Achieving an Optimal Childhood Vaccine Policy

Opel, Douglas J.; Schwartz, Jason L.; Omer, Saad B.; Silverman, Ross D.; Duchin, Jeff; Kodish, Eric; Diekema, Douglas S.; Marcuse, Edgar K.; Orenstein, Walt

doi:10.1001/jamapediatrics.2017.1868

Cited by 22 publications

(17 citation statements)

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“…As has been demonstrated by past policy changes, uptake in vaccination rates by communities requires multiple measures ( S1 Table ). It has been pointed out that a vertical policy change, such as the one highlighted above, should be accompanied by expanded horizontal efforts to increase access to vaccines and booster shots, educational programs, and awareness campaigns [ 12 – 14 ]. For instance, healthcare providers might play a greater role in promoting vaccination.…”

Section: Discussionmentioning

confidence: 99%

“…Furthermore, greater community involvement through churches, neighborhood clinics, and provaccination celebrity allies would help to reach both undervaccinated communities—who are affected by vaccine access-related issues—and unvaccinated groups. Recently, Opel and colleagues identified key policies in the areas of enforcement and reimbursement for pediatricians or other providers who advise vaccine-hesitant parents [ 14 ]. As indicated by the increase in NME rates despite ND’s policy passage to increase vaccine supply without physician education ( S1 Table ), it is critical to achieve community buy-in through targeted education campaigns.…”

Section: Discussionmentioning

confidence: 99%

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The state of the antivaccine movement in the United States: A focused examination of nonmedical exemptions in states and counties

et al. 2018

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

The state of the antivaccine movement in the United States: A focused examination of nonmedical exemptions in states and counties

et al. 2018

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“…The simplification of the medical exemption process in California, introduced in Senate Bill 277 alongside the elimination of non-medical exemptions, may thus be partly to blame for the sharp increase in medical exemptions at the start of the 2016-2017 school year [19, 39]. While the child’s healthcare professional is often in the best position to offer relevant counsel on immunization to vaccine-hesitant parents [40], parents may put pressure on providers to obtain medical exemptions and/or turn to more sympathetic providers [11]. Additionally, recent studies have shown a rise in conditional admissions after an exemption policy change [11] (which is not something we included in our analysis), thus further consideration of effect of this category of students is also needed [12].…”

Section: Discussionmentioning

confidence: 99%

“…From an ethical standpoint, which approach is preferable between making non-medical exemptions harder to get through administrative or time-consuming hurdles, and outright elimination of non-medical exemptions is far from settled [45, 46]. Even though there is a strong legal basis that would allow states to ban non-medical exemptions [13], partial elimination targeting diseases whose transmission is primarily school based such as measles may be preferable to avoid further strengthening anti-vaccine sentiments [40]. Communication around the benefits and safety of vaccines should represent a key component of any elimination effort, even though education of vaccine-refusing parents has proven challenging [47].…”

Section: Discussionmentioning

confidence: 99%

Getting personal: how vaccination exemptions shape herd immunity

Garnier

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et al. 2018

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Background: State-mandated school entry immunization requirements in the United States play an important role in achieving high vaccine coverage and preventing outbreaks of vaccine-preventable diseases. Most states allow non-medical exemptions that let children remain unvaccinated on the basis of personal beliefs. However, the ease of obtaining such exemptions varies, resulting in a patchwork of state vaccination exemption laws, contributing to heterogeneity in vaccine coverage across the country. In this study, we evaluate epidemiological effects and spatial variations in non-medical exemption rates in the context of vaccine 1 policies. Methods and Findings:We first analyzed the correlation between non-medical exemption rates and vaccine coverage for three significant childhood vaccinations and found that higher rates of non-medical exemptions were associated with lower vaccination rates of school-aged children in all cases. We then identified a subset of states where exemption policy has recently changed and found that the effects on statewide non-medical exemption rates varied widely.Focusing further on Vermont and California, we illustrated how the decrease in non-medical exemptions due to policy change was concurrent to an increase in medical exemptions (in CA) or religious exemptions (in VT). Finally, a spatial clustering analysis was performed for Connecticut, Illinois, and California, identifying clusters of high non-medical exemption rates in these states before and after a policy change occurred. The clustering analyses show that policy changes affect spatial distribution of non-medical exemptions within a state.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.Immunization requirements for school-entry date back to 1922 and have played a key role in 1 achieving high levels of vaccine coverage against communicable diseases in the United States 2 [1]. This patchwork of childhood immune protection, however, is punctured by a hetero-3 geneous set of state-specific vaccination exemption rules. Medical exemptions to mandated 4 vaccinations are available in all 50 states, and 47 offer non-medical exemptions in some form. 5Namely, 18 states offer personal belief exemptions for those who object to vaccinations for 6 philosophical or moral reasons. In the remaining states offering non-medical exemptions, 7 they are limited to religious beliefs. In the remaining three states (California, Mississippi, 8 and West Virginia), only medical exemptions are available. While this has been the policy 9 in Mississippi and West Virginia for decades [2], the ban on non-medical exemptions in Cal-10 ifornia (enacted by CA Senate Bill 277 in January 2016) was motivated by the 2015 measles 11 outbreak in the state [3] in which suboptimal vaccination rates in school-aged children was 12 an important factor in the magnitude of the outbreak [4]. 13The ease of obtaining non-medical exemptions vari...

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“…The policy debate surrounding vaccine hesitancy in the US has focused on vaccine exemptions, which provide an option for parents to waive current vaccination requirements for entry into school or daycare [9–11]. Currently, 18 states allow nonmedical exemptions to school vaccine requirements based on philosophical, personal, or other beliefs [4, 12].…”

Section: Introductionmentioning

confidence: 99%

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

et al. 2019

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BackgroundVaccine 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 findingsWe 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.ConclusionsIn 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 exem...

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Achieving an Optimal Childhood Vaccine Policy

Abstract: Conflict of Interest Disclosures: Dr Opel is supported by the Greenwall Faculty Scholars Program in Bioethics. Dr Kodish has had consulting relationships with Biogen and Solid GT to provide guidance on matters of research ethics. No other disclosures are reported.

Cited by 22 publications

References 25 publications

The state of the antivaccine movement in the United States: A focused examination of nonmedical exemptions in states and counties

The state of the antivaccine movement in the United States: A focused examination of nonmedical exemptions in states and counties

Getting personal: how vaccination exemptions shape herd immunity

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

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