Middle School Vaccination Requirements and Adolescent Vaccination Coverage

Middle School Vaccination Requirements and Adolescent Vaccination Coverage Erin Bugenske, MPH Health Services Research & Evaluation Branch Immunization Services Division National Center for Immunization & Respiratory Diseases

Background q Since 2005, new vaccines have been licensed by the FDA and recommended for adolescents by the ACIP § Tdap – tetanus/diphtheria/ acellular pertussis vaccine § MCV 4 – meningococcal conjugate vaccine § HPV – human papillomavirus vaccine* *Recommended for females only at this time

Background q Pre-2006 middle school requirements: § Hepatitis B: 36 states § Td booster: 22 states q Experience from Hepatitis B and childhood vaccines show school requirements can rapidly raise coverage levels substantially § Much slower rise in children and adolescents not subject to vaccination requirements Averhoff et al. 2004, Fogarty et al. 2004, Jacobs et al. 2004, Wilson et al. 2005, Olshen et al. 2007

Research Question Do states with middle school entry requirements for Td/Tdap, MCV 4, and/or HPV vaccines have higher vaccination coverage levels for these vaccines compared to states with no requirements?

Methods q Middle school entry requirements in place at start of 2008 -2009 school year for 50 states plus DC q Data sources • Centers for Disease Control & Prevention (CDC) • Immunization Action Coalition (IAC) • National Conference of State Legislatures (NCSL)

Types of Requirements q States placed into one of 3 mutually exclusive categories based on type of requirement for each vaccine § Vaccination requirements § Education requirements § No requirement

Methods/Vaccination Coverage q 2009 National Immunization Survey. Teen (NIS-Teen) • Random-digit-dialed household survey of parents of adolescents aged 13 -17 years • Provider-reported vaccination history q Analysis limited to those adolescents with provider-reported vaccination histories (N=20, 066) • HPV analysis limited to first dose among females

2008 -2009 Middle School Entry Requirements q Tetanus booster • 14 Tdap-specific, 17 Td-containing requirements q MCV 4 • 3 require receipt of vaccine • 10 require education of parents q HPV • 1 requires receipt of vaccine* • 5 require education of parents q 31 states had ≥ 1 vaccination requirement *Law allows for broad opt-outs beyond traditional exemptions

Tetanus Booster Middle School Entry Requirements, 2008 -2009 School Year

Tetanus booster coverage rates by requirement status 100% P < 0. 0001* 90% 80% 70% 60% 50% 40% 79, 8% 30% 69, 5% 20% 10% 0% Vaccination Req (31) No Req (20)

Tdap coverage levels by type of requirement 100, 0% 90, 0% P < 0. 0001* 80, 0% 70, 0% 60, 0% 50, 0% 40, 0% 30, 0% 64, 0% 55, 9% 20, 0% 49, 2% 10, 0% Tdap-specific Req (14)Td-containing Req (17) No Req (20)

MCV 4 Middle School Entry Requirements, 2008 -2009 School Year

MCV 4 vaccine coverage levels by type of requirement 100% 90% P < 0. 0001* 80% 70% 60% 50% 40% 30% 70, 5% 20% 51, 0% 53, 4% Education Req (10) No Req (38) 10% 0% Vaccination Req (3)

HPV Middle School Entry Requirements, 2008 -2009 School Year

HPV coverage rates by requirement status 100% 90% P = 0. 7005 80% 70% 60% 50% 40% 30% 20% 45, 0% 44, 2% Req (6) No Req (45) 10% 0% *Given only 1 requirement for HPV vaccination, all HPV requirements grouped together under ‘Education’

Vaccine coverage levels by type of requirement 100% 90% 80% 70% 60% HPV* 50% MCV 4 40% Td/Tdap 30% 20% 10% 0% Vaccination Req Education Req No Req *Given only 1 requirement for HPV vaccination, all HPV requirements grouped together under ‘Education’

Overall* coverage rates by type of requirement(s) 100% 90% 80% 70% 60% 50% P < 0. 0001* 40% 30% 20% 42, 2% 35, 4% 42, 1% 10% 0% 1+ Vaccination Reqs Education Reqs Only (7) (32) No Reqs (12) * ≥ 1 dose Td or Tdap, ≥ 1 dose MCV 4, ≥ 1 dose HPV (females only)

Limitations q Older teens not directly affected by 2008 -2009 requirements q Rate of exemptions to middle school requirements not yet known q Limited number of states have requirements for MCV 4 & HPV § Use caution when interpreting results

Summary q Vaccination requirements were associated with higher coverage for tetanus booster and MCV 4 § No association between education requirements and coverage levels for MCV 4 and HPV vaccine § No association between ≥ 1 vaccination requirement and receipt of all recommended vaccines q States with Tdap-specific requirements had significantly higher Tdap coverage than states with Td-containing or no requirements

Discussion q Education-only requirements unique to middle school and college mandates q There may be reasons that states pursue educational requirements over vaccination requirements § Lack of political, public, or financial support for vaccination requirement § Do not appear to be associated with higher coverage, but this may change over time

Discussion q Several factors should be taken into consideration before implementing a requirement § Partnership § Infrastructure § Consistency § Support National Vaccine Advisory Committee. Mandates for adolescent immunizations: recommendations from the National Vaccine Advisory Committee. American Journal of Preventive Medicine. 2008; 35(2): 145 -151.

Effect of ≥ 1 Requirement(s) q Even if a state does not have the resources/support for multiple requirements, the existence of ≥ 1 requirement might lead to higher coverage for other vaccines § Opportunity to administer all recommended vaccines at visit for required vaccine(s) § Need to better understand reasons for not administering all recommended vaccines at visit

Middle School Vaccination Requirement Update q Since the 2008 -2009 school year… § 21 new/updated requirements for Tdap • 14 replaced older Td requirements • 7 completely new requirements § 6 new requirements for MCV 4 § 1 new requirement for HPV

Future Research q Impact of at least 1 vaccination requirement on coverage for other adolescent vaccines q Monitor impact of educational requirements over time q Work to improve reporting of school survey data § Age-specific coverage & exemption rates

Acknowledgments q Shannon q Allison Stokley (NCIRD/ISD) Kennedy (NCIRD/ISD) q Christina Dorell (NCIRD/ISD)