Omer Saad B, Pan William K Y, Halsey Neal A, Stokley Shannon, Moulton Lawrence H, Navar Ann Marie, Pierce Mathew, Salmon Daniel A
Department of International Health, Institute for Vaccine Safety, Johns Hopkins Bloomberg School of Public Health, Baltimore, Md, USA.
JAMA. 2006 Oct 11;296(14):1757-63. doi: 10.1001/jama.296.14.1757.
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.
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.
State-level exemption rates and pertussis incidence.
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.
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.
学校免疫要求在美国控制疫苗可预防疾病方面发挥了重要作用。大多数州对学校要求提供非医学豁免（宗教或个人信仰）。豁免者感染和传播疾病的风险增加。豁免政策对于在美国呈地方性流行的百日咳可能尤为重要。
确定（1）在仅提供宗教豁免与个人信仰豁免的州中，非医学豁免率是否不同且一直在增加；（2）在获得豁免程序简单与中等以及简单与困难的州中，非医学豁免率是否不同且一直在增加；（3）百日咳发病率是否与给予个人信仰豁免的政策、获得豁免的难易程度以及接受父母签名作为符合学校免疫要求的充分证明有关。
设计、设置和参与者：我们分析了1991年至2004年各州入学时的非医学豁免率以及1986年至2004年18岁及以下人群的百日咳发病率数据。
州一级的豁免率和百日咳发病率。
从2001年至2004年，允许个人信仰豁免的州的非医学豁免率高于仅提供宗教豁免的州，并且在2002年至2003年期间，与豁免程序中等和困难的州相比，豁免程序容易的州的非医学豁免率更高。在提供个人信仰豁免的州中，平均豁免率从1991年的0.99%以每年平均6%的速度增加到2004年的2.54%。在豁免程序容易的州中，豁免率从1991年的1.26%以每年5%的速度增加到2004年的2.51%。在仅提供宗教豁免或豁免程序中等和困难的州中，未观察到统计学上的显著变化。在针对人口统计学进行调整的多变量分析中，豁免程序更容易（发病率比=1.53；95%置信区间，1.10 - 2.14）和提供个人信仰豁免（发病率比=1.48；95%置信区间，1.03 - 2.13）与百日咳发病率增加有关。
允许个人信仰豁免和容易给予豁免与美国非医学豁免率较高且不断增加有关。给予个人信仰豁免的州政策以及豁免程序容易的州与百日咳发病率增加有关。各州应审查其豁免政策，以确保对百日咳和其他疫苗可预防疾病的控制。
