Change in Medical Exemptions From Immunization in California After Elimination of Personal Belief Exemptions

Abstract

California Senate bill (SB) 277 eliminated the personal belief exemption (PBE) provision from the state's school-entry vaccine mandates prior to the 2016-2017 school year. Previously, vaccine-hesitant parents could acquire a PBE for their child based on philosophical or religious beliefs. Now, the only pathway for an unvaccinated kindergartener to enter a public or private school in California is with a medical exemption (ME), which requires a written statement from a licensed physician describing the medical reasons that immunization is unsafe. 1 Previously, MEs were only granted to children with a contraindication to vaccination; however, SB 277 gave physicians broader discretion to grant MEs for reasons other than a contraindication, including family medical history. 2,3 One concern voiced after the passage of SB 277 was whether vaccine-hesitant parents would seek MEs as replacements for PBEs and would find physicians willing to oblige them. 4 We evaluated the statewide change in MEs in the first year under SB 277 and whether MEs increased in regions with high PBE use prior to its enactment.Methods | We used publicly available data from the California Department of Public Health's yearly Kindergarten Immunization Assessment reports. Each year, all schools are required to submit kindergarten enrollment, vaccination, and exemption data; more than 95% of all kindergarteners are represented in the yearly reports, which include statewide and county-level data. We extracted the statewide ME and PBE percentages for incoming kindergarteners from 1996 to 2016. We calculated and mapped the 1-year change in ME percentage (2015 to 2016) for counties and used Pearson correlation to test whether county-level change in ME percentage was associated with PBE use in the year prior to the implementation of SB 277. We used ArcGIS (Esri), version 10.

Getting personal: how vaccination exemptions shape herd immunity

“…Indeed, both the increase in religious exemptions in Vermont and in medical exemptions in California points towards parents seeking alternative exemptions whenever possible. The positive relationship between increase in medical exemptions and past rates of non-medical exemptions at the county level in California also supports this idea [19]. An increase in medical exemption could be expected in response to any increase in the difficult of obtaining non-medical exemptions [11].…”

“…The decrease also appeared much slower in the second year after philosophical exemptions were banned. Similarly, in California, the sharp decrease in non-medical exemption rates was partly matched by a concurrent increase of medical exemptions from 0.17% in 2015-2016 to 0.51% in 2016-2017 (Figure 2B), probably in relation to how California Senate Bill 277 has provided for more physician discretion in the assessment of medical exemptions [19]. Reported exemption levels reached near zero as early as 2017-2018.…”

“…However, states where non-medical exemptions are hard to obtain have only slightly higher medical exemption rates if the procedure to obtain these exemptions remains stringent [38]. 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].…”

“…In addition, in 2016, Vermont disallowed philosophical exemptions to only allow religious exemptions [18]. Finally, the state of California has strengthened its school immunization policies twice in the past decade: non-medical exemptions were made harder to obtain in 2013, and in 2015 new non-medical exemptions were barred from the beginning of the 2016-2017 school year [19]. For these states, we compiled data on non-medical exemptions in kindergartens from the Centers for Disease Control and Prevention (CDC) online annual school report results between 2003-2004 and 2010-2011, and from published annual surveys from school year 2011-2012 to school year 2017-2018 [20, 21, 22, 14, 23, 24, 15].…”

The Roles of Neighborhood Composition and Autism Prevalence on Vaccination Exemption Pockets: A Population-wide Study

“…California now prohibits PBEs. However, disallowing PBEs seems to have driven some parents to medical exemptions (38). Banning PBEs could also concentrate unvaccinated children in independent study schools (39, 40).…”