Background

As conscientious vaccination exemption (CVE) percentages rise across the United States, so does the risk and occurrence of outbreaks of vaccine-preventable diseases such as measles. In the state of Texas, the median CVE percentage across school systems more than doubled between 2012 and 2018. During this period, the proportion of schools surpassing a CVE percentage of 3% rose from 2% to 6% for public schools, 20% to 26% for private schools, and 17% to 22% for charter schools. The aim of this study was to investigate this phenomenon at a fine scale.

Methods and findings

Here, we use beta regression models to study the socioeconomic and geographic drivers of CVE trends in Texas. Using annual counts of CVEs at the school system level from the 2012–2013 to the 2017–2018 school year, we identified county-level predictors of median CVE percentage among public, private, and charter schools, the proportion of schools below a high-risk threshold for vaccination coverage, and five-year trends in CVEs. Since the 2012–2013 school year, CVE percentages have increased in 41 out of 46 counties in the top 10 metropolitan areas of Texas. We find that 77.6% of the variation in CVE percentages across metropolitan counties is explained by median income, the proportion of the population that holds a bachelor's degree, the proportion of the population that self-reports as ethnically white, the proportion of the population that is English speaking, and the proportion of the population that is under the age of five years old. Across the 10 top metropolitan areas in Texas, counties vary considerably in the proportion of school systems reporting CVE percentages above 3%. Sixty-six percent of that variation is explained by the proportion of the population that holds a bachelor’s degree and the proportion of the population affiliated with a religious congregation. Three of the largest metropolitan areas—Austin, Dallas–Fort Worth, and Houston—are potential vaccination exemption "hotspots," with over 13% of local school systems above this risk threshold. The major limitations of this study are inconsistent school-system-level CVE reporting during the study period and a lack of geographic and socioeconomic data for individual private schools.

Conclusions

In this study, we have identified high-risk communities that are typically obscured in county-level risk assessments and found that public schools, like private schools, are exhibiting predictable increases in vaccination exemption percentages. As public health agencies confront the reemerging threat of measles and other vaccine-preventable diseases, findings such as ours can guide targeted interventions and surveillance within schools, cities, counties, and sociodemographic subgroups.

中文翻译：

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回归分析：2012年至2018年，德克萨斯州各学校的八年级儿童在幼儿园中进行了认真的疫苗接种豁免。

背景

随着全美尽职尽责的疫苗接种免除率（CVE）的提高，麻疹等可预防疫苗的疾病的风险和爆发也随之增加。在德克萨斯州，2012年至2018年期间，整个学校系统中CVE的中位数增加了一倍以上。在此期间，超过3％CVE的学校比例从公立学校的2％上升到6％，从20％上升到6％。私立学校为26％，特许学校为17％至22％。这项研究的目的是对这种现象进行大规模的调查。

方法和发现

在这里，我们使用Beta回归模型来研究德克萨斯州CVE趋势的社会经济和地理驱动因素。使用2012-2013学年至2017-2018学年在学校系统级别的CVE年度计数，我们确定了公立，私立和特许学校中县级CVE百分比中位数的预测指标，高-低级别学校的比例疫苗接种覆盖率的风险阈值以及CVE的五年趋势。自2012-2013学年以来，德克萨斯州前十大都会区中的46个县中的41个县的CVE百分比有所增加。我们发现，大城市县CVE百分比变化的77.6％是由收入中位数，拥有本科学历的人口比例，自我报告为白人的人口比例，会说英语的人口比例，以及五岁以下的人口比例。在得克萨斯州的十大都会区中，各县的报告CVE百分比高于3％的学校系统比例差异很大。这种变化的百分之六十六是由拥有本科学历的人口比例和与宗教会同的人口比例解释的。奥斯汀，达拉斯-沃思堡和休斯敦这三个最大的大都市区是潜在的免疫苗接种“热点”，超过13％的本地学校系统超过了此风险阈值。

结论

在这项研究中，我们确定了在县级风险评估中通常被掩盖的高风险社区，并发现公立学校（如私立学校）的疫苗接种豁免率呈现出可预测的增长。当公共卫生机构面对麻疹和其他可预防疫苗的疾病不断增加的威胁时，我们这样的发现可以指导学校，城市，县和社会人口学子群中的有针对性的干预和监测。