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      Trends in Personal Belief Exemption Rates Among Alternative Private Schools: Waldorf, Montessori, and Holistic Kindergartens in California, 2000–2014

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          Abstract

          <p class="first" id="d493836e164"> <i>Objectives.</i> To evaluate trends in rates of personal belief exemptions (PBEs) to immunization requirements for private kindergartens in California that practice alternative educational methods. </p><p id="d493836e169"> <i>Methods.</i> We used California Department of Public Health data on kindergarten PBE rates from 2000 to 2014 to compare annual average increases in PBE rates between schools. </p><p id="d493836e174"> <i>Results.</i> Alternative schools had an average PBE rate of 8.7%, compared with 2.1% among public schools. Waldorf schools had the highest average PBE rate of 45.1%, which was 19 times higher than in public schools (incidence rate ratio = 19.1; 95% confidence interval = 16.4, 22.2). Montessori and holistic schools had the highest average annual increases in PBE rates, slightly higher than Waldorf schools (Montessori: 8.8%; holistic: 7.1%; Waldorf: 3.6%). </p><p id="d493836e179"> <i>Conclusions.</i> Waldorf schools had exceptionally high average PBE rates, and Montessori and holistic schools had higher annual increases in PBE rates. Children in these schools may be at higher risk for spreading vaccine-preventable diseases if trends are not reversed. </p>

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          Vaccine hesitancy: Causes, consequences, and a call to action.

          Vaccine hesitancy reflects concerns about the decision to vaccinate oneself or one's children. There is a broad range of factors contributing to vaccine hesitancy, including the compulsory nature of vaccines, their coincidental temporal relationships to adverse health outcomes, unfamiliarity with vaccine-preventable diseases, and lack of trust in corporations and public health agencies. Although vaccination is a norm in the U.S. and the majority of parents vaccinate their children, many do so amid concerns. The proportion of parents claiming non-medical exemptions to school immunization requirements has been increasing over the past decade. Vaccine refusal has been associated with outbreaks of invasive Haemophilus influenzae type b disease, varicella, pneumococcal disease, measles, and pertussis, resulting in the unnecessary suffering of young children and waste of limited public health resources. Vaccine hesitancy is an extremely important issue that needs to be addressed because effective control of vaccine-preventable diseases generally requires indefinite maintenance of extremely high rates of timely vaccination. The multifactorial and complex causes of vaccine hesitancy require a broad range of approaches on the individual, provider, health system, and national levels. These include standardized measurement tools to quantify and locate clustering of vaccine hesitancy and better understand issues of trust; rapid, independent, and transparent review of an enhanced and appropriately funded vaccine safety system; adequate reimbursement for vaccine risk communication in doctors' offices; and individually tailored messages for parents who have vaccine concerns, especially first-time pregnant women. The potential of vaccines to prevent illness and save lives has never been greater. Yet, that potential is directly dependent on parental acceptance of vaccines, which requires confidence in vaccines, healthcare providers who recommend and administer vaccines, and the systems to make sure vaccines are safe.
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            Geographic clustering of nonmedical exemptions to school immunization requirements and associations with geographic clustering of pertussis.

            School immunization requirements are important in controlling vaccine-preventable diseases in the United States. Forty-eight states offer nonmedical exemptions to school immunization requirements. Children with exemptions are at increased risk of contracting and transmitting vaccine-preventable diseases. The clustering of nonmedical exemptions can affect community risk of vaccine-preventable diseases. The authors evaluated spatial clustering of nonmedical exemptions in Michigan and geographic overlap between exemptions clusters and clusters of reported pertussis cases. Kulldorf's scan statistic identified 23 statistically significant census tract clusters for exemption rates and 6 significant census tract clusters for reported pertussis cases between 1993 and 2004. The time frames for significant space-time pertussis clusters were August 1993-September 1993, August 1994-February 1995, May 1998-June 1998, April 2002, May 2003-July 2003, and June 2004-November 2004. Census tracts in exemptions clusters were more likely to be in pertussis clusters (odds ratio = 3.0, 95% confidence interval: 2.5, 3.6). The overlap of exemptions clusters and pertussis clusters remained significant after adjustment for population density, proportion of racial/ethnic minorities, proportion of children aged 5 years or younger, percentage of persons below the poverty level, and average family size (odds ratio = 2.7, 95% confidence interval: 2.2, 3.3). Geographic pockets of vaccine exemptors pose a risk to the whole community. In addition to monitoring state-level exemption rates, health authorities should be mindful of within-state heterogeneity.
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              Nonmedical exemptions to school immunization requirements: secular trends and association of state policies with pertussis incidence.

              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. 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. 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. State-level exemption rates and pertussis incidence. 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. 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.
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                Author and article information

                Journal
                American Journal of Public Health
                Am J Public Health
                American Public Health Association
                0090-0036
                1541-0048
                January 2017
                January 2017
                : 107
                : 1
                : 108-112
                Article
                10.2105/AJPH.2016.303498
                5207363
                27854520
                350931d1-18b9-4dd5-af52-7c480fec9c33
                © 2017
                History

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