Checklist for School-Entry Checklist for School-Entry Immunization MandatesImmunization Mandates

Kim ThorburnKim Thorburn

Medical DirectorPlanned Parenthood of the Inland

NorthwestSpokane, WA

To Mandate or Not to To Mandate or Not to MandateMandate

• Effective Public Effective Public Health ToolHealth Tool– Improves coverageImproves coverage– Prevents VPDsPrevents VPDs– Minimizes Minimizes

outbreaks & outbreaks & responseresponse

• ConsiderationsConsiderations– PragmaticPragmatic– LegalLegal– EthicalEthical

Pragmatic ConsiderationsPragmatic Considerations

• Less intrusive meansLess intrusive means• Community threat from poor coverageCommunity threat from poor coverage• Vaccine effectivenessVaccine effectiveness• Effect on person-to-person transmissionEffect on person-to-person transmission• Vaccine safetyVaccine safety• SupplySupply• CostCost• Potential contribution to inequityPotential contribution to inequity• Administrative burdenAdministrative burden• AcceptanceAcceptance

Legal ConsiderationsLegal Considerations

• Constitutional standard to “protect Constitutional standard to “protect the public health & public safety”the public health & public safety”

• ExemptionsExemptions

• Process for enacting mandatesProcess for enacting mandates

• EnforcementEnforcement

Ethical ConsiderationsEthical Considerations

• Imposition of state’s protective Imposition of state’s protective (police) power(police) power– Transmissibility of infectionTransmissibility of infection– Prevention of risk behaviorPrevention of risk behavior– Individual responsibility in preventing Individual responsibility in preventing

community harmcommunity harm

• Pharmaceutical industry & mandatesPharmaceutical industry & mandates

Implementing School Immunization Mandates: Lessons Learned

Anne Bailowitz, MD, MPH

Baltimore City Health Department

August 20, 2008

Problem Definition

• Maryland 2005: hepatitis B and varicella vaccines mandated for 5th-9th graders

• Baltimore April 2006: 23,469 students out of compliance (29% of students)

• “Great leap forward” – single grade vs multigrade mandated phase-in

Goal

• Full compliance by September 2006

• Full compliance by January 2007

Strategy

• The stick: risk of school exclusion for non-compliance via mandate (COMAR 10.06.04)

• A carrot for BCHD: database monitoring of iz problems and progress via mandatory reporting to Baltimore’s Immunization Registry Program (BIRP)

• Carrots for parents: letters; media (radio/TV/bus); autodialer; food gift cards

• Collaborators: BCPSS, Housing, community health providers, private docs, iz coalition, BCHD

TOOLS

Baltimore City Public School

Out of Vaccination Compliant Students by Home Address

As of Feb 2, 2007

Implementation

• Communication to parents: letters; media• Maximize public clinics: extended hours daily,

Saturday, and via mobile clinic (TIKE)• Capacitate schools to outreach/ immunize:

refrigerators supplied; vaccines stocked; consents obtained; data transfer to BCHD

• Vaccination days at schools with high out-of-compliance numbers

Evaluation

• PDSA and QI – what works?• Evaluation of media efficacy via questionnaire:

callers to BCHD; parents at clinic sites; and physicians in private practice

• All surveys indicated: school letter most effective communication (89% office callers; 63% clinic parents; 78% private practices)

• 2nd most effective media tool: radio ads (1% office callers; 10% clinic parents; 30% private practices)

Summary

• The simplest approach is sometimes best- the (free) school letter gets the message out

• Mandates can help: state and city regulations• Money talks: three supplemental grants• Collaboration is key: School System, Health

Department, City Housing Department, health care providers

• Agency ties formed during this campaign will facilitate rapid responses to more urgent events in the future

Questions?

Anne Bailowitz, MD, MPH

Chief, Bureau of Child Health & Immunization

Baltimore City Health Department

(E) Anne.Bailowitz@baltimorecity.gov

(P) 410.236.9285

King County and Washington State Experience:

School Immunization RequirementsKrista Rietberg, Epidemiologist, Public Health – Seattle & King County

•Strong support for school requirements to assure high immunization rates.•Desire to have provider and population acceptance first (HPV, varicella).•Philosophical exemptions allowed, some school districts high exemption rates•Concern about opening opportunity for negative changes (e.g. Thimerosal issue).