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Background: While employers are increasingly considering and implementing COVID-19 vaccination requirements, little is known about the reasons offered by employees seeking religious exemptions.Methods: We conducted a mixed methods analysis of all the requests for religious exemptions submitted during the initial implementation of a COVID-19 vaccination requirement at a single academic medical center in the United States.Results: Five hundred sixty-five (3.4%) employees requested religious exemptions. At least 305 (54.0%) requesters had job titles suggesting that they had direct patient contact. Four hundred ninety-nine (88.3%) of requesters self-identified as Christian, of whom 120 (21.2%) identified as Roman Catholic. Requesters offered 0 to 8 (mean 2.7) categories of reasons for their request. The most frequently stated reasons pertained to the use of fetal cell lines in vaccine development and manufacturing (382, 67.6%), interest in maintaining purity (221, 39.1%), or belief in divine healing (172, 30.4%). Some requesters also volunteered evidence of the sincerity of their beliefs including examples of their religious practices (116, 20.5%), other practices (66, 11.7%), and emotional states (32, 5.7%). One hundred fifty-two applications (26.9%) contained text copied without attribution, primarily from sample religious exemption request letters available on the Internet.Conclusions: Most requesters focused on the use of fetal cell lines in the development or manufacturing of the vaccines as the justification for their request. The development of vaccines that are not reliant on fetal cell lines may increase vaccination rates. Understanding reasons for religious exemption requests may inform vaccine education and vaccination policies.

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In the United States (U.S.), only five states or territories require human papillomavirus (HPV) vaccination for school attendance, even though almost all U.S. jurisdictions have debated adopting this type of policy. In this U.S. based study, we sought to estimate the level of support for HPV vaccine school-entry requirements with varying exemption policies and documentation procedures to obtain exemptions. Between July and August 2019, we conducted a web-based survey with a national sample of 1,109 U.S. parents of 11- to 17-year-olds. The survey assessed support for four school-entry vaccine requirement policies: without exemption or with exemption for medical, religious or philosophical reasons. Analyses used multivariable logistic regression to assess correlates of support for each policy. Overall, 38% of parents agreed with laws requiring HPV vaccination for school attendance without exemptions. When including exemption provisions, agreement increased to 45% for philosophical reasons, 50% for religious reasons, and 59% for medical reasons. Parents more often agreed on requirements without any exemptions if they were female (OR = 1.37, 95% CI:1.01-1.87), their child had initiated HPV vaccination (OR = 2.05, 95% CI:1.50-2.87), reported high levels of vaccine confidence (OR = 2.41, 95% CI:1.77-3.27), or reported having values similar to those of the people in their community (OR = 1.85, 95% CI:1.39-2.47). Parents more often agreed with requirements that included religious or philosophical exemptions if they reported having values similar to their community or high levels of psychological reactance (all p <.05). Many parents also supported requiring a written notice signed by a health care provider (40%) or religious leader (49%) to obtain a medical or religious exemption, respectively. In conclusion, exemption policies greatly increase parent support of school-entry requirements for HPV vaccination but may decrease their impact in practice. A large number of U.S. parents support strict documentation to obtain exemptions, signaling a promising area of policymaking to strengthen vaccine policies for school attendance.

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Using National Immunization Survey Child and Teen (2008-2017), we associated state vaccination requirements with hepatitis A (Hep A) vaccination rates in children and adolescents. States with school entry or both childcare and school entry requirements were associated with 35%-40% higher Hep A vaccination rates, compared with states without such requirements.

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Vaccination enrollment requirements are an important tool used to improve vaccination coverage among school-aged children. However, all states permit varying exemptions that allow students to stay enrolled without receiving some (or all) vaccinations. In Arizona, schools are required to report vaccination data on their kindergarten and 6th grade students annually to the Arizona Department of Health Services (ADHS). We analyzed trends in herd immunity and personal belief exemptions in Arizona schools from 2015 to 2018. We also identified multiple correlates of herd immunity at the school level. Our results demonstrate decreased herd immunity statewide and by school type and an increased rate of personal belief exemptions during this period. These findings contribute to the body of literature suggesting that vaccine hesitancy is growing, resulting in suboptimal vaccination coverage for children. Moreover, this research has several policy implications, especially for states permitting multiple exemption types and lax exemption criteria.

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INTRODUCTION: The growing proportion of parents filing personal belief exemptions (PBEs) from school-based vaccine requirements, and the clustering of PBEs in particular schools and communities, could weaken herd immunity and increase vaccine-preventable disease. Alignment of vaccine opposition with a particular political party or ideology could substantially increase PBEs. This study extends our understanding of the link between vaccine refusal and politics by identifying longitudinal associations between neighborhood political composition and school-level prevalence of PBEs between 2000 and 2015 in California. METHODS: California Department of Public Health data on PBEs in kindergartens were matched with political party registration and voting data from the California Statewide Database. Variables for partisan composition and for conservative political ideology, as well as school and neighborhood controls, were used to estimate both mixed-effects and fixed-effects regression models. RESULTS: PBE rates increased more rapidly in schools located in highly Republican neighborhoods, and were three times higher than PBE rates in highly Democratic neighborhoods in 2013 (6.6% compared to 2.2%). Mixed-effects models predict a 2.3 percentage-point increase in PBEs between 2007 and 2013 for schools in neighborhoods one standard deviation above the mean for % Republican (59%), compared to a 0.8-point increase for schools in neighborhoods one standard deviation below the mean (24% Republican). Similar results were obtained when using a measure of neighborhood conservatism and when models were estimated using fixed effects. CONCLUSIONS: Results indicate growing opposition to mandatory vaccinations in Republican/conservative neighborhoods, which could increase PBE clustering and increase the likelihood for outbreaks of disease in areas where conservative values are widely shared.

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Rates of vaccine-preventable diseases have increased in the United States in recent years, largely due to parental refusals of recommended childhood immunizations. Empirical studies have demonstrated a relationship between nonvaccination rates and permissive state vaccine exemption policies, indicating that legal reforms may promote higher immunization rates. This article reviews relevant data and considers the legal landscape. It analyzes federal and state Constitutional law, concluding that religious and personal belief exemptions to school-entry vaccine mandates are not constitutionally required. It identifies public health, bioethical, and policy considerations relevant to the choice among legal approaches employed by states to promote parental compliance. The article describes a range of legal tools that may help promote parental cooperation with immunization recommendations.

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Vaccination of healthcare personnel (HCP) is an important component of worker and patient safety, yet vaccination rates are lagging. The findings from Taddei et al.'s study of healthcare personnel immunization attitudes and practices in Florence, Italy provides further data of the importance of routine assessment of and recommendations for vaccines for HCP in order to improve coverage.

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OBJECTIVE: Using qualitative methods, we explored the implementation of California's 2007 influenza immunization requirements of hospital-based health care personnel (HCP). METHODS: We conducted nine case studies of California hospitals with different HCP vaccination rates and policies. Case studies consisted of interviewing 13 hospital representatives and analyzing relevant hospital documents, including influenza policies. We also conducted 13 semi-structured phone interviews with key state and county public health officials, union representatives, and officials of various professional healthcare organizations. RESULTS: Our qualitative results suggest that California's vaccination requirements likely did not increase influenza vaccination uptake among HCP. The law was not strong enough to compel hospitals with low and medium vaccination rates to improve their vaccination efforts, and hospitals with high vaccination rates were able to comply fully with the law by continuing to do what they were already doing - namely offering vaccinations to HCP, providing education about the risks of influenza and the benefits of vaccination, and obtaining signed declinations from those who refuse vaccination. Nonetheless, we found that by publicly raising the issue of influenza vaccination in the context of public safety and healthcare quality, California's law encouraged hospitals to develop and implement data systems to monitor the effectiveness of vaccination promotion efforts and prompted discussions, and, in some cases, adoption of stricter vaccination requirements at hospital or county levels. CONCLUSIONS: Our findings generally support the literature that suggests that permissive influenza vaccination requirements, though politically feasible, provide little direct incentive for hospitals to focus efforts on increasing HCP vaccination rates.

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