Mandates for adolescent immunizations: Recommendations from the
Adolescent Working Group of the National Vaccines Advisory Committee
(working title)

**Introduction**

Compulsory or mandated vaccinations for school entry are credited with
helping the United States achieve high childhood vaccination coverage
rates and subsequently low rates of vaccine-preventable disease among
young children. \[Orenstein, 1999; Hinman, 2002\] While school mandates
have proven to be a valuable public health tool, they have also
generated concern and debate regarding their ability to balance the
public's health and individual/parental rights. An increasingly complex
immunization schedule and broader focus on vaccinating older age groups
have led most states to adopt at least one school vaccine mandate
directed at adolescents (Table 1).

[]{.mark}

In response to a request by the Assistant Secretary for Health, the
Adolescent Working Group of the National Vaccine Advisory Committee
(NVAC) recently assessed issues related to the development of a
comprehensive and successful adolescent immunization program in the
United States. \[NVAC, 2007\] As part of that assessment, the Working
Group identified immunization mandates as one of the issues requiring
national attention. This paper examines the issue of adolescent
vaccination mandates, highlights several points to consider regarding
adolescent mandates, and offers several recommendations to the Assistant
Secretary for Health for jurisdictions considering implementation of an
adolescent vaccination mandate (Table 2).

**Adolescent Vaccines**

In 1996, to strengthen the delivery of vaccines to adolescents along
with other recommended clinical preventive services, the Advisory
Committee on Immunization Practices (ACIP) recommended a preventive
health visit for adolescents aged 11-12 years. \[CDC, 1996a\] At that
time, the tetanus and diphtheria toxoids (Td) booster was the only
vaccine recommended for routine administration to adolescents; the
second dose of measles-containing vaccine, three doses of the hepatitis
B vaccine, and the varicella vaccine were recommended only if an
adolescent had not been vaccinated during childhood (or in the case of
varicella vaccine, if an adolescent also had no reliable history of
disease). These catch-up recommendations were also relatively new,
having been added to the recommended schedule in 1989
(Measles-containing vaccine), 1991 (Hepatitis B vaccine), and 1996
(varicella vaccine). \[CDC, 1989; CDC, 1991; CDC, 1996b\]

Over the following decade, these adolescent vaccine recommendations
remained the same; however since January 2005, three new vaccines have
been licensed and recommended for adolescents: tetanus and diphtheria
toxoids and acellular pertussis vaccine (Tdap); tetravalent
meningococcal conjugate vaccine (MCV4); and human papillomavirus vaccine
(HPV). The recommended age range for routinely administering these
vaccines is also 11-12 years, and catch-up vaccination is recommended
for previously unvaccinated older adolescents. \[CDC, 2007a; CDC, 2006a;
CDC, 2005a; CDC, 2007b\] Additional vaccines currently in development
will likely be added to the adolescent vaccination schedule in the
future.

[]{.mark}

**Vaccine Mandates**

In the United States, school mandates for immunization are created and
enforced at the state level, either through legislative or regulatory
mechanisms. \[Orenstein, 1999\] The first vaccine mandate in the U. S.
was enacted in 1809 and required the general public of Massachusetts to
be vaccinated for smallpox; school mandates for smallpox vaccination
appeared several years later with the recognition that frequent and
close contact in the school setting resulted in children being
particularly vulnerable to transmission of the disease. \[Hinman, 2002\]
At the time, smallpox was the only vaccine-preventable disease;
subsequent mandates were added or expanded as new vaccines were
developed. While concerns about the conflict between personal freedom
and the duty of the state to protect the public's health have always
been a part of the dialogue surrounding vaccine mandates, the
constitutionality of vaccine mandates in general \[Jacobson v.
Massachusetts, 197 U.S. 11 (1905)\], and school entry mandates in
particular \[Zucht v. King, 260 U.S. 174 (1922)\], has been reaffirmed
by the United States Supreme Court. \[Orenstein, 1999\]

Regular enforcement of school-based mandates is more recent and is
attributed to efforts in the 1970s to control measles transmission, when
it was demonstrated that a decrease in measles incidence in Alaska
followed strict enforcement of measles vaccine requirements for
schoolchildren. \[Middaugh, 1978; Orenstein, 1999\] School mandates for
adolescents have also been associated with increased vaccination
coverage levels \[Averhoff, 2004; Jacobs, 2004; Fogarty, 2004; Wilson,
2005; Olshen, 2007\]. As of the 2005-2006 school year, mandates for
entry into middle school existed in 21 states for the Td booster, in 47
states for two doses of measles-containing vaccine, in 33 states for
three doses of hepatitis B vaccine, in 24 states for varicella vaccine,
and in one state for the HPV vaccine (Table 1). Legislation that would
require HPV vaccine administration, funding, or education is also
currently pending in a majority of states. \[National Conference of
State Legislatures, 2007\]

**Considerations**

Issues to address when considering an adolescent vaccine mandate
include: vaccine cost, funding, supply, safety, and effectiveness;
target population, community and school district support, disease burden
and transmission, and existing vaccine exemption policies and
legislation/regulation. Priorities unique to each jurisdiction should
also be identified and included in the decision-making process, and
adequate time for planning and implementation of a proposed mandate is
important to ensure that all considerations are fully addressed.

[Vaccine costs and funding]{.underline}

It is crucial that there is adequate political will at the state
government level to ensure vaccine financing issues are resolved before
a mandate is put into place. In the United States, vaccines are funded
with a combination of federal, state, and private money. For children
through 18 years of age, there are usually five sources of funding: the
federally-funded Vaccines for Children (VFC) program, state budget
allocations, federal budget allocations made under Section 317 of the
Public Health Service Act (known as "Section 317 funds"), private
insurance, and out-of-pocket spending. It is estimated that
approximately 46 percent of U.S. children receive vaccines funded
through the VFC program and an additional 45 percent of children have
their vaccines paid for either through private insurance or
out-of-pocket spending; however, vaccine availability for the remaining
nine percent of children is dependent on variable levels of Section 317
funding, appropriated through Congress on a yearly basis, and to state
budgets, which can also vary substantially from one year to the next.
\[CDC, unpublished data\] Inadequate Section 317 funding combined with
limited or uncertain state budgets for vaccines result in gaps among
children and adolescents who either do not meet VFC program eligibility
criteria, lack private insurance, or have parents/guardians with
insufficient personal income to pay for all costs associated with
vaccination. \[Lee, 2007\] Moreover, the addition of each new vaccine,
like HPV, adds further stress to a system that is already strained; some
states have reported a limited ability to provide newer vaccines to
underinsured children. \[Lee, 2007\] NVAC and other experts have
recommended increases in Section 317 funding in order to address this
issue. \[US Department of Health and Human Services, 2005\]

For adolescents who either have health insurance policies that cover
recommended vaccines or are eligible to receive vaccines through the VFC
program, vaccine price may not be an issue; however, other direct and
indirect costs of care may still be barriers. For the remaining
adolescents who cannot receive recommended vaccines through either
mechanism, vaccine price may significantly affect their ability to
comply with a vaccination mandate. Adequate provider reimbursement for
vaccine delivery is also needed to ensure healthcare providers'
continued ability to vaccinate their patients. A state may choose to
delay implementing a school mandate for a vaccine until the necessary
funds to purchase and deliver the vaccine are available. It is also
important to note that the initial implementation of a vaccine
mandate---including education, planning, and record keeping---can entail
significant costs apart from routine vaccine purchase and delivery. Such
costs should also be considered when discussing new vaccine mandates.

[Vaccine supply]{.underline}

Having an adequate supply of vaccine is essential for the successful
implementation of any school mandate. Because many new vaccines are
produced by only one or two manufacturers, the vaccine supply may be
vulnerable to production capacity limitations or disruptions, especially
during initial introduction. For example, the meningococcal conjugate
vaccine was licensed in January 2005 and recommended for adolescents in
May 2005. A shortage occurred in May 2006 which led the ACIP to issue
interim recommendations to defer vaccination of children aged 11 to 12
years for several months. \[CDC, 2006b\]

Vaccine shortages alone cause confusion and frustration. When such
shortages involve vaccines that have been mandated for school entry,
such problems are compounded. It may be necessary to suspend a mandate
when vaccine shortages occur; this affects children, parents, healthcare
providers, and school administrators. Suspended mandates can also create
a tremendous amount of work for school health personnel, since they will
likely be responsible for ensuring that the student population is
compliant with the mandate once the vaccine supply becomes adequate.

[Vaccine safety and effectiveness]{.underline}

It has been argued that immunizations, which are given to otherwise
healthy individuals, carry a greater ethical burden to prove their
safety than therapeutic interventions. \[Chen, 1999\] Although newly
developed vaccines undergo extensive testing for their safety prior to
being licensed by the Food and Drug Administration, \[Jacobson, 2001\]
the public may be hesitant to receive a newly licensed vaccine until it
has a proven safety record. Because serious adverse events after
vaccination, such as anaphylaxis, are rare, prelicensure clinical trials
may not feasibly enroll enough participants to detect them (e.g., an
adverse event that occurs after 1 in one million vaccinations may
require a clinical trial of at least one million people to detect a
single case, and many more than one million to determine with some
certainty that an adverse event is associated with the vaccine).
Clinical trials will also be unable to evaluate the safety of new
vaccines in groups not included in the trial, or the occurrence of
delayed adverse events or adverse events in subpopulations of vaccine
recipients. For these reasons, postlicensure safety monitoring among the
larger, general population is an important component of vaccine safety.
\[Spier, 2004; Tozzi, 2004; Jacobson, 2001\] The disadvantage of this
approach is that a vaccine may already be in use among the general
public before a serious vaccine-associated adverse event is detected.
\[Ellenberg, 2001\] One example of this scenario was the withdrawal of
the first US-licensed rotavirus vaccine from the U.S. market in 1999
after its association with intussusception (a rare, potentially
life-threatening form of intestinal obstruction) among vaccine
recipients. \[CDC, 1999\] If a vaccine is mandated for school entry soon
after it is licensed and recommended, and a serious adverse event is
found to be associated with the vaccine, the vaccine's use (and any
corresponding mandate) may be suspended or discontinued. This may lead
to public suspicion of and opposition to all existing and future vaccine
mandates and could also erode confidence in the overall immunization
program. Similarly, while vaccine effectiveness is studied extensively
during clinical trials, long-term studies of vaccine efficacy under
actual delivery conditions are not feasible before licensure. \[Hviid,
2006\] A longer interval between licensure and mandate would also allow
for studies of postlicensure vaccine effectiveness in the general
population, which could in turn strengthen public confidence in the
utility of recommended vaccines.

[Target population]{.underline}

Understanding the target population for receipt of a vaccine will help
guide policymakers to determine which students should be included in a
school mandate. For example, a vaccine recommended for 11 and 12 year
olds would call for a mandate for entry into 6^th^ or 7^th^ grade. If
there are catch-up recommendations for older populations, which is
typical for newly licensed vaccines, a state may want to implement a
mandate that affects a wider school population (e.g. 6^th^ -- 12^th^
grade) so that more students can benefit from the new vaccine. However,
implementation may not be feasible on this large a scale. When a new
mandate is being considered, data on current vaccine coverage levels in
the target population can be used to assess the scope of implementation
efforts needed to achieve desired public health outcomes.

A potential source of controversy may occur when a mandate is directed
at only a segment of the student population. For example, the HPV
vaccine is currently only licensed for females, although it may be
licensed for males in the future. A vaccine mandate directed
specifically at female students might have to go through the legislative
or regulatory process a second time if the vaccine were later
recommended for male students as well. Some policymakers may also find a
school mandate directed toward females discriminatory in nature and may
prefer not to enact a mandate until it can be implemented among the
entire target population.

[Community and school district support]{.underline}

Support from the community and school system is important to the
successful implementation of a vaccine mandate. Since schools are
involved in enforcement, it is essential that they support the mandate
and are willing and able to accept the workload increase that the new
mandate may create. Schools will also incur the associated
administrative costs related to tracking and enforcement of compliance
with the mandate, and it is unclear how or if those costs would be
covered by the state. This would occur in the context of the many
competing priorities that schools face with ever-shrinking resources,
and could lead to resentment of future unfunded vaccine mandates.
Likewise, parent support for a new vaccine is important both for the
implementation of a new mandate and for the continued success of the
overall immunization program. For example, recent studies of parents,
adolescents, and healthcare providers have demonstrated variable support
for the HPV vaccine; however, concerns have also been raised about
vaccinating younger adolescents and mandating a vaccine for school entry
when the disease is not transmitted through casual contact. \[Kahn,
2003; Mays, 2004; Boehner, 2005; Kahn, 2005; Zimet, 2005; Colgrove,
2006\]

[]{.mark}

[Disease burden and transmission]{.underline}

Disease burden is an important factor to consider in developing vaccine
mandates. This includes both the likelihood of disease exposure and the
potential morbidity and mortality associated with infection. While the
incidence of many vaccine-preventable diseases has been dramatically
reduced due to high vaccination coverage levels, persons in the U.S. may
still be exposed; for instance, importation of measles disease is
possible through international travel of unvaccinated individuals.
\[CDC, 2006d\] Other vaccine-preventable diseases, such as pertussis,
are still endemic in the United States. \[CDC, 2006a\]

The mode of disease transmissibility should also be considered when
discussing vaccine mandates. Early school mandates, such as those for
smallpox or measles vaccines, were passed on the rationale that they
prevent diseases that are highly contagious in the school setting and
cause a high level of absenteeism among the student population. Some
argue that Hepatitis B vaccine mandates were an exception; however,
transmission of Hepatitis B is possible in the school setting. \[CDC,
2006c\]

One of the new vaccines currently recommended for adolescents
(quadrivalent HPV vaccine) prevents infection that is not transmitted
through casual contact in the classroom. Although the HPV vaccine is
expected to have tremendous impact on improving adolescent, and
ultimately adult health, when or if it should be mandated is
controversial. However, it is of note that a recent analysis of
outpatient healthcare visits by U.S. adolescents aged 11-21 years from
1994-2003 found that only nine percent of those visits were for
preventive care. \[Rand, 2007\] Given this low use of preventive care,
mandates may still be helpful in facilitating vaccination coverage in
adolescents, even for diseases that are not easily transmitted through
casual contact, by acting as an incentive for adolescents to seek
primary care.

[Exemption policies and existing legislation/regulation]{.underline}

As of March 2006, all states permitted medical exemptions to school
immunization requirements. In addition, 48 states allowed religious
exemptions and 19 states had a provision for personal belief exemptions.
\[Omer, 2006\] Personal belief exemptions include religious,
philosophical and any other unspecified non-medical exemptions. Personal
belief exemptions provide the option for parents/guardians to opt out of
vaccination for children if vaccination conflicts with their religious
or personal beliefs. While personal belief exemptions may be viewed as
an important protection of individual rights, such exemptions can result
in an increased risk of disease for unimmunized individuals and their
communities. \[Feikin, 2000; Salmon, 1999\]

Past research has demonstrated that the ease of obtaining a personal
belief exemption is associated with the rate of exemptions taken by
parents; in other words, some parents may file exemptions because they
are more convenient than completing the immunization schedule. \[Rota,
2001\] Likewise, objection to a specific vaccine (as opposed to the
process of vaccination in general) may lead parents to file an
exemption, creating a "culture of refusal" in which exemptions to school
mandates become increasingly common. One proposed solution is an
informed refusal process that includes parent education and annual
renewal. \[Salmon, 2005\] This can help reduce the likelihood that
parents will file exemptions solely for convenience, especially as new
recommendations and mandates make the immunization schedule more complex
and costly.

**Summary: NVAC Adolescent Working Group Recommendations Regarding State
Vaccine Mandates**

In light of the considerations outlined above, NVAC recommends that the
Assistant Secretary for Health encourage jurisdictions considering
adolescent immunization mandates to:

**Secure Partnerships:** Secure the input and partnership of state and
local immunization program personnel and adolescent healthcare providers
in drafting legislation/regulation regarding mandating adolescent
vaccines. Work closely with school administrators and school health
personnel to ensure that potential school-level administrative and
enforcement burdens are minimized.

**Address Infrastructure and Financing:** Use the expert input of
partners to address infrastructure issues that may impact the
implementation of an adolescent vaccine mandate. These include such
issues as: vaccine purchasing, supply, storage, safety profile, uptake,
and target population. Identify and plan for all direct and indirect
costs of vaccine administration, including adequate provider
reimbursement and costs associated with implementing a new mandate, to
ensure equitable access to mandated vaccines.

**Be Consistent with Existing Policies:** Look for ways to incorporate
new mandates as seamlessly as possible into existing vaccine
legislation/regulation, and ensure that new mandates do not contradict
existing legislation/regulation in areas such as reporting of coverage
levels, penalties for non-compliance (e.g., being held out of school),
and immunization information system reporting requirements. Consistency
with existing policies may also minimize vaccine-specific or convenience
exemptions when a new vaccine is introduced.

**Seek Support:** Ensure that adequate political and public support
exists before incorporating an adolescent vaccine mandate into existing
state legislation/regulation. Education of parents and healthcare
providers on vaccines, vaccine-preventable diseases, and mandates is
encouraged to secure public understanding and support, increase
voluntary uptake, and to minimize the administrative burden on school
health personnel.

After ACIP recommendations are made, policymakers should allow for an
adequate time to address the above considerations prior to determining
whether or not to create and implement a mandate for any vaccine. As
recommended by the Association of Immunization Managers (AIM), this
implementation period would allow policymakers to consider and address
critical elements related to vaccine introduction as well as seek the
input of state and local health department personnel, thereby improving
a school mandate's potential effectiveness in increasing vaccination
coverage. \[AIM, 2006\] The Washington State Board of Health has also
developed guidelines for the adoption of state vaccine mandates, in an
effort to outline locally-relevant criteria that can be applied by
decision makers as new vaccines are licensed. \[Washington State Board
of Health, 2006\] These criteria include, among others, review of
vaccine effectiveness, disease burden, and implementation issues.
Thorough consideration of such issues before moving forward with a
school mandate will help ensure that the full public health benefit of
vaccines recommended for adolescents is realized and that the U.S.
immunization program is strengthened overall.

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Table 1. Vaccination mandates for middle school entry^1^, United States,
2005-2006.

+-------------+-----+---------+-------------+--------+-------+-------+
| **State**   | *   | **He    | **Measles** | **Var  | *     | **HPV |
|             | *Td | patitis |             | icella | *MCV4 | ^4^** |
|             | ^2^ | B       | **(2^nd^    | (n     | ^3^** |       |
|             | (n  | (       | dose;       | =24)** |       | **(n  |
|             | =21 | n=33)** | n=47)**     |        | **(n  | =1)** |
|             | )** |         |             |        | =0)** |       |
+-------------+-----+---------+-------------+--------+-------+-------+
| **Alabama** | **  |         | **X**       |        |       |       |
|             | X** |         |             |        |       |       |
+-------------+-----+---------+-------------+--------+-------+-------+
| **Alaska**  | **  | **X**   | **X**       |        |       |       |
|             | X** |         |             |        |       |       |
+-------------+-----+---------+-------------+--------+-------+-------+
| **Arizona** | **  | **X**   | **X**       | **X**  |       |       |
|             | X** |         |             |        |       |       |
+-------------+-----+---------+-------------+--------+-------+-------+
| *           |     | **X**   | **X**       | **X**  |       |       |
| *Arkansas** |     |         |             |        |       |       |
+-------------+-----+---------+-------------+--------+-------+-------+
| **C         |     | **X**   | **X**       | **X**  |       |       |
| alifornia** |     |         |             |        |       |       |
+-------------+-----+---------+-------------+--------+-------+-------+
| *           |     | **X**   | **X**       |        |       |       |
| *Colorado** |     |         |             |        |       |       |
+-------------+-----+---------+-------------+--------+-------+-------+
| **Co        |     | **X**   | **X**       | **X**  |       |       |
| nnecticut** |     |         |             |        |       |       |
+-------------+-----+---------+-------------+--------+-------+-------+
| *           |     | **X**   | **X**       |        |       |       |
| *Delaware** |     |         |             |        |       |       |
+-------------+-----+---------+-------------+--------+-------+-------+
| **Florida** | **  | **X**   | **X**       |        |       |       |
|             | X** |         |             |        |       |       |
+-------------+-----+---------+-------------+--------+-------+-------+
| **Georgia** |     | **X**   | **X**       | **X**  |       |       |
+-------------+-----+---------+-------------+--------+-------+-------+
| **Hawaii**  |     | **X**   | **X**       | **X**  |       |       |
+-------------+-----+---------+-------------+--------+-------+-------+
| **Idaho**   |     | **X**   | **X**       |        |       |       |
+-------------+-----+---------+-------------+--------+-------+-------+
| *           | **  | **X**   | **X**       |        |       |       |
| *Illinois** | X** |         |             |        |       |       |
+-------------+-----+---------+-------------+--------+-------+-------+
| **Indiana** |     |         | **X**       | **X**  |       |       |
+-------------+-----+---------+-------------+--------+-------+-------+
| **Iowa**    |     | **X**   | **X**       |        |       |       |
+-------------+-----+---------+-------------+--------+-------+-------+
| **Kansas**  | **  |         | **X**       |        |       |       |
|             | X** |         |             |        |       |       |
+-------------+-----+---------+-------------+--------+-------+-------+
| *           | **  | **X**   | **X**       |        |       |       |
| *Kentucky** | X** |         |             |        |       |       |
+-------------+-----+---------+-------------+--------+-------+-------+
| **          | **  | **X**   | **X**       | **X**  |       |       |
| Louisiana** | X** |         |             |        |       |       |
+-------------+-----+---------+-------------+--------+-------+-------+
| **Maine**   |     |         | **X**       | **X**  |       |       |
+-------------+-----+---------+-------------+--------+-------+-------+
| *           |     |         | **X**       |        |       |       |
| *Maryland** |     |         |             |        |       |       |
+-------------+-----+---------+-------------+--------+-------+-------+
| **Mass      | **  | **X**   | **X**       | **X**  |       |       |
| achusetts** | X** |         |             |        |       |       |
+-------------+-----+---------+-------------+--------+-------+-------+
| *           | **  | **X**   | **X**       | **X**  |       |       |
| *Michigan** | X** |         |             |        |       |       |
+-------------+-----+---------+-------------+--------+-------+-------+
| **          | **  | **X**   | **X**       | **X**  |       |       |
| Minnesota** | X** |         |             |        |       |       |
+-------------+-----+---------+-------------+--------+-------+-------+
| **Mi        |     |         |             |        |       |       |
| ssissippi** |     |         |             |        |       |       |
+-------------+-----+---------+-------------+--------+-------+-------+
| *           | **  | **X**   | **X**       |        |       |       |
| *Missouri** | X** |         |             |        |       |       |
+-------------+-----+---------+-------------+--------+-------+-------+
| **Montana** | **  |         | **X**       |        |       |       |
|             | X** |         |             |        |       |       |
+-------------+-----+---------+-------------+--------+-------+-------+
| *           |     | **X**   | **X**       | **X**  |       |       |
| *Nebraska** |     |         |             |        |       |       |
+-------------+-----+---------+-------------+--------+-------+-------+
| **Nevada**  | **  | **X**   | **X**       | **X**  |       |       |
|             | X** |         |             |        |       |       |
+-------------+-----+---------+-------------+--------+-------+-------+
| **New       | **  | **X**   | **X**       | **X**  |       |       |
| Hampshire** | X** |         |             |        |       |       |
+-------------+-----+---------+-------------+--------+-------+-------+
| **New       |     | **X**   |             |        |       |       |
| Jersey**    |     |         |             |        |       |       |
+-------------+-----+---------+-------------+--------+-------+-------+
| **New       | **  | **X**   | **X**       |        |       |       |
| Mexico**    | X** |         |             |        |       |       |
+-------------+-----+---------+-------------+--------+-------+-------+
| **New       |     | **X**   | **X**       | **X**  |       |       |
| York**      |     |         |             |        |       |       |
+-------------+-----+---------+-------------+--------+-------+-------+
| **North     |     |         |             |        |       |       |
| Carolina**  |     |         |             |        |       |       |
+-------------+-----+---------+-------------+--------+-------+-------+
| **North     |     |         | **X**       |        |       |       |
| Dakota**    |     |         |             |        |       |       |
+-------------+-----+---------+-------------+--------+-------+-------+
| **Ohio**    |     |         | **X**       |        |       |       |
+-------------+-----+---------+-------------+--------+-------+-------+
| *           |     | **X**   | **X**       | **X**  |       |       |
| *Oklahoma** |     |         |             |        |       |       |
+-------------+-----+---------+-------------+--------+-------+-------+
| **Oregon**  |     | **X**   | **X**       | **X**  |       |       |
+-------------+-----+---------+-------------+--------+-------+-------+
| **Pen       |     | **X**   | **X**       | **X**  |       |       |
| nsylvania** |     |         |             |        |       |       |
+-------------+-----+---------+-------------+--------+-------+-------+
| **Rhode     | **  | **X**   | **X**       | **X**  |       |       |
| Island**    | X** |         |             |        |       |       |
+-------------+-----+---------+-------------+--------+-------+-------+
| **South     |     | **X**   | **X**       |        |       |       |
| Carolina**  |     |         |             |        |       |       |
+-------------+-----+---------+-------------+--------+-------+-------+
| **South     |     |         | **X**       |        |       |       |
| Dakota**    |     |         |             |        |       |       |
+-------------+-----+---------+-------------+--------+-------+-------+
| **          |     | **X**   | **X**       |        |       |       |
| Tennessee** |     |         |             |        |       |       |
+-------------+-----+---------+-------------+--------+-------+-------+
| **Texas**   | **  | **X**   | **X**       | **X**  |       |       |
|             | X** |         |             |        |       |       |
+-------------+-----+---------+-------------+--------+-------+-------+
| **Utah**    | **  |         | **X**       | **X**  |       |       |
|             | X** |         |             |        |       |       |
+-------------+-----+---------+-------------+--------+-------+-------+
| **Vermont** | **  | **X**   | **X**       |        |       |       |
|             | X** |         |             |        |       |       |
+-------------+-----+---------+-------------+--------+-------+-------+
| *           |     | **X**   | **X**       |        |       | **X** |
| *Virginia** |     |         |             |        |       |       |
+-------------+-----+---------+-------------+--------+-------+-------+
| **W         |     | **X**   | **X**       | **X**  |       |       |
| ashington** |     |         |             |        |       |       |
+-------------+-----+---------+-------------+--------+-------+-------+
| **West      |     |         | **X**       |        |       |       |
| Virginia**  |     |         |             |        |       |       |
+-------------+-----+---------+-------------+--------+-------+-------+
| **          |     | **X**   | **X**       | **X**  |       |       |
| Wisconsin** |     |         |             |        |       |       |
+-------------+-----+---------+-------------+--------+-------+-------+
| **Wyoming** | **  | **X**   | **X**       |        |       |       |
|             | X** |         |             |        |       |       |
+-------------+-----+---------+-------------+--------+-------+-------+

^1^An X indicates a mandate as of the 2005-2006 school year. (Source:
CDC. <http://www2.cdc.gov/nip/schoolsurv/immunizationrqmts.htm>,
accessed June 29, 2007).

^2^Td=Tetanus and diphtheria vaccine; As of the 2005-2006 school year,
no states required tetanus-diphtheria-acellular pertussis vaccine (Tdap)
for middle school entry.

^3^MCV4=tetravalent meningococcal conjugate vaccine.

^4^HPV=human papillomavirus vaccine (Source: National Conference of
State Legislatures.
<http://www.ncsl.org/programs/health/HPVvaccine.htm#hpvlegis>, accessed
June 29, 2007).

Table 2. Summary of NVAC Adolescent Working Group Recommendations
Regarding State Vaccine Mandates.

+-----------------------------------------------------------------------+
| NVAC recommends that the Assistant Secretary for Health encourage     |
| jurisdictions considering adolescent immunization mandates to:        |
|                                                                       |
| **Secure Partnership:** Secure the input and partnership of state and |
| local immunization program personnel and adolescent healthcare        |
| providers in drafting legislation/regulation regarding mandating      |
| adolescent vaccines. Work closely with school administrators and      |
| school health personnel to ensure that potential school-level         |
| administrative and enforcement burdens are minimized.                 |
|                                                                       |
| **Address Infrastructure and Financing:** Use the expert input of     |
| partners to address infrastructure issues that may impact the         |
| implementation of an adolescent vaccine mandate. These include such   |
| issues as: vaccine purchasing, supply, storage, safety profile,       |
| uptake, and target population. Identify and plan for all direct and   |
| indirect costs of vaccine administration, including adequate provider |
| reimbursement and costs associated with implementing a new mandate,   |
| to ensure equitable access to mandated vaccines.                      |
|                                                                       |
| **Be Consistent with Existing Policies:** Look for ways to            |
| incorporate new mandates as seamlessly as possible into existing      |
| vaccine legislation/regulation, and ensure that new mandates do not   |
| contradict existing legislation/regulation in areas such as reporting |
| of coverage levels, penalties for non-compliance (e.g., being held    |
| out of school), and immunization information system reporting         |
| requirements. Consistency with existing policies may also minimize    |
| vaccine-specific or convenience exemptions when a new vaccine is      |
| introduced.                                                           |
|                                                                       |
| **Seek Support:** Ensure that adequate political and public support   |
| exists before incorporating an adolescent vaccine mandate into        |
| existing state legislation/regulation. Education of parents and       |
| healthcare providers on vaccines, vaccine-preventable diseases, and   |
| mandates is encouraged to secure public understanding and support,    |
| increase voluntary uptake, and to minimize the administrative burden  |
| on school health personnel.                                           |
+-----------------------------------------------------------------------+