Overview of activity

In response to a new school-entry requirement affecting adolescents, the New York State Department of Health Bureau of Immunization took a variety of steps to support its implementation.

Adolescent ages targeted

Public and private school students entering grades 7 and 12.

Background/impetus for the activity

In New York State, new school immunization requirements must be added by the state legislature; then regulations consistent with statutory requirements may be revised or promulgated. In June 2015, the state legislature passed a bill to require meningococcal vaccine for students entering grades 7 and 12, effective Sept. 1, 2016. The bill was signed into law in October 2015. The New York State Department of Health Bureau of Immunization was not involved in initiating the new law, but did support the bill. Once the bill passed, the Bureau took many steps to ensure smooth implementation of the new requirement.

Description of activity

Once the bill passed the legislature, the Immunization Bureau began drafting amendments to the public health regulations related to school immunization requirements. To amend the regulations, the Bureau referred to language used for prior school immunization requirements and to the ACIP recommendations. Although the law refers generally to “meningococcal vaccine,” the requirement is written specific to meningococcal conjugate vaccine (MCV4). For the 2016-2017 school year, one dose of MCV4 is required before grade 7 and a total of two doses are required before grade 12 (unless the first dose was received on or after a student’s 16th birthday). The one-dose MCV4 requirement steps up a grade each year (eg, for the 2017- 2018 school year, one dose is required for entry into both grade 7 and 8).

Soon after the bill was passed, the Bureau sent a letter to health care providers and schools that included basic information on the new requirement, so they could prepare for its implementation. A second letter was sent as a notification of the 45-day public comment period for the proposed regulation and to provide more detail on the requirement.

The Bureau looked at MCV4 coverage rates in both NIS-Teen and the New York State IIS (NYSIIS). In 2014, NIS-Teen data, the New York State-specific rate for one dose at aged 13 to 17 years was comparable to the national average (75% vs 79%, respectively, with overlapping confidence intervals), while the rate for two or more doses at aged 17 (available at the national level only) was 29%; NYSIIS rates were similar. The Immunization Bureau also developed and ran various test scenarios (eg, unusual schedules) in NYSIIS to anticipate implementation issues. The Bureau used these data to create outreach materials designed to increase awareness of the second dose recommendation

To educate health care providers, school staff with immunization-related responsibilities, and parents about the new requirement, the Immunization Bureau:

• Updated a chart prepared annually for schools that summarizes and explains school-entry requirements (April 2016)
• Developed frequently asked questions (FAQs) documents for both health care providers and schools (April 2016)
• Held a webinar for health care providers discussing the new school immunization requirement, the ACIP recommendations, and best practices for getting adolescents immunized (January 2016)
• Held a webinar for schools focused on the new school immunization requirements and how to implement them (March 2016)
• Created a flyer for parents (see file library below) that was posted on the Bureau’s website and made available to schools and health care providers as parent handouts; it was translated into five languages (January-February 2016)
• Created a flyer for parents (see file library below) that was posted on the Bureau’s website and made available to schools and health care providers as parent handouts; it was translated into five languages (January-February 2016)
• Conducted a media campaign (February-May 2016) with television, radio, digital, and social media messaging, as well as a smaller online campaign in Summer 2016 for a back-to-school reminder
• Distributed copies of the parent flyers to local health departments (LHDs) during an annual meeting (March 2016) and asked them to hand deliver them to health care providers

To monitor uptake and compliance with the new requirement, the Bureau monitors MCV4 coverage in NYSIIS and plans to look at data from its Annual School Survey.

Role of immunization program and other agencies/groups involved

The Bureau was responsible for amending the regulations, developing and sending materials to health care providers and schools, and setting up NYSIIS to monitor coverage rates. These regulations were adopted in accordance with the requirements in the New York State Administrative Procedure Act (SAPA).

Throughout the process the Immunization Bureau worked very closely with the State Education Department, especially on the language of the regulations. The Bureau also worked with the New York City Department of Health and Mental Hygiene, which is a separate CDC awardee but is covered by the same statewide school requirements, on the wording of the new regulations and supporting materials. Together the three parties held a number of calls with the state association representing private and parochial schools to inform and gather feedback from its members on the new requirement.

The Bureau also worked with its LHD partners, who have in-depth knowledge of their school populations. The LHDs worked closely with schools in their jurisdiction to support efforts to get adolescents immunized.

The media campaign was managed internally through the state’s Bureau of Marketing and Creative Communications, a division of the Public Affairs Group. They created the advertisements and contracted with a video production company to produce the video advertisement, and with a media buyer for advertising placement. Printing of materials was done in house. Bureau staff conducted the webinars.

Dissemination

The Bureau disseminates information about new school immunization requirements to providers and schools through existing listservs, by posting on its public web page, and through the state’s health commerce system (HCS); HCS accounts are required for all schools and medical professionals.

Intersection with other program activities

Addressing the new school immunization requirement overlapped with the regular duties of the Immunization Bureau’s NYSIIS and school assessment staff.

Funding

The media campaign was largely supported by state funds, with support for staff time and a small amount for the media campaign supported by the Bureau’s CDC cooperative agreement.

Staffing

Key staff members involved included the Immunization Program Manager, the Bureau’s Adult and Adolescent Immunization Coordinator and School Assessment Coordinator, NYSIIS staff, and the Division of Legal Affairs.

Implementation status

The media campaign has ended, although the Bureau will continue social media postings (eg, Facebook, Twitter) during back-to-school time. The Bureau conducts an annual webinar on school requirements for the upcoming school year, which is usually held in March for the start of the school year in the fall. The Immunization Bureau also annually updates materials such as the immunization chart and FAQs documents.

Successes

• It was helpful for the Immunization Program to have nearly a year’s head start from the time when the bill initially passed the legislature to the date of implementation.
• Based on feedback from school nurses, the lead time gave them ample time to screen students’ records in NYSIIS and alert parents that doses were needed.
• The parent flyer has been well received by parents and schools. Also, several Immunization Programs have asked permission to adapt the flyer for their own school requirements. The Bureau also received positive feedback on the media campaign and webinars.
• The LHDs were an important partner. Many were very proactive in holding clinics in the schools, working closely with schools to promote clinics in other locations, and extending their usual immunization clinic hours. They vaccinated large numbers of adolescents in a short period of time to ensure that they met the new requirement.
• NYSIIS has been a great tool to monitor progress, and NYSIIS coverage data are encouraging. As of December 2016, coverage of one dose had improved 8 percentage points from the prior year. For students in grade 12, looking at either two doses or one dose at aged 16 years or older, coverage had increased by 28 percentage points, which far exceeded the Bureau’s expectations.

Challenges

• The Bureau was surprised by the number of calls it received regarding adolescents who had received two doses of MCV4 prior to aged 16 (which means they needed a third dose). The Bureau thought this would be a rare situation related to medical indications. The issue seems to be that some providers gave the first dose earlier than aged 11 to 12 years and then gave the second dose 5 years after that, prior to aged 16.
• Most public schools have school nurses, but private schools often do not have any medical personnel on staff. NYSIIS indicates whether doses are valid or invalid and whether the series is complete, but if a student’s information is incomplete in NYSIIS or the school does not use NYSIIS, nonmedical staff may have difficulty interpreting whether students meet the requirement.
• There were some concerns about students in grade 12 potentially not qualifying to graduate if they missed too many days of school due to noncompliance with the meningococcal vaccine requirement. The second MCV4 dose is challenging in part because students are not required to receive a physical for grade 12, and older adolescents often do not routinely visit a health care provider other than the subset requiring sports physicals. Anticipating this challenge, the Bureau sent information to providers specific to the second dose in February 2016, including the rationale for the second dose recommendation and helpful handouts from the Immunization Action Coalition’s Give2MCV4.org project. These materials were well received.
• The Tdap (grade 6) and MCV4 (grade 7) school-entry requirements are required at different grades. Therefore, guidance and clarification about this was provided to schools, providers, and parents.
• NYSIIS does not record a student’s grade level, so age is used as a proxy for calculating coverage rates in NYSIIS. For students in grade 7, the proxy is ages 12 years and 0 days to 12 years and 364 days, with a similar range for 17-year-olds representing 12th graders, understanding that some children in those groups are actually in the grade above or below
• While the law refers to “meningococcal vaccine” generally, the Bureau specifies in its materials that the MenB vaccine may not be substituted in place of the required MCV4 vaccine.

Other lessons learned/advice to other programs

• Engage partners (eg, providers, schools, LHDs) as broadly and early as possible. The more time they are given to prepare for new school requirements, have their questions answered, and disseminate information to parents, the less chance that the requirements take anyone by surprise.
• When preparing for implementation of new school requirements, it is helpful to add more staff, if possible, to handle incoming calls. The Bureau experienced very high call volumes in the summer and fall, even with all the materials that were disseminated.
• Keep an eye on vaccine supply. The Bureau notified its VFC providers in early summer, to encourage them to have an ample supply of meningococcal vaccine in stock. With the recent emphasis on reducing wastage, providers are sometimes too conservative in their vaccine orders. There were occasional concerns about providers running out of vaccine, but for the most part, the Bureau believes this messaging was effective.
• IIS can be very helpful to support new school requirements, such as to explore potential implementation issues and monitor the impact on coverage rates.

For more information

Contact Elizabeth Rausch-Phung, Immunization Program Manager, in the New York State Department of Health Bureau of Immunization at (518) 473-4437 or elizabeth.rausch-phung@health.ny.gov

NYS Resources: School Requirments