Personal belief exemptions (PBEs) from mandated school entry vaccinations have increased in California over the past decade. Infectious disease outbreaks in the state may be associated with the aggregation of intentionally unvaccinated children within schools. We sought to quantify the exposure of California kindergartners to children with PBEs at school.
We used cross-sectional California Department of Public Health data on 3 kindergarten cohorts to define and calculate multiple measures of exposure to children with exemptions, including interaction and aggregation indices, for the state as a whole (2008-2010) and by county (2010).
In 2010, the PBE rate in California was 2.3 per 100 students, and the school PBE rate for the average kindergartner with a PBE was 15.6 per 100. More than 7000 kindergartners in California attend schools with PBE rates greater than 20 per 100, including 2700 kindergartners with PBEs. Exposure measures vary considerably across counties.
Our results suggest increasing levels of exposure among kindergarten students in California to other kindergartners with PBEs. Our data provide a concrete set of metrics through which public health and education officials can identify high-risk areas as targets for policy and programmatic interventions.
[Show abstract][Hide abstract] ABSTRACT: Previous models of vaccine education have not addressed differences in levels and motives of vaccine concerns in parents. These differences may require changes in education approaches based on type of parental concern. Addressing vaccine concerns will require a multi-modal approach involving more than just a pediatrician or primary health care provider, as well as more than one educational approach.
[Show abstract][Hide abstract] ABSTRACT: Many pediatric practices have adopted vaccine policies that require parents who refuse to vaccinate according to the ACIP schedule to find another health care provider. Such policies may inadvertently cluster unvaccinated patients into practices that tolerate non vaccination or alternative schedules, turning them into risky pockets of low herd immunity. The objective of this study was to assess the effect of provider zero-tolerance vaccination policies on the clustering of intentionally unvaccinated children. We developed an agent-based model of parental vaccine hesitancy, provider non-vaccination tolerance, and selection of patients into pediatric practices. We ran 84 experiments across a range of parental hesitancy and provider tolerance scenarios. When the model is initialized, all providers accommodate refusals and intentionally unvaccinated children are evenly distributed across providers. As provider tolerance decreases, hesitant children become more clustered in a smaller number of practices and eventually are not able to find a practice that will accept them. Each of these effects becomes more pronounced as the level of hesitancy in the population rises. Heterogeneity in practice tolerance to vaccine hesitant parents has the unintended result of concentrating susceptible individuals within a small number of tolerant practices, while providing little if any compensatory protection to adherent individuals. These externalities suggest an agenda for stricter policy regulation of individual practice decisions.
[Show abstract][Hide abstract] ABSTRACT: The intention to delay or avoid vaccines that are recommended by the Advisory Committee on Immunization Practices can be described as "vaccine hesitancy." While outright refusal of all vaccines is uncommon, hesitancy is seen on a regular basis in most primary care offices, resulting in immunization delay and prolonged susceptibility to preventable disease. The consequences of vaccine hesitancy include the potential for resurgence of vaccine preventable infections. Open, honest, and frank discussions with hesitant patients and their families can assist in their understanding of the importance of vaccines. While many experienced providers are able to do so in an intuitive manner, others may benefit from developing a systemic framework for such discussions. An understanding of the history and rationale for vaccine hesitancy is a first step in regaining lost public confidence in our robust immunization programs.
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