April 2000
ATLANTA - Hepatitis B (HepB); measles, mumps and rubella (MMR); tetanus and diphtheria toxoids (Td) and varicella vaccines have been recommended for children ages 11-12 since 1996. However, a recent survey shows that without a school entry requirement, many children do not receive them.
California implemented a HepB and MMR (MMR, M-M-R, Merck & Co., Inc.) vaccination requirement July 1, 1999. A total of 477,584 seventh-grade students were affected. It is estimated that if these children all receive the three required doses of HepB vaccine, 20,059 hepatitis B virus (HBV) infections and 168 HBV-related chronic liver disease deaths may be avoided in their lifetime.
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To assist in planning and implementing the new law, the San Diego County Health Department expanded its 1998 infant and adult vaccination survey to include fifth and sixth graders.
San Diego County households were randomly sampled by telephone in April 1998. Parents with children entering the fifth or sixth grade were asked to use their parent-held vaccination record to report vaccination history. If this could not be located, parents were asked to recall which vaccinations the child received. Participating parents were asked for consent to obtain their child's vaccination history from their health care provider. Hepatitis B vaccine, MMR, Td and varicella vaccine (Varivax, Merck & Co., Inc.) data were obtained.
A total of 489 (66%) households participated. Vaccination histories were verified for 203 (41.5%) children. Verification methods included parent-held records, provider records and both. Reasons some histories could not be verified included: a written record could not be located by the parent; provider could not be contacted; medical record could not be located, or the medical record lacked vaccination data.
Of children with verified histories, 15.8% had received three doses of HepB vaccine, and 26.6% had received one or two doses. Seventy percent of these children had received two doses of MMR. Of children who had no history of chickenpox, 16.2% had received varicella vaccine. Td boosters were received by 9.4% of children. Fifth and sixth grade vaccination coverage was similar.
Among children whose vaccination information could not be verified, 44.1% of parents reported that their children had received three doses of hepatitis B vaccine, and 5.6% reported that their child had received one or two doses. Reported coverage for two doses of MMR was 82.5%, and coverage for Td was 80.5%. Among children with no history of chickenpox, varicella vaccine coverage was 31.1%.
Confounding factors in the survey include the possibility of incomplete provider or parent-held records and the unknown accuracy of parental recall.
School entry vaccination requirements are considered effective at increasing vaccination coverage and preventing disease among children and adolescents. These requirements have been especially helpful in increasing hepatitis B vaccination, which has been emphasized because of the substantial disease burden of the disease among adolescents and young adults.
"When you're talking about hepatitis B vaccine, the law makes a big difference in getting kids vaccinated," said Francisco Averhoff, MD, MPH, medical epidemiologist with the National Immunization Program at the Centers for Disease Control and Prevention. "Without a law there's a low-grade use of vaccine, but when the law comes into play, all of a sudden there's a jump in the number of doses of vaccine being administered. It suggests that these kids are undervaccinated."
In Florida, where HepB immunization for middle school entry has been required since 1997, 61.8% of students were in compliance by November 1997. The remainder were on schedule or exempted from immunization.
Fourteen states and the District of Columbia have hepatitis B vaccination requirements for middle school entry, and six states have requirements that will go into effect later this year or next year. Eight states (Alaska, Arkansas, Kansas, Maine, Montana, New Jersey, West Virginia and Wyoming) have no hepatitis B vaccination law. Of these, Kansas and West Virginia have mandatory prenatal screening. idc
For more information:
- CDC. Vaccination coverage among adolescents 1 year before the institution of a seventh grade school entry vaccination requirement - San Diego, California, 1998. MMWR.2000;49(5):101-102.
- CDC. Effectiveness of a seventh grade school entry vaccination requirement - statewide and Orange County, Florida, 1997-1998. MMWR.1998;47(34):711-715.
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