The 2016 California policy to eliminate nonmedical vaccine exemptions and changes in vaccine coverage: An empirical policy analysis

Autoři: Sindiso Nyathi aff001;  Hannah C. Karpel aff002;  Kristin L. Sainani aff001;  Yvonne Maldonado aff001;  Peter J. Hotez aff004;  Eran Bendavid aff008;  Nathan C. Lo aff009
Působiště autorů: Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, California, United States of America aff001;  New York University School of Medicine, New York, New York, United States of America aff002;  Division of Infectious Diseases, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, United States of America aff003;  Texas Children's Hospital Center for Vaccine Development, Departments of Pediatrics and Molecular Virology and Microbiology, Baylor College of Medicine, Houston, Texas, United States of America aff004;  Department of Biology, Baylor University, Waco, Texas, United States of America aff005;  Hagler Institute for Advanced Study at Texas A&M University, College Station, Texas, United States of America aff006;  James A. Baker III Institute for Public Policy, Rice University, Houston, Texas, United States of America aff007;  Center for Population Health Sciences, Division of Primary Care and Population Health, Department of Medicine, Stanford University, Stanford, California, United States of America aff008;  Department of Medicine, University of California, San Francisco, San Francisco, California, United States of America aff009
Vyšlo v časopise: The 2016 California policy to eliminate nonmedical vaccine exemptions and changes in vaccine coverage: An empirical policy analysis. PLoS Med 16(12): e32767. doi:10.1371/journal.pmed.1002994
Kategorie: Research Article
doi: 10.1371/journal.pmed.1002994



Vaccine hesitancy, the reluctance or refusal to receive vaccination, is a growing public health problem in the United States and globally. State policies that eliminate nonmedical (“personal belief”) exemptions to childhood vaccination requirements are controversial, and their effectiveness to improve vaccination coverage remains unclear given limited rigorous policy analysis. In 2016, a California policy (Senate Bill 277) eliminated nonmedical exemptions from school entry requirements. The objective of this study was to estimate the association between California’s 2016 policy and changes in vaccine coverage.

Methods and findings

We used a quasi-experimental state-level synthetic control analysis and a county-level difference-in-differences analysis to estimate the impact of the 2016 California policy on vaccination coverage and prevalence of exemptions to vaccine requirements (nonmedical and medical). We used publicly available state-level data from the US Centers for Disease Control and Prevention on coverage of measles, mumps, and rubella (MMR) vaccination, nonmedical exemption, and medical exemption in children entering kindergarten. We used county-level data individually requested from state departments of public health on overall vaccine coverage and exemptions. Based on data availability, we included state-level data for 45 states, including California, from 2011 to 2017 and county-level data for 17 states from 2010 to 2017. The prespecified primary study outcome was MMR vaccination in the state analysis and overall vaccine coverage in the county analysis.

In the state-level synthetic control analysis, MMR coverage in California increased by 3.3% relative to its synthetic control in the postpolicy period (top 2 of 43 states evaluated in the placebo tests, top 5%), nonmedical exemptions decreased by 2.4% (top 2 of 43 states evaluated in the placebo tests, top 5%), and medical exemptions increased by 0.4% (top 1 of 44 states evaluated in the placebo tests, top 2%). In the county-level analysis, overall vaccination coverage increased by 4.3% (95% confidence interval [CI] 2.9%–5.8%, p < 0.001), nonmedical exemptions decreased by 3.9% (95% CI 2.4%–5.4%, p < 0.001), and medical exemptions increased by 2.4% (95% CI 2.0%–2.9%, p < 0.001). Changes in vaccination coverage across counties after the policy implementation from 2015 to 2017 ranged from −6% to 26%, with larger increases in coverage in counties with lower prepolicy vaccine coverage. Results were robust to alternative model specifications. The limitations of the study were the exclusion of a subset of US states from the analysis and the use of only 2 years of postpolicy data based on data availability.


In this study, implementation of the California policy that eliminated nonmedical childhood vaccine exemptions was associated with an estimated increase in vaccination coverage and a reduction in nonmedical exemptions at state and county levels. The observed increase in medical exemptions was offset by the larger reduction in nonmedical exemptions. The largest increases in vaccine coverage were observed in the most “high-risk” counties, meaning those with the lowest prepolicy vaccine coverage. Our findings suggest that government policies removing nonmedical exemptions can be effective at increasing vaccination coverage.

Klíčová slova:

California – Children – MMR vaccine – Pediatrics – Public and occupational health – Schools – Vaccination and immunization – Vaccines


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2019 Číslo 12

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