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

Figures & data

Table 1. Demographic information of survey respondents

CHOP Primary care site counties	Survey responses	Years as clinician	Number (%)
Suburbs	69 (64%)	<5 years	12 (11%)
Philadelphia	39 (36%)	5–9 years	15 (14%)
		10–15 years	24 (22%)
		16–20 years	12 (11%)
Role	Number (%)	21–30 years	23 (21%)
MD/NP*	83 (78%)	>30 years	19 (17%)
RN**	14 (9%)	N/A	5 (5%)
Practice Manager	10 (13%)

*MD = medical doctor.

*NP = nurse practitioner.

**RN = registered nurse.

Figure 1. Likert scale responses to statements about awareness and communication of requirements

Figure 2. Likert scale responses to statements about attitudes and beliefs about new requirements

Figure 3. Likert scale responses to statements about practice implementation

Table 2. Additional comments from survey respondents about implementation

“I didn’t see it affect our workload much because most of our patients follow the CDC immunization schedule that we recommend. Mostly I found that parents were worried about letters from school – in some cases the vaccine was needed, in most other cases the child was already up to date.”	“This did not affect us since we already offered the appropriate vaccines and just had a few patients that needed [immunizations] as a result of the change which we were able to accommodate in our regular work flow”
“I would estimate that the majority of our patients were up to date on these vaccine requirements already and have personally only encountered a few cases where I’ve needed to schedule extra catch up vaccines.”	“I think parents are/were caught off guard last year when their child was being told they could not attend school, or had 5 days, until they received the mandated vaccines. We then received panic phone calls of parents who wanted an appointment immediately and this caused major challenges to the office.”
“5 day window was terrible and resulted in patient stampede. Unsure if 4th IPV timing mandate before Kindergarten = AAP recommendation between 4–6 years. A great deal of patients might not have had their 5 year old checkup yet but would get IPV vaccine then, instead they had to come in for shot visit only.”	“School[s] were not communicative with our practice. This would have been a great opportunity for collaboration to help keep the patients UTD and safe. Instead we had children who were not technically overdue from the ACIP schedule, who were kept out of school until they could secure an [appointment]. This led to missed days of school which were unnecessary and harmful to the parent.”
“We did get a flurry of panicked parents who thought their children were not up to date, but very few needed an extra vaccine visit. Nearly all kids of our kids were up to date regardless of the “new” requirement. The only “new” part is that the parents are given less time to make sure their child is vaccinated after the start of the school year.”	“It was absolute madness trying to get these kids in. We ate the labor cost for overtime etc. Clearly no thought was given regarding the impact on those that have to administer the vaccines. If we couldn’t get them in right away, we became the bad guys. It is also absurd that these kids must have them 5 days before school, particularly those that just need a booster dose of something, but have the rest of the series.”

Table 3. Vaccine up-to-date proportions in 2016 vs. 2017 by vaccine, age, county, and dose

Vaccine	Ages	County		Proportion of eligible patients vaccinated – 1st dose			Proportion of eligible patients vaccinated – 2nd dose
			September 2016	September 2017	p-value	September 2016	September 2017	p-value
Tdap	12–13	New Jersey	91.9%	89.9%	0.021
	12–13	Philadelphia	86.9%	88.5%	0.018
	12–13	Suburbs	91.0%	91.7%	0.079
MCV4	12–13	New Jersey	92.2%	90.0%	0.010
	12–13	Philadelphia	86.9%	88.7%	0.008
	12–13	Suburbs	91.1%	92.0%	0.022
	17–18	New Jersey	93.6%	95.0%	0.053	62.2%	69.0%	<.001
	17–18	Philadelphia	90.5%	94.1%	<.001	69.8%	74.2%	<.001
	17–18	Suburbs	96.1%	97.0%	.002	72.1%	79.8%	<.001
MenB	17–18	New Jersey	5.9%	31.7%	<.001	1.8%	14.2%	<.001
	17–18	Philadelphia	10.2%	40.6%	<.001	1.7%	14.2%	<.001
	17–18	Suburbs	18.1%	49.8%	<.001	7.1%	30.0%	<.001
HPV	12–13	New Jersey	21.4%	35.7%	<.001	Proportion of eligible patients vaccinated – completion dose
	12–13	Philadelphia	71.8%	77.9%	<.001
	12–13	Suburbs	40.3%	51.0%	<.001
	17–18	New Jersey	59.0%	63.8%	.001	47.5%	54.8%	<.001
	17–18	Philadelphia	82.1%	85.8%	<.001	68.8%	73.4%	<.001
	17–18	Suburbs	73.7%	76.5%	<.001	61.8%	67.4%	<.001

Table

	Agree	Somewhat agree	Neutral	Somewhat disagree	Disagree	I don’t know
My facility had difficulty meeting the demand for the required vaccinations.
My facility had more requests for immunization visits as a result of the new vaccine requirements.
My facility incurred additional expenses as a result of the new vaccine requirements.
My facility had sufficient staff time to meet increased demand from new vaccine requirements.
My facility had sufficient availability to schedule back-to-back immunization appointments.
My facility had sufficient vaccine supply to meet increased demand from the new vaccine requirements.
Staff at my facility felt comfortable answering questions about the new school vaccine requirements.

Table

	Agree	Somewhat agree	Neutral	Somewhat disagree	disagree	I don’t know
I received sufficient information about the new school immunization requirements.
Parents were aware of the new immunization requirements prior to the appointment.
Patients/Parents of child(ren) understood the need of required vaccines prior to the appointment.
The new immunization requirements will help protect more kids.
More parents will request an exemption to school immunization requirements because of the policy.

Table

	Always	Often	Sometimes	Rarely	Never
HPV-9
MenB
Hep A