1. Checklist for School-Entry Immunization Mandates Kim Thorburn Medical Director Planned Parenthood of the Inland Northwest Spokane, WA

2. To Mandate or Not to Mandate Effective Public Health ToolEffective Public Health Tool –Improves coverage –Prevents VPDs –Minimizes outbreaks & response ConsiderationsConsiderations –Pragmatic –Legal –Ethical

3. Pragmatic Considerations Less intrusive means Less intrusive means Community threat from poor coverage Community threat from poor coverage Vaccine effectiveness Vaccine effectiveness Effect on person-to-person transmission Effect on person-to-person transmission Vaccine safety Vaccine safety Supply Supply Cost Cost Potential contribution to inequity Potential contribution to inequity Administrative burden Administrative burden Acceptance Acceptance

4. Legal Considerations Constitutional standard to protect the public health & public safety Constitutional standard to protect the public health & public safety Exemptions Exemptions Process for enacting mandates Process for enacting mandates Enforcement Enforcement

5. Ethical Considerations Imposition of states protective (police) power Imposition of states protective (police) power –Transmissibility of infection –Prevention of risk behavior –Individual responsibility in preventing community harm Pharmaceutical industry & mandates Pharmaceutical industry & mandates

6. Implementing School Immunization Mandates: Lessons Learned Anne Bailowitz, MD, MPH Baltimore City Health Department August 20, 2008

7. Problem Definition Maryland 2005: hepatitis B and varicella vaccines mandated for 5 th -9 th graders Baltimore April 2006: 23,469 students out of compliance (29% of students) Great leap forward – single grade vs multigrade mandated phase-in

8. Goal Full compliance by September 2006 Full compliance by January 2007

9. 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 Baltimores 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

10. TOOLS

14. 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

15. 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) 2 nd most effective media tool: radio ads (1% office callers; 10% clinic parents; 30% private practices)

16. 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

17. Questions? Anne Bailowitz, MD, MPH Chief, Bureau of Child Health & Immunization Baltimore City Health Department (E) Anne.Bailowitz@baltimorecity.gov (P) 410.236.9285

18. King County and Washington State Experience: School Immunization Requirements Krista 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).