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01.12.2018 | Research article | Ausgabe 1/2018 Open Access

BMC Public Health 1/2018

Examining the spatiotemporal evolution of vaccine refusal: nonmedical exemptions from vaccination in California, 2000–2013

BMC Public Health > Ausgabe 1/2018
Paul L. Delamater, Timothy F. Leslie, Y. Tony Yang
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The online version of this article (https://​doi.​org/​10.​1186/​s12889-018-5368-y) contains supplementary material, which is available to authorized users.



Vaccine hesitancy continues to be an issue throughout the United States, as numerous vaccine hesitant parents are choosing to exempt their children from school-entry vaccination requirements for nonmedical reasons, despite the safety and effectiveness of vaccines. We conduct an analysis of how vaccine refusal, measured by the use of nonmedical exemptions (based on personal or religious beliefs) from vaccination (NMEs), evolved across space and over time in California.


Using school-entry data from the California Department of Public Health, we examined NMEs for students entering kindergarten in California from 2000 to 2013. We conduct global and local spatial autocorrelation analysis to determine whether NME use became more geographically clustered over the study period and whether the location of local clusters of high use were temporally stable. We conducted a grouping analysis that identified the general temporal trends in NME use over the time period.


The use of NMEs increased from 0.73% of all kindergarteners in 2000 to 3.09% in 2013 and became more geographically clustered over the study period. Local geographic clusters of high use were relatively isolated early in the study period, but expanded in size over time. The grouping analysis showed that regions with high NME use early in the study period were generally few (15% of all US Census tracts) and relatively isolated. Regions that had low initial NME use and moderate to large increases over the study period were located in close proximity to the initial high use regions. The grouping analysis also showed that roughly half of all tracts had 0% or very low NME use throughout the study period.


We found an observable spatial structure to vaccine refusal and NME use over time, which appeared to be a self-reinforcing process, as well as a spatially diffusive process. Importantly, we found evidence that use of NMEs in the initially isolated regions appeared to stimulate vaccine refusal in geographically proximal regions. Thus, our results suggest that efforts aimed at decreasing future NME use may be most effective if they target regions where NME use is already high, as well as the nearby regions.
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