Impact of school-entry vaccination requirement changes on clinical practice implementation and adolescent vaccination rates in metropolitan Philadelphia

Awareness, communication, and attitudes toward requirements

Most respondents learned about the new school-entry vaccination requirements by a notice from the Pennsylvania Department of Health (31%) or a notice from the Children’s Hospital of Philadelphia (21%). Other sources of information included other clinic staff (16%), notice from the county Department of Health (12%), and other parents (9%). Infrequently (<12%), respondents cited letters from the schools of their own children, school nurses, professional organizations, and the news media. Respondents were able to select multiple options for sources of information.

One third of the responses indicated that their primary care practice did not directly communicate with parents in general about vaccines required for school or send information about new requirements (34%). For those who indicated that they do communicate with parents, the most common methods of communication were phone calls (25%) or in-person during office visits (14%). Only 13% of responses indicated that the respondent did not know about the communication strategy. Other methods of communication included letters (7%) and website updates (5%). For the new 2017–2018 school-entry vaccination requirements, about a third (31%) of survey respondents indicated that they did not know about any additional outreach activities performed by their clinic and 30% indicated that no outreach communication about the new requirements was performed. Among those whose primary care site did perform outreach about the new school-entry vaccination requirements, communication methods included phone calls (20%) as well as posters/fliers in waiting room (11%), letters (4%), and website updates (2%). In-person during office visits was not mentioned as a common communication method for the new requirements.

The majority of respondents strongly or somewhat agreed (79%) that “Staff at my facility felt comfortable answering questions about the new school vaccine requirements.” (Figure 1). The majority of respondents strongly or somewhat agreed (70%) with the statement “I received sufficient information about the new school immunization requirements.” (Figure 1). Over half of respondents strongly or somewhat agreed (57%) that “Parents were aware of the new immunization requirements prior to the appointment.” (Figure 1). The majority of respondents strongly or somewhat agreed (66%) with the statement “Patients/Parents of child(ren) understood the need of required vaccines prior to the appointment.” (Figure 1).

When asked if parents of patients mentioned any of the following communication strategies, 73% of respondents indicated that parents mentioned prompts from their child’s school to get back-to-school vaccinations, compared to 14% of respondents indicating parents mentioned reminder phone calls and 13% who reported that parents mentioned reminder letters.

The majority of respondents strongly or somewhat agreed that the new requirements will help protect more children (91%) (Figure 2).

Practice implementation strategies

A quarter of total respondents (25%) indicated that their practice did not engage in any new activities to meet the new 2017–2018 school-entry vaccination requirements. For respondents (N = 66; 75%) who did indicate practice engagement, the following activities were the most commonly selected: additional staff time for immunization visits (20%), reminder-recall phone calls (16%), extended hours for immunization-only visits (15%), and extended staff time to identify children who were not up-to-date for required vaccines (12%).

When asked which activities their practice would use for the 2018–2019 school year to meet the new requirements, 27% of total participants reported that no new activities would be used. For respondents (73%) who did plan practice engagement, the following activities were the most commonly selected: additional staff time for immunization visits (19%), reminder-recall phone calls (14%), and extended hours for immunization-only visits (14%).

The majority of respondents strongly or somewhat agreed (62%) with the statement “My facility had more requests for immunization visits as a result of the new vaccine requirements” (Figure 3). However, the majority strongly or somewhat disagreed (68%) that “My facility had difficulty meeting the demand for the required vaccinations” (Figure 3). The majority of respondents did not know whether (38%) or disagreed (36%) that their facility incurred additional expenses after the new vaccine requirements (Figure 3). About half of respondents strongly or somewhat agreed (52%) with the statement “My facility had sufficient staff time to meet increased demand from new vaccine requirements” while a similar proportion strongly or somewhat agreed that their facility had sufficient availability to schedule back-to-back immunization appointments” (Figure 3). Most respondents strongly or somewhat agreed (78%) that their facility had sufficient vaccine supply to meet increased demand from the new vaccine requirements (Figure 3).

Between publication of the new school-entry vaccination requirements in the spring 2017 and the beginning of the 2017–2018 school year, most respondents answered that the average amount of time between an appointment request and the appointment date for a well visit was more than 2 months (34%) or 1–2 months (25%) while a quarter indicated that they did not know the average timeframe. On the other hand, for that same time period, most respondents answered that the average amount of time between an appointment request and the appointment date for an immunization-only visit was immediately (33%) or 1–2 weeks (42%). When asked about offering recommended, not required, vaccines at the back-to-school immunization visit, the following percentages of respondents indicated that they “Always” offer the vaccine: HPV-9 (88%), MenB (82%), and Hepatitis A (82%) vaccines.

Quotes from survey respondents

Providers and practice managers were also asked to provide additional comments related to the introduction and implementation of Pennsylvania’s new school-entry vaccination requirements. Some respondents mentioned, “For the most part the Pennsylvania school requirements were already met by all our patients” while others mentioned that “it was absolute madness trying to get these kids in” (Table 2). Respondents who found that the requirements led to additional workload mentioned scheduling issues and labor costs as the most common challenges their practice faced. One comment noted an unintended consequence of scheduling related to this requirement: “I feel this has caused children who are not up to date with well visits to come in for vaccines only and then some do not return for their annual well check.”

Respondents also noted schools’ limited communication with primary care practices stating “This would have been a great opportunity for collaboration to help keep the patients [up-to-date] and safe … ” and “In many cases, the parent did not know what was due. In some cases, the records of the school were not updated.”

While many respondents generally were “glad PA is finally taking a stronger position on making sure kids are properly immunized,” multiple respondents questioned the usefulness and introduction of the new requirements. One comment stated, “I think the letters that came out to families from the school district were too harsh regarding the new vaccine requirements. Most of the families that were affected are families that already believe in vaccines and want to do the right thing. It seems funny to harass that group of parents, when PA still allows other parents to simply write a letter saying they philosophically disagree.”

Required vaccines for students entering 7th grade: Tdap and MCV4

One dose of Tdap and one dose of MCV4 are required for all students entering 7th grade.¹⁹ For all Pennsylvania practices, the proportion of eligible 12–13-year-old children who received one dose of Tdap and MCV4 vaccines by September 15 increased slightly between 2016 and 2017 (89.7% to 90.7% for Tdap and 89.7% to 90.9% for MCV4). Within Philadelphia county practices, the proportion of eligible 12–13-year-old children who received one dose of Tdap and MCV4 vaccines by September 15 of 2016 vs. 2017 increased from 86.9% to 88.5% for Tdap (p = .018) and 86.9% to 88.7% for MCV4 (p = .008). Among suburban practices, there was no significant increase for Tdap (91.0% to 91.7%, p = .079) while MCV4 rates increased from 91.1% to 92.0% (p = .022). However, at the CHOP primary care practices in New Jersey that are outside the purview of these new vaccine requirements, the proportion of eligible 12–13-year-old children who received one dose of Tdap or MCV4 vaccine by September 15 slightly decreased (91.9% to 89.9%, p = .021 and 92.2% to 90.0%, p = .010, respectively).

Required vaccines for students entering 12th grade

An additional booster dose of MCV4 vaccine after 16 years of age is required in Philadelphia for all students entering 12th grade.¹⁹ For all Pennsylvania practices, the proportion of eligible 17–18-year-old adolescents who received the second dose of MCV4 vaccine by September 15 increased from 71.4% in 2016 to 78.0% in 2017. Among Philadelphia county practices, the proportion of eligible 17–18-year-old adolescents who received MCV4 in 2016 vs. 2017 increased from 69.8% to 74.2% (p < .001) with a similar significant increase among suburban practices (72.1% in 2016 to 79.8% in 2017, p < .001) (Table 3). For New Jersey practices, the proportion of eligible 17–18-year-old adolescents who had received a second dose of MCV4 vaccine by September 15 also significantly increased from 62.2% in 2016 to 69.0% in 2017 (p < .001).

Recommended but not required vaccines: MenB and HPV

Two doses of MenB vaccine are recommended using shared clinical decision-making for adolescents 16–23 years of age, with a preference at 16–18 years of age.²⁰ For all Pennsylvania practices, the proportion of eligible 17–18-year-old adolescents who had received the first dose of the MenB vaccine by September 15 significantly increased from 15.5% in 2016 to 46.8% in 2017 (p < .001). Among Philadelphia county practices, the proportion of eligible 17–18-year-old adolescents who received one dose of the MenB vaccine by September 15 increased from 10.2% in 2016 to 40.6% in 2017 (p < .001) (Table 3). Within Suburban practices, the proportion of eligible 17–18-year-old adolescents who had received one dose of MenB vaccine by September 15 increased from 18.1% in 2016 to 49.8% in 2017 (p < .001) (Table 3). Furthermore, for all New Jersey practices, the proportion of eligible 17–18-year-old adolescents who received one dose of MCV4 vaccine by September 15 also increased from 5.9% in 2016 to 31.7% in 2017 (p < .001) (Table 3).

A two-dose series of HPV vaccine is recommended for children ages 9–14 at initial vaccination, preferably at ages 11–12 years, and a three-dose series of HPV vaccine is recommended for children ages 15+ at initial vaccination.²⁰ For all Pennsylvania practices, the proportions of eligible 12–13-year-old children who received the first dose of HPV vaccine by September 15 increased from 50.3% in 2016 to 59.6% in 2017. Among Philadelphia county practices, the proportion of eligible 12–13-year-old children who received a first dose of HPV vaccine by September 15 increased from 71.8% in 2016 to 77.9% in 2017 (p < .001) (Table 3), while among suburban practices, the proportion of eligible 12–13-year-old children who received the first dose of HPV vaccine by September 15 increased from 40.3% in 2016 to 51.0% in 2017 (p < .001) (Table 3). Similarly, for all New Jersey practices, the proportion of eligible 12–13-year-old children who received the first dose of HPV vaccine by September 15 increased from 21.4% in 2016 to 35.7% in 2017 (p < .001) (Table 3).

For all Pennsylvania practices, the proportions of eligible adolescents 17–18 years of age who initiated (first dose) or completed (second and/or third dose) the series of HPV vaccine by September 15 increased from 76.5% in 2016 to 79.5% in 2017 and 64.0% in 2016 and 69.2% in 2017, respectively. At Philadelphia practices, the proportions of eligible adolescents 17–18 years of age who initiated or completed the series of HPV vaccine by September 15 increased from 82.1% in 2016 to 85.8% in 2017 (p < .001) and 68.8% in 2016 to 73.4% in 2017 (p < .001), respectively (Table 3). Significant increases were also noted among eligible 17–18-year-old adolescents in Suburban practices (73.7% in 2016 to 76.5% in 2017, p < .001 for series initiation and 61.8% in 2016 to 67.4% in 2017, p < .001 for series completion) (Table 3). Similarly, for all New Jersey practices, the proportions of eligible adolescents 17–18 years of age who initiated or completed the series of HPV vaccine by September 15 also increased from 59.0% in 2016 to 63.8% in 2017 (p = .002) and 47.5% in 2016 and 54.8% in 2017 (p < .001), respectively (Table 3).