1. The Rise of Medical and Religious Exemptions to Vaccination in Texas National Immunization Conference May 12, 2004 Julie Townsend Monica Gamez

2. Exemptions to Vaccination in Texas Since 1971, Texas has allowed both medical and religious exemptions Since 1971, Texas has allowed both medical and religious exemptions In 2003, the Texas Legislature passed a provision allowing for a conscientious exemption to vaccination In 2003, the Texas Legislature passed a provision allowing for a conscientious exemption to vaccination

3. Exemption Trends in Texas Has the number of students attending public school in Texas with medical or religious exemptions increased over time? Has the number of students attending public school in Texas with medical or religious exemptions increased over time?

4. Objective To examine the trends in the percentage of school-aged children with medical or religious exemptions on file attending public schools in Texas To examine the trends in the percentage of school-aged children with medical or religious exemptions on file attending public schools in Texas

5. Data Collection Annual Report of Immunization Status in Texas Schools Annual Report of Immunization Status in Texas Schools  Self-reported survey completed by public school districts and accredited private schools  Conducted by the Texas Department of Health (TDH) Immunization Division annually  Aggregate data on the immunization status of students  Currently, the immunization status of ALL students is assessed (K – 12)

6. Texas Schools 2003 – 2004 School Year 4,133,878 students attending public school (K – 12) 4,133,878 students attending public school (K – 12) 1,258 school districts 1,258 school districts

7. Data Analysis 1997 – 2002 data analyzed from the Annual Report of Immunization Status in Texas Schools 1997 – 2002 data analyzed from the Annual Report of Immunization Status in Texas Schools Total number and percentage of students enrolled in public school with medical or religious exemptions Total number and percentage of students enrolled in public school with medical or religious exemptions By vaccine antigen: DTaP/DTP/Td, Measles, Mumps, Rubella, Polio, Hepatitis B, Hepatitis A, Varicella By vaccine antigen: DTaP/DTP/Td, Measles, Mumps, Rubella, Polio, Hepatitis B, Hepatitis A, Varicella

9. Trends in Medical and Religious Exemptions in Texas Public Schools, 1997 – 2002 Vaccine Antigen 199719981999200020012002 DTaP/DTP 0.11 % 0.10%0.10%0.10%0.13%0.13% Polio 0.09 % 0.09%0.09%0.09%0.13%0.11% Measles 0.08 % 0.08%0.08%0.10%0.10%0.11% Mumps 0.09%0.09%0.10%0.10%0.11% Rubella 0.08%0.09%0.12%0.10%0.12% HepB0.18%0.15%0.14%0.15%0.17% HepA0.11%0.08%0.09%0.04% Varicella0.77%1.07%1.16%

10. Trends in Exemptions to the Varicella Vaccine Requirement

11. Rise in Exemptions for Varicella Vaccine No clear reason for the rise in varicella vaccine exemptions No clear reason for the rise in varicella vaccine exemptions Physicians writing medical exemptions for students with disease history? Physicians writing medical exemptions for students with disease history? Students with a disease history already exempt from the requirement Students with a disease history already exempt from the requirement

12. Data Limitations Overall number of students with exemptions for any vaccine not collected Overall number of students with exemptions for any vaccine not collected Self-reported data Self-reported data Vaccine requirements vary by age group Vaccine requirements vary by age group

13. Conscientious Exemptions Passed by the Texas Legislature in 2003 Passed by the Texas Legislature in 2003 Includes religious beliefs Includes religious beliefs Applies to child care facilities, schools, and institutions of higher education Applies to child care facilities, schools, and institutions of higher education May be excluded from school in times of emergency or epidemic May be excluded from school in times of emergency or epidemic Requires notarized form Requires notarized form TDH is prohibited from maintaining a record of names of individuals requesting the form TDH is prohibited from maintaining a record of names of individuals requesting the form

14. Conscientious Exemptions Timeline Provisional procedures for exemption were implemented September 1, 2003 Provisional procedures for exemption were implemented September 1, 2003 Final rules were adopted March 11, 2004 Final rules were adopted March 11, 2004  Requires written requests for affidavit  Allows exemption for one or more vaccines  Affidavit form is valid for two years

15. Implementing Immunization Rules Original requests are returned with forms Original requests are returned with forms Affidavit forms are pre-printed with child’s name and date of birth Affidavit forms are pre-printed with child’s name and date of birth Benefits and Risks of Vaccination fact sheet is included with forms. Benefits and Risks of Vaccination fact sheet is included with forms. Data collected include: Data collected include:  Number of affidavit forms requested  Number of children for whom forms were requested  Geographical data (zip code)

16. Implementing Immunization Rules Current Data on Affidavit Requests (as of 4/27/2004): Number of forms sent out: 10,241 Number of forms sent out: 10,241 Number of requests received: 2,434 Number of requests received: 2,434 Number of children: 4,089 Number of children: 4,089

17. Conclusion The number of exemptions claimed for school-aged children is small, but appears to be on the rise The number of exemptions claimed for school-aged children is small, but appears to be on the rise The varicella vaccine has the largest percentage of students with an exemption The varicella vaccine has the largest percentage of students with an exemption At this time, it is unknown if the new conscientious exemption provision will cause the percentage of students with an exemption to increase in Texas At this time, it is unknown if the new conscientious exemption provision will cause the percentage of students with an exemption to increase in Texas

18. Contact Information Julie Townsend, Epidemiologist Julie Townsend, Epidemiologist  Julie.Townsend@tdh.state.tx.us Monica Gamez, Compliance Coordinator Monica Gamez, Compliance Coordinator  Monica.Gamez@tdh.state.tx.us