the policy and epidemiology of mandates in the us & europe · saad b. omer director, yale...
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Saad B. OmerDirector, Yale Institute for Global Health
The policy and epidemiology of mandates in the US & Europe
@SaadOmer3
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Reasons For Non-Vaccination Among Measles Cases2000-2015
Other156 (31%)
Nonmedical exemptions
349 (69%)
43% of all cases
Phadke et al. JAMA, 2016
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1 2 3 4 5 6 7 8 9
Percen
t of
mea
sles
ca
ses
Time in weeks
Vaccination status of measles cases by week
Unvaccinated
Unknown vaccination status
Vaccinated
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Cumulative Epidemic Curve of 16 Measles Outbreaks 2000 - 2015, United States
Phadke et al. JAMA, 2016
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Brewer et al., Psychol Sci Public Interest. 2017
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School Immunization Requirements
State laws (not federal)
3 types of exemptions allowed
1. Medical2. Religious
3. Personal belief(philosophical)
Major role in low rates of vaccine
preventable diseases
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Ease of Obtaining Vaccine Exemptions –by State
Omer et al., New England Journal of Medicine . 2012Figure (with updated 2013 data) created by Mother Jones
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Ease of Obtaining Vaccine Exemptions in the U.S. - by State
Exemption Policies & Whooping Cough Incidence, 1986-2004
Omer et al., JAMA, 2006
Exemption ease
Incidence Rate Ratio
Difficult Reference
Medium 1.35 (0.96-1.91)
Easy 1.53 (1.10-2.14)
Omer et al., New England Journal of Medicine . 2012Figure (with updated 2013 data) created by Mother Jones
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Non-Medical Exemptions by Year 1991 - 2003
0.0%
0.5%
1.0%
1.5%
1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
Exe
mpt
ion
Rat
e
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Nonmedical Exemptions for States With Religious Exemptions and With Personal Belief Exemptions
1991 - 2004
Data updated
Only Religious Exemptions Permitted Personal Belief Exemptions Permitted
Omer et al., Journal of American Medical Association, 2006
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Nonmedical Exemptions by Ease of Exemption 1991 - 2007
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Easy Exemption Policy
Medium Exemption Policy
Difficult Exemption Policy
Data updatedOmer et al., JAMA, 2006
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Mean (95% CI) Rates of Nonmedical Exemptions by Type of Exemption, 2006–2011
Omer et al., NEJM, 2012
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Omer et al., New Eng Journal of Medicine, 2012 13
Mean (95% CI) Rates of Nonmedical Exemptions by Ease of Exemption,
2006–2011
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Relative Locations of Pertussis Space-time Clusters & Exemptions Spatial Clusters
Unadjusted OR
3.0 (2.5 – 3.6)
Adjusted OR
2.7 (2.2 – 3.3)
Overlap of
Exemptions
Clusters with
Pertussis Clusters
Omer et al., Am. J. Epi., 2008
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Washington Exemption Law
• SB 5005• Educational counseling and signed form from a licensed (in WA) health care
provider in order to obtain a nonmedical exemption
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1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Law in effect July 22, 2011
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Impact of Change in Washington Exemption Law
0%
2%
4%
6%
8%
10%
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
An
y Ex
emp
tio
n R
ate
Year
Overall (Before) Overall (After)
Regression Line (Before) Regression Line (After)
16Omer et al., Pediatrics, 2017
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Omer et al., New Eng Journal of Medicine, 2009 17
WA State Counties’ School Entry Exemption Rates -2006-2007
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Delamater et al., 2019, Pediatrics
Elimination of Nonmedical Immunization Exemptions in California & School-Entry Vaccine Status
(home schoolers etc.)
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Clusters of high not-up-to-date rates in California
Not Up-To-Date Rates
Pingali et al., 2019, JAMA
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Association of State Non-medical Exemption Policies With Medical Exemption Rates
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Stadlin, Bednarczyk, Omer JID 2012
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Difficult Medium Easy
Me
dic
al E
xem
pti
on
s /1
00
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0
Non Medical Exemption Category
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Parent reports to VAERS increased after introduction of SB277 in California
10%
15%
20%
25%
30%
2011-12 2012-13 2013-14 2014-15 2015-16 2016-17 2017-18
Par
ent
rep
ort
s
CA
TX
SB2
77
Hause at al., unpublished data
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Reporting time increased after introduction of SB277 (parent reports)
0
5
10
15
20
25
30
35
2011-12 2012-13 2013-14 2014-15 2015-16 2016-17 2017-18
Med
ian
tim
e to
rep
ort
School year
CA
TX
SB2
77
Hause et al., unpublished data
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Association Between Mandatory Vaccination Policies and Measles Vaccination Rates
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+ 3.7 (1.7, 5.7) + 3,8 (1.2, 6.4)
+ 0,8 (0.5, 1.2)
0
1
2
3
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5
6
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Mandatory Vaccination* Mandatory Vaccination withoutNon-Medical Exemptions*
Financial Penalty for Non-Compliance (per €500)*
Perc
ent
Dif
fere
nce
(95
% C
I)
Differences in Measles Vaccination Rates by Vaccine Policy
*p-value < 0.01Vaz et al., Pediatrics, In press
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Association Between Mandatory Vaccination Policies and Pertussis Vaccination Rates
+ 2.1 (0.3, 4.2) + 2.1 (-1.7, 5.9)
+ 1.1 (1.0, 1.3)
-3
-2
-1
0
1
2
3
4
5
6
7
Mandatory Vaccination* Mandatory Vaccination withoutNon-Medical Exemptions
Financial Penalty for Non-Compliance (per €500)*
Perc
ent
Dif
fere
nce
(95
% C
I)
Difference in Pertussis Vaccination Rates by Vaccine Policy
*p-value < 0.05Vaz et al., Pediatrics, In press
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Effects of potential legislative and administrative actions on vaccine up-to-date rates
Delamater et al., Unpublished
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Omer, New York Times (Op-Ed), Feb 2015
In-person counseling
Procedures to review each request for exemption
Sign a form that discusses the risks of non-vaccination
Letter elaborating on the reason their child should be exempt
Obtain the form by specifically requesting from the state or local health department, vs. downloading it online
Annual renewal
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28Omer, Betch, Leask; Nature; 2019
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Acknowledgments
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Thank You!
@YaleGH@SaadOmer3