Abstract
Background
Vaccine hesitancy in low vaccine coverage “hot spots” has led to recent outbreaks of vaccine-preventable diseases across the United States. State policies to improve vaccine coverage by restricting non-medical (personal belief) exemptions are heavily debated and their effectiveness is unclear due to limited rigorous policy analysis. In 2016, a California policy (SB 277) eliminated non-medical exemptions from kindergarten requirements. To address the ongoing debate on such policies, we performed a quasi-experimental, controlled analysis of the policy’s impact on vaccine and exemption outcomes.
Methods
We used state vaccine coverage and exemption data (2011–2017) from the CDC and health data from public sources. We prespecified a primary outcome of MMR coverage (%) and secondary outcomes of medical and non-medical exemptions (%). We included covariates related to socioeconomic and health measures (e.g., insurance, well child visits) and pre-2016 mean coverage. Using the synthetic control method, with 2016 as the treatment year and a 2-year post-policy period, we constructed a “control” California, from a weighted sum of states. We used permutation testing to repeat the process for each of the other states and their unique synthetic control, to determine whether there was a meaningful difference in California (i.e., a change in California’s coverage relative to its control in the top 5th percentile of states). We tested the model’s sensitivity to various analytical assumptions.
Results
Of 43 control states, synthetic California was predominantly comprised of Idaho, Mississippi, and Arkansas, and had a good pre-policy match on outcomes. MMR coverage in California increased by 3.2% relative to synthetic California in the post period (Top 1 of 44 states, Figure 1). Medical exemptions increased by 0.4%, while non-medical exemptions decreased by 2.2% in the post-period (Top 1 of 43 states). The model was robust to changes in covariates and control states.
Conclusion
The policy resulted in a meaningful increase in MMR coverage and reduction in non-medical exemptions. We measured a modest increase in medical exemptions, but this was offset by the larger reduction in non-medical exemptions. State policies removing non-medical exemptions can be effective in increasing vaccination coverage.
Disclosures
All authors: No reported disclosures.
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