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Published in final edited form as: Vaccine. 2025 Feb 21;52:126888. doi: 10.1016/j.vaccine.2025.126888 Search in PMC Search in PubMed View in NLM Catalog Add to search Attitudes of California School Personnel on Potential COVID-19 Vaccine Mandates and State Law SB277 to Remove Nonmedical Vaccine Exemptions Matthew Z Dudley Matthew Z Dudley a Institute for Vaccine Safety, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA b Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA Find articles by Matthew Z Dudley a, b , Alexander J Zapf Alexander J Zapf b Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA c Department of Epidemiology, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA 02115, USA Find articles by Alexander J Zapf b, c , Paul Delamater Paul Delamater d Department of Geography and Carolina Population Center, The University of North Carolina, 123 West Franklin St., Suite 210, Chapel Hill, NC 27516, USA Find articles by Paul Delamater d , Tina M Proveaux Tina M Proveaux a Institute for Vaccine Safety, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA b Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA Find articles by Tina M Proveaux a, b , Holly B Schuh Holly B Schuh a Institute for Vaccine Safety, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA e Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA Find articles by Holly B Schuh a, e , Alison M Buttenheim Alison M Buttenheim f Department of Family and Community Health, School of Nursing, University of Pennsylvania, 418 Curie Boulevard, Philadelphia, PA 19104-4217, USA g Center for Health Incentives and Behavioral Economics, Perelman School of Medicine, University of Pennsylvania, 1118 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104-6021, USA h Leonard Davis Institute of Health Economics, University of Pennsylvania, 3641 Locust Walk Philadelphia, Pennsylvania, Philadelphia, PA, USA Find articles by Alison M Buttenheim f, g, h , Jason L Schwartz Jason L Schwartz i Department of Health Policy and Management, Yale School of Public Health, 60 College Street New Haven, CT 06520-0834, USA Find articles by Jason L Schwartz i , Nicola P Klein Nicola P Klein j Kaiser Permanente Vaccine Study Center, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612, USA Find articles by Nicola P Klein j , Kristin Goddard Kristin Goddard j Kaiser Permanente Vaccine Study Center, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612, USA Find articles by Kristin Goddard j , Kavin M Patel Kavin M Patel k Yale School of Medicine, 333 Cedar St, New Haven, CT 06510, USA Find articles by Kavin M Patel k , Saad B Omer Saad B Omer l Peter O’Donnell Jr. School of Public Health, UT Southwestern, 5323 Harry Hines Blvd, Dallas, TX 75390, USA Find articles by Saad B Omer l , Daniel A Salmon Daniel A Salmon a Institute for Vaccine Safety, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA b Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA m Department of Health Behavior Society, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA Find articles by Daniel A Salmon a, b, m Author information Article notes Copyright and License information a Institute for Vaccine Safety, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA b Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA c Department of Epidemiology, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA 02115, USA d Department of Geography and Carolina Population Center, The University of North Carolina, 123 West Franklin St., Suite 210, Chapel Hill, NC 27516, USA e Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA f Department of Family and Community Health, School of Nursing, University of Pennsylvania, 418 Curie Boulevard, Philadelphia, PA 19104-4217, USA g Center for Health Incentives and Behavioral Economics, Perelman School of Medicine, University of Pennsylvania, 1118 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104-6021, USA h Leonard Davis Institute of Health Economics, University of Pennsylvania, 3641 Locust Walk Philadelphia, Pennsylvania, Philadelphia, PA, USA i Department of Health Policy and Management, Yale School of Public Health, 60 College Street New Haven, CT 06520-0834, USA j Kaiser Permanente Vaccine Study Center, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612, USA k Yale School of Medicine, 333 Cedar St, New Haven, CT 06510, USA l Peter O’Donnell Jr. School of Public Health, UT Southwestern, 5323 Harry Hines Blvd, Dallas, TX 75390, USA m Department of Health Behavior Society, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA ✉ Address correspondence to : Matthew Z. Dudley, Institute for Vaccine Safety, Johns Hopkins University Bloomberg School of Public Health, 615 N. Wolfe Street, w5041, Baltimore, Maryland 21205. [email protected] . Issue date 2025 Apr 11. PMC Copyright notice PMCID: PMC11975493 NIHMSID: NIHMS2061758 PMID: 39985971 The publisher's version of this article is available at Vaccine Abstract California passed Senate Bill 277 in 2015, eliminating nonmedical exemptions to school immunization requirements. California elementary school personnel who worked with parents on meeting school immunization requirements were surveyed in 2022. Of the 122 survey respondents, half (50%) were school principals, 11% were registrars, 9% were health clerks, and 7% were nurses. Only one-quarter (26%) believed their school had authority to deny medical exemptions. Almost half supported COVID-19 vaccine mandates for children in elementary (43%), middle (44%), and high (49%) schools. Almost half (42%) were concerned that children’s immune systems could be weakened by too many shots, and nearly one-third thought immunizations do more harm than good (32%). Among our sample of California schools, many personnel working with parents on meeting immunization requirements were not clinically trained, were unaware of their responsibility to deny invalid medical exemptions, and had vaccine concerns. Vaccine education for school personnel and further involvement of school nurses in the implementation and enforcement of school immunization requirements could have a positive impact on vaccine coverage and disease prevention. Keywords: Immunization requirements, vaccine mandates, vaccine policy, SB277, California, COVID-19 Introduction Senate Bill (SB) 277 is a California (CA) state law passed in 2015 to eliminate nonmedical (e.g., religious or personal belief) exemptions to school immunization requirements,( 1 ) making CA the first state in almost 30 years to do so.( 2 ) Rates of nonmedical exemptions had been steadily increasing in the decades prior to SB277 across the US,( 3 ) particularly in CA.( 4 ) Geographical clustering of nonmedical vaccine exemptions contributed to previous US outbreaks of measles and pertussis.( 5 – 8 ) The political will to pass SB277 likely arose from the aftermath of the measles outbreak that began at Disneyland earlier in 2015.( 9 ) Most measles cases in the outbreak had nonmedical exemptions, allowing students to attend school and potentially spread the disease despite not being up to date on their vaccines.( 10 ) Statewide childhood vaccine coverage increased initially following SB277’s passing,( 11 ) though this may have been largely due to pre-SB277 efforts to educate about and enforce correct application of conditional entrance requirements.( 2 ) The proportion of kindergarten students in the 2014–2015 school year who received all required vaccines was 90.4%; this increased to 92.8% in 2015–2016, and peaked at 95.6% in 2016–2017. However, coverage declined slightly over the next several years, and dipped back to 92.8% in 2021–2022 before rebounding to 94.0% in 2021–2022, though coverage and data collection may have been temporarily affected by the COVID-19 pandemic.( 12 ) Despite initial political momentum,( 13 , 14 ) COVID-19 vaccines have not been added to school immunization requirements. Instead of a centralized review mechanism, SB277 gave schools the authority to accept or deny the medical exemption requests of their student population, leading to varied interpretation of SB277’s regulatory language across jurisdictions and school districts.( 15 ) This made school personnel critical to implementing school immunization requirements, as they both counsel parents and grant exemptions,( 16 ) despite no specific criteria for assessing the validity of medical exemptions defined in the bill.( 1 ) The CA Department of Public Health (CDPH) later stipulated that medical exemptions must be issued by a Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) licensed in CA,( 17 ) and must meet applicable criteria defined by the Advisory Committee on Immunization Practices (ACIP) of the United States (US) Centers for Disease Control and Prevention (CDC),( 18 ) but school personnel without clinical training may still struggle to interpret these criteria. SB277’s language regarding individualized education programs (IEP) also caused much confusion for schools.( 15 ) The federal Individuals with Disabilities Education Act required schools to provide an IEP for all students with a disability that impacts their learning.( 19 ) Students with IEPs have varying amounts of participation with other students in classroom and other school activities, though recently special education has trended towards trying to include students with IEPs in general education classroom settings more.( 15 ) While SB277 stated that it should not prohibit access to any special education or related services required by an IEP, it did not address students with IEPs in general education classroom settings.( 1 ) The number of medical exemptions increased after SB277,( 2 , 20 ) and many of these new medical exemptions were not for valid contraindications to vaccination.( 15 , 21 ) This is evidence of a replacement effect; some parents who would have obtained a nonmedical exemption likely instead obtained a medical exemption, even if unwarranted. In response, two new laws were passed in 2019 to increase oversight of medical exemptions. Senate Bill 276 (SB276) required CDPH to review medical exemptions from schools in which fewer than 95% of students had received all required vaccines (or failed to report their coverage data) and from doctors who have written five or more medical exemptions during the year.( 22 ) Senate Bill 714 (SB714) required regular reauthorization of permanent exemptions and limited temporary exemptions to one year.( 23 ) The vaccine knowledge, attitudes, and beliefs (KABs) and training of school personnel tasked with enforcing school immunization requirements varies by school and affects the likelihood of student exemption requests being granted.( 24 , 25 ) A 2004 survey among a stratified random sample of school personnel in Colorado, Massachusetts, Missouri, and Washington found that school nurses were more likely than other school personnel to believe in the utility and safety of vaccination, and that children attending schools with a nurse reviewing their immunization status were less likely to have an exemption than children attending schools with other school personnel reviewing their immunization status (Odds Ratio: 0.39; 95% Confidence Interval: 0.28–0.56).( 25 ) Likewise, a 2021 survey among a stratified random sample of school personnel in California found that nurses were more likely than other school personnel to believe in the importance of vaccination and less likely to have vaccine concerns; however, this survey also found that schools with a nurse responsible for student vaccination records were more likely to have granted a medical exemption request compared to schools relying on other school personnel (OR: 2.11; 95%CI: 1.34–3.36).( 24 ) We conducted a cross-sectional survey of California elementary school personnel responsible for working with parents on meeting school immunization requirements in 2022, after initial disruptions from the COVID-19 pandemic had largely ceased and most schools had returned to in-person education. This manuscript describes the vaccine KABs of participating personnel as well as their school’s implementation and enforcement of immunization requirements, and examines differences in survey responses by nurses vs other school personnel, at least one vs no exemption granted, and trust in CDC. Materials and Methods Sample Vaccination data was obtained from CDPH. Reference data for CA schools, including contact information, were downloaded from the California Department of Education website.( 26 ) Of the 8140 elementary schools listed, we excluded those that did not report vaccination or enrollment data for kindergarteners in the 2019–2020 school year (n=141), those missing reference information (n=233), and those classified as virtual (n=76), leaving 7,690 eligible schools remaining. Of these, we randomly selected 800 schools for recruitment (400 as the initial set, and 400 as a backup set in case of a low response rate). Recruitment On March 31, 2022, we mailed packets containing a disclosure letter, survey, post-marked return envelope, and a gift card incentive to these schools, following the methodology used for our previous survey of CA school personnel.( 24 ) Packets for 10 schools were returned by the US postal service due to address issues; these schools were then excluded from our sample. For all other schools who did not respond to the initial mailing, a second mailing was sent in May 2022, and a follow-up letter was sent in June 2022. Survey instructions specified that surveys should be completed by the person at the school who works with parents on meeting school immunization requirements. Surveys could either be completed on paper or online; paper surveys returned by mail were scanned into digital data using PaperSurvey.io.( 27 ) Consent was obtained from all respondents through the accompanying disclosure letter. The Emory University Institutional Review Board approved the study (IRB00089885). Survey Content The survey instrument was based on our previous surveys of school personnel.( 24 , 25 ) Surveys captured characteristics of the respondents, such as their role in the school, and inquired about SB277 implementation and enforcement at the school level, such as how parents were notified, who is eligible for conditional admission, who has authority and what are acceptable reasons to write and deny medical exemptions, and which types of exemptions were requested and granted. Survey items assessed support for existing vaccine mandates, as well as support for and anticipated difficulty of potentially mandating COVID-19 for school children of varying ages. Additional survey items covered vaccine KABs of school personnel, including components of the Health Belief Model such as perceived susceptibility to and severity of vaccine preventable diseases (VPDs) and perceived vaccine benefits and safety. School personnel were asked to rate their use of and trust in various sources of vaccine information. Trust in CDC was measured using a previously validated 14-item scale.( 28 ) The survey instrument is included as Appendix 1 . Data Analyses Likert and other scale response options were dichotomized to represent affirmative versus negative responses (e.g., agree vs. disagree, support vs. do not support). Neutral scale responses (e.g., do not know) were classified as affirmative for survey items measuring anti-vaccine attitudes and as negative for items measuring pro-vaccine attitudes to make the affirmative and negative groups more even and enable greater statistical power for stratification. Survey responses were summarized and stratified by nurses vs other school personnel (e.g., principals, registrars, clerks), at least one vs no exemption granted, and trust in CDC. Personnel who did not identify their role at the school (23%) were treated as other school personnel, since their survey responses resembled those of other school personnel rather than those of nurses. Differences between strata were tested for statistical significance (p<0.05) using Pearson’s Chi-Squared Test. Data were analyzed using Stata (version 16).( 29 ) A composite, linear score was created for the construct scale measuring trust in CDC ( Appendix 2 ).( 28 ) Scores were generated using a numerator summing responses to scale items (each 5-point Likert scale response was scored 0–4), and a denominator representing the total possible score (accounting for missing data). After multiplying by 100, the scale ranged from 0 to 100 (with 100 representing maximum possible trust and 0 representing maximum possible distrust). The Cronbach’s alpha of this scale was estimated as 0.89, indicating strong reliability.( 30 ) The continuous score was also dichotomized at the middle (50) to create “high trust” and “low trust” groups, in order to improve interpretability and facilitate comparisons between populations. Results Sample Of the 790 CA elementary school personnel invited to participate, 122 (15%) completed the survey ( Table 1 ). Of these, half (50%) were school principals, 11% were registrars, 9% were health clerks, and 7% were nurses. Table 1. Characteristics of Participating School Personnel and Their Schools’ Exemption Practices, and Differences Between Nurses and Other School Personnel Total N=122 Nurses a N=9 Other School Personnel a N=113 p-value b Characteristics of Participating School Personnel What is your role in your school? <0.01 District nurse 3 (2%) 3 (33%) 0 (0%) Health Clerk 11 (9%) 0 (0%) 11 (10%) Registrar 13 (11%) 0 (0%) 13 (12%) School nurse 6 (5%) 6 (67%) 0 (0%) School principal 61 (50%) 0 (0%) 61 (54%) Missing 28 (23%) 0 (0%) 28 (25%) How many years have you been the school’s person working on immunization requirements? 0.93 ≤1 16 (13%) 1 (11%) 15 (13%) 2–3 18 (15%) 2 (22%) 16 (14%) 4–9 26 (21%) 3 (33%) 23 (20%) 10+ 24 (20%) 3 (33%) 21 (19%) Missing 38 (31%) 0 (0%) 38 (34%) School Practices Parents were notified about SB277 83 (68%) 8 (89%) 75 (66%) 0.16 How were parents notified? Sent written communication home 42 (55%) 6 (75%) 36 (52%) 0.22 Sent email communication home 39 (51%) 3 (38%) 36 (52%) 0.43 Posted written information at school 18 (23%) 2 (25%) 16 (23%) 0.91 Posted information on school website 30 (39%) 3 (38%) 27 (39%) 0.93 Included information in kindergarten registration materials 29 (38%) 5 (63%) 24 (35%) 0.13 Held meeting at school 4 (5%) 0 (0%) 4 (6%) 0.48 What categories of students does the school consider eligible for conditional admission? Temporary Medical Exemptions 71 (61%) 8 (89%) 63 (58%) 0.07 Missing dose(s) but not due for any dose(s) at time of school entry 62 (53%) 5 (56%) 57 (53%) 0.87 Missing dose(s) but scheduled appointment to receive these dose(s) 70 (60%) 5 (56%) 65 (60%) 0.79 Child has some doses 17 (15%) 1 (11%) 16 (15%) 0.76 Do Not Know 9 (8%) 0 (0%) 9 (8%) 0.37 Who has authority to write a medical exemption? Doctor/physician (MD and/or DO) 111 (94%) 8 (89%) 103 (94%) 0.49 Physician’s Assistant 18 (15%) 1 (11%) 17 (16%) 0.72 Nurse 6 (5%) 0 (0%) 6 (6%) 0.47 Nurse Practitioner 11 (9%) 2 (22%) 9 (8%) 0.17 Chiropractor 2 (2%) 0 (0%) 2 (2%) 0.68 Homeopathic Doctor 3 (3%) 0 (0%) 3 (3%) 0.61 Someone at the school has authority to deny a medical exemption request 29 (26%) 5 (63%) 24 (23%) 0.01 Who at the school level has final authority to accept/deny a medical exemption request? School principal 18 (30%) 2 (29%) 16 (30%) 0.93 School board 12 (20%) 1 (14%) 11 (21%) 0.69 School nurse 24 (40%) 5 (71%) 19 (36%) 0.07 Legal counsel 6 (10%) 2 (29%) 4 (8%) 0.08 Do Not Know 7 (12%) 0 (0%) 7 (13%) 0.31 What is an acceptable reason for denying a medical exemption request? Form not signed by a physician 52 (90%) 4 (57%) 48 (94%) <0.01 Form does not state whether permanent or temporary 27 (47%) 2 (29%) 25 (49%) 0.31 Form does not state there is a medical condition contraindicating vaccination 29 (50%) 2 (29%) 27 (53%) 0.23 Reason provided is not a valid medical contraindication 22 (38%) 1 (14%) 21 (41%) 0.17 What is the most recent year for which you have data? 0.56 2020 or earlier 6 (5%) 0 (0%) 6 (5%) 2021 51 (42%) 4 (44%) 47 (42%) 2022 41 (34%) 5 (56%) 36 (32%) Missing 24 (20%) 0 (0%) 24 (21%) Student Exemptions At least one exemption requested for kindergarten this school year 36 (35%) 4 (44%) 32 (34%) 0.53 Temporary Medical Exemptions 14 (14%) 1 (13%) 13 (14%) 0.88 Medical Exemptions 16 (19%) 2 (25%) 14 (18%) 0.63 Conditional Entrants 15 (19%) 1 (17%) 14 (19%) 0.89 (grandfathered) Personal Belief Exemptions 5 (6%) 1 (14%) 4 (5%) 0.36 At least one exemption granted for kindergarten this school year 33 (34%) 4 (44%) 29 (33%) 0.49 Temporary Medical Exemptions 13 (14%) 1 (13%) 12 (14%) 0.89 Medical Exemptions 14 (17%) 2 (29%) 12 (16%) 0.40 Conditional Entrants 15 (19%) 1 (17%) 14 (20%) 0.86 (grandfathered) Personal Belief Exemptions 2 (3%) 0 (0%) 2 (3%) 0.67 Pertussis/Whooping cough vaccine 15 (20%) 1 (20%) 14 (20%) 0.99 MMR vaccine 19 (26%) 1 (20%) 18 (26%) 0.76 As a result of SB277, at least one student (from your school) has: Moved out of state 21 (27%) 2 (33%) 19 (26%) 0.71 Gotten an exemption due to individualized education program (IEP) status 16 (23%) 2 (33%) 14 (22%) 0.54 Started homeschooling 21 (32%) 1 (20%) 20 (33%) 0.56 Since Fall 2016, at least one student with IEP has been excluded from programs including extracurricular activities at your school due to vaccination status 1 (1%) 0 (0%) 1 (1%) 0.76 At least one student at school has IEP and: Is up-to-date on immunizations 78 (93%) 8 (100%) 70 (92%) 0.41 Has a medical exemption 23 (27%) 4 (50%) 19 (25%) 0.13 Is a conditional entrant 12 (14%) 3 (38%) 9 (12%) 0.05 Open in a new tab a Nurses compared to other school personnel (e.g., principals, registrars, clerks); respondents who did not identify their role at the school (19%) were treated as other school personnel b boldface indicates statistical significance (p<0.05) using Pearson’s Chi-Squared Test School Exemption Practices Two-thirds (68%) of participating schools notified parents about SB277. One-third of schools received (35%) and granted (34%) at least one exemption request for kindergarten during the most recent school year ( Table 1 ). More than half of schools consider students with temporary medical exemptions (61%), students missing dose(s) but not due for any at time of school entry (53%), and students missing dose(s) but who have scheduled an appointment to receive them (60%) eligible for conditional admission. One-quarter (26%) of respondents reported that their school had someone with the authority to deny a medical exemption request. The most commonly reported school personnel with final authority to accept or deny a medical exemption request were school nurses (40%), followed by school principles (30%) and school boards (20%). Because of SB277, one-third of schools (32%) had at least one student start homeschooling, and about one-quarter of schools had at least one student move out of state (27%) or get an exemption due to IEP status (23%). Knowledge, Attitudes, and Beliefs Regarding Vaccines and Vaccine-Preventable Diseases About two-thirds of respondents thought an 8-year-old would likely become seriously ill if contracting measles (68%) or pertussis (66%), followed by mumps (59%), COVID-19 (58%), influenza (51%), and varicella (49%) ( Table 2 ). Fewer respondents perceived COVID-19 vaccine as safe for children (65%) than pertussis (85%), measles-mumps-rubella (MMR) (83%), influenza (83%), and varicella (84%) vaccines. Almost half (42%) of respondents were concerned that children’s immune systems could be weakened by too many shots. Nearly one-third of respondents thought immunizations do more harm than good (32%), and more than one-quarter did not think vaccines strengthen the immune system (28%). Table 2. Vaccine Knowledge, Attitudes, and Beliefs (KABs) of Participating School Personnel, and Differences Between Nurses and Other School Personnel Total N=122 Nurses a N=9 Other School Personnel a N=113 p-value b An unimmunized child in California is likely to get this disease by 12 years old: Pertussis/whooping cough 55 (49%) 7 (78%) 48 (47%) 0.07 Measles 45 (40%) 7 (78%) 38 (37%) 0.02 Mumps 38 (34%) 5 (56%) 33 (32%) 0.15 Influenza 83 (74%) 9 (100%) 74 (72%) 0.06 Varicella/chicken pox 64 (58%) 7 (78%) 57 (56%) 0.21 COVID-19 81 (74%) 7 (78%) 74 (73%) 0.77 It would be serious for an 8-year-old child to develop: Pertussis/whooping cough 72 (65%) 9 (100%) 63 (62%) 0.02 Measles 74 (68%) 9 (100%) 65 (65%) 0.03 Mumps 65 (59%) 7 (88%) 58 (57%) 0.09 Influenza 56 (51%) 6 (67%) 50 (50%) 0.32 Varicella/chicken pox 54 (49%) 5 (56%) 49 (49%) 0.69 COVID-19 64 (58%) 5 (56%) 59 (58%) 0.89 This vaccine is safe for children: Pertussis/whooping cough 93 (85%) 9 (100%) 84 (83%) 0.18 MMR 93 (83%) 9 (100%) 84 (82%) 0.16 Influenza 94 (83%) 9 (100%) 85 (82%) 0.16 Varicella/chicken pox 94 (84%) 9 (100%) 85 (83%) 0.17 COVID-19 71 (65%) 6 (67%) 65 (64%) 0.89 When a child receives all of the recommended vaccines, how much do the following benefit? The child 102 (91%) 9 (100%) 93 (90%) 0.33 The community (e.g., family, child’s playmates, people in the child’s neighborhood) 101 (91%) 8 (100%) c 93 (90%) 0.36 The student’s doctor 70 (64%) 8 (89%) 62 (61%) 0.10 The government 69 (62%) 9 (100%) 60 (59%) 0.01 Companies that make vaccines 90 (82%) 9 (100%) 81 (80%) 0.14 School 99 (88%) 9 (100%) 90 (87%) 0.26 Health insurance companies/HMOs 80 (72%) 8 (100%) c 72 (70%) 0.07 Agreement With Statements Regarding Vaccines I am concerned that children's immune systems could be weakened by too many shots 47 (42%) 3 (33%) 44 (43%) 0.58 Vaccines strengthen the immune system 82 (72%) 9 (100%) 73 (70%) 0.05 Immunizations do more harm than good 36 (32%) 1 (11%) 35 (34%) 0.16 Agreement With Statements Regarding Vaccine Mandates I am opposed to immunization requirements because they go against freedom of choice 42 (37%) 2 (22%) 40 (38%) 0.34 I am opposed to immunization requirements because parents know what is best for their children 41 (37%) 2 (22%) 39 (38%) 0.34 Immunization requirements protect children from getting diseases from unimmunized children 81 (72%) 7 (78%) 74 (72%) 0.70 Parents should be allowed to send their children to school even if not vaccinated 46 (41%) 2 (22%) 44 (43%) 0.23 I support making COVID-19 vaccines mandatory for elementary school children 47 (43%) 2 (25%) 45 (45%) 0.28 It would be hard to implement or enforce a COVID-19 mandate for elementary school children 78 (72%) 6 (75%) 72 (72%) 0.86 I expect a lot of push back from parents if a COVID-19 vaccine mandate for elementary school children was implemented 69 (64%) 7 (88%) 62 (63%) 0.16 I support making COVID-19 vaccines mandatory for middle school children 48 (44%) 2 (25%) 46 (46%) 0.25 It would be hard to implement or enforce a COVID-19 mandate for middle school children 67 (63%) 6 (75%) 61 (62%) 0.45 I expect a lot of push back from parents if a COVID-19 vaccine mandate for middle school children was implemented 57 (53%) 5 (63%) 52 (52%) 0.57 I support making COVID-19 vaccines mandatory for high school children 53 (49%) 3 (38%) 50 (50%) 0.51 It would be hard to implement or enforce a COVID-19 mandate for high school children 64 (58%) 6 (67%) 58 (57%) 0.57 I expect a lot of push back from parents if a COVID-19 vaccine mandate for high school children was implemented 55 (50%) 5 (56%) 50 (49%) 0.71 Open in a new tab a Nurses compared to other school personnel (e.g., principals, registrars, clerks); respondents who did not identify their role at the school (19%) were treated as other school personnel b boldface indicates statistical significance (p<0.05) using Pearson’s Chi-Squared Test c % is of the subtotal responding to the survey item; total respondents fluctuate slightly by survey item, as there was occasional non-response to individual items Vaccine Mandates More than one-third (37%) of respondents opposed immunization requirements (because these requirements violate freedom of choice and because parents know what is best for their children), and 41% thought parents should be allowed to send their children to school even if unvaccinated ( Table 2 ). Almost half of respondents supported making COVID-19 vaccines mandatory for children in elementary (43%), middle (44%), and high (49%) schools. COVID-19 vaccines mandates at the elementary school level were expected to be difficult (72%) and to create pushback from parents (65%) more so than at the middle (63% and 53%, respectively) and high (58% and 50%, respectively) school levels. Use of and Trust in Sources of Vaccine Information Three-quarters (75%) of school personnel obtained vaccine information from doctors, making doctors’ advice the most frequently reported source of vaccine information ( Table 3 ). About half of school personnel reported obtaining vaccine information from printed materials from doctors (such as Vaccine Information Statements) (60%), CDPH (59%), local/county health departments (55%), CDC (47%), and school nurses (44%). School personnel also trusted the accuracy of vaccine information most frequently from doctors (93%), followed by local/county health departments (90%), printed materials from doctors (89%), CDPH (88%), CDC (84%), and professional medical organizations (80%). Nearly two-thirds (64%) of respondents reported trusting the accuracy of vaccine information from the National Vaccine Information Center (NVIC), though only 5% reported obtaining information from NVIC. Two-thirds (67%) of respondents had high trust in CDC per our construct scale. Table 3. Trust in Sources of Vaccine Information for Participating School Personnel, and Differences Between Nurses and Other School Personnel Total N=122 Nurses a N=9 Other School Personnel a N=113 p-value b Trust in Centers for Disease Control & Prevention (CDC) – dichotomous scale indicator (high trust vs low trust) c 76 (67%) 5 (56%) 71 (68%) 0.44 How much confidence or trust do you have in the following organization? Local/County Health Department 99 (86%) 7 (78%) 92 (87%) 0.45 California Department of Public Health 97 (84%) 8 (89%) 89 (84%) 0.70 CDC 99 (86%) 6 (67%) 93 (88%) 0.08 Food and Drug Administration (FDA) 98 (85%) 8 (89%) 90 (85%) 0.75 Student’ doctor 104 (91%) 8 (89%) 96 (91%) 0.80 Health Care System 94 (82%) 8 (89%) 86 (81%) 0.56 Media 39 (35%) 1 (11%) 38 (37%) 0.12 In the past, where or from whom have you obtained information about vaccines? Doctors’ advice 79 (75%) 5 (56%) 74 (76%) 0.17 School nurses 47 (44%) 5 (56%) 42 (43%) 0.48 Printed materials from doctor (such as Vaccine Information statements) 64 (60%) 7 (78%) 57 (59%) 0.26 Professional organizations, such as doctors/nurses' associations 39 (37%) 5 (56%) 34 (35%) 0.22 Alternative doctors, such as chiropractor or acupuncturist 5 (5%) 1 (11%) 4 (4%) 0.34 Parents/Friends 21 (20%) 0 (0%) 21 (22%) 0.12 Religious leaders and organizations 4 (4%) 0 (0%) 4 (4%) 0.53 Media (TV, radio, newspapers, books, magazines) 24 (23%) 0 (0%) 24 (25%) 0.09 Social Media (Facebook, Twitter) 9 (8%) 0 (0%) 9 (9%) 0.34 Blogs 3 (3%) 0 (0%) 3 (3%) 0.59 Shots for School website 40 (38%) 5 (56%) 35 (36%) 0.25 Local/county health departments 58 (55%) 5 (56%) 53 (55%) 0.96 California Department of Public Health 63 (59%) 5 (56%) 58 (60%) 0.80 CDC 50 (47%) 3 (33%) 47 (48%) 0.38 FDA 19 (18%) 2 (22%) 17 (18%) 0.73 Vaccine Companies 10 (9%) 2 (22%) 8 (8%) 0.17 National Vaccine Information Center 6 (6%) 1 (11%) 5 (5%) 0.46 Immunization Action Coalition 2 (2%) 1 (11%) 1 (1%) 0.03 National Academy of Sciences (aka Institute of Medicine) 5 (5%) 1 (11%) 4 (4%) 0.34 Level of trust in the accuracy of vaccine information from the following: Doctors’ advice 104 (93%) 9 (100%) 95 (92%) 0.39 Printed materials from doctor (Vaccine Information Statements) 100 (89%) 9 (100%) 91 (88%) 0.28 Professional organizations, such as doctors/nurses' associations 90 (80%) 9 (100%) 81 (79%) 0.12 Alternative doctors, such as chiropractor or acupuncturist 52 (46%) 4 (44%) 48 (47%) 0.90 Parents/Friends 42 (38%) 4 (44%) 38 (38%) 0.69 Religious leaders and organizations 19 (17%) 2 (22%) 17 (17%) 0.67 Media (TV, radio, newspapers, books, magazines) 35 (32%) 2 (22%) 33 (32%) 0.53 Social Media (Facebook, Twitter) 12 (11%) 0 (0%) 12 (12%) 0.28 Blogs 9 (8%) 0 (0%) 9 (9%) 0.35 Local/County Health Departments 100 (90%) 8 (100%) d 92 (89%) 0.33 California Department of Public Health 94 (88%) 6 (86%) 88 (88%) 0.86 CDC 92 (84%) 6 (75%) 86 (85%) 0.45 FDA 79 (77%) 5 (71%) 74 (77%) 0.73 Vaccine Companies 54 (50%) 6 (75%) 48 (48%) 0.15 National Vaccine Information Center 68 (64%) 5 (71%) 63 (64%) 0.68 National Academy of Sciences (aka Institute of Medicine) 62 (59%) 6 (75%) 56 (58%) 0.34 Open in a new tab a Nurses compared to other school personnel (e.g., principals, registrars, clerks); respondents who did not identify their role at the school (19%) were treated as other school personnel b boldface indicates statistical significance (p<0.05) using Pearson’s Chi-Squared Test c see Appendix 2 d % is of the subtotal responding to the survey item; total respondents fluctuate slightly by survey item, as there was occasional non-response to individual items Differences Between Nurses and Other School Personnel Compared to other school personnel, schools with nurses working with parents on meeting school immunization requirements were more likely to indicate someone on staff had the authority to deny medical exemption requests (63% vs 23%, p=0.01). Nurses were less likely to consider no physician signature an acceptable reason for denying a medical exemption request (57% vs 94%, p<0.01). Nurses were more likely to perceive VPDs such as pertussis (100% vs 62%, p=0.02) and measles (100% vs 65%, p=0.03) as serious for children. No differences in support for vaccine mandates or trust in sources of vaccine information were found between nurses and other school personnel. Differences Between Schools Granting and Not Granting Exemptions Schools granting at least one exemption for kindergarten that school year were more likely than schools not granting at least one exemption to consider temporary medical exemptions eligible for conditional admission (81% vs 56%, p=0.02), as well as students missing dose(s) but not due for any dose(s) at time of school entry (81% vs 52%, p<0.01) ( Appendix 3 ). Schools granting exemptions were less likely to consider whether the reason provided was a valid medical contraindication acceptable as a reason for denying a medical exemption request (13% vs 53%, p<0.01). Personnel from schools granting exemptions were more likely to agree that children’s immune systems could be weakened by too many immunizations (53% vs 31%, p=0.03), oppose immunization requirements because parents know what is best for their children (50% vs 29%, p=0.05), expect it to be hard to implement or enforce a COVID-19 mandate for high school children (72% vs 48%, p=0.03), and expect a lot of push back from parents if a COVID-19 vaccine mandate for high school children was implemented (67% vs 42%, p=0.02). Personnel from schools granting exemptions were less likely to trust the media (6% vs 27%, p=0.02). Differences Between School Personnel With High and Low Trust in CDC School personnel with high trust in CDC perceived greater susceptibility to and severity of most VPDs and greater safety of vaccines such as pertussis, measles, mumps, influenza, and COVID-19 than personnel with low trust in CDC ( Appendix 4 ). Personnel with high trust in CDC were much more likely to agree with positive vaccine attitudes, disagree with negative vaccine attitudes, and support mandated vaccination for schoolchildren of all ages (p<0.01). Personnel with high trust in CDC also had higher trust in other government organizations, healthcare professionals, and the media (p<0.01). Discussion In this survey of CA elementary school personnel, most schools did not have a clinically trained person (e.g., nurse) working with parents on meeting immunization requirements, and most personnel believed there was no one at their school with the authority to deny medical exemptions. More than half of surveyed school personnel did not support COVID-19 vaccine school mandates at any age, and more than one-third did not support school immunization requirements in general. Many school personnel had concerns about vaccines, particularly that vaccines weaken children’s immune systems. These findings illuminate a threat to the implementation and enforcement of immunization requirements in CA. School personnel working with parents on meeting immunization requirements may be unaware of their school’s responsibility to interpret the validity of medical exemptions, and even if aware, may lack the clinical training to do so confidently and effectively. Many school personnel harbor vaccine misconceptions, and some do not support the very school immunization requirements which they are tasked with implementing and enforcing. Increasing numbers of medical exemptions,( 2 , 20 ) many of which did not cite valid contraindications,( 15 , 21 ) suggest that some hesitant parents are circumventing the intent of SB277. If many school personnel do not believe anyone at their school has the authority to deny medical exemptions as our data suggest, many of these questionable medical exemptions will go unchecked. Despite concerns that SB277 would incentivize parents to remove their children from schools, quantitative analyses do not suggest an association with increased homeschooling.( 31 ) One-third of the schools in our sample reported that at least one student began homeschooling due to SB277, though this may be largely speculative given school personnel are unlikely to be certain why most students begin homeschooling. However, examples of parents beginning to homeschool their children due to SB277 have been identified in qualitative studies.( 32 , 33 ) Together, this implies SB277 may have factored into some parents’ decision to homeschool, though not enough to see a large trend. In the fall of 2021, CA Governor Gavin Newsom announced that COVID-19 vaccination would be mandated for public and private school entry through 12 th grade once federally approved.( 14 ) However, despite full approval in July 2022 for adolescents 12 years and older,( 34 ) plans to mandate COVID-19 vaccine for school entry appear to have been put on hold (if not abandoned altogether).( 35 ) This decision likely avoids a conflict, as our data reflect limited support for COVID-19 vaccine school mandates among those who would be tasked with enforcing them. However, given that our survey was administered around the time COVID-19 vaccines were first authorized for US children younger than 5 years of age, it is possible that support for and expected parental cooperation with COVID-19 vaccine mandates at the elementary school level have grown as more young children have been safely vaccinated. We found some differences between nurses and other school personnel in our analysis, but not to the extent we expected, given that nurses have long recognized the importance of vaccination more than other school personnel.( 24 , 25 ) This may indicate changing attitudes among nurses; while vaccine coverage and support for mandates is typically much higher among healthcare providers than the general public, recent data shows nurses lag behind MDs in COVID-19 vaccine confidence and coverage as well as in the strength of their recommendations for patients to receive COVID-19 and other routine vaccines (e.g., influenza, MMR, pertussis, HPV, shingles, pneumococcal).( 36 , 37 ) More likely, however, is that we did not have enough nurses in our sample to detect differences between nurses and other school personnel, even if they existed. Our data suggest that some of the survey respondents who were not school nurses themselves worked with school nurses in the implementation and enforcement of school immunization requirements; of the 24 respondents reporting that school nurses had final authority to accept or deny a medical exemption request at their school, 19 were not nurses themselves (which was 36% of the non-nurses who responded to this survey question). However, of the more than three-quarters (94/122, 77%) of participating schools whose survey respondents were not nurses and did not report nurse authority to accept or deny medical exemption requests, it is likely that at least some had no clinically trained person working with parents on immunization requirements. One-third of schools nationwide (and two-thirds of schools in the Western region of the U.S.) do not have access to a full-time school nurse.( 38 ) Since healthcare providers are the most credible source of vaccine information for parents,( 39 , 40 ) vaccine information from school nurses is likely to be more trusted by parents than information from other school personnel. Thus, by having a school nurse counsel parents about school immunization requirements, schools can improve their support of parental vaccine decision-making.( 16 ) Limitations The main limitation of our survey data is the low response rate of invited school personnel (leading to limited power and potential selection bias). Schools were extremely busy during the COVID-19 pandemic and, despite repeated attempts to follow up with our school contacts, many did not respond. Perhaps this is an indication of SB277 implementation and enforcement being deprioritized during the pandemic, although it may just be the result of many school personnel not devoting time to a survey given their many other responsibilities amidst the end of the school year and the approach of their summer break. The low response rate predisposes our data to selection bias; schools and school personnel who responded to the survey may be different than those who did not. Since survey responses were anonymous, we were unable to accurately compare participating and non-participating schools, or look at differences in survey responses based on school demographic factors or student vaccine coverage/exemption rates. Our findings should thus be interpreted with caution, and not assumed to be representative of all CA schools or school personnel. The timing of the survey meant that school personnel were asked about potential COVID-19 vaccine mandates for elementary school children just prior to EUA of COVID-19 vaccines for children younger than 5 years of age, and some may have answered those questions differently if asked after the EUA. Since the proportion of participating schools granting at least one exemption is nearly the same as the proportion receiving at least one exemption request, and granted exemption validity was not assessed by the survey, the differences in survey responses between schools granting and not granting at least one exemption may mostly reflect the differences in schools receiving and not receiving at least one exemption request, and thus cannot be assumed to indicate factors associated with strict and/or proper enforcement of SB277. Our methods for classifying neutral survey responses in dichotomous measures may have led to a slight overestimation of anti-vaccine attitudes. Finally, our data are cross-sectional, descriptive, and reliant on self-reporting, which risks both human error and recall and reporting biases. Further research is needed to confirm and expand upon our findings and monitor trends over time. In particular, studies to review exemption requests for validity across schools could help identify factors associated with proper implementation of school vaccine mandates and inform related vaccine policy and practice. Conclusion Among our sample of CA schools, many did not have a clinically trained person (e.g., nurse) working with parents on meeting school immunization requirements. Many school personnel thought no one at the school had the authority to deny medical exemptions, did not support COVID-19 vaccine mandates for school at any age, and had vaccine concerns. Vaccine education for school personnel and further involvement of school nurses in the implementation and enforcement of school immunization requirements could have a positive impact on vaccine coverage and disease prevention. Supplementary Material 1 NIHMS2061758-supplement-1.pdf (623KB, pdf) Figure 1. Open in a new tab Phases of Recruitment Highlights. California school personnel who helped parents meet immunization requirements were surveyed. Most school personnel who worked on immunization requirements were not clinically trained. Many school personnel had concerns about vaccines and vaccine mandates. Most personnel were unaware of their responsibility to deny invalid medical exemptions. Acknowledgments Funding/Support This work was supported by the National Institutes of Health (NIH) under Grant R01AI125405. Conflicts of Interest Matthew Dudley has received research support from Merck. Daniel Salmon has received research support from Merck and serves on advisory boards for Merck, Janssen, Sanofi and Moderna. Matthew Dudley and Daniel Salmon have received funding from the Vaccination Confidence Fund, which is jointly funded by Facebook and Merck. Alexander Zapf received support from Merck and Johnson and Johnson. Holly Schuh served as a (paid) health advisor to the University of Roehampton that provided guidance on recovery-building and future pandemic preparedness (including views on vaccines/vaccination) and understanding citizen engagement in the G7 in 2021-22 (during the presented study). Nicola Klein has received research support from Pfizer Sanofi Pasteur, Merck, GSK, Seqirus and CDC and is a member of the International Vaccine Institute Expert Panel on Hecolin. Saad Omer has received funding from the Bill and Melinda Gates Foundation, NIH, PATH, NIAID, UNICEF, and CDC and serves on the Gavi Vaccine Alliance Board and the Board of Trustees for the Sabin Vaccine Institute. All other authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Footnotes Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. 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