1. The Chicago Department of Public Health Effect of a School Entry Vaccination Requirement on Racial and Ethnic Disparities in Hepatitis B Vaccination Coverage Levels Enrique Ramirez Immunization Program

2. The Chicago Department of Public Health Background 1994- ACIP, AAP, and AAFP recommend routine hepatitis B vaccination at 11-12 years of age 1997 – State of Illinois mandated hepatitis B vaccination for students entering 5 th grade Hepatitis B vaccination coverage levels among 13-15 year-olds, 2003 – 52%* –School entry requirements may have contributed to this increase *Stokley S. Adolescent Vaccination Coverage Levels: Results from the 1997-2003 National Health Interview Survey; March 6, 2006; Atlanta, GA.

3. The Chicago Department of Public Health Illinois State Requirement, 1997 Completion of  3 doses of hepatitis B vaccine before 5 th grade entry Students who initiated vaccine series exempt from exclusion for up to one year after initiating the series Medical and religious exemptions allowed

4. The Chicago Department of Public Health Objective Describe the effect of the 5th grade requirement on racial and ethnic disparities in hepatitis B vaccine coverage levels among Chicago Public Schools students

5. The Chicago Department of Public Health Methods Retrospective cohort study of Chicago Public Schools’ (CPS) seniors, 2000-2005 CPS provided Chicago Department of Public Health (CDPH) with students’ vaccination information from health database –Vaccination dates –Date of birth –Race (self-reported as white, black, Hispanic, Asian, Native American) –Gender –Medical/religious exemption status

6. The Chicago Department of Public Health Student Cohorts 12 th Grade Entry5 th Grade EntryCohort 20001993Pre-mandate 20011994Pre-mandate 20021995Pre-mandate 20031996Pre-mandate 20041997Post-mandate 20051998Post-mandate

7. The Chicago Department of Public Health Coverage Level Determination Determined hepatitis B coverage levels for each cohort from 12 th grade back to 2 nd grade Compared pre-mandate cohorts’ coverage levels to post-mandate cohorts’ coverage levels –Chi-square test Determined coverage levels by race and ethnic group at 5 th and 9 th grade entry

8. The Chicago Department of Public Health CPS Students Total : 106,541 (range: 14,950 – 19,703) Female : 55% (range: 54 – 55%) Black : 50% (range: 50 – 51%) Hispanic : 33% (range: 30 – 34%) White : 12% (range: 11 – 13%) Asian : 5% (range: 5 – 6%) Native American : <.5% Medical and religious exemptions < 3.2% (range: 1.4 – 3.2%)

9. The Chicago Department of Public Health Hepatitis B Coverage Levels by Grade and Year of 5 th Grade Entry 1998 1997 1996 1995 1994 1993 Post-mandate Pre-mandate Grade

10. The Chicago Department of Public Health Hepatitis B Vaccination Coverage Levels by Race/Ethnicity at 5 th Grade Entry Pre-mandatePost-mandate

11. The Chicago Department of Public Health Hepatitis B Vaccination Coverage Levels by Race/Ethnicity at 9 th Grade Entry Post-mandatePre-mandate

12. The Chicago Department of Public Health Summary Mandates requiring  3 doses of hepatitis B vaccination before 5 th grade entry resulted in a dramatic increase in vaccination coverage levels among Chicago Public Schools students In the post-mandate cohorts, differences in coverage levels between white, black, or Hispanic students eliminated by 9 th grade –Protects most students prior to onset of sexual activity; the most common mode of disease transmission

13. The Chicago Department of Public Health Discussion School mandates may be useful in increasing immunization coverage levels and eliminating disparities for recently recommended adolescent vaccines –MCV4, Tdap, HPV High coverage levels and elimination of disparities by 9 th grade particularly relevant to HPV vaccine –HPV sexually acquired –Higher rate of HPV and cervical cancer among blacks, Hispanics, and females

14. The Chicago Department of Public Health Limitations Required enrollment through 12 th grade –Did not take into account failure rates and dropout rates –Students who drop-out may be less likely to get vaccinated Demographic characteristics and socioeconomic status of CPS students are not reflective of the general population –May not be able to generalize to other settings

15. The Chicago Department of Public Health Acknowledgements Chicago Department of Public Health Sue Gerber Maribel Chavez-Torres Cook County Hospital Robert Weinstein Arthur Evans Chicago Public Schools Robert LoSasso Ken Papineau Illinois Department of Public Health Karen McMahon