Faculty Opinions recommendation of Nonmedical exemptions to school immunization requirements: secular trends and association of state policies with pertussis incidence.

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Abstract
This paper demonstrates that small differences in state-level exemptions policy for immunization (only religious versus personal belief exemption, and ease of obtaining exemptions) in different states in the United States were associated with pertussis incidence rates about 50% higher in states where exemptions were more easily granted; this has implications for examining immunization policies. Many interventions for changing health behaviours such as immunization or smoking focus on individual choices and beliefs. While in the United States, all states allowed medical exemptions from state-mandated school immunization requirements, states varied in non-medical exemptions policy and ease of obtaining exemptions. The authors analysed 1991-2004 state level rates of non-medical exemptions at school entry and 1986 through 2004 pertussis incidence data for individuals aged 18 years or younger. They found that in multivariate analyses adjusting for demographics, easier granting of exemptions and availability of personal belief exemptions were associated with increased pertussis incidence. While variations in collecting and reporting exemption data by state might have occurred, these differences were likely to be random in relation to data on pertussis incidence which were independently obtained and unlikely to explain the significant associations. Different countries obviously have different policies with respect to immunization, but this paper shows how even very small variations in policy within one country may have a major influence on individual behaviours such as immunization uptake and subsequent manifest public health impact, in this case, on pertussis incidence. How generalisable these results may be to other health related behaviours is unclear, but they point to the need for more research on how relative subtle variations in the external environment may have a profound influence on individual behavioural choices and health outcomes.

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