Exemptions From Mandatory Immunization After Legally Mandated Parental Counseling

Omer, Saad B.; Allen, Kristen; Chang, Ding; Guterman, L. Beryl; Bednarczyk, Robert A.; Jordan, Lyndon Alexander; Buttenheim, Alison M.; Jones, Malia; Hannan, Claire; deHart, M. Patricia; Salmon, Daniel A.

doi:10.1542/peds.2017-2364

Cited by 37 publications

(36 citation statements)

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“…(While this figure includes medical exemptions, these made up a very small fraction of the total number of exemptions.) [56] In the context of large pertussis outbreaks in multiple states in 2010 that included Washington, the state health department submitted an agency request to the legislature for a change in the state's exemption law. They sought to "Reduce the convenience of nonmedical exemptions only to the extent exempting is equal to the effort required to vaccinate (or provide proof of vaccination)" and "Increase public education and awareness of the dangers of vaccine-preventable disease and the benefits of immunization."…”

Section: Washingtonmentioning

confidence: 99%

Recent vaccine mandates in the United States, Europe and Australia: A comparative study

Attwell

Navin

Lopalco

et al. 2018

Vaccine

Self Cite

110

135

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Background In response to recent outbreaks of vaccine-preventable diseases and concerns around vaccine refusal, several high-income countries have adopted or reformed vaccine mandate policies. While all make it more difficult for parents to refuse vaccines, the nature and scope of 'mandatory vaccination' is heterogeneous, and there has been no attempt to develop a detailed, comparative systematic account of the possible forms mandates can take. Methods We compare the construction, introduction / amendment, and operation of six new high profile vaccine mandates in Australia, France, Germany, Italy, California, and Washington. We rank these policies in order of their relative restrictiveness and analyze other differences between them. Results New mandate instruments differ in their effects on behavior, and with regard to their structure, exemptions, target populations, consequences and enforcement. We identify diverse means by which vaccine mandates can restrict behaviors, various degrees of severity, and different gradations of intensity in enforcement. Conclusion We suggest that politico-cultural context and vaccine policy history are centrally important factors for vaccine mandate policymakers to consider. It matters whether citizens trust their governments to limit individual freedom in the name of public health, and whether citizens have previously been subjected to vaccine mandates. Furthermore, political communities must consider the diverse mechanisms by which they may construct vaccine mandate policies; whether through emergency decrees or ordinary statutes, and how (or whether) to involve various stakeholder groups in developing and implementing new vaccine mandate policies.

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Section: Washingtonmentioning

confidence: 99%

Recent vaccine mandates in the United States, Europe and Australia: A comparative study

Attwell

Navin

Lopalco

et al. 2018

Vaccine

Self Cite

110

135

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show abstract

“…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]. 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].…”

Section: Discussionmentioning

confidence: 93%

“…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%

“…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]. Variable proportions of conditional admissions could, for instance, partly explain the noise in the association between NME rates and vaccination rates.…”

Section: Discussionmentioning

confidence: 99%

“…Childhood vaccination rates tend to be lower in states with more permissive exemption policies [9], and a recent analysis has shown that in states allowing personal belief exemptions, higher levels of exemptions were associated with lower levels of measles, mumps, and rubella (MMR) vaccination in children attending kindergarten in the school year 20162017 [10]. Change in vaccination mandates increasing the difficulty for parents to obtain non-medical exemptions have had positive impacts on vaccination rates, including in Washington in 2011 [11] and California from the 2012-2013 school year [12]. However, assessing the association between policy changes and non-medical exemption rates remains necessary in other states and policy contexts.…”

Section: Introductionmentioning

confidence: 99%

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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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The True Cost of Measles Outbreaks During the Postelimination Era

Sundaram

Guterman

Omer

2019

JAMA

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A large measles outbreak in Washington State has prompted officials to declare a state of emergency. As of March 4, 2019, the Washington State Health Department reported 71 confirmed cases, 1 with the majority of cases among individuals who were not vaccinated or who had an unverified vaccination status. The outbreak is centered in a geographic cluster of persistently high vaccine exemption rates among young children. 2 This cluster has persisted despite the overall reduction in vaccine exemptions in the state of Washington, subsequent to the introduction of legally mandated health care practitioner counseling of parents seeking vaccine exemptions. 2 During the past 5 years, a series of similar measles outbreaks have occurred across the United States. In 2014, a large outbreak of 383 cases, occurring primarily among unvaccinated Amish communities in Ohio, was associated with a large measles outbreak in the Philippines. In 2014-2015, a large measles outbreak first reported at Disneyland in California resulted in 147 cases of measles. 3 In 2017, a 75-case outbreak was reported in Minnesota in a Somali-American community with poor vaccination coverage. This community was the focus of some antivaccination advocates.

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Exemptions From Mandatory Immunization After Legally Mandated Parental Counseling

Abstract: States in the United States and jurisdictions in other countries should consider adding parental counseling by health care provider as a requirement for obtaining exemptions to vaccination requirements.

Cited by 37 publications

References 15 publications

Recent vaccine mandates in the United States, Europe and Australia: A comparative study

Recent vaccine mandates in the United States, Europe and Australia: A comparative study

Getting personal: how vaccination exemptions shape herd immunity

The True Cost of Measles Outbreaks During the Postelimination Era

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