title: Personal Belief Exemptions to Vaccination in California: A Spatial Analysis.
abstract: BACKGROUND
  School vaccination rates in California have fallen as more parents opt for personal belief exemptions (PBEs) for their children. Our goals were to (1) spatially analyze PBE patterns over time, (2) determine correlates of PBEs, and (3) examine their spatial overlap with personal medical exemptions (PMEs).
  
  
  METHODS
  PBE and PME data for California kindergarten classes from the 2001/2002 to 2013/2014 school years were matched to the locations of schools. Nonspatial clustering algorithms were implemented to group 5147 schools according to their trends in PBE percentages among kindergartners. Cluster assignments were mapped and hotspot analysis was performed to find areas in California where schools sharing trends in PBEs over time were colocated. Schools were further associated both with school-level data on minority enrollment and free and reduced price lunch participation and with charter/private and rural/urban status. Spatial regression was implemented to determine which school-level variables were correlated with PBE rates in the 2013/2014 school year.
  
  
  RESULTS
  Distinct spatial patterns are observed in California when PBE cluster assignments are mapped. Results indicate that schools belonging to the "high PBE" cluster are spatially buffered from those in "low PBE" areas by "medium PBE" schools. Further, PBE rates are positively associated with the percentage of white students, charter status, and private schools.
  
  
  CONCLUSIONS
  Hotspots of high PBE schools are in some cases colocated with schools that have elevated PME rates, prompting concern that herd immunity is diminished for school populations where students have no choice but to remain unvaccinated.
authors.affiliation: Departments of Geographical and Sustainability Sciences, and Epidemiology, University of Iowa, Iowa City, Iowa margaret-carrel@uiowa.edu.
authors.forename: Margaret
authors.initials: M
authors.lastname: Carrel
authors.affiliation: Departments of Geographical and Sustainability Sciences, and.
authors.forename: Patrick
authors.initials: P
authors.lastname: Bitterman
mesh_terms: D002140:California; D002648:Child; D002675:Child, Preschool; D003469:Culture; D005260:Female; D006801:Humans; D008297:Male; D012574:Schools / Q000706:statistics & numerical data*; D062206:Spatial Analysis; D013334:Students / Q000706:statistics & numerical data*; D014611:Vaccination / Q000523:psychology* / Q000706:statistics & numerical data