Geographic clustering of nonmedical exemptions to school immunization requirements and associations with geographic clustering of pertussis

Am J Epidemiol. 2008 Dec 15;168(12):1389-96. doi: 10.1093/aje/kwn263. Epub 2008 Oct 15.


School immunization requirements are important in controlling vaccine-preventable diseases in the United States. Forty-eight states offer nonmedical exemptions to school immunization requirements. Children with exemptions are at increased risk of contracting and transmitting vaccine-preventable diseases. The clustering of nonmedical exemptions can affect community risk of vaccine-preventable diseases. The authors evaluated spatial clustering of nonmedical exemptions in Michigan and geographic overlap between exemptions clusters and clusters of reported pertussis cases. Kulldorf's scan statistic identified 23 statistically significant census tract clusters for exemption rates and 6 significant census tract clusters for reported pertussis cases between 1993 and 2004. The time frames for significant space-time pertussis clusters were August 1993-September 1993, August 1994-February 1995, May 1998-June 1998, April 2002, May 2003-July 2003, and June 2004-November 2004. Census tracts in exemptions clusters were more likely to be in pertussis clusters (odds ratio = 3.0, 95% confidence interval: 2.5, 3.6). The overlap of exemptions clusters and pertussis clusters remained significant after adjustment for population density, proportion of racial/ethnic minorities, proportion of children aged 5 years or younger, percentage of persons below the poverty level, and average family size (odds ratio = 2.7, 95% confidence interval: 2.2, 3.3). Geographic pockets of vaccine exemptors pose a risk to the whole community. In addition to monitoring state-level exemption rates, health authorities should be mindful of within-state heterogeneity.

Publication types

  • Comparative Study
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Adolescent
  • Age Distribution
  • Child
  • Cluster Analysis
  • Female
  • Health Policy*
  • Humans
  • Immunization / statistics & numerical data*
  • Incidence
  • Male
  • Pertussis Vaccine / administration & dosage*
  • Retrospective Studies
  • Schools*
  • Sex Distribution
  • United States / epidemiology
  • Whooping Cough / epidemiology
  • Whooping Cough / prevention & control*


  • Pertussis Vaccine