8 months to 5 days: what happened when Pennsylvania changed the vaccination regulations for provisional enrollment?

ABSTRACT

In March 2017, the Pennsylvania Department of Health reduced the time allowed to demonstrate compliance with school-entry vaccination requirements from eight months to five days. We describe changes in provisional enrollment, vaccine exemptions, and vaccine coverage rates before and after the new regulation. Across Pennsylvania, provisional enrollment decreased from 11.1% in 2016/17 to 2.5% in 2017/18 (77% relative decrease). Personal belief exemptions continued a modest upward trend, similar to previous years, and medical exemptions remained steady. Among kindergartners, coverage with ≥ 2 doses of MMR vaccine and 2 doses of Varicella vaccine increased; similar increases were seen for the MCV and Tdap vaccines among 7th graders. However, improvements in coverage and reductions in provisional enrollment were not consistent across counties. Provisional enrollment in Philadelphia County during the 2017/18 school year (10.4%) did not substantially decrease. The statewide reduction in provisional enrollment suggests that the new regulations accomplished the goal of increasing the proportion of students who are up-to-date on required vaccines at the beginning of the school year without a significant increase in vaccine exemptions. However, the persistence of high provisional enrollment in some counties points to additional barriers to this goal in some schools and regions.

KEYWORDS:

• Provisional enrollment
• vaccine requirements

In the US, child vaccination coverage targets are achieved through school-entry vaccine mandates. Children are required to be fully up-to-date on required vaccinations unless they have a medical or nonmedical (religious, philosophical/personal belief) exemption. Additionally, in 45 states students can also enter school if they have started, but not completed a multiple-dose vaccine series;¹ these children are categorized as “provisional” or “conditional” entrants and can continue to attend school while catching up on required vaccinations.² In response to years of ongoing high provisional enrollment rates, which were considerably higher than medical and nonmedical exemption rates, the Pennsylvania Department of Health reduced the grace period for provisional entrants from eight months to five days following the first day of school beginning with the 2017/18 school year.³ The goal of shortening the provisional enrollment time in Pennsylvania was to increase the number of students who are up-to-date on vaccination at the beginning of the school year.

Across the country, most recent efforts to increase vaccine coverage among schoolchildren have focused on limiting nonmedical exemptions.^4–6 However, efforts to limit provisional enrollment may also be effective in increasing the number of students who are up-to-date on their vaccines at the time of school-entry. For example, a 2015 campaign led by the California Department of Public Health to improve appropriate use of the provisional enrollment status resulted in a 2.5% reduction in provisional enrollment in the first year (36% relative reduction) and an additional 2.5% reduction in the second year (57% relative reduction).^7–9 There is substantial cross-state variation in the maximum duration of provisional or conditional enrollment, often referred to as the “grace period”. Among the 27 states reporting provisional enrollment during the 2016/17 school year, twelve states reported higher percentages of provisional enrollment compared to the percentage of students with exemptions from ≥1 vaccines – Pennsylvania had the highest reported provisional enrollment among those 27 states.²

Prior to 2017/18, students in Pennsylvania could be provisionally enrolled in school for up to eight months, almost the full school year, if the student had received one dose of a multi-dose vaccine, was not yet due for the next dose, and had a plan to complete the remaining doses noted in their school health record. The new regulations have reduced the provisional period from eight months to five days with new requirements for multi-dose vaccines: if a student does not have all the required doses of vaccines for school-entry, needs additional doses, and the next dose of vaccine is medically appropriate (based on the Advisory Committee on Immunization Practices recommendations for minimum elapsed time between doses¹⁰) then the student must receive that dose within the first five days of school or risk being excluded. If the next dose is not the final dose in a multi-dose series, the student must also provide a medical certificate within the first five days of school outlining the plan for obtaining the remaining vaccine doses. If a student does not have all the required doses of vaccines for school-entry and the next dose of vaccine is not medically appropriate, the student must provide a medical certificate within the first five days of school outlining the plan school for obtaining the required vaccinations – students who fulfill these criteria would be classified as provisional entrants since they would be compliant with requirements despite not being up-to-date on vaccines for school-entry. If a student has not received a vaccine for which only a single dose is required on the child’s first day of attendance for that school year (for example, Tdap for 7th grade entry), the child should be excluded from school unless they have an exemption.¹¹

One potential concern with shortening the provisional period in Pennsylvania from eight months to five days is that it could lead to an increase in vaccine exemption requests if parents were not able to get their child vaccinated in time and chose to claim an exemption rather than risk exclusion. This could create a replacement effect where students who were not-up-date during the provisional period could continue to be not-up-date via an exemption. In order to understand what happened in Pennsylvania after the implementation of this new regulation, we used publicly available vaccination data reported to the Pennsylvania Department of Health from school districts from the 2014/15 school year through the 2017/18 school year for kindergartners and 7th graders.¹² Using these data, we described proportions of provisional enrollment, medical and non-medical exemptions, and required vaccine receipt, before and after the new regulations. In addition to examining statewide trends, we also examined trends by the 2013 National Center for Health Statistics urban and rural county-level classification schemes¹³ in order to explore differences among the two large central metro counties in Pennsylvania (Philadelphia and Allegheny counties) compared to the rest of the state.

After the reduced provisional period was introduced at the beginning of the 2017/18 school year, the statewide rate of provisional enrollment at kindergarten and seventh grade immediately decreased from 11.1% to 2.5% (a 77% relative decrease, see Figure 1). Religious and philosophical exemptions continued a modest upward trend (1.0% in 2016/17 to 1.3% in 2017/18 and 1.5% in 2016/17 to 1.7% in 2017/18, respectively, see Figure 1); medical exemption rates remained steady at 0.6%. Overall, the percent of students entering kindergarten and seventh grade not up-to-date on vaccination decreased from 14.1% in 2016/17 to 6.1% in 2017/18. Among kindergartners, following the provisional period reduction, there were increases in uptake of ≥2 doses of MMR (measles-mumps-rubella) vaccine (93.7% in 2016/17 to 96.8% in 2017/18) and 2 doses of the Varicella vaccine (92.9% in 2016/17 to 96.4% in 2017/18). Among 7th graders, the largest improvements were seen for the first MCV (meningococcal vaccine) dose (85.1% in 2016/17 to 94.8% in 2017/18) and first Tdap/TD (Tetanus and diphtheria) vaccine dose (85.7% in 2016/17 to 94.8% in 2017/18).

Figure 1. Rates of provisional enrollment, medical exemptions and non-medical exemptions in Pennsylvania: 2014–2108

While the proportion of provisional enrollment decreased and the proportion of students up-to-date for required vaccines increased within Pennsylvania, the impact of the new regulations was not uniform among counties across the state. Of specific interest was Philadelphia County, where the percentage of provisional enrollment in 2017/18 did not substantially decrease from 2016/17 (12.5% to 10.4%) and was the highest of the sixty-seven counties in the state. On average across the state, there was a 9.3% reduction in the provisional enrollment rate from the 2016/17 to 2017/18 school year – Philadelphia county had a 2.1% reduction which was the lowest reduction in the state besides Montour County which saw an increase from 1.1% to 2.8%.

Compared to Allegheny County, the other large central metro in Pennsylvania where Pittsburgh is located, Philadelphia County’s provisional enrollment rate is much higher and has consistently been higher over time. For example, in Allegheny County, provisional enrollment decreased substantially from 4.3% in 2016/17 to 0.8% in 2017/18. (Table 1) However, it’s important to note that Allegheny County’s provisional enrollment rates have been consistently lower than the state average since the 2014/15 school year. Given that the new regulations did not have the same impact in all counties across the state, it is important to examine why Philadelphia County’s provisional enrollment rate was high prior to the reduction of the provisional period and why it did not decrease substantially afterward similar to other counties in Pennsylvania.

Table 1. Rates of provisional enrollment, medical exemptions, and non-medical exemptions by school year and rural-urban classification schemes in Pennsylvania

	2014/15			2015/16			2016/17			2017/18
	Provisional Enrollment	Medical Exemption	Non-Medical Exemption^a	Provisional Enrollment	Medical Exemption	Non-Medical Exemption^a	Provisional Enrollment	Medical Exemption	Non-Medical Exemption^a	Provisional Enrollment	Medical Exemption	Non-Medical Exemption^a
Pennsylvania	13.4	0.4	1.1	7.6	0.5	1.2	11.1	0.6	1.2	2.5	0.6	1.5
Philadelphia County	9.9	0.08	0.3	9.6	0.2	0.3	12.5	0.9	0.3	10.4	0.6	0.4
Allegheny County	3.9	0.5	1.2	2.0	0.6	1.0	4.3	0.7	1.1	0.8	0.6	1.2
Large Fringe Metro^b,c (n = 11)	13.9	0.5	1.3	7.3	0.4	1.4	10.9	0.4	1.4	1.6	0.5	1.7
Medium Metro^b,d (n = 14)	15.0	0.5	1.1	8.6	0.6	1.2	13.0	0.5	1.2	2.3	0.6	1.6
Small Metro^b,e (n = 10)	13.4	0.5	1.2	5.7	0.5	1.4	8.9	0.6	1.4	1.3	0.9	1.8
Non-Metropolitan^f (n = 30)	12.3	0.4	1.6	6.2	0.4	1.8	11.0	0.3	2.0	1.4	0.5	2.2

^aNon-Medical Exemption rates include the average percentage of religious and philosophical exemptions

^bAverage rates among all counties that were classified to each classification scheme

^cLarge Fringe Metro: Counties in metropolitan statistical areas of 1 million or more population

^dMedium Metro: Counties in metropolitan statistical areas of populations of 250,000 to 999,999.

^eCounties in metropolitan statistical areas of populations less than 250,000.

^fThe Non-Metropolitan category includes counties that are classified as Micropolitan or Noncore

We propose some factors that might be impacting provisional enrollment in Philadelphia.

Philadelphia County has the largest pre-K to grade 12 public school enrollment in the state, with ~197,000 students and 16,000 first graders enrolled in 2017/18. For comparison, first grade enrollment in Philadelphia exceeds the total pre-K to grade 12 enrollment in 40 other counties in Pennsylvania.¹⁴ The larger school system and larger school enrollment in Philadelphia county means more student records for school nurses to review within a short period of time, in addition to other beginning of the school year priorities. Given a shortage of school nurses in Philadelphia,¹⁵ this may have played a role in the less than substantial reductions in provisional enrollment due to reduced workforce to review these records and follow up on plans recorded in the health record to receive additional vaccine doses, if necessary. While school districts in Pennsylvania did report increased efforts to communicate the new changes as well as promote vaccination clinics to help students and families comply with the new regulations, there were also reports of schools across the state excluding students due to failure to comply with the new regulations.^16,17

Schools are charged with ensuring that students receive required vaccines, but schools are also charged with ensuring that children are in school. These conflicting goals may have put pressure on schools to allow students to be provisionally enrolled, even if the student does not meet the requirements. This may be what is happening in Philadelphia – in recent years the Philadelphia School District has discouraged school nurses from excluding unvaccinated students to maintain enrollment and reduce recidivism. This is in direct contrast to the state health departments guidelines.¹⁸ The decision to exclude a child from school is a decision that schools do not take lightly – especially for vulnerable families in which parents work hourly wages, or parents do not have resources to provide for care within school hours. Additionally, schools receive funding from the state based on average daily attendance so excluding students from attending school based on their vaccination records can put school staff in a challenging position.¹⁹ These competing priorities have likely contributed to Philadelphia County’s high provisional enrollment rate prior to the reduction in the grace period and its lack of a decrease afterward.

In addition to having a large student population, Philadelphia County has the largest percentage of children on Medicaid (54%) than any other county in Pennsylvania and 32% of children under the age of 18 years old live in poverty.^20,21 Logistical barriers to getting children up-to-date on vaccination prior to school-entry for low-income families can be difficult due to parents’ work schedules or difficulties accessing transportation – these factors may continue to contribute to the high provisional enrollment rate in Philadelphia County. Additionally, there are regulations that allow for a temporary waiver of vaccination requirements for certain students including if the child is unable to locate his/her records due to a disaster, if the child transfers into the school, if there is a national vaccine shortage or if the child is homeless.¹¹ In a large county like Philadelphia with a diverse student population, these temporary waiver of vaccination requirements may have also contributed to the provisional enrollment rate.

Based on one year of data after the regulations were implemented, there was promising increase in the number of Kindergartners and 7th grade students who are up-to-date on vaccines. As parents, schools, and vaccine providers adjust to the new regulations, it is likely that provisional enrollment will continue to decrease. However, in Philadelphia, in order to continue to reduce provisional enrollment there will need to be an increased effort among school districts, school nurses and parents to ensure that students fulfill requirements in a timely manner. One tool to improve implementation of requirements is enforcement. The possibility of exclusion may have been a very strong motivator for parents to get their children up-to-date or get a vaccine exemption – without this motivator in Philadelphia, we may continue to see higher than average provisional enrollment rates. Future studies should examine perspectives of healthcare providers, school nurses and parents to determine if the new regulations posed as a disruption to the vaccination services in Philadelphia – these data together will provide a more complete understanding of why provisional enrollment rates did not steeply decline, as they did in the rest of the state, after the implementation of this new regulation.

Overall, the new regulations in Pennsylvania are accomplishing the goal of increasing the proportion of students who are up-to-date or in compliance with requirements for vaccines at the beginning of the school year without a significant increase in exemption rates. There has been increasing attention to changes to vaccine exemption law in the US as result of large-scale vaccine preventable disease outbreaks occurring; however, it may be equally important to focus on provisionally admitted students as they constitute a large proportion of the not-up-to-date students in many regions and states. Vaccination policies/regulations that focus on children who have started, but not completed, required vaccine series have shown to be an effective approach to increase vaccination rates at school entry.

Abbreviations

MMR measles-mumps-rubella

MCV meningococcal vaccine

TD tetanus and diphtheria

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The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Financial disclosure

All authors have indicated they have no financial relationships relevant to this article to disclose.

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