Elimination of Nonmedical Immunization Exemptions in California and School-Entry Vaccine Status

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. WHAT'S KNOWN ON THIS SUBJECT: Recently, California has attempted to increase the number of kindergarteners entering school who are fully up-to-date on required vaccinations. SB277 eliminated the nonmedical exemption option; however, the law also contains several provisions allowing students not up-to-date to enter school. WHAT THIS STUDY ADDS: We found that the percentage of kindergarteners who were not up-to-date on school-entry vaccinations decreased after eliminating nonmedical exemptions. However, we found evidence that nonmedical exemptions were replaced by other mechanisms allowing kindergarteners not up-to-date on vaccinations to enter school.

Mandate vaccination with care

“…In 2015, California became the third US state to eliminate all non-medical exemptions, and the first state to do so in more than three decades. This change in the law was preceded by a 2014 administrative initiative to reduce the misuse of a school admission process involving 'conditional entrants' -children who have started the required vaccination schedule but haven't completed it 6 . (Since 1979, children in California have been allowed to attend school as conditional entrants -but before 2014, only some schools followed up with parents, and some children were never fully vaccinated 6 .…”

“…However, this change seems to be mainly associated with the administrative crackdown on conditional entrants. Following the elimination of non-medical exemptions, many parents with strong objections to vaccination simply acquired medical exemptions instead, educated their children at home, enrolled them in independent study programmes that do not require classroom-based instruction, or found other loopholes 6 .…”

Religious Vaccine Exemptions in Kindergartners: 2011–2018

“…In 2016, California eliminated all nonmedical exemptions. 1 Delamater et al 21 studied the rate of medical exemptions in California before and after the legislative change, finding that medical exemptions decreased in the first year after the change. However, by the second year, medical exemption rates rose, and geographic analyses showed that the areas with rising medical exemption rates coincided with areas that previously had high rates of nonmedical exemptions.…”

The landscape of childhood vaccine exemptions in the United States

“…The case of California highlights the importance of studying exemption trends across time. We see that there is a plunge in exemptions following the removal of non-medical exemptions followed by an increase in the exemption level, perhaps indicating that vaccine hesitant individuals found other means to obtain exemptions 3,4,18 . Figure 4 demonstrates total exemptions across data reported years by state, broken down into medical exemptions, religious exemptions, philosophical exemptions, or unknown.…”