1. 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

2. 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 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 mos., immunization of this CA cohort

3. 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”.

4. 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

5. 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.

6. 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.

7. 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

8. 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: Public: (84 Charter) Private: 158
% of Schools with K Enrollment ≥ 10 with ≥ 10 % PBEs: (421/7173)*100: 5.9%
*Kindergarten Enrollment ≥ 10 students

9. 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

10. 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

11. 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%

12. 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)

13. 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)

14. 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.

15. 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

16. 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

17. 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%)

18. 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

19. 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

20. 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