Childhood Vaccine Exemption Policy: The Case for a Less Restrictive Alternative

Why Parents Say No to Having Their Children Vaccinated against Measles: A Systematic Review of the Social Determinants of Parental Perceptions on MMR Vaccine Hesitancy

Ongoing outbreaks of measles threaten its elimination status in the United States. Its resurgence points to lower parental vaccine confidence and local pockets of unvaccinated and undervaccinated individuals. The geographic clustering of hesitancy to MMR indicates the presence of social drivers that shape parental perceptions and decisions on immunization. Through a qualitative systematic review of published literature (n = 115 articles; 7 databases), we determined major themes regarding parental reasons for MMR vaccine hesitancy, social context of MMR vaccine hesitancy, and trustworthy vaccine information sources. Fear of autism was the most cited reason for MMR hesitancy. The social drivers of vaccine hesitancy included primary care/healthcare, education, economy, and government/policy factors. Social factors, such as income and education, exerted a bidirectional influence, which facilitated or hindered vaccine compliance depending on how the social determinant was experienced. Fear of autism was the most cited reason for MMR hesitancy. Vaccine hesitancy to MMR and other childhood vaccines clustered in middle- to high-income areas among mothers with a college-level education or higher who preferred internet/social media narratives over physician-based vaccine information. They had low parental trust, low perceived disease susceptibility, and were skeptical of vaccine safety and benefits. Combating MMR vaccine misinformation and hesitancy requires intersectoral and multifaceted approaches at various socioecological levels to address the social drivers of vaccine behavior.

The case against COVID-19 vaccine mandates in pediatric solid organ transplantation

BACKGROUND

The American Society of Transplantation in conjunction with the International Society for Heart and Lung Transplantation released a joint statement on August 13, 2021 in which they strongly recommend that solid organ transplant (SOT) recipients and their eligible household members and close contacts be vaccinated against SARS-CoV-2 with an approved COVID-19 vaccine. Some SOT programs have gone further and will refuse to list or transplant candidates unless the candidate and their household are vaccinated against SARS-CoV-2.

METHODS

Two general pediatrician-ethicists use current best evidence and moral theory to argue why it is unethical to mandate COVID-19 vaccination for pediatric SOT candidates, their primary support person, and their households.

RESULTS

Pediatric vaccine mandates are most justifiable when they prevent the harm of a serious vaccine preventable disease (VPD) in children in settings where transmission is highly likely and there are no alternatives that are effective in preventing transmission that intrude less on individual freedom. An additional justification for a vaccine mandate in the SOT context is stewardship of a scarce resource if there is significant risk of graft loss from the VPD to an unvaccinated SOT candidate or recipient. Current evidence does not support fulfillment of these criteria in pediatric solid organ transplantation.

CONCLUSIONS

Making SOT listing contingent on COVID-19 vaccination is problematic. Though there is some risk of harm to a pediatric SOT candidate in remaining unvaccinated, the risk of harm of not being listed and transplanted is greater and overriding.

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

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

Vaccination Policies: Between Best and Basic Interests of the Child, between Precaution and Proportionality

How should liberal-democratic governments deal with emerging vaccination hesitancy when that leads to the resurgence of diseases that for decades were under control? This article argues that vaccination policies should be justified in terms of a proper weighing of the rights of children to be protected against vaccine-preventable diseases and the rights of parents to raise their children in ways that they see fit. The argument starts from the concept of the ‘best interests of the child involved’. The concept is elaborated for this context into the dual regime structure in which parents have fiduciary authority over what they consider to be best for their child, and the state has fiduciary authority over a child’s basic interests. This argument leads to conditional mandatory vaccination programs that should be informed by a correct balancing of the two legal principles of proportionality and precaution. This results in contextual childhood vaccination policies of upscaling interference: a three-tiered approach of increased intrusion, from voluntary program when possible and mandatory or even compulsory programs when necessary to protect the child’s basic interests.

Imperfect Immunization Communication on School District Websites: A Mixed-Methods Review

Schools and school districts are key to U.S. vaccination policies: They communicate immunization enrollment requirements and enforce them during registration. This article presents a mixed-methods study of how Michigan's 537 districts communicate about vaccine mandates through public-facing websites. It reports the results of a qualitative analysis (n = 50) of websites from Southeast Michigan and a quantitative analysis of all (n = 537) Michigan's district websites. School district websites engage in diverse health promotion practices surrounding immunization, from encouraging vaccination to neutral messaging and to encouraging exemptions. Most provide scant immunization information and few promote the importance of immunization for individual and community health. We recommend that school nurses, district staff, and health authorities collaborate to ensure that school district communication promotes immunization and does not promote nonmedical exemptions. This can lead schools to embrace immunization as an essential activity for their own functioning rather than as an unwelcome requirement imposed by outside agents.

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

Background

State-mandated school entry immunization requirements in the United States play an important role in achieving high vaccine coverage, but variations in vaccine exemption policies result in a patchwork of vaccine coverage across the country.

Methods

In this study, we evaluate epidemiological effects and spatial variations in nonmedical exemption (NME) rates in the context of vaccine policies. We first analyze the correlation between NME rates and vaccine coverage for 3 significant childhood vaccinations. Furthermore, we assess the effects of policy changes in a subset of states, using a correlative approach at the state level and performing a clustering analysis at the county level.

Results

We find that higher rates of exemptions are associated with lower vaccination rates of school-aged children in all cases. In a subset of states where exemption policy has recently changed, we show that the effects on statewide NME rates vary widely and that decreases in NMEs can lead to an increase in other types of exemptions. Finally, our clustering analysis in California, Illinois, and Connecticut shows that policy changes affect the spatial distribution of NMEs.

Conclusions

Our work suggests that vaccination policies have significant impacts on patterns of herd immunity. Our findings can be used to develop evidence-based vaccine legislation.

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

BACKGROUND

Vaccine hesitancy, the reluctance or refusal to receive vaccination, is a growing public health problem in the United States and globally. State policies that eliminate nonmedical ("personal belief") exemptions to childhood vaccination requirements are controversial, and their effectiveness to improve vaccination coverage remains unclear given limited rigorous policy analysis. In 2016, a California policy (Senate Bill 277) eliminated nonmedical exemptions from school entry requirements. The objective of this study was to estimate the association between California's 2016 policy and changes in vaccine coverage.

METHODS AND FINDINGS

We used a quasi-experimental state-level synthetic control analysis and a county-level difference-in-differences analysis to estimate the impact of the 2016 California policy on vaccination coverage and prevalence of exemptions to vaccine requirements (nonmedical and medical). We used publicly available state-level data from the US Centers for Disease Control and Prevention on coverage of measles, mumps, and rubella (MMR) vaccination, nonmedical exemption, and medical exemption in children entering kindergarten. We used county-level data individually requested from state departments of public health on overall vaccine coverage and exemptions. Based on data availability, we included state-level data for 45 states, including California, from 2011 to 2017 and county-level data for 17 states from 2010 to 2017. The prespecified primary study outcome was MMR vaccination in the state analysis and overall vaccine coverage in the county analysis. In the state-level synthetic control analysis, MMR coverage in California increased by 3.3% relative to its synthetic control in the postpolicy period (top 2 of 43 states evaluated in the placebo tests, top 5%), nonmedical exemptions decreased by 2.4% (top 2 of 43 states evaluated in the placebo tests, top 5%), and medical exemptions increased by 0.4% (top 1 of 44 states evaluated in the placebo tests, top 2%). In the county-level analysis, overall vaccination coverage increased by 4.3% (95% confidence interval [CI] 2.9%-5.8%, p < 0.001), nonmedical exemptions decreased by 3.9% (95% CI 2.4%-5.4%, p < 0.001), and medical exemptions increased by 2.4% (95% CI 2.0%-2.9%, p < 0.001). Changes in vaccination coverage across counties after the policy implementation from 2015 to 2017 ranged from -6% to 26%, with larger increases in coverage in counties with lower prepolicy vaccine coverage. Results were robust to alternative model specifications. The limitations of the study were the exclusion of a subset of US states from the analysis and the use of only 2 years of postpolicy data based on data availability.

CONCLUSIONS

In this study, implementation of the California policy that eliminated nonmedical childhood vaccine exemptions was associated with an estimated increase in vaccination coverage and a reduction in nonmedical exemptions at state and county levels. The observed increase in medical exemptions was offset by the larger reduction in nonmedical exemptions. The largest increases in vaccine coverage were observed in the most "high-risk" counties, meaning those with the lowest prepolicy vaccine coverage. Our findings suggest that government policies removing nonmedical exemptions can be effective at increasing vaccination coverage.

Legislative and administrative actions to increase vaccination coverage in Washington schools

Current outbreaks of vaccine-preventable diseases in the U.S. highlight the consequences of declining levels of vaccination coverage. Attempts to increase coverage by banning or restricting nonmedical exemptions from school-entry vaccination requirements disregard children not up to date on vaccination who already attend school and those who are not up to date for reasons other than vaccine hesitancy. We analyze the potential effects of legislative and administrative options to increase vaccination coverage in Washington schools. We constructed a grade-specific model of the detailed vaccination status for all required vaccines and the MMR vaccine specifically for all children in the state's school system. We used scenario modeling to evaluate the effects of potential legislative and administrative actions on the percent of students up to date on all required vaccines and the MMR vaccine from 2018 to 2030. Our analysis shows that eliminating nonmedical exemptions may not be the optimal solution for reducing disease outbreak risk. Instead, focusing on children not up to date for reasons other than nonmedical exemption could have a larger impact and does not carry the controversy that accompanies attempts to ban or restrict nonmedical exemptions. Further, implementing a one-time catch-up period for all children not up to date would increase coverage promptly. Evidence-based policymaking is an essential component of efforts to reduce the risk of disease outbreaks in U.S. schools, and analysis of potential legislative and administrative actions complement these efforts.

Conditional admission, religious exemption type, and nonmedical vaccine exemptions in California before and after a state policy change

Recent measles and pertussis outbreaks in the US have focused national attention on state laws governing exemptions from mandatory vaccines for school entry. After several years of increases in nonmedical exemptions in California, the state assembly passed Assembly Bill 2109 in 2012, making nonmedical exemptions more difficult to obtain by requiring parents to obtain a signature from a health care provider. We used data from the California Department of Public Health to describe changes in the overall prevalence of personal belief exemptions and compositional changes in immunization status for the school years 2012-2013 through 2015-2016. Following the implementation of Assembly Bill 2109, the statewide exemption rate declined from 3.1% in 2013 to 2.5% in 2014 and then to 2.3% in 2015, representing a 25% reduction from the 2013 peak. Continued surveillance of exemption rates and vaccine refusal are needed to monitor and protect herd immunity against vaccine-preventable diseases.

The evolution of immunization waiver education in Michigan: A qualitative study of vaccine educators

BACKGROUND

In 2015, Michigan implemented an education requirement for parents who requested nonmedical exemptions from school or daycare immunization mandates. Michigan required parents to receive education from public health staff, unlike other states, whose vaccine education requirements could be completed online or at physicians' offices.

METHODS AND FINDINGS

Results of focus group interviews with 39 of Michigan's vaccine waiver educators, conducted during 2016 and 2017, were analyzed to identify themes describing educators' experiences of waiver education. The core theme that emerged from the data was that educators changed their perception of the purpose of waiver education, from convincing vaccine-refusing parents to vaccinate their children to promoting more diffuse and forward-looking goals.

CONCLUSIONS

Michigan, and other communities that require vaccine waiver education, ought to investigate whether and how waiver education contributes to public health goals other than short-term vaccination compliance. Research shows that education requirements can decrease nonmedical exemption rates by discouraging some parents from applying for exemptions, but further studies are needed to identify ways in which waiver education can promote other public health goals, while minimizing costs and burdens on staff.

Refusal of Vaccination: A Test to Balance Societal and Individual Interests

While all states in the United States require certain vaccinations for school attendance, all but three allow for religious exemptions to receiving such vaccinations, and 18 allow for exemptions on the basis of other deeply held personal beliefs. The rights of parents to raise children as they see fit may conflict with the duty of the government and society to protect the welfare of children. In the U.S., these conflicts have not been settled in a uniform and consistent manner. We apply a test that provides a concrete and formal rubric to evaluate such conflicts. For some vaccinations, based on the individual medical characteristics of the disease and the risks of being unvaccinated, the test would suggest that permitting conscientious exemptions is ethical. However, for vaccinations protecting against other diseases that are more severe or easily transmitted, the test would suggest that the federal government may ethically impose laws that deny such exemptions.

On religious and secular exemptions: A case study of childhood vaccination waivers

This paper analyses exemptions to general law through the prism of vaccine waivers in the United States. All US states legally require the vaccination of children prior to school or daycare entry; however, this obligation is accompanied with a system of medical, religious, and/or philosophical exemptions. Nonmedical exemptions became subject of discussion after the 2015 Disneyland measles outbreak in California, which unequivocally brought to light what had been brewing below the surface for a while: a slow but steady decline in vaccination rates in Western societies, resulting in the reoccurrence of measles outbreaks. This can be traced back to an increasing public questioning of vaccines by a growing anti-vaccination movement. In reaction to the outbreak and the public outrage it generated, several states proposed-and some already passed-bills to eliminate nonmedical exemptions. I analyze two questions. First, can legal exemptions from mandatory childhood vaccination schemes for parents who are opposed to vaccination (still) be justified? Second, should legal exemptions be limited to religious objections to vaccination, or should they also be granted to secular objections? Although the argument in the paper starts from the example of the US, it seeks to provide a more general philosophical reflection on the question of exemptions from mandatory childhood vaccination.

Medical Versus Nonmedical Immunization Exemptions for Child Care and School Attendance

Routine childhood immunizations against infectious diseases are an integral part of our public health infrastructure. They provide direct protection to the immunized individual and indirect protection to children and adults unable to be immunized via the effect of community immunity. All 50 states, the District of Columbia, and Puerto Rico have regulations requiring proof of immunization for child care and school attendance as a public health strategy to protect children in these settings and to secondarily serve as a mechanism to promote timely immunization of children by their caregivers. Although all states and the District of Columbia have mechanisms to exempt school attendees from specific immunization requirements for medical reasons, the majority also have a heterogeneous collection of regulations and laws that allow nonmedical exemptions from childhood immunizations otherwise required for child care and school attendance. The American Academy of Pediatrics (AAP) supports regulations and laws requiring certification of immunization to attend child care and school as a sound means of providing a safe environment for attendees and employees of these settings. The AAP also supports medically indicated exemptions to specific immunizations as determined for each individual child. The AAP views nonmedical exemptions to school-required immunizations as inappropriate for individual, public health, and ethical reasons and advocates for their elimination.