Mass Probation: Effects of Sentencing Severity on Mental Health for Black and White Individuals.

BACKGROUND: Incarceration is associated with negative impacts on mental health. Probation, a form of community supervision, has been lauded as an alternative. However, the effect of probation versus incarceration on mental health is unclear. Our objective was to estimate the impact on mental health of reducing sentencing severity at individuals' first adult criminal-legal encounter. METHODS: We used the US National Longitudinal Survey on Youth 1997, a nationally representative dataset of youth followed into their mid-thirties. Restricting to those with an adult encounter (arrest, charge alone or no sentence, probation, incarceration), we used parametric g-computation to estimate the difference in mental health at age 30 (Mental Health Inventory-5) if (1) everyone who received incarceration for their first encounter had received probation and (2) everyone who received probation had received no sentence. RESULTS: Among 1835 individuals with adult encounters, 19% were non-Hispanic Black and 65% were non-Hispanic White. Median age at first encounter was 20. Under hypothetical interventions to reduce sentencing, we did not see better mental health overall (Intervention 1, incarceration to probation: RD = -0.01; CI = -0.02, 0.01; Intervention 2, probation to no sentence: RD = 0.00; CI = -0.01, 0.01) or when stratified by race. CONCLUSION: Among those with criminal-legal encounters, hypothetical interventions to reduce sentencing, including incremental sentencing reductions, were not associated with improved mental health. Future work should consider the effects of preventing individuals' first criminal-legal encounter.

Spatial Clustering of Tobacco Retailers Near US Public Schools.

INTRODUCTION: Previous studies have found that tobacco retailers cluster near schools. However, all retail outlets may be located near each other and near schools due to existing infrastructure and zoning policies. We assessed whether tobacco retailers cluster near schools in the United States more than expected when accounting for existing retail locations. AIMS AND METHODS: We identified 322 056 probable tobacco retailers, 95 110 public schools, and more than 3.8 million businesses comparable to tobacco retailers in land use and business type. We created 500 simulated tobacco retailer datasets by randomly selecting from the larger list of businesses. For each simulated dataset, we calculated the distance from schools to the nearest tobacco retailer (proximity) and the count of tobacco retailers within 800 m of schools (density). Observed proximity and density values were compared to 95% coverage intervals from the 500 simulations. We stratified analyses by urbanicity, percentage of students in the free and reduced-priced lunch program (FRLP), and percentage of Hispanic/Latino, non-Hispanic Black, and non-Hispanic white students. RESULTS: Tobacco retailers were closer to schools in rural areas, cities, and towns and more dense around schools in rural areas, cities, and suburbs compared to random locations in potential retail space. Schools with more students receiving FRLP had higher density than expected while schools with fewer students receiving FRLP had lower density than expected. Within rural areas, clustering did not vary across sociodemographic groups. Within non-rural areas, there were inequities in clustering by racial, ethnic, and socioeconomic school composition. CONCLUSIONS: Tobacco retailers cluster near schools after accounting for existing business patterns. There are inequities in clustering by sociodemographic school composition. IMPLICATIONS: This study provides compelling evidence that tobacco retailers cluster near US public schools and that there are racial, ethnic, and socioeconomic inequities in clustering, even when accounting for overall retail location patterns. Given that public schools tend to reflect neighborhood demographics, policies to limit tobacco retailers near schools may reduce both school-based and neighborhood-based inequities.

Naloxone Accessibility by Standing Order in North Carolina Community Pharmacies.

BACKGROUND: According to a standing order in North Carolina (NC), naloxone can be purchased without a provider prescription. OBJECTIVE: The objective of this study is to examine whether same-day naloxone accessibility and cost vary by pharmacy type and rurality in NC. METHODS: A cross-sectional telephone audit of 202 NC community pharmacies stratified by pharmacy type and county of origin was conducted in March and April 2023. Trained "secret shoppers" enacted a standardized script and recorded whether naloxone was available and its cost. We examined the relationship between out-of-pocket naloxone cost, pharmacy type, and rurality. RESULTS: Naloxone could be purchased in 53% of the pharmacies contacted; 26% incorrectly noting that naloxone could be filled only with a provider prescription and 21% did not sell naloxone. Naloxone availability by standing order was statistically different by pharmacy type (chain/independent) (χ2 = 20.58, df = 4, P value < 0.001), with a higher frequency of willingness to dispense according to the standing order by chain pharmacies in comparison to independent pharmacies. The average quoted cost for naloxone nasal spray at chain pharmacies was $84.69; the cost was significantly more ($113.54; P < 0.001) at independent pharmacies. Naloxone cost did not significantly differ by pharmacy rurality (F2,136 = 2.38, P = 0.10). CONCLUSION: Approximately half of NC community pharmacies audited dispense naloxone according to the statewide standing order, limiting same-day access to this life-saving medication. Costs were higher at independent pharmacies, which could be due to store-level policies. Future studies should further investigate these cost differences, especially as intranasal naloxone transitions from a prescription only to over-the-counter product.

Fine-scale spatial clustering of measles nonvaccination that increases outbreak potential is obscured by aggregated reporting data.

The United States experienced historically high numbers of measles cases in 2019, despite achieving national measles vaccination rates above the World Health Organization recommendation of 95% coverage with two doses. Since the COVID-19 pandemic began, resulting in suspension of many clinical preventive services, pediatric vaccination rates in the United States have fallen precipitously, dramatically increasing risk of measles resurgence. Previous research has shown that measles outbreaks in high-coverage contexts are driven by spatial clustering of nonvaccination, which decreases local immunity below the herd immunity threshold. However, little is known about how to best conduct surveillance and target interventions to detect and address these high-risk areas, and most vaccination data are reported at the state-level-a resolution too coarse to detect community-level clustering of nonvaccination characteristic of recent outbreaks. In this paper, we perform a series of computational experiments to assess the impact of clustered nonvaccination on outbreak potential and magnitude of bias in predicting disease risk posed by measuring vaccination rates at coarse spatial scales. We find that, when nonvaccination is locally clustered, reporting aggregate data at the state- or county-level can result in substantial underestimates of outbreak risk. The COVID-19 pandemic has shone a bright light on the weaknesses in US infectious disease surveillance and a broader gap in our understanding of how to best use detailed spatial data to interrupt and control infectious disease transmission. Our research clearly outlines that finer-scale vaccination data should be collected to prevent a return to endemic measles transmission in the United States.

Students Provisionally Enrolled Due to Vaccination Requirements: Variation in State Laws and Rates.

This research examined the laws and regulations surrounding provisional enrollment in schools across the United States. Provisional enrollment refers to children who have started, but not completed, their required vaccinations and are allowed to attend school while completing their vaccinations. We found that nearly all states have laws regarding provisional enrollment, with 5 essential components to compare the laws including vaccine- and dose-specific requirements, type of personnel permitted to authorize, length of time that the children have to become up to date on their vaccinations (grace period), follow-up procedures, and consequences for noncompliance. In addition, we found that the percentage of provisionally enrolled kindergarteners varied greatly from state to state, with some states having less than 1% of provisionally enrolled kindergarteners and others having more than 8% between school years 2015-2016 and 2020-2021. We suggest that reducing the number of provisional entrants could be an alternative intervention to increase vaccination coverage.

Trends in the Number and Type of Tobacco Product Retailers, United States, 2000-2017.

INTRODUCTION: Tobacco product retailers provide access to tobacco products and exposure to tobacco marketing. Without a national tobacco retailer licensing system in the United States, there are no estimates of national trends in tobacco retailer numbers and store type over time. METHODS: We developed a protocol to identify likely tobacco retailers across the United States between 2000 and 2017 using industry codes and retailer names in the annual National Establishment Time Series (NETS) database. We calculated annual counts of tobacco retailers in seven store-type categories and annual numbers of tobacco retailers that opened and closed. RESULTS: We estimate that there were 317 492 tobacco product retailers in 2000; the number grew to 412 536 in 2009 before falling to 356 074 in 2017, for a net 12% increase overall. Gas/convenience stores and grocery stores accounted for more than two thirds of all retailers. On average, new openings accounted for 8.0% of the total retailers, whereas 7.3% of retailers closed or stopped selling tobacco each year, with stronger market volatility following the Great Recession. Since 2011, there was a disproportionate reduction in tobacco-selling pharmacies and an increase in both tobacco-specialty shops and tobacco-selling discount stores. CONCLUSIONS: During two decades when smoking declined, tobacco retailer availability increased in the United States. The economic climate, corporate and public policies, and new tobacco products may all contribute to trends in tobacco retailer availability. State and local jurisdictions considering tobacco retailer policies may find retailer trend information useful for forecasting or evaluating potential policy impacts. IMPLICATIONS: This study provides historic data tracking tobacco retailers in the United States between 2000 and 2017, documenting trends that unfolded as the general economic market contracted and grew, with greater regulation of the tobacco retailer environment. These data provide a context for better understanding future changes in the tobacco retailer market. In addition, the protocol established in this study could be applied in any US-based location without tobacco retailer licensing to allow identification of stores and tracking of trends.

Racial Disparities in Coronavirus Disease 2019 (COVID-19) Mortality Are Driven by Unequal Infection Risks.

BACKGROUND: As of 1 November 2020, there have been >230 000 deaths and 9 million confirmed and probable cases attributable to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the United States. However, this overwhelming toll has not been distributed equally, with geographic, race/ethnic, age, and socioeconomic disparities in exposure and mortality defining features of the US coronavirus disease 2019 (COVID-19) epidemic. METHODS: We used individual-level COVID-19 incidence and mortality data from the state of Michigan to estimate age-specific incidence and mortality rates by race/ethnic group. Data were analyzed using hierarchical Bayesian regression models, and model results were validated using posterior predictive checks. RESULTS: In crude and age-standardized analyses we found rates of incidence and mortality more than twice as high than for Whites for all groups except Native Americans. Blacks experienced the greatest burden of confirmed and probable COVID-19 (age-standardized incidence, 1626/100 000 population) and mortality (age-standardized mortality rate, 244/100 000). These rates reflect large disparities, as Blacks experienced age-standardized incidence and mortality rates 5.5 (95% posterior credible interval [CrI], 5.4-5.6) and 6.7 (95% CrI, 6.4-7.1) times higher than Whites, respectively. We found that the bulk of the disparity in mortality between Blacks and Whites is driven by dramatically higher rates of COVID-19 infection across all age groups, particularly among older adults, rather than age-specific variation in case-fatality rates. CONCLUSIONS: This work suggests that well-documented racial disparities in COVID-19 mortality in hard-hit settings, such as Michigan, are driven primarily by variation in household, community, and workplace exposure rather than case-fatality rates.

Measuring Multiple Dimensions and Indices of Nonvaccination Clustering in Michigan, 2008-2018.

Michigan experienced a significant measles outbreak in 2019 amidst rising rates of nonmedical vaccine exemptions (NMEs) and low vaccination coverage compared with the rest of the United States. There is a critical need to better understand the landscape of nonvaccination in Michigan to assess the risk of vaccine-preventable disease outbreaks in the state, yet there is no agreed-upon best practice for characterizing spatial clustering of nonvaccination, and numerous clustering metrics are available in the statistical, geographical, and epidemiologic literature. We used school-level data to characterize the spatiotemporal landscape of vaccine exemptions in Michigan for the period 2008-2018 using Moran's I, the isolation index, the modified aggregation index, and the Theil index at 4 spatial scales. We also used nonvaccination thresholds of 5%, 10%, and 20% to assess the bias incurred when aggregating vaccination data. We found that aggregating school-level data to levels commonly used for public reporting can lead to large biases in identifying the number and location of at-risk students and that different clustering metrics yielded variable interpretations of the nonvaccination landscape in Michigan. This study shows the importance of choosing clustering metrics with their mechanistic interpretations in mind, be it large- or fine-scale heterogeneity or between- and within-group contributions to spatial variation.

Which Definition of Rurality Should I Use?: The Relative Performance of 8 Federal Rural Definitions in Identifying Rural-Urban Disparities.

BACKGROUND: The federal government uses multiple definitions for identifying rural communities based on various geographies and different elements of rurality. OBJECTIVES: The objectives of this study were to: (1) assess the degree to which rural definitions identify the same areas as rural; and (2) assess rural-urban disparities identified by each definition across socioeconomic, demographic, and health access and outcome measures. RESEARCH DESIGN: We determined the rural status of each census tract and calculated the rural-urban disparity resulting from each definition, as well as across the number of definitions in which tracts were designated as rural (rurality agreement). SUBJECTS: The population in 72,506 census tracts. MEASURES: We used 8 federal rural definitions. Population characteristics included percent with a bachelor's degree, income below 200% poverty, population density, percent with health insurance and whether various health care services were within 30 minutes driving time of the tract centroid. RESULTS: The rural population varied from slightly < 6.9 million people to >75.5 million across definitions. The largest rural-urban disparities were found using Urban Influence Codes. Urbanized Area and Urbanized Cluster tended to generate smaller disparities. Population characteristics such as population density and percent White had notable discontinuities across levels of rurality, while others such as percent with a bachelor's degree and income below 200% poverty varied continuously. CONCLUSIONS: Rural-urban populations and disparities were sensitive to the specific definition and the relative strength of definitions varied across population characteristics. Researchers and policymakers should carefully consider the choice of outcome and region when deciding the most appropriate rural definition.

Integrating Surveillance Data to Estimate Race/Ethnicity-specific Hysterectomy Inequalities Among Reproductive-aged Women: Who's at Risk?

BACKGROUND: Inequalities by race and ethnicity in hysterectomy for noncancerous conditions suggest that some subgroups may be shouldering an unfair burden of procedure-associated negative health impacts. We aimed to estimate race- and ethnicity-specific rates in contemporary hysterectomy incidence that address three challenges in the literature: exclusion of outpatient procedures, no hysterectomy prevalence adjustment, and paucity of non-White and non-Black estimates. METHODS: We used surveillance data capturing all inpatient and outpatient hysterectomy procedures performed in North Carolina from 2011 to 2014 (N = 30,429). Integrating data from the Behavior Risk Factor Surveillance System and US Census population estimates, we calculated prevalence-corrected hysterectomy incidence rates and differences by race and ethnicity. RESULTS: Prevalence-corrected estimates show that non-Hispanic (nH) Blacks (62, 95% confidence interval [CI] = 61, 63) and nH American Indians (85, 95% CI = 79, 93) per 10,000 person-years (PY) had higher rates, compared with nH Whites (45 [95% CI = 45, 46] per 10,000 PY), while Hispanic (20, 95% CI = 20, 21) and nH Asian/Pacific Islander rates (8, 95% CI = 8.0, 8.2) per 10,000 PY were lower than nH Whites. CONCLUSION: Through strategic surveillance data use and application of bias correction methods, we demonstrate wide differences in hysterectomy incidence by race and ethnicity. See video abstract at, http://links.lww.com/EDE/B657.

Examining vaccination coverage in Germany: spatiotemporal clustering of MMR coverage, 2008-14.

Vaccine hesitancy is an increasing global health threat but much of the recent research has centred on the USA. European countries provide an interesting context due to increases in vaccine-preventable disease outbreaks as well as variability in vaccination laws. We investigated the spatiotemporal clustering of Measles, Mumps, and Rubella vaccination coverage in Germany, a country with a historic absence of compulsory vaccination laws. We also examined measles incidence in the context of the spatiotemporal clustering results. While we did not identify strong spatial patterns of geographic clustering in Germany, our results suggest a potential relationship between measles incidence and vaccination coverage cluster status.

Travel Time to Title X Facilities and Teenage Birth Rates in North Carolina.

OBJECTIVES: In the United States, Title X facilities are understood to be an effective starting point for improving teenagers' reproductive health outcomes, including unintended pregnancy. We investigate geographic accessibility of Title X facilities and the relationship between geographic accessibility of Title X facilities and teenage birth rates in the state of North Carolina (NC). METHODS: Vehicular travel time from each ZCTA to its nearest Title X facility was calculated using a geographic information system and summarized as the indicator of geographic accessibility. We used bivariate and multiple spatial lag regressions to evaluate the relationship between ZCTA-level teenage birth rates (n = 754) in 2016 and geographic accessibility to a Title X facility, as well as socioeconomic and demographic factors. RESULTS: Nearly 60% of teenage women lived 30 min or less from a Title X funded facility, while approximately 12% of women lived 60 min or more from the nearest facility. In the regression models, percent non-Hispanic White, percent Hispanic, percent in Poverty, percent not enrolled in school, and population density were associated with teenage birth rates; however, geographic accessibility was only associated in the bivariate model. CONCLUSIONS: Our findings show that geographic accessibility of Title X facilities is lower in NC than in other states. However, our results suggest that geographic accessibility is not related to teenage birth rates. Overall, these findings may indicate that publicly funded family planning facilities are underutilized by proximal populations or factors other than proximity act as a barrier to utilization.

Complexity of the Basic Reproduction Number (R0).

The basic reproduction number (R0), also called the basic reproduction ratio or rate or the basic reproductive rate, is an epidemiologic metric used to describe the contagiousness or transmissibility of infectious agents. R0 is affected by numerous biological, sociobehavioral, and environmental factors that govern pathogen transmission and, therefore, is usually estimated with various types of complex mathematical models, which make R0 easily misrepresented, misinterpreted, and misapplied. R0 is not a biological constant for a pathogen, a rate over time, or a measure of disease severity, and R0 cannot be modified through vaccination campaigns. R0 is rarely measured directly, and modeled R0 values are dependent on model structures and assumptions. Some R0 values reported in the scientific literature are likely obsolete. R0 must be estimated, reported, and applied with great caution because this basic metric is far from simple.

Using floating catchment area (FCA) metrics to predict health care utilization patterns.

BACKGROUND: Floating Catchment Area (FCA) metrics provide a comprehensive measure of potential spatial accessibility to health care services and are often used to identify geographic disparities in health care access. An unexplored aspect of FCA metrics is whether they can be useful in predicting where people actually seek care. This research addresses this question by examining the utility of FCA metrics for predicting patient utilization patterns, the flows of patients from their residences to facilities. METHODS: Using more than one million inpatient hospital visits in Michigan, we calculated expected utilization patterns from Zip Codes to hospitals using four FCA metrics and two traditional metrics (simple distance and a Huff model) and compared them to observed utilization patterns. Because all of the accessibility metrics rely on the specification of a distance decay function and its associated parameters, we conducted a sensitivity analysis to evaluate their effects on prediction accuracy. RESULTS: We found that the Three Step FCA (3SFCA) and Modified Two Step FCA (M2SFCA) were the most effective metrics for predicting utilization patterns, correctly predicting the destination hospital for nearly 74% of hospital visits in Michigan. These two metrics were also the least sensitive to changes to the distance decay functions and parameter settings. CONCLUSIONS: Overall, this research demonstrates that FCA metrics can provide reasonable predictions of patient utilization patterns and FCA utilization models could be considered as a substitute when utilization pattern data are unavailable.

Associations of Statewide Legislative and Administrative Interventions With Vaccination Status Among Kindergartners in California.

Importance: California implemented 3 interventions to increase uptake of vaccines. In 2014, Assembly bill 2109 tightened requirements for obtaining a personal belief exemption. A 2015 campaign provided educational materials to school staff on the proper application of conditional admission for kindergartners who were not up to date on required vaccinations. In 2016, Senate bill 277 eliminated personal belief exemptions. Prior research has not evaluated these 3 interventions together with regard to the vaccination status of students. Objective: To assess the changes in the yearly rates of kindergartners who were not up to date on required vaccinations who were entering school during the period of the interventions, by focusing on geographic clustering and the potential contacts of these kindergartners. Design, Setting, and Participants: Observational study that used cross-sectional school-entry data from 2000-2017 to calculate the rates of kindergartners attending California schools who were not up to date on required vaccinations. Exposures: Assembly bill 2109, a conditional admission education program, and Senate bill 277. Main Outcomes and Measures: The primary outcome was the yearly rate of kindergartners without up-to-date vaccination status. The secondary outcomes were (1) the modified aggregation index, which was used to assess the potential within-school contacts among kindergartners without up-to-date vaccination status, (2) the number of geographic clusters of schools with rates for kindergartners without up-to-date vaccination status that were higher than the rates for schools located outside the cluster, and (3) the number of schools located inside the geographic clusters. Results: In California between 2000 and 2017, 9 323 315 children started attending kindergarten and 721 593 were not up to date on required vaccinations. Prior to the interventions, the statewide rate of kindergartners without up-to-date status for required vaccinations increased from 7.80% during 2000 to 9.84% during 2013 and then decreased after the interventions to 4.87% during 2017. The percentage chance for within-school contact among kindergartners without up-to-date vaccination status decreased from 26.02% during 2014 to 4.56% (95% CI, 4.21%-4.99%) during 2017. During 2012-2013, there were 124 clusters that contained 3026 schools with high rates of kindergartners without up-to-date vaccination status. During 2014-2015, there were 93 clusters that contained 2290 schools with high rates of kindergartners without up-to-date vaccination status. During 2016-2017, there were 110 clusters that contained 1613 (95% CI, 1565-1691) schools. Conclusions and Relevance: In California, statewide legislative and educational interventions were associated with a decrease in the yearly rates of kindergartners without up-to-date vaccination status. These interventions also were associated with reductions in the number of schools inside the clusters with high rates of kindergartners without up-to-date vaccination status and the potential for contact among these kindergartners.

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

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

Cancer and Social Media: A Comparison of Traffic about Breast Cancer, Prostate Cancer, and Other Reproductive Cancers on Twitter and Instagram.

Social media are often heralded as offering cancer campaigns new opportunities to reach the public. However, these campaigns may not be equally successful, depending on the nature of the campaign itself, the type of cancer being addressed, and the social media platform being examined. This study is the first to compare social media activity on Twitter and Instagram across three time periods: #WorldCancerDay in February, the annual month-long campaigns of National Breast Cancer Awareness Month (NBCAM) in October and Movember in November, and during the full year outside of these campaigns. Our results suggest that women's reproductive cancers - especially breast cancer - tend to outperform men's reproductive cancer - especially prostate cancer - across campaigns and social media platforms. Twitter overall generates substantially more activity than Instagram for both cancer campaigns, suggesting Instagram may be an untapped resource. However, the messaging for both campaigns tends to focus on awareness and support rather than on concrete actions and behaviors. We suggest health communication efforts need to focus on effective messaging and building engaged communities for cancer communication across social media platforms.

Kindergarten Vaccination Status in California After Changes to Medical Exemption Policy.

This study evaluates changes in medical exemptions and geographic distribution of kindergarteners in California not up to date on vaccination after changes to state legislation.

Sociodemographic Predictors of Vaccination Exemptions on the Basis of Personal Belief in California.

OBJECTIVES: We examined the variability in the percentage of students with personal belief exemptions (PBEs) from mandatory vaccinations in California schools and communities according to income, education, race, and school characteristics. METHODS: We used spatial lag models to analyze 2007-2013 PBE data from the California Department of Public Health. The analyses included school- and regional-level models, and separately examined the percentage of students with exemptions in 2013 and the change in percentages over time. RESULTS: The percentage of students with PBEs doubled from 2007 to 2013, from 1.54% to 3.06%. Across all models, higher median household income and higher percentage of White race in the population, but not educational attainment, significantly predicted higher percentages of students with PBEs in 2013. Higher income, White population, and private school type significantly predicted greater increases in exemptions from 2007 to 2013, whereas higher educational attainment was associated with smaller increases. CONCLUSIONS: Personal belief exemptions are more common in areas with a higher percentage of White race and higher income.

Variation in Vaccination Data Available at School Entry Across the United States.

OBJECTIVES: To compile substate-level data on US school-age children's vaccination rates. METHODS: For states that did not have suitable data online, in 2015 we submitted information requests to the state health department and followed up with the state's Freedom of Information Act when necessary. RESULTS: The accessibility, scale, and types of vaccination data varied considerably. Whereas 26 states provided data online, 14 released data only after a Freedom of Information Act request. School or school-district data were available for 24 states, 19 at the county level, 2 at the health department level, and 6 provided no substate-level data. CONCLUSIONS: Effective vaccination policy requires a robust understanding of vaccination behavior. Some states make it difficult to access data or provide low-resolution data of limited value for identifying vaccination behavior.