Nonmedical exemptions to school immunization requirements: Secular trends and association of state policies with pertussis incidence

Saad B. Omer, William K Y Pan, Neal A Halsey, Shannon Stokley, Lawrence Hale Moulton, Ann Marie Navar, Mathew Pierce, Daniel Salmon

Research output: Contribution to journalArticle

Abstract

Context: School immunization requirements have played a major role in controlling vaccine-preventable diseases in the United States. Most states offer nonmedical exemptions to school requirements (religious or personal belief). Exemptors are at increased risk of acquiring and transmitting disease. The role of exemption policies may be especially important for pertussis, which is endemic in the United States. Objective: To determine if (1) the rates of nonmedical exemptions differ and have been increasing in states that offer only religious vs personal belief exemptions; (2) the rates of nonmedical exemptions differ and have been increasing in states that have easy vs medium and easy vs difficult processes for obtaining exemptions; and (3) pertussis incidence is associated with policies of granting personal belief exemptions, ease of obtaining exemptions, and acceptance of parental signature as sufficient proof of compliance with school immunization requirements. Design, Setting, and Participants: We analyzed 1991 through 2004 state-level rates of nonmedical exemptions at school entry and 1986 through 2004 pertussis incidence data for individuals aged 18 years or younger. Main Outcome Measures: State-level exemption rates and pertussis incidence. Results: From 2001 through 2004, states that permitted personal belief exemptions had higher nonmedical exemption rates than states that offered only religious exemptions, and states that easily granted exemptions had higher nonmedical exemption rates in 2002 through 2003 compared with states with medium and difficult exemption processes. The mean exemption rate increased an average of 6% per year, from 0.99% in 1991 to 2.54% in 2004, among states that offered personal belief exemptions. In states that easily granted exemptions, the rate increased 5% per year, from 1.26% in 1991 to 2.51% in 2004. No statistically significant change was seen in states that offered only religious exemptions or that had medium and difficult exemption processes. In multivariate analyses adjusting for demographics, easier granting of exemptions (incidence rate ratio=1.53; 95% confidence interval, 1.10-2.14) and availability of personal belief exemptions (incidence rate ratio=1.48; 95% confidence interval, 1.03-2.13) were associated with increased pertussis incidence. Conclusions: Permitting personal belief exemptions and easily granting exemptions are associated with higher and increasing nonmedical US exemption rates. State policies granting personal belief exemptions and states that easily grant exemptions are associated with increased pertussis incidence. States should examine their exemption policies to ensure control of pertussis and other vaccine-preventable diseases.

Original languageEnglish (US)
Pages (from-to)1757-1763
Number of pages7
JournalJournal of the American Medical Association
Volume296
Issue number14
DOIs
StatePublished - Oct 11 2006

Fingerprint

Whooping Cough
Immunization
Incidence
Confidence Intervals
Pertussis Vaccine
Vaccines
Multivariate Analysis
Demography
Outcome Assessment (Health Care)

ASJC Scopus subject areas

  • Medicine(all)

Cite this

Nonmedical exemptions to school immunization requirements : Secular trends and association of state policies with pertussis incidence. / Omer, Saad B.; Pan, William K Y; Halsey, Neal A; Stokley, Shannon; Moulton, Lawrence Hale; Navar, Ann Marie; Pierce, Mathew; Salmon, Daniel.

In: Journal of the American Medical Association, Vol. 296, No. 14, 11.10.2006, p. 1757-1763.

Research output: Contribution to journalArticle

@article{6b41aecb1a884b6d9feb74804401cf6b,
title = "Nonmedical exemptions to school immunization requirements: Secular trends and association of state policies with pertussis incidence",
abstract = "Context: School immunization requirements have played a major role in controlling vaccine-preventable diseases in the United States. Most states offer nonmedical exemptions to school requirements (religious or personal belief). Exemptors are at increased risk of acquiring and transmitting disease. The role of exemption policies may be especially important for pertussis, which is endemic in the United States. Objective: To determine if (1) the rates of nonmedical exemptions differ and have been increasing in states that offer only religious vs personal belief exemptions; (2) the rates of nonmedical exemptions differ and have been increasing in states that have easy vs medium and easy vs difficult processes for obtaining exemptions; and (3) pertussis incidence is associated with policies of granting personal belief exemptions, ease of obtaining exemptions, and acceptance of parental signature as sufficient proof of compliance with school immunization requirements. Design, Setting, and Participants: We analyzed 1991 through 2004 state-level rates of nonmedical exemptions at school entry and 1986 through 2004 pertussis incidence data for individuals aged 18 years or younger. Main Outcome Measures: State-level exemption rates and pertussis incidence. Results: From 2001 through 2004, states that permitted personal belief exemptions had higher nonmedical exemption rates than states that offered only religious exemptions, and states that easily granted exemptions had higher nonmedical exemption rates in 2002 through 2003 compared with states with medium and difficult exemption processes. The mean exemption rate increased an average of 6{\%} per year, from 0.99{\%} in 1991 to 2.54{\%} in 2004, among states that offered personal belief exemptions. In states that easily granted exemptions, the rate increased 5{\%} per year, from 1.26{\%} in 1991 to 2.51{\%} in 2004. No statistically significant change was seen in states that offered only religious exemptions or that had medium and difficult exemption processes. In multivariate analyses adjusting for demographics, easier granting of exemptions (incidence rate ratio=1.53; 95{\%} confidence interval, 1.10-2.14) and availability of personal belief exemptions (incidence rate ratio=1.48; 95{\%} confidence interval, 1.03-2.13) were associated with increased pertussis incidence. Conclusions: Permitting personal belief exemptions and easily granting exemptions are associated with higher and increasing nonmedical US exemption rates. State policies granting personal belief exemptions and states that easily grant exemptions are associated with increased pertussis incidence. States should examine their exemption policies to ensure control of pertussis and other vaccine-preventable diseases.",
author = "Omer, {Saad B.} and Pan, {William K Y} and Halsey, {Neal A} and Shannon Stokley and Moulton, {Lawrence Hale} and Navar, {Ann Marie} and Mathew Pierce and Daniel Salmon",
year = "2006",
month = "10",
day = "11",
doi = "10.1001/jama.296.14.1757",
language = "English (US)",
volume = "296",
pages = "1757--1763",
journal = "JAMA - Journal of the American Medical Association",
issn = "0098-7484",
publisher = "American Medical Association",
number = "14",

}

TY - JOUR

T1 - Nonmedical exemptions to school immunization requirements

T2 - Secular trends and association of state policies with pertussis incidence

AU - Omer, Saad B.

AU - Pan, William K Y

AU - Halsey, Neal A

AU - Stokley, Shannon

AU - Moulton, Lawrence Hale

AU - Navar, Ann Marie

AU - Pierce, Mathew

AU - Salmon, Daniel

PY - 2006/10/11

Y1 - 2006/10/11

N2 - Context: School immunization requirements have played a major role in controlling vaccine-preventable diseases in the United States. Most states offer nonmedical exemptions to school requirements (religious or personal belief). Exemptors are at increased risk of acquiring and transmitting disease. The role of exemption policies may be especially important for pertussis, which is endemic in the United States. Objective: To determine if (1) the rates of nonmedical exemptions differ and have been increasing in states that offer only religious vs personal belief exemptions; (2) the rates of nonmedical exemptions differ and have been increasing in states that have easy vs medium and easy vs difficult processes for obtaining exemptions; and (3) pertussis incidence is associated with policies of granting personal belief exemptions, ease of obtaining exemptions, and acceptance of parental signature as sufficient proof of compliance with school immunization requirements. Design, Setting, and Participants: We analyzed 1991 through 2004 state-level rates of nonmedical exemptions at school entry and 1986 through 2004 pertussis incidence data for individuals aged 18 years or younger. Main Outcome Measures: State-level exemption rates and pertussis incidence. Results: From 2001 through 2004, states that permitted personal belief exemptions had higher nonmedical exemption rates than states that offered only religious exemptions, and states that easily granted exemptions had higher nonmedical exemption rates in 2002 through 2003 compared with states with medium and difficult exemption processes. The mean exemption rate increased an average of 6% per year, from 0.99% in 1991 to 2.54% in 2004, among states that offered personal belief exemptions. In states that easily granted exemptions, the rate increased 5% per year, from 1.26% in 1991 to 2.51% in 2004. No statistically significant change was seen in states that offered only religious exemptions or that had medium and difficult exemption processes. In multivariate analyses adjusting for demographics, easier granting of exemptions (incidence rate ratio=1.53; 95% confidence interval, 1.10-2.14) and availability of personal belief exemptions (incidence rate ratio=1.48; 95% confidence interval, 1.03-2.13) were associated with increased pertussis incidence. Conclusions: Permitting personal belief exemptions and easily granting exemptions are associated with higher and increasing nonmedical US exemption rates. State policies granting personal belief exemptions and states that easily grant exemptions are associated with increased pertussis incidence. States should examine their exemption policies to ensure control of pertussis and other vaccine-preventable diseases.

AB - Context: School immunization requirements have played a major role in controlling vaccine-preventable diseases in the United States. Most states offer nonmedical exemptions to school requirements (religious or personal belief). Exemptors are at increased risk of acquiring and transmitting disease. The role of exemption policies may be especially important for pertussis, which is endemic in the United States. Objective: To determine if (1) the rates of nonmedical exemptions differ and have been increasing in states that offer only religious vs personal belief exemptions; (2) the rates of nonmedical exemptions differ and have been increasing in states that have easy vs medium and easy vs difficult processes for obtaining exemptions; and (3) pertussis incidence is associated with policies of granting personal belief exemptions, ease of obtaining exemptions, and acceptance of parental signature as sufficient proof of compliance with school immunization requirements. Design, Setting, and Participants: We analyzed 1991 through 2004 state-level rates of nonmedical exemptions at school entry and 1986 through 2004 pertussis incidence data for individuals aged 18 years or younger. Main Outcome Measures: State-level exemption rates and pertussis incidence. Results: From 2001 through 2004, states that permitted personal belief exemptions had higher nonmedical exemption rates than states that offered only religious exemptions, and states that easily granted exemptions had higher nonmedical exemption rates in 2002 through 2003 compared with states with medium and difficult exemption processes. The mean exemption rate increased an average of 6% per year, from 0.99% in 1991 to 2.54% in 2004, among states that offered personal belief exemptions. In states that easily granted exemptions, the rate increased 5% per year, from 1.26% in 1991 to 2.51% in 2004. No statistically significant change was seen in states that offered only religious exemptions or that had medium and difficult exemption processes. In multivariate analyses adjusting for demographics, easier granting of exemptions (incidence rate ratio=1.53; 95% confidence interval, 1.10-2.14) and availability of personal belief exemptions (incidence rate ratio=1.48; 95% confidence interval, 1.03-2.13) were associated with increased pertussis incidence. Conclusions: Permitting personal belief exemptions and easily granting exemptions are associated with higher and increasing nonmedical US exemption rates. State policies granting personal belief exemptions and states that easily grant exemptions are associated with increased pertussis incidence. States should examine their exemption policies to ensure control of pertussis and other vaccine-preventable diseases.

UR - http://www.scopus.com/inward/record.url?scp=33749659678&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=33749659678&partnerID=8YFLogxK

U2 - 10.1001/jama.296.14.1757

DO - 10.1001/jama.296.14.1757

M3 - Article

C2 - 17032989

AN - SCOPUS:33749659678

VL - 296

SP - 1757

EP - 1763

JO - JAMA - Journal of the American Medical Association

JF - JAMA - Journal of the American Medical Association

SN - 0098-7484

IS - 14

ER -