School-entry Vaccination Research Articles

School-Entry Vaccine Policies: States' Responses To Federal Recommendations Varied From Swift To Substantially Delayed.

School-entry immunization requirements are a valuable strategy to reduce the spread of vaccine-preventable diseases. This research examined the temporal relationship between recommendations issued by the federal Advisory Committee on Immunization Practices (ACIP) and corresponding school-entry requirements adopted by states for adolescent meningococcal ACWY (MenACWY) and tetanus, diphtheria, and acellular pertussis (Tdap) vaccines. A legal epidemiological review of statutes, regulations, and state agency guidance identified school-entry policies across fifty states and Washington, D.C. Researchers measured the number of months between the date of an ACIP recommendation and the effective dates for state policies that were in place through the 2023-24 school year. All fifty-one jurisdictions had school-entry requirement policies for Tdap vaccination, and thirty-six had school-entry requirements for MenACWY vaccination. The average period between ACIP's recommendations and state policy adoption was 4.94, 9.61, and 8.24 years for Tdap and for MenACWY first and booster doses, respectively. This analysis found diverse timelines and notable delays for both Tdap and MenACWY school-entry requirement policies. This heterogeneity and patchwork of state requirements underscores the need for ACIP to evaluate the role of these policies in reducing vaccine-preventable diseases across the United States.

School Vaccine Coverage and Medical Exemption Uptake After the New York State Repeal of Nonmedical Vaccination Exemptions

Although New York State (NYS) recently adopted legislation eliminating nonmedical vaccination exemption options from school-entry requirements, the implications of the law for school vaccine coverage and medical vaccine exemption uptake have not been examined. To evaluate the implications of the repeal of school-entry nonmedical vaccination exemptions for vaccine coverage and medical exemption uptake at NYS schools outside of New York City (NYC). This cohort study had an interrupted time-series design and used generalized estimating equation models to examine longitudinal school immunization compliance data from the 2012 to 2013 through 2021 to 2022 school years. The cohort comprised NYS public and nonpublic schools, excluding NYC schools, with any students enrolled in kindergarten to 12th grade. Eligible schools had enrollment and immunization data before and after the implementation of the Senate Bill 2994A legislation. Data analyses were conducted in July 2023. Senate Bill 2994A was passed in June 2019, eliminating school-entry nonmedical vaccination exemptions. Since compliance with the law was evaluated for most students during the next school year, the 2019 to 2020 school year was considered to be the law's effective date. The primary outcomes were school vaccine coverage (defined as the percentage of students at each school who completed grade-appropriate requirements for all required vaccines) and medical exemption uptake (defined as the percentage of students at each school who received a medical exemption). Among the 3821 eligible schools, 3632 (95.1%) were included in the analysis, representing 2794 (96.9% of eligible) public schools and 838 (89.2% of eligible) nonpublic schools. The implementation of Senate Bill 2994A was associated with absolute increases in mean vaccine coverage of 5.5% (95% CI, 4.5%-6.6%) among nonpublic schools and 0.9% (95% CI, 0.7%-1.1%) among public schools, with additional annual increases in vaccine coverage observed through the 2021 to 2022 school year. The law's implementation was also associated with a 0.1% (95% CI, 0.0%-0.1%) mean absolute decrease in medical vaccination exemption uptake at both public and nonpublic schools, and small but significant mean annual decreases in medical vaccination exemptions (0.02%; 95% CI, 0.01%-0.03%) through the end of the study period. Results of this cohort study suggested that repeal of school-entry nonmedical vaccination exemptions was associated with increased vaccine coverage at NYS schools outside of NYC. Coverage gains were not replaced by increases in medical vaccination exemptions.

Impact of a hypothetical COVID-19 vaccine mandate on parental likelihood to vaccinate children: Exploring school-related concerns and vaccination decision-making

ObjectiveWe assessed the impact of a hypothetical school-entry COVID-19 vaccine mandate on parental likelihood to vaccinate their child. MethodsWe collected demographics, COVID-19-related school concerns, and parental likelihood to vaccinate their child from parents of patients aged 3–16 years seen across nine pediatric Emergency Departments from 06/07/2021 to 08/13/2021. Wilcoxon signed-rank test compared pre- and post-mandate vaccination likelihood. Multivariate linear and logistic regression analyses explored associations between parental concerns with baseline and change in vaccination likelihood, respectively. ResultsVaccination likelihood increased from 43% to 50% with a hypothetical vaccine mandate (Z = -6.69, p < 0.001), although most parents (63%) had no change, while 26% increased and 11% decreased their vaccination likelihood. Parent concerns about their child contracting COVID-19 was associated with greater baseline vaccination likelihood. No single school-related concern explained the increased vaccination likelihood with a mandate. ConclusionParental school-related concerns did not drive changes in likelihood to vaccinate with a mandate.

Provisional Entrants, Exemptions, and Kindergarteners Up-to-Date on Vaccination Before and After a Regulatory Change in Pennsylvania, 2015-2019.

Before the 2017-2018 school year, Pennsylvania shortened the grace period for provisional entrants-kindergarteners who are not up-to-date on vaccination and do not have medical or nonmedical exemption-from 8 months to 5 days. We analyzed the impact of this change on school-entry vaccination status. Using data from the Pennsylvania Department of Health for school years 2015-2016 through 2018-2019, we examined state-level trends in Pennsylvania kindergarteners' vaccination status, including the percentage who were up-to-date on each required vaccine, provisionally enrolled, medically exempted from vaccination, and nonmedically exempted from vaccination. Using the Spearman correlation coefficient, we assessed associations at the school level among changes in kindergarteners' vaccination status after the grace period was shortened. From 2016-2017 to 2017-2018, the provisional entrance rate of kindergarteners in Pennsylvania decreased substantially after the change in the grace period (from 8.1% to 2.2%), the medical exemption rate remained stable, and the nonmedical exemption rate increased slightly (from 1.8% to 2.5%). The percentage of kindergarteners up-to-date on required vaccines increased or remained stable across the study period except for polio, which decreased from 97.9% in 2015-2016 to 96.2% in 2018-2019. The change in provisional entrance rate was negatively associated with change in kindergarteners up-to-date on required vaccines (ρ range, -0.30 to -0.70) but not with change in medical or nonmedical exemptions (ρ range, -0.01 to -0.08). Efforts to reduce provisional entrants may increase the percentage of kindergarteners up-to-date on vaccinations at school entry without a corresponding increase in exemptions.

A review of immunization legislation for children in English- and Dutch-speaking Caribbean countries.

To assess the legislative frameworks concerning childhood vaccination in the English- and Dutch-speaking Caribbean and propose a model legislative framework for Caribbean countries. This study included a survey of 22 countries and territories in the Caribbean regarding legal vaccination mandates for school entry, budget allocations, sanctions, or exemptions. A legal consultant conducted a comprehensive search and analysis of legislation regarding vaccination among 13 Caribbean countries/territories. A comparative analysis of the legislation under five themes-legislative structure, mandatory vaccination, national immunization schedule, sanctions, and exemptions-formed the basis for the proposed model legislation. Among the 22 Caribbean countries/territories, 17 (77%) had legislation mandating vaccination, 16 (94%) mandated vaccination for school entry, 8 (47%) had a dedicated budget for immunization programs, and 13 (76%) had no legislated national schedules. The source of legislation includes six (35%) using the Education Act, eight (47%) the Public Health Act, and five (29%) a free-standing Vaccination Act. Three countries/territories-Jamaica, Montserrat, and Saint Lucia-had immunization regulations. In 12 (71%) of the 17 countries with legislation, sanctions were included, and 10 (59%) permitted exemptions for medical or religious/philosophical beliefs. Several countries in the Caribbean have made failure to vaccinate a child an offense. By summarizing the existing legislative frameworks and approaches to immunization in the Caribbean, the analysis guides policymakers in making effective changes to immunization legislation in their own countries.

Abstract A025: HPV and COVID-19 vaccines attitudes and preferred sources of information among adults living in Puerto Rico

Abstract Prior to the COVID-19 pandemic, Puerto Rico (PR) had one of the highest Human Papillomavirus (HPV) vaccine rates in the United States. Yet, widespread misleading information about the COVID-19 vaccine might negatively impact HPV vaccine attitudes. This study aims to assess and compare HPV and COVID-19 vaccines attitudes toward school-entry policies among adults living in PR. A convenience sample of 222 adults (≥21 years old) living in PR were recruited through social media and completed an online survey from November 2021 to January 2022. Participants answered questions about HPV and COVID-19 vaccines knowledge (ranging from 0=none to 3=high knowledge), attitudes toward vaccination policies for school-entry, and perceptions of trusted and untrusted sources of information. Descriptive statistics were computed to identify the demographics characteristics of the participants. We also estimated the prevalence ratio (PRadjusted) using a logistic regression model to assess the magnitude of association between COVID-19 vaccination for the school-entry policy and HPV vaccination for school-entry policy agreement, adjusting for different confounders. The mean age of the study sample was 36.73 ± 11.18 years. The majority of the sample were female (87%, n=194), with at least some college of education (92%; n=205) and employed (61%; n=165). One-fifth of the participants reported having children between ages 11 and 16 (n=46). Participants’ perceived knowledge about the HPV vaccine was moderate (mean=1.72; SD=1.12), while for COVID-19 vaccine was moderately high (mean=2.47; SD=.68). The most trusted form of information for HPV and COVID-19 vaccines were health care providers (42% and 17%, respectively), the Centers for Disease Control and Prevention (35% and 55%, respectively), and the Department of Health (15% and 19%, respectively). The least trusted source of information included social media (40% and 39%, respectively), friends and family (23% n=47, and 17% n=33, respectively), and the Department of Health (15% n=30, and 18% n=36, respectively). More than half of the participants agreed that HPV (76% n=156) and COVID vaccines (69% n=136) should be required for school-entry. Agreement with COVID-19 vaccination for the school-entry policy was significantly associated with HPV vaccination for school-entry policy agreement (PRadjusted:1.96; 95% CI:1.48-2.61) after controlling for age, sex, education, and having children between age 11 and 16. Findings suggest that adults living in PR have an overall positive attitude about mandatory HPV and COVID-19 vaccination school-entry policies, and these attitudes are interrelated. Yet, it is concerning that the Department of Health is identified as one of the least trusted sources of information, as it has a prominent role in implementing HPV and COVID-19 vaccine policies in PR. Further research should elucidate why the Department of Health is considered an untrusted source of information among adults living in PR and evaluate the implications of the COVID-19 pandemic on HPV vaccine attitudes and adherence rates. Citation Format: Jessica N. Rivera-Rivera, Olga L. Díaz-Miranda, Diana T. Medina-Laabes, Erick Suárez, Ana P. Ortiz, Vivian Colón-López. HPV and COVID-19 vaccines attitudes and preferred sources of information among adults living in Puerto Rico [abstract]. In: Proceedings of the 15th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2022 Sep 16-19; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr A025.

Support for HPV vaccine school-entry requirements in the United States: The role of exemption policies

In the United States (U.S.), only five states or territories require human papillomavirus (HPV) vaccination for school attendance, even though almost all U.S. jurisdictions have debated adopting this type of policy. In this U.S. based study, we sought to estimate the level of support for HPV vaccine school-entry requirements with varying exemption policies and documentation procedures to obtain exemptions. Between July and August 2019, we conducted a web-based survey with a national sample of 1,109 U.S. parents of 11- to 17-year-olds. The survey assessed support for four school-entry vaccine requirement policies: without exemption or with exemption for medical, religious or philosophical reasons. Analyses used multivariable logistic regression to assess correlates of support for each policy. Overall, 38% of parents agreed with laws requiring HPV vaccination for school attendance without exemptions. When including exemption provisions, agreement increased to 45% for philosophical reasons, 50% for religious reasons, and 59% for medical reasons. Parents more often agreed on requirements without any exemptions if they were female (OR = 1.37, 95% CI:1.01–1.87), their child had initiated HPV vaccination (OR = 2.05, 95% CI:1.50–2.87), reported high levels of vaccine confidence (OR = 2.41, 95% CI:1.77–3.27), or reported having values similar to those of the people in their community (OR = 1.85, 95% CI:1.39–2.47). Parents more often agreed with requirements that included religious or philosophical exemptions if they reported having values similar to their community or high levels of psychological reactance (all p <.05). Many parents also supported requiring a written notice signed by a health care provider (40%) or religious leader (49%) to obtain a medical or religious exemption, respectively. In conclusion, exemption policies greatly increase parent support of school-entry requirements for HPV vaccination but may decrease their impact in practice. A large number of U.S. parents support strict documentation to obtain exemptions, signaling a promising area of policymaking to strengthen vaccine policies for school attendance.

In ongoing efforts to vaccinate communities against COVID-19, pharmacists must address fear and misinformation

In ongoing efforts to vaccinate communities against COVID-19, pharmacists must address fear and misinformation

Recommended Childhood and Adolescent Immunization Schedule: United States, 2022.

Recommended Childhood and Adolescent Immunization Schedule: United States, 2022.

Evaluation of Trends in Homeschooling Rates After Elimination of Nonmedical Exemptions to Childhood Immunizations in California, 2012-2020

In 2015, California passed Senate Bill No. 277 (SB 277) and became the first state in more than 30 years to eliminate nonmedical exemptions to mandatory childhood immunizations for school entry. One concern that emerged was that the law created an incentive for parents to remove children from brick-and-mortar schools to bypass the immunization requirements. To assess the trends in homeschooling rates after the elimination of nonmedical exemptions to the requirement of childhood immunizations for school entry. This preintervention-postintervention cross-sectional study calculated homeschooling rates as the number of students in kindergarten through grade 8 (K-8) enrolled through each of California's 3 homeschooling mechanisms (independent study program, private school affidavit, and private school satellite program) divided by all K-8 students enrolled in the same academic year. Data on homeschooling rates were obtained from the California Department of Education. Interrupted time series analyses were conducted using a linear regression model in which the outcome variable was the percentage of students enrolled in a homeschool program before and after SB 277. Data were collected and analyzed from October 3, 2012, to October 2, 2019. Passage of SB 277, which eliminated nonmedical exemptions to childhood immunizations for school entry. Homeschooling rates for K-8 students. Among the students included in the analysis, the homeschooling enrollment for K-8 students in California increased from 35 122 students (0.8%) during the 2012-2013 school year to 86 574 students (1.9%) during the 2019-2020 school year; however, the implementation of SB 277 was not associated with an increase in the percentage of students enrolled in homeschooling programs in California beyond the secular trend. The increase in homeschooling was greatest for the lower grade levels: kindergarten homeschooling enrollment increased from 2068 students (0.4%) in the 2012-2013 school year to 10 553 students (1.9%) in the 2019-2020 school year, whereas the grade 8 homeschool enrollment rate increased from 5146 students (1.0%) in the 2012-2013 school year to 10 485 students (2.0%) in the 2019-2020 school year. Independent study programs accounted for 20 149 students (45.3%) of homeschooling enrollment, private school affidavits accounted for 19 333 students (43.5%), and private school satellite programs accounted for 4935 students (11.1%) during the 2015-2016 school year. The findings of this study suggest that legislative action to limit nonmedical exemptions for compulsory vaccination for school entry is not associated with removal of students from classroom-based instruction in brick-and-mortar institutions.

Spatial Clustering of Vaccine Exemptions on the Risk of a Measles Outbreak.

Areas of increased school-entry vaccination exemptions play a key role in epidemics of vaccine-preventable diseases in the United States. California eliminated nonmedical exemptions in 2016, which increased overall vaccine coverage but also rates of medical exemptions. We examine how spatial clustering of exemptions contributed to measles outbreak potential pre- and postpolicy change. We modeled measles transmission in an empirically calibrated hypothetical population of youth aged 0 to 17 years in California and compared outbreak sizes under the observed spatial clustering of exemptions in schools pre- and postpolicy change with counterfactual scenarios of no postpolicy change increase in medical exemptions, no clustering of exemptions, and lower population immunization levels. The elimination of nonmedical exemptions significantly reduced both average and maximal outbreak sizes, although increases in medical exemptions resulted in more than twice as many infections, on average, than if medical exemptions were maintained at prepolicy change levels. Spatial clustering of nonmedical exemptions provided some initial protection against random introduction of measles infections; however, it ultimately allowed outbreaks with thousands more infections than when exemptions were randomly distributed. The large-scale outbreaks produced by exemption clusters could not be reproduced when exemptions were distributed randomly until population vaccination was lowered by >6 percentage points. Despite the high overall vaccinate rate, the spatial clustering of exemptions in schools was sufficient to threaten local herd immunity and reduce protection from measles outbreaks. Policies strengthening vaccine requirements may be less effective if alternative forms of exemptions (eg, medical) are concentrated in existing low-immunization areas.

Duration of protection against Bordetella pertussis infection elicited by whole-cell and acellular vaccine priming in Polish children and adolescents

BackgroundIn the context of reported resurgence of pertussis in the last decade, researchers hypothesized that acellular (aP) pertussis vaccines elicit a shorter-lived protection compared to whole-cell (wP) pertussis vaccines. However, in the studies seeking to demonstrate this hypothesis, exposure to each vaccine type was not concurrent, and contradictory epidemiologic modeling questioned its validity. The context of pertussis vaccination history in Poland, with both vaccine types used concurrently in comparable proportions, provided an opportunity to investigate this hypothesis. We sought to compare waning of protection by primary series vaccine type by measuring anti-pertussis toxin antibody concentrations as proxy for recent infection. Materials and methodsSerological samples from 2,745 children and adolescents aged ≥5 years and <16 years and with completed 5-dose pertussis vaccination series were tested by ELISA for pertussis toxin (PT) antibodies. Participants were stratified by type of priming vaccine (wP or aP). Vaccination timeliness and priming-specific trends in anti-PT antibody levels by time since last vaccine dose were analyzed. ResultsA total of 1,161 (42.5%) children received wP vaccines, and 1,314 (48.1%) received aP vaccines for their primary series and toddler booster. Overall, 53.57% of the subjects received doses 2–4 in a timely manner, while only 41.52% received all 5 doses at the recommended intervals. Using GMCs or seropositivity measures, both priming groups showed a re-increase in anti-PT antibody levels signing infection in recent years from 8 years after the school-entry booster onward. Comparisons did not show any significant differences between the two groups in the timing or intensity of this re-increase. ConclusionOur results clearly confirm that vaccine-elicited immunity against pertussis wanes among adolescents even after a complete infant, toddler and school-entry vaccination series. The timing and intensity of the waning of protection appear similar with whole-cell as with acellular pertussis vaccines.

The association between state-based provisional attendance periods and adolescent middle school-entry vaccination coverage

The rise of vaccine-preventable disease outbreaks calls for a deeper understanding of the impact of policy on school-entry vaccine compliance. Provisional attendance policies vary by state but permit under-vaccinated students a limited period to attend school while receiving their immunizations. The primary objective of this study was to clarify the relationship between annual immunization coverage and state provisional policies for a single-dose of school-entry-required adolescent vaccinations: tetanus, diphtheria, pertussis (Tdap), meningococcal conjugate (MCV4), and human papillomavirus (HPV). From June 22, 2020 to August 20, 2020, the Immunization Action Coalition and state-level Department of Health (DOH) webpages were reviewed with email confirmation with a DOH representative to determine provisional period policy. Vaccination coverage for Tdap, MCV4, and HPV were obtained from the Center for Disease Control's National Immunization Survey. Overall, 49 states and D.C. legally mandate exclusion of vaccine noncompliant adolescents, and the majority of jurisdictions assign responsibility for exclusion to local school officials (84%). Complete provisional period data was obtained for 46/51 jurisdictions. The effect of provisional period length categorized as 0 days (18 jurisdictions, 35.3%), 1 to 30 days (18 jurisdictions, 35.3%), 31+ days (10 jurisdictions, 19.6%), and “unclear” (5 jurisdictions with incomplete data, 9.8%) had no significant association with annual adolescent vaccination coverage for Tdap (p = 0.82), MCV4 (p = 0.08), and HPV (p = 0.76). Provisional policies may not increase vaccination coverage as anticipated. Unintended consequences, such as increased nonmedical exemptions and increased demands on clinical providers, are additional factors to consider.

Upgrading the school entry vaccination record check strategy to improve varicella vaccination coverage: results from a quasi-experiment study

ABSTRACT Background The school entry vaccination record check strategy (SECS) is an appropriate opportunity to recommend vaccines for students to improve vaccination coverage (VC). However, it is only utilized for providing necessary catch-up vaccination for students who are missing the Expanded Program on Immunization (EPI) vaccines in China. We aimed to address that gap and quantify the relationship between the SECS policy and the increase of coverage in varicella vaccine (VarV). Methods We employed a pretest and posttest quasi-experimental design to examine the effect of the upgraded SECS policy on the change of VarV coverage in newly enrolled students in Lu’an, 2019–2020. Results Eight hundred participants were randomly divided into the control group (C group, 31.8%), the telephone-based intervention group (T group, 31.2%), and the written notification intervention group (W group, 37.0%). Totally, 84 students received VarV during the study period, with a VC of 10.5%. The possibility of vaccination in the T group (RR = 4.9, 95% CI:2.2–10.9) and W group (RR = 5.2, 95% CI:2.4–11.5) was significantly higher than that in the C group (p< .001). Conclusions Our study demonstrates that the upgraded SECS produce a positive effect on improving the VC of VarV. This nudge strategy may decrease varicella outbreaks in schools in China, especially in provinces where VarV is not introduced into EPI.

Personal belief exemptions for school-entry vaccinations, vaccination rates, and academic achievement

Nonmedical exemptions from school-entry vaccine mandates are receiving increased policy and public health scrutiny. This paper examines how expanding the availability of exemptions influences vaccination rates in early childhood and academic achievement in middle school. We leverage 2003 legislation that granted personal belief exemptions (PBE) in Texas and Arkansas, two states that previously allowed exemptions only for medical or religious regions. We find that PBE decreased vaccination coverage among Black and low-income preschoolers by 16.1% and 8.3%, respectively. Furthermore, we find that those cohorts affected by the policy change in early childhood performed less well on standardized tests of academic achievement in middle school. Estimated effects on test scores were largest for Black students and economically disadvantaged students.

Improving Vaccination Coverage in Children and Adolescents: The Role of Professional Societies.

Improving Vaccination Coverage in Children and Adolescents: The Role of Professional Societies.

Increasing vaccination coverage: The school entry vaccination record check program in Guizhou Province China, 2003–2018

BackgroundGuizhou Province of China implements a vaccination program specifying that children’s vaccination records are to be checked upon entry to kindergarten and primary school; children missing one or more recommended vaccinations are to be offered the missed vaccinations; school-level vaccination coverage levels are assessed at the time of school enrollment and six months later to monitor compliance rates. MethodsWe obtained the number of doses of each vaccine in the national immunization schedule that were administered before and six months after kindergarten and school enrollment and reported to Guizhou Province during 2004 through 2018. We determined temporal trends in coverage of the second dose of measles-containing vaccine (MCV2) and other vaccines, incidence of measles, and number of school-based measles outbreaks. ResultsMCV2 coverage at kindergarten entry increased from 53% in 2004 to 98% in 2018. Among children missing one or more vaccinations, the six-month catch-up rate of MCV2 increased from 80% in 2004 to 99% in 2018. Among primary school children, coverage of MCV2 and other recommended vaccines had similar increases. The annual incidence of measles among Guizhou’s total population declined from 280 per million in 2003 to 0.3 per million in 2018. There have been no measles outbreaks in kindergartens or schools since 2015. ConclusionsChecking vaccination record at kindergartens and primary schools and providing necessary catch-up vaccination was associated with increased coverage of measles and other vaccines, lower incidence of measles, and an apparent end to school-based measles outbreaks. Guizhou’s experience of checking vaccination records at school enrollment led to implementation of this strategy in other provinces. In 2019, the kindergarten and school entry vaccination record check program was incorporated into China’s national vaccine law.

The impact of school-entry mandates on social inequalities in human papillomavirus vaccination.

Fundamental cause theory (FCT) is influential for explaining the enduring relationship between social position and health, yet few empirical studies test FCT’s contention that policy supporting the equal distribution of interventions across populations can help reduce health inequalities. Following human papillomavirus (HPV) vaccine approval, complex socioeconomic and racial-ethnic inequalities emerged in distinct stages of the diffusion of this health innovation. Virginia and the District of Columbia were the first U.S. jurisdictions to implement school-entry HPV vaccination mandates for sixth-grade girls, offering an opportunity to test whether inequalities in HPV vaccination are mitigated by policy that seeks to standardize the age of vaccine administration and remove barriers to knowledge about the vaccine. Using data from the 2008, 2009, 2011, 2012, and 2013 National Immunization Survey–Teen (N = 4579) and a triple-difference approach, this study tests whether vaccine mandates are associated with smaller socioeconomic and racial-ethnic inequalities in health provider recommendation and vaccine uptake. It finds mandates were associated with improvements in provider recommendation and vaccine uptake for some socioeconomic and racial-ethnic groups. However, mandates also likely led to a decline in HPV vaccine series completion overall. Implications of these findings for informing FCT and vaccination policy are discussed.

Association Between Human Papillomavirus Vaccination School-Entry Requirements and Vaccination Initiation

Human papillomavirus (HPV) vaccination coverage is suboptimal in the US. The association between HPV vaccination requirements for school entry and HPV vaccination coverage remains to be studied. To examine the association between HPV vaccination school-entry requirements and vaccination initiation in jurisdictions with such vaccination policies (ie, Virginia, the District of Columbia, and Rhode Island) compared with other regions of the US, as determined by the National Center for Chronic Disease Prevention and Health Promotion. In a population-based, cross-sectional study, 2017 data from the National Immunization Survey-Teen database were used to determine HPV vaccination initiation. Data from 2008 to 2017 were then examined to assess the association between HPV vaccination school-entry policies and vaccination initiation. Data were obtained for adolescents aged 13 to 17 years in the US with health care professional-reported HPV vaccination histories (cross-sectional study, n = 4784; pre-post policy comparisons, n = 42 431). This study was conducted from May 1, 2019, to March 31, 2020. State-level HPV vaccination school-entry requirements from 2008 to 2017. Health care professional-confirmed HPV vaccination initiation. The 2017 cross-sectional study included 4784 adolescents aged 13 to 17 years (2228 [46.6%] girls; 2556 [53.4%] boys; mean [SD] age, 15.0 [1.4] years; interquartile range, 14-16 years). Compared with nonpolicy jurisdictions within the same region, Rhode Island and the District of Columbia, which have HPV immunization school-entry requirements, had higher levels of HPV vaccination initiation (Rhode Island: adjusted odds ratio [aOR], 4.34; 95% CI, 2.16-10.00; District of Columbia: aOR, 2.35; 95% CI, 1.39-4.19). However, compared with regional nonpolicy states, Virginia's HPV vaccination initiation did not differ significantly (aOR, 1.01; 95% CI, 0.72-1.42). The 2008-2017 pre-post policy comparisons involved 42 431 adolescents aged 13-17 years (22 362 [52.7%] girls; 20 069 [47.3%] boys; mean [SD] age, 15.0 [1.4] years; interquartile range, 14-16 years). Postpolicy levels of HPV vaccination initiation in girls was significantly higher in Rhode Island (aOR, 3.12; 95% CI, 1.92-5.07) than prepolicy values. Similar changes were noted for postpolicy HPV vaccination initiation in boys in the District of Columbia (aOR, 6.36; 95% CI, 4.27-9.46) and Rhode Island (aOR, 5.84; 95% CI, 3.92-8.69) compared with prepolicy measures. With respect to regional nonpolicy states during the same period, both girls and boys in Rhode Island and boys in the District of Columbia experienced larger increases in HPV vaccination initiation. For example, in Rhode Island, boys aged 16 to 17 years had 7.32 (95% CI, 3.56-15.06) times the change in pre-post policy HPV vaccination initiation, while girls aged 16 to 17 years had 1.28 (95% CI, 0.60-2.73) times the change. In the District of Columbia, boys had 6.36 (95% CI, 4.27-9.46) times the change in pre-post policy HPV vaccination initiation. The findings of this study suggest that HPV vaccination school-entry requirements are associated with increases in vaccination initiation. Expanding such policies may increase HPV vaccination in the US.

Abstract D030: Arguments in favor and against the new HPV school entry implementation in Puerto Rico: Content analysis of online media coverage

Abstract Background: In August 2018, Puerto Rico (PR) adopted the Human papillomavirus (HPV) vaccine as a school-entry requirement for all students (male and female) 11 to 12 years old. Information about HPV shared in online media outlets may influence vaccine hesitancy, uptake, and parental decision. Before and after the requirement took effect, news coverage of this policy promoted discussions by groups in favor of the vaccine as well as the uproar of anti-vaccine groups, which may have influenced parental perceptions of the school-entry policy. Objective: This qualitative study explored arguments in favor of and against HPV vaccination and the new school-entry vaccination policy among parents, stakeholders, and coalitions in Puerto Rico. Methods: A systematic review was conducted to identify digital media reports related to the HPV vaccination policy and its implementation in PR from January 2017 to December 2018. This analysis focuses only on the codes extracted from the arguments provided by different organizations, coalitions and parents interviewed in the media. A grounded theory approach was used to identify emergent arguments discussed during this period in the news reports. ATLAS.ti 8 was used to facilitate data manipulation and retrieval. Results: Of all the quotes analyzed, 78% were coded as negative (against), 19% were positive (in favor) and only 3% were neutral towards the new HPV school-entry policy. The analysis identified emergent themes related arguments in favor of and against the HPV vaccine policy implementation. Positive arguments frequently discussed, included the following themes: 1) importance of the HPV vaccine for cancer prevention; 2) acknowledgment of sexual practices/activities in youth and 3) healthcare provider recommendation. Primary themes that emerged in arguments against the HPV school-entry policy included: 1) patient autonomy; 2) the right of parents to be informed about the vaccine; 3) lack of education regarding the efficacy of the vaccine; 4) potential risk of vaccines; and 5) pharmaceutical and economic interests. Conclusion: This study explored the most emerging arguments discussed in the media before and during the implementation of the HPV school entry policy in Puerto Rico. Most information disseminated was against this new policy. Media shared online was not balanced, which can lead to the promotion of vaccine hesitancy. Future online media coverage could expand the scope of information and provide a balanced, unbiased overview of this school-entry policy from a more comprehensive range of reliable sources. Citation Format: Glizette O Arroyo-Morales, Vilnery Rivera-Figueroa, Roxana Soto-Abreu, Manuel E Rivera-Encarnación, Olga L Diaz-Miranda, Diana T Medina-Laabels, Ana P Ortiz-Martinez, Erick L Suárez-Pérez, Maria E Fernández, Pamela C Hull, Vivian Colón-López. Arguments in favor and against the new HPV school entry implementation in Puerto Rico: Content analysis of online media coverage [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr D030.