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A Case-Control Study

Daniel A. Salmon, PhD, MPH; Lawrence H. Moulton, PhD; Saad B. Omer, MBBS, MPH; M. Patricia deHart, ScD; Shannon Stokley, MPH; Neal A. Halsey, MD

Arch Pediatr Adolesc Med. 2005;159:470-476.

Background  The rate of nonmedical exemptions to school immunization requirements has been increasing, and children with exemptions have contributed to outbreaks of vaccine-preventable diseases.

Objectives  To determine why parents claim nonmedical exemptions and to explore differences in perceptions of vaccines and vaccine information sources between parents of exempt and fully vaccinated children.

Design  Case-control study.

Setting  Colorado, Massachusetts, Missouri, and Washington.

Participants  Surveys were mailed to the parents of 815 exempt children (cases) and 1630 fully vaccinated children (controls randomly selected from the same grade and school) recruited from 112 private and public elementary schools. Surveys were completed by 2435 parents (56.1%).

Main Outcome Measures  Parental reports.

Results  Most children (209 [75.5%] of 277) with nonmedical exemptions received at least some vaccines. The most common vaccine not received was varicella (147 [53.1%] of 277 exempt children). The most common reason stated for requesting exemptions (190 [69%] of 277) was concern that the vaccines might cause harm. Parents of exempt children were significantly more likely than parents of vaccinated children to report low perceived vaccine safety and efficacy, a low level of trust in the government, and low perceived susceptibility to and severity of vaccine-preventable diseases. Parents of exempt children were significantly less likely to report confidence in medical, public health, and government sources for vaccine information and were more likely to report confidence in alternative medicine professionals than parents of vaccinated children.

Conclusion  Continued efforts must be made to educate parents about the utility and safety of vaccines, especially parents requesting nonmedical exemptions to school immunization requirements.

Author Affiliations: Institute for Vaccine Safety, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Md (Drs Salmon, Moulton, Omer, and Halsey); Immunization Program, Washington State Department of Health, Olympia (Dr deHart); and National Immunization Program, Centers for Disease Control and Prevention, Atlanta, Ga (Dr Stokley).

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