Personal Belief Exemptors (PBEs) Vaccination Status of CA Kindergarten Personal Belief Exemptors (PBEs) Teresa Lee MPH, Madina Sharifi MSW , and Steve Nickell PhD School Assessments Program Immunization Branch California Department of Public Health NIC April 2010

School Assessment Overview In Fall, schools with Kindergartens are required by law (CHSC§120375(c) & CCR§6075) to report the immunization status of new entrants – most of reporting (99%) is now submitted online In Spring, 3% to 5% of schools with kindergarten are randomly selected for follow-up validation of immunization status. LHD staff conduct school site visits, interview school staff, xerox official School IZ Records, and IZ data entered into a database. Data are used to estimate age-specific, e.g. 19-35 mos., immunization status of this CA cohort In Fall, schools with Kindergartens are required by law (CHSC§120375(c) & CCR§6075) to report the immunization status of new entrants – most of reporting (99%) is now done online In Spring, 3% to 5% of schools with kindergarten are randomly chosen for follow-up validation of immunization status. LHD staff visit schools, xerox official School IZ Records, and IZ data entered into a database. Data are used to estimate age-specific, e.g. 19-35 mos., immunization of this CA cohort

CA School Immunization Law Immunization Requirements at Kindergarten Entry: 4+ DTP, 3+ Pol, 2 MMR, 3 Hep B, 1 Var Exemptions and Procedure Permanent and Temporary Medical Personal Beliefs (PBE) “shall be granted upon filing with the [school] a letter or affidavit from the pupil’s parent…that such immunization is contrary to his or her beliefs” School immunization requirements have a played a major role in controlling vaccine-preventable diseases in the U.S. California school immunization law requires kindergartners at school entry to have received 4 doses of DTP, 3 doses of Polio, 2 doses of MMR, 3 doses of Hepatitis B and 1 dose of varicella. Kindergarten students are allowed permanent and temporary medical exemptions as well as personal beliefs exemptions. A personal beliefs exemption “shall be granted upon filing with the school a letter of affividat from the pupil’s parent…that such immunization is contrary to his or her beliefs”.

1977: Requirements for DTP, polio, measles passed, effective Jan 1, 1978; Started annual assessments 1979: Requirements for mumps and rubella added, effective Jan 1, 1980 1995: Requirement for hepatitis B added, effective Aug 1, 1997 1999: Requirement for varicella added, effective Jul 1, 2001

Rates of PBEs Among Children Entering Kindergarten by County, 2000 vs. 2008 In 2000, only one county indicated in red, had more than 5% of its kindergarten students taking a personal beliefs exemption.

Rates of PBEs Among Children Entering Kindergarten by County, 2000 vs. 2008 In 2000, only one county indicated in red, had more than 5% of its kindergarten students taking a personal beliefs exemption.

Number and Percentage of CA Kindergartens. with > 10% PBEs, 2000 vs 421 (5.9%) 148 (2.0%) 2000: Total Number of Schools with Kindergarten: 8473 Total Number of Schools with Kindergarten Enrollment ≥ 10: 7418 Total Number of Schools with Kindergarten Enrollment ≥ 10 with ≥ 10 % PBEs: 148 % of Schools with K Enrollment ≥ 10 with ≥ 10 % PBEs: (148/7418)*100: 2% 2008: Total Number of Schools with Kindergarten: 8219 Total Number of Schools with Kindergarten Enrollment ≥ 10: 7173 Total Number of Schools with Kindergarten Enrollment ≥ 10 with ≥ 10 % PBEs: 421 % of Schools with K Enrollment ≥ 10 with ≥ 10 % PBEs: (421/7173)*100: 5.9% *Kindergarten Enrollment ≥ 10 students

Number and Percentage of CA Kindergartens. with > 10% PBEs, 2000 vs Between 2000 to 2008, there has been a more than two fold increase in the number and percent of schools with greater than 10 percent personal beliefs exemptions among kindergarten students. 2000: Total Number of Schools with Kindergarten: 8473 Total Number of Schools with Kindergarten Enrollment ≥ 10: 7418 Total Number of Schools with Kindergarten Enrollment ≥ 10 with ≥ 10 % PBEs: All: 148; Public: 59 ; Private: 89 % of Schools with K Enrollment ≥ 10 with ≥ 10 % PBEs: (148/7418)*100: 2% 2008: Total Number of Schools with Kindergarten: 8219 Total Number of Schools with Kindergarten Enrollment ≥ 10: 7173 All: 421 Public: 263 (84 Charter) Private: 158 % of Schools with K Enrollment ≥ 10 with ≥ 10 % PBEs: (421/7173)*100: 5.9% *Kindergarten Enrollment ≥ 10 students

PBE Study California 2009 Two-fold Purpose Method To evaluate vaccination status of kindergarten PBEs Determine whether ‘high’ PBE schools were different from ‘standard’ PBE schools Method Collected and analyzed PBE records from: a Random sample of kindergartens and the Top 50 PBE kindergartens Two-fold Purpose To evaluate vaccination status of kindergarten PBEs Determine whether ‘high’ PBE schools were different from ‘standard’ PBE schools Method Collected and analyzed immunization records of personal beliefs exemptors from: a Random sample of kindergartens and the Top 50 PBE kindergartens

Personal Beliefs Exemptions Comparison of PBE Rates, School Size, and % Private in Random Sample and Top 50 PBE Kindergartens, California 2009 Group Total Students Personal Beliefs Exemptions Average School Size % Private Schools No. % Random Sample 15,471 247 1.9 ± 0.22 70 29 Top 50 PBE Sample 3,489 1,117 31.8 ± 1.55 60 22 Random: 10 Charter Schools Top 50: 25 Charter Schools

Comparison of IZ Record Status in Random Sample and Top 50 PBE Kindergartens, California 2009 Group Total Schools Schools w >1 PBE # PBE records reviewed # PBE w/ IZ Records % of PBEs w/ IZ records Random Sample 259 103 247 136 55.1% Top 50 PBE Sample 50 1,107 512 46.3%

Percent of Nonblank PBE Records Missing At Least One Dose in a Series % of PBEs Looking at the percentage of records missing at least one dose of any required vaccine among nonblank records: 32.3 percent of records were missing at least one dose of Hep B (40/124) 33.9 percent of records were missing the one required varicella dose (42/124) 66.9 percent of records were missing at least one dose of polio (83/124) 73.4 percent of nonblank records were missing at least one dose of DTP (91/124) 75.8 percent were missing at least one dose of MMR (94/124) 202 records were missing at least one DTP vaccine; 116 records were missing all doses of DTP (4) 194 records were missing at least one polio vaccine ; 120 records were missing all doses of Polio (3) 205 records were missing at least 1 MMR vaccine; 133 records were missing all doses of MMR (2) 151 records were missing at least 1 HepB; 128 records were missing all doses of HepB (3) 153 records were missing the one required Varicella dose; 153 records were missing all doses of Var (1)

Percent of Nonblank PBE Records Missing All Doses in Series % of PBEs You can see that students taking an exemption for the 4+ dose DTP series locatedon the far left comprised only 4 percent of the nonblank exemptor records for both samples.. You can see that, for the 3 dose Polio requirement, twice as many students chose an exemption as compared to those taking an exemption for the 4+ doses of DTP. Likewise twice as many students took an exemption for the 2 doses of MMR as compared with those taking the exemption for the 3 doses of polio. For those taking the exemption for the 3 doses of Hepatitis B, Taking a look at the last vaccine requirement, one dose of varicella, you can see here that varicella was exempted the most. four percent (or 5/124) were missing all doses of DTP 7.3 percent (or 9/124) were missing all doses of Polio 13.7 (or 22/124) percent were missing the two required doses of MMR 17.7 (or 17/124) percent were missing the three required dose of Hep B And 33.9 (or 42/124) percent were missing the one required varicella dose 202 records were missing at least one DTP vaccine; 116 records were missing all doses of DTP (4) 194 records were missing at least one polio vaccine ; 120 records were missing all doses of Polio (3) 205 records were missing at least 1 MMR vaccine; 133 records were missing all doses of MMR (2) 151 records were missing at least 1 HepB; 128 records were missing all doses of HepB (3) 153 records were missing the one required Varicella dose; 153 records were missing all doses of Var (1)

Site Visit Survey Local health department conducted school site visit interviews with school personnel involved in the review of student’s immunization status to gather information regarding personnel training, school immunization law related practices, knowledge, and attitudes. The survey was comprised of 17 questions. School practices varied significantly between the random sample and the Top 50 PBE sample in the following areas.

Survey Results 84.5 66.0 < .01 7.8 30.0 < .0001 Questions Random (%) Top 50 P-value School informs parent of exemptor that child will be excluded if there's a vaccine preventable disease outbreak. 84.5 66.0 < .01 Parents given option of signing PBE statement as short-term alternative while they seek current records to complete student's required immunizations 7.8 30.0 < .0001 The frequency of respondents who answered yes to the following questions differed between

Conclusions ‘High’ PBE schools may further potentiate undervaccination by encouraging selection of the PBE option by parents lacking documentation or with underimmunized children at kindergarten enrollment As PBEs rates continue to increase, public health officials will need to pay particular attention to ‘high’ PBE schools as they are sites of concentrated vaccine-preventable disease risk

Conclusions This study shows that the majority of kindergarten PBEs in CA are partially vaccinated, as ~50% had IZ records on file at their schools. A review of these records revealed that students with PBEs were most likely to be undervaccinated against MMR (74.6%) and least likely to be undervaccinated against Hep B (31.8%) This study shows that the majority of kindergarten PBEs in CA are partially vaccinated, as ~50% had IZ records on file at their schools. A review of these records revealed that students with PBEs were most likely to be undervaccinated against at least one dose of MMR (74.6%) and least likely to be undervaccinated against at least one dose of Hep B (31.8%)

Conclusions Comparison of PBE IZ records in ‘high’ PBE kindergartens with those in a ‘random sample’ of kindergartens revealed greater vaccine-preventable disease risk among PBEs in the ‘high’ PBE kindergartens, including: A lower average number of vaccine doses received per PBE (7.5 vs. 8.4, p<.05) A higher percentage of PBEs who had no protection (i.e. no vaccination doses) against Polio, Hepatitis B, MMR, and Varicella

Possible Follow-Up PBE Study California 2009 Future Steps Find out more about blank records Assess risk of disease and outbreaks associated with PBEs Identify characteristics of parents who elect PBEs

Acknowledgements Immunization Branch Wendi Cate Kathy Harriman John Hetsko Cindy Klaisle Steve Nickell Rina Shaikh Madina Sharifi Rob Schechter Jason Stubbs John Talarico Karen Turner Kathleen Winter Steve Vantine Local Health Department IZ Coordinators School Principals/Administrators