Nonmedical exemptions to school immunization requirements - Secular trends and association of state policies with pertussis incidence
Nonmedical exemptions to school immunization requirements - Secular trends and association of state policies with pertussis incidence
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DOI：
10.1001/jama.296.14.1757
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发表时间：
2006-10-11
影响因子：
120.7
通讯作者：
Salmon, Daniel A.
中科院分区：
文献类型：
--
作者：
Omer, Saad B.;Pan, William K. Y.;Salmon, Daniel A.
背景在美国，学校免疫要求在控制疫苗可预防的疾病方面发挥了重要作用。大多数州对学校要求(宗教或个人信仰)提供非医疗豁免。豁免者感染和传播疾病的风险增加。对于在美国流行的百日咳来说，豁免政策的作用可能特别重要。目的确定：(1)非医疗豁免的比率是否不同，并且在仅提供宗教和个人信仰豁免的州中一直在上升；(2)非医疗豁免的比率不同，在获得豁免的程序容易与中等和容易与困难的州中一直在上升；(3)百日咳发病率与给予个人信仰豁免、容易获得豁免、接受父母签字作为遵守学校免疫要求的充分证据的政策有关。设计、设置和参与者我们分析了1991年至2004年入学时非医疗免免率和1986至2004年18岁或18岁以下个人的百日咳发病率数据。主要结果衡量州级豁免率和百日咳发病率。结果从2001年到2004年，允许个人信仰豁免的州比只提供宗教豁免的州的非医疗豁免率更高，与中等和困难豁免程序的州相比，容易获得豁免的州在2002至2003年间的非医疗豁免率更高。在提供个人信仰豁免的州中，平均免税率每年平均增加6%，从1991年的0.99%上升到2004年的2.54%。在容易获得豁免的州，这一比率每年增长5%，从1991年的1.26%上升到2004年的2.51%。在只提供宗教豁免或具有中等和困难的豁免程序的州，没有看到统计上的显著变化。在调整人口统计学因素的多因素分析中，更容易给予豁免(发病率比=1.53；95%可信区间为1.10-2.14)和可获得个人信仰豁免(发病率比=1.48；95%可信区间为1.03-2.13)与百日咳发病率的增加有关。结论允许个人信仰豁免和容易给予豁免与更高和更高的非医疗豁免率相关。给予个人信仰豁免的州政策和容易给予豁免的州与百日咳发病率的增加有关。各国应审查其豁免政策，以确保控制百日咳和其他疫苗可预防的疾病。
Context 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.Objective 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.Design, Setting, and Participants 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.Main Outcome Measures State-level exemption rates and pertussis incidence.Results 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.Conclusions 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.