to 4.56% (95% CI, 4.21%-4.99%) during 2017. During 2012-2013, there were 124 clusters that contained 3026 schools with high rates of kindergartners without up-to-date vaccination status. During 2014-2015, there were 93 clusters that contained 2290 schools with high rates of kindergartners without up-to-date vaccination status. During 2016-2017, there were 110 clusters that contained 1613 (95% CI, 1565-1691) schools. CONCLUSIONS AND RELEVANCE In California, statewide legislative and educational interventions were associated with a decrease in the yearly rates of kindergartners without up-to-date vaccination status. These interventions also were associated with reductions in the number of schools inside the clusters with high rates of kindergartners without up-to-date vaccination status and the potential for contact among these kindergartners.
Collapse
Affiliation(s)
| | - Paul L. Delamater
- Department of Geography, Carolina Population Center, University of North Carolina, Chapel Hill
| | - Alison M. Buttenheim
- Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia
| | - Daniel A. Salmon
- Department of International Health, Johns Hopkins University, Baltimore, Maryland
| | | | - Saad B. Omer
- Department of Epidemiology, Emory University, Atlanta, Georgia
- Hubert Department of Global Health, Emory University, Atlanta, Georgia
- Now with the Yale Institute for Global Health, Yale University, New Haven, Connecticut
- Now with the Department of Medicine, School of Medicine, Yale University, New Haven, Connecticut
- Now with the Department of Epidemiology of Microbial Diseases, School of Public Health, Yale University, New Haven, Connecticut
| |
Collapse
|
22
|
Delamater PL, Pingali SC, Buttenheim AM, Salmon DA, Klein NP, Omer SB. Elimination of Nonmedical Immunization Exemptions in California and School-Entry Vaccine Status. Pediatrics 2019; 143:e20183301. [PMID: 31113831 PMCID: PMC6564056 DOI: 10.1542/peds.2018-3301] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/13/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES California implemented Senate Bill 277 (SB277) in 2016, becoming the first state in nearly 30 years to eliminate nonmedical exemptions from immunization requirements for schoolchildren. Our objectives were to determine (1) the impacts of SB277 on the percentage of kindergarteners entering school not up-to-date on vaccinations and (2) if geographic patterns of vaccine refusal persisted after the implementation of the new law. METHODS At the state level, we analyzed the magnitude and composition of the population of kindergarteners not up-to-date on vaccinations before and after the implementation of SB277. We assessed correlations between previous geographic patterns of nonmedical exemptions and patterns of the remaining entry mechanisms for kindergarteners not up-to-date after the law's implementation. RESULTS In the first year after SB277 was implemented, the percentage of kindergartners entering school not up-to-date on vaccinations decreased from 7.15% to 4.42%. The conditional entrance rate fell from 4.43% to 1.91%, accounting for much of this decrease. Other entry mechanisms for students not up-to-date, including medical exemptions and exemptions for independent study or homeschooled students, largely replaced the decrease in the personal belief exemption rate from 2.37% to 0.56%. In the second year, the percentage of kindergartners not up-to-date increased by 0.45%, despite additional reductions in conditional entrants and personal belief exemptions. The correlational analysis revealed that previous geographic patterns of vaccine refusal persisted after the law's implementation. CONCLUSIONS Although the percentage of incoming kindergarteners up-to-date on vaccinations in California increased after the implementation of SB277, we found evidence for a replacement effect.
Collapse
Affiliation(s)
- Paul L Delamater
- Department of Geography and Carolina Population Center, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Departments of
| | | | - Alison M Buttenheim
- Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Daniel A Salmon
- Department of International Health, Johns Hopkins University, Baltimore, Maryland; and
| | - Nicola P Klein
- Kaiser Permanente Vaccine Study Center, Oakland, California
| | - Saad B Omer
- Global Health, Emory University, Atlanta, Georgia
| |
Collapse
|
23
|
Jones M, Buttenheim AM, Salmon D, Omer SB. Mandatory Health Care Provider Counseling For Parents Led To A Decline In Vaccine Exemptions In California. Health Aff (Millwood) 2019; 37:1494-1502. [PMID: 30179562 DOI: 10.1377/hlthaff.2018.0437] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Receipt of childhood vaccinations in the US has been declining, and outbreaks of preventable infectious diseases have become more common. In response, in 2014 California implemented a policy change for exemptions from mandatory vaccines for school enrollment. Data on fifteen successive cohorts of kindergarteners enrolled in public and private schools between school years 2001-02 and 2015-16 were analyzed for changes in vaccination trends. The results show an increase in the prevalence and clustering of vaccine exemptions from 2001-02 through 2013-14, followed by a modest decline after implementation of a policy mandating health care provider counseling for vaccine exemption. Clustering of vaccine exemptions increased over the study period and was less responsive to the policy change than were exemption rates overall. Nor did the policy change uniformly reduce the clustering of at-risk students across counties. Trends in the use of conditional admission showed strong school-level clustering and remained relatively stable. The policy change was effective at reducing exemption rates but did not uniformly reduce clustering of exemptions. The results suggest the need to evaluate the causes of local-area clustering and to adopt a statewide policy that addresses clustering of vaccine exemptions within schools and counties.
Collapse
Affiliation(s)
- Malia Jones
- Malia Jones ( ) is an assistant scientist in health geography at the Applied Population Laboratory, University of Wisconsin System, in Madison
| | - Alison M Buttenheim
- Alison M. Buttenheim is an associate professor of nursing at the School of Nursing and an assistant professor of health policy at the Perelman School of Medicine, University of Pennsylvania, in Philadelphia
| | - Daniel Salmon
- Daniel Salmon is an associate professor of international health at the Johns Hopkins University Bloomberg School of Public Health, in Baltimore, Maryland
| | - Saad B Omer
- Saad B. Omer is the William H. Foege Professor of Global Health and Epidemiology at the Rollins School of Public Health and a professor of pediatrics at the School of Medicine at Emory University, in Atlanta, Georgia
| |
Collapse
|
24
|
Bednarczyk RA, King AR, Lahijani A, Omer SB. Current landscape of nonmedical vaccination exemptions in the United States: impact of policy changes. Expert Rev Vaccines 2019; 18:175-190. [PMID: 30572729 DOI: 10.1080/14760584.2019.1562344] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
INTRODUCTION In the United States, high childhood vaccination coverage has reduced the morbidity and mortality due to vaccine-preventable diseases. The success of vaccination programs in achieving this high coverage is due, in part, to vaccination mandates for school entry. All states have such mandates, but there is heterogeneity across the states in the allowance of non-medical exemptions (e.g. religious or personal belief exemptions) to these mandates. AREAS COVERED We examine historical trends in non-medical exemption prevalence in the US, discuss recent state-level policy changes that may impact non-medical exemption prevalence, and review recent studies on the association between non-medical exemptions and infectious disease outbreaks. EXPERT COMMENTARY State-level implementation of mandates, and related allowances for medical and non-medical exemptions, varies greatly across the United States. Non-medical exemption rates have increased over the last two decades, with an increased risk of disease outbreaks in clusters of children with non-medical exemptions due to differences in state laws. Recent efforts to address non-medical exemption rates range from incorporating additional administrative requirements for exemptions and disallowance of any non-medical exemptions. Continued monitoring is needed to evaluate the impact of these changes on exemption rates, to develop optimal childhood vaccination policy across the United States.
Collapse
Affiliation(s)
- Robert A Bednarczyk
- a Hubert Department of Global Health, Rollins School of Public Health , Emory University , Atlanta , GA , USA.,b Department of Epidemiology, Rollins School of Public Health , Emory University , Atlanta , GA , USA.,c Emory Vaccine Center , Emory University , Atlanta , GA , USA
| | - Adrian R King
- a Hubert Department of Global Health, Rollins School of Public Health , Emory University , Atlanta , GA , USA
| | - Ariana Lahijani
- a Hubert Department of Global Health, Rollins School of Public Health , Emory University , Atlanta , GA , USA
| | - Saad B Omer
- a Hubert Department of Global Health, Rollins School of Public Health , Emory University , Atlanta , GA , USA.,b Department of Epidemiology, Rollins School of Public Health , Emory University , Atlanta , GA , USA.,c Emory Vaccine Center , Emory University , Atlanta , GA , USA.,d Department of Pediatrics , School of Medicine, Emory University , Atlanta , GA , USA
| |
Collapse
|
25
|
Mohanty S, Buttenheim AM, Joyce CM, Howa AC, Salmon D, Omer SB. California's Senate Bill 277: Local Health Jurisdictions' Experiences With the Elimination of Nonmedical Vaccine Exemptions. Am J Public Health 2018; 109:96-101. [PMID: 30495995 DOI: 10.2105/ajph.2018.304768] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Objectives. To understand the experiences of local health jurisdictions with Senate Bill 277 (SB277), the California law that eliminated nonmedical vaccine exemptions for public- and private-school entry.Methods. We conducted semistructured telephone interviews with health officers and local health department (LHD) staff in California between August and September 2017.Results. Two overall themes emerged: (1) vague legislative and regulatory language led to variation in the interpretation and implementation of SB277, and (2) lack of centralized review of medical exemptions allowed medical exemptions that are not consistent with valid contraindications for immunizations to be accepted. Variation in the interpretation and implementation was commonly reported with provisions related to individualized education programs and special education, and independent study programs and homeschooling. Without a centralized review of medical exemption requests, respondents reported variation in the interpretation of which specialties of physicians can write medical exemptions, which conditions constitute a valid contraindication for immunization, and the process for reporting a questionable or suspicious medical exemption.Conclusions. The regulatory language within SB277 led to variation in how the law was interpreted and implemented within and across LHD jurisdictions and school districts.
Collapse
Affiliation(s)
- Salini Mohanty
- Salini Mohanty, Alison M. Buttenheim, and Caroline M. Joyce are with the University of Pennsylvania, School of Nursing, Philadelphia. Alison M. Buttenheim is also with the Center for Health Incentives and Behavioral Economics, Perelman School of Medicine of the University of Pennsylvania. Amanda C. Howa and Saad B. Omer are with Emory University, Rollins School of Public Health, Atlanta, GA. Daniel Salmon is with Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD
| | - Alison M Buttenheim
- Salini Mohanty, Alison M. Buttenheim, and Caroline M. Joyce are with the University of Pennsylvania, School of Nursing, Philadelphia. Alison M. Buttenheim is also with the Center for Health Incentives and Behavioral Economics, Perelman School of Medicine of the University of Pennsylvania. Amanda C. Howa and Saad B. Omer are with Emory University, Rollins School of Public Health, Atlanta, GA. Daniel Salmon is with Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD
| | - Caroline M Joyce
- Salini Mohanty, Alison M. Buttenheim, and Caroline M. Joyce are with the University of Pennsylvania, School of Nursing, Philadelphia. Alison M. Buttenheim is also with the Center for Health Incentives and Behavioral Economics, Perelman School of Medicine of the University of Pennsylvania. Amanda C. Howa and Saad B. Omer are with Emory University, Rollins School of Public Health, Atlanta, GA. Daniel Salmon is with Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD
| | - Amanda C Howa
- Salini Mohanty, Alison M. Buttenheim, and Caroline M. Joyce are with the University of Pennsylvania, School of Nursing, Philadelphia. Alison M. Buttenheim is also with the Center for Health Incentives and Behavioral Economics, Perelman School of Medicine of the University of Pennsylvania. Amanda C. Howa and Saad B. Omer are with Emory University, Rollins School of Public Health, Atlanta, GA. Daniel Salmon is with Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD
| | - Daniel Salmon
- Salini Mohanty, Alison M. Buttenheim, and Caroline M. Joyce are with the University of Pennsylvania, School of Nursing, Philadelphia. Alison M. Buttenheim is also with the Center for Health Incentives and Behavioral Economics, Perelman School of Medicine of the University of Pennsylvania. Amanda C. Howa and Saad B. Omer are with Emory University, Rollins School of Public Health, Atlanta, GA. Daniel Salmon is with Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD
| | - Saad B Omer
- Salini Mohanty, Alison M. Buttenheim, and Caroline M. Joyce are with the University of Pennsylvania, School of Nursing, Philadelphia. Alison M. Buttenheim is also with the Center for Health Incentives and Behavioral Economics, Perelman School of Medicine of the University of Pennsylvania. Amanda C. Howa and Saad B. Omer are with Emory University, Rollins School of Public Health, Atlanta, GA. Daniel Salmon is with Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD
| |
Collapse
|
26
|
Mohanty S, Buttenheim AM, Joyce CM, Howa AC, Salmon D, Omer SB. Experiences With Medical Exemptions After a Change in Vaccine Exemption Policy in California. Pediatrics 2018; 142:peds.2018-1051. [PMID: 30373910 PMCID: PMC6314187 DOI: 10.1542/peds.2018-1051] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/01/2018] [Indexed: 11/24/2022] Open
Abstract
UNLABELLED : media-1vid110.1542/5804909532001PEDS-VA_2018-1051Video Abstract OBJECTIVES: In 2015, California passed Senate Bill 227 (SB277), eliminating nonmedical vaccine exemptions for school entry. Our objective for this study was to describe the experiences of health officers and immunization staff addressing medical exemption requests under SB277. METHODS We conducted semistructured telephone interviews between August 2017 and September 2017 with health officers and immunization staff from local health jurisdictions in California. Interviews were recorded, transcribed, and analyzed for key themes. RESULTS We conducted 34 interviews with 40 health officers and immunization staff representing 35 of the 61 local health jurisdictions in California. Four main themes emerged related to experiences with medical exemptions: (1) the role of stakeholders, (2) reviewing medical exemptions received by schools, (3) medical exemptions that were perceived as problematic, and (4) frustration and concern over medical exemptions. Generally, local health jurisdictions described a narrow role in providing support and technical assistance to schools. Only 5 jurisdictions actively tracked medical exemptions received by schools, with 1 jurisdiction facing a lawsuit as a result. Examples were provided of medical exemptions that listed family history of allergies and autoimmune diseases as contraindications for immunization and of physicians charging steep fees for medical exemptions. Participants also reported concerns about the increase in medical exemptions after the implementation of SB277. CONCLUSIONS Participants reported many challenges and concerns with medical exemptions under SB277. Without additional legal changes, including a standardized review of medical exemptions, some physicians may continue to write medical exemptions for vaccine-hesitant parents, potentially limiting the long-term impact of SB277.
Collapse
Affiliation(s)
- Salini Mohanty
- Department of Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania;
| | - Alison M. Buttenheim
- Department of Family and Community Health, University
of Pennsylvania School of Nursing, Philadelphia, Pennsylvania;,Center for Health Incentives and Behavioral
Economics, Perelman School of Medicine, University of Pennsylvania,
Philadelphia, Pennsylvania
| | - Caroline M. Joyce
- Department of Family and Community Health, University
of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
| | | | - Daniel Salmon
- Department of International Health and Health
Behavior Society, Bloomberg School of Public Health, Johns Hopkins University,
Baltimore, Maryland
| | - Saad B. Omer
- Hubert Department of Global Health and,Department of Epidemiology, Rollins School of Public
Health;,Department of Pediatrics, School of Medicine;
and,Emory Vaccine Center, Emory University, Atlanta,
Georgia
| |
Collapse
|
27
|
Attwell K, Navin MC, Lopalco PL, Jestin C, Reiter S, Omer SB. Recent vaccine mandates in the United States, Europe and Australia: A comparative study. Vaccine 2018; 36:7377-7384. [PMID: 30337171 DOI: 10.1016/j.vaccine.2018.10.019] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 10/03/2018] [Accepted: 10/04/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND In response to recent outbreaks of vaccine-preventable diseases and concerns around vaccine refusal, several high-income countries have adopted or reformed vaccine mandate policies. While all make it more difficult for parents to refuse vaccines, the nature and scope of 'mandatory vaccination' is heterogeneous, and there has been no attempt to develop a detailed, comparative systematic account of the possible forms mandates can take. METHODS We compare the construction, introduction/amendment, and operation of six new high profile vaccine mandates in Australia, France, Germany, Italy, California, and Washington. We rank these policies in order of their relative restrictiveness and analyze other differences between them. RESULTS New mandate instruments differ in their effects on behavior, and with regard to their structure, exemptions, target populations, consequences and enforcement. We identify diverse means by which vaccine mandates can restrict behaviors, various degrees of severity, and different gradations of intensity in enforcement. CONCLUSION We suggest that politico-cultural context and vaccine policy history are centrally important factors for vaccine mandate policymakers to consider. It matters whether citizens trust their governments to limit individual freedom in the name of public health, and whether citizens have previously been subjected to vaccine mandates. Furthermore, political communities must consider the diverse mechanisms by which they may construct vaccine mandate policies; whether through emergency decrees or ordinary statutes, and how (or whether) to involve various stakeholder groups in developing and implementing new vaccine mandate policies.
Collapse
Affiliation(s)
- Katie Attwell
- Political Science and International Relations, University of Western Australia, 35 Stirling Highway, Crawley 6009, Australia.
| | - Mark C Navin
- Department of Philosophy, Oakland University, 146 Library Drive, Rochester, MI 48309-4479, USA
| | - Pier Luigi Lopalco
- Department of Translational Research on New Technologies in Medicine and Surgery, University of Pisa, Lungarno Antonio Pacinotti, 43, 56126 Pisa Pl, Italy
| | - Christine Jestin
- Sante Publique France, 12 rue du Val d'Osne, 94415 Saint-Maurice Cedex, France
| | - Sabine Reiter
- Infectious Diseases, Antimicrobial Resistance, Hygiene, Vaccination Federal Ministry of Health, Bundesministerium für Gesundheit Referat, 322 Friedrichstraße 108, 10117 Berlin, Germany
| | - Saad B Omer
- Rollins School of Public Health, Emory University, 1518 Clifton Road NE, Atlanta, GA 20211, USA
| |
Collapse
|