Experiences With Medical Exemptions After a Change in Vaccine Exemption Policy in California

Mohanty, Salini; Buttenheim, Alison M.; Joyce, Caroline M.; Howa, Amanda C.; Salmon, Daniel A.; Omer, Saad B.

doi:10.1542/peds.2018-1051

Cited by 39 publications

(31 citation statements)

References 14 publications

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“…22 Local health officers and immunization staff in California have expressed concerns over the validity of medical exemptions post-SB277 and physicians who are potentially "selling" them. 23 The state-level increases and the high correlation between 2017 medical exemption rates and pre-SB277 personal belief exemption rates (Fig 2D) offer additional evidence that parents have been seeking (and physicians have been providing) medical exemptions under potentially questionable circumstances since SB277 was implemented. Recently, a prominent California physician was put on probation by the state's medical board for providing an improper medical exemption, and .25 similar complaints are pending against other physicians.…”

Section: Discussionmentioning

confidence: 90%

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

Delamater

Pingali²,

Buttenheim

et al. 2019

Pediatrics

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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.

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Section: Discussionmentioning

confidence: 90%

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

Delamater

Pingali²,

Buttenheim

et al. 2019

Pediatrics

Self Cite

View full text Add to dashboard Cite

show abstract

“…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].…”

Section: Discussionmentioning

confidence: 99%

Getting personal: how vaccination exemptions shape herd immunity

Garnier

Sb³

et al. 2018

Preprint

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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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“…In all states, medical exemptions from immunizations can be obtained for conditions such as those resulting in immunosuppression or in cases of known adverse reaction to past immunizations. These exemptions have traditionally remained at levels low enough to not represent a threat to herd immunity, although recent dynamics such as that observed in California may change this assessment in the future [4][5][6] . Most other states offer religious exemptions, in which individuals cite personal religious beliefs that preclude vaccination, while others allow philosophical exemptions, which encompasses any personal belief against receiving a vaccination.…”

Section: Background and Summarymentioning

confidence: 99%

The landscape of childhood vaccine exemptions in the United States

et al. 2020

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Once-eliminated vaccine-preventable childhood diseases, such as measles, are resurging across the United States. Understanding the spatio-temporal trends in vaccine exemptions is crucial to targeting public health intervention to increase vaccine uptake and anticipating vulnerable populations as cases surge. However, prior available data on childhood disease vaccination is either at too rough a spatial scale for this spatially-heterogeneous issue, or is only available for small geographic regions, making general conclusions infeasible. Here, we have collated school vaccine exemption data across the United States and provide it at the county-level for all years included. We demonstrate the fine-scale spatial heterogeneity in vaccine exemption levels, and show that many counties may fall below the herd immunity threshold. We also show that vaccine exemptions increase over time in most states, and non-medical exemptions are highly prevalent where allowed. Our dataset also highlights the need for greater data sharing and standardized reporting across the United States.

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Experiences With Medical Exemptions After a Change in Vaccine Exemption Policy in California

Cited by 39 publications

References 14 publications

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

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

Getting personal: how vaccination exemptions shape herd immunity

The landscape of childhood vaccine exemptions in the United States

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