1. Student Immunization Requirements of U.S. Health Professional Schools
Megan C. Lindley1, Suchita A. Lorick1, Jovonni Spinner2, Andrea Krull2, Gina Mootrey1, Faruque Ahmed1, Rosa Myers3, Raymond Strikas2
1 National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA
2 National Vaccine Program Office, U.S. Department of Health and Human Services, Washington, DC
3 Office on Women’s Health Region 3, U.S. Department of Health and Human Services, Philadelphia, PA

2. Disclosure Information
The authors have no financial or other conflicts of interest to disclose
The findings and conclusions in this presentation have not been formally disseminated by CDC or HHS and should not be construed to represent any agency determination or policy

3. Background
Coverage for recommended vaccines among U.S. healthcare personnel (HCP) is unknown or suboptimal, particularly for influenza
Immunization policies of schools training HCP may impact future vaccine uptake by health professionals and patients

4. Objective
Characterize student immunization requirements and related policies of health professional (HP) schools in the U.S. and Puerto Rico (P.R.)

5. Methods: Survey
Surveyed all medical, baccalaureate nursing and osteopathic medical schools in the U.S. and P.R. (N=760)
ed invitation to self-administered web-based survey using membership lists of national HP schools organizations
Completed by Deans, Student Affairs Deans, Student Health nurses

6. Methods: Data Collected
Demographics: region, public/private, entering class size, number of years admitting students
Student compliance: deadline, consequences
Vaccination policy: guidelines informing policy, frequency of review, responsible party
Vaccinations required for entering students
Proof of immunity accepted
Allowable exemptions
Influenza vaccine: provision, advertising, tracking

7. Methods: Follow-Up Fielded November 2008 – January 2009
Low initial response rate (~44%)
Non-responding and partially responding schools received phone calls and individual s
Minimum of two attempts via telephone
Follow-up continued through early March
Final response rate: 73.8%

8. Methods: Analysis Frequencies calculated
Differences in vaccination requirements assessed by:
Region, school type, public/private status, entering class size
Requirements for entering students compared to Advisory Committee on Immunization Practices (ACIP) recommendations for HCP vaccination

9. Results - Respondents 561 of 760 schools (74%) responded
Medical: 76.0% (98/129)
Nursing: 72.7% (440/605)
Osteopathic Medical: 88.5% (23/26)
Analysis restricted to 558 schools reporting they have a policy for vaccinating entering students
Three nursing schools with no policy

10. Compliance with Requirements
Nursing %
(n=437)
Medical %
(n=98)
Osteopathic Med. %
(n=23)
Deadline for compliance:
Before classes start
41.0
56.2
65.3
Prior to clinical work
50.6*
9.2
21.7
Consequences:
Cannot register for class
26.1
54.1
43.5
Cannot do clinical work
93.4
73.5
87.0
Exemptions allowed:
Medical
79.9
80.6
60.9**
Religious
57.2
53.1
34.8
Personal Belief
31.8
27.6
30.4
These do not add to 100% because (1) only most common responses submitted and (2) because “other” responses not yet back-coded (preliminary data).
*p< **p<0.05

11. Review of School Vaccination Policy
Nursing %
Medical %
Osteopathic Medical %
Interval for review:
Annually
70.0
73.5
82.6
Every two years
8.0
6.1
8.7
Guidelines influencing policy:
ACIP/HCP recs
59.0
90.8
73.9
ACHA* recs
27.2
29.6
Clinical work sites
80.8
60.2
69.6
Dean’s judgment
22.7
15.3
39.1
Who monitors guidelines:
Dean of Students
5.7
39.8
43.5
Dean of Program
56.1
7.1
17.4
Student Health director
35.7
61.2
*ACHA: American College Health Association

12. School Requirements vs. ACIP Recommendations
Vaccine
Nursing %
Medical %
Osteopathic Medical %
Measles
97.7
99.0
91.3
Mumps
96.8
Rubella
97.9
95.7
Hepatitis B
95.0
95.9
Varicella
89.2
95.9*
82.6 Td
81.5
75.5
73.9
Tdap
65.0
70.4
Td / Tdap
88.8
87.0
Influenza
18.3
16.3
17.4
Note that influenza is the only ‘annual’ vaccine.
*p<0.05

13. Provision of Influenza Vaccination
Nursing %
Medical %
Osteopathic Medical%
Influenza vaccine offered:
At no cost to student
29.8
70.4
26.1
Fee at time of vaccination
45.1
16.3
30.4
Not offered
18.0
3.1
13.0
If not offered, why not?
Too expensive
13.9
100
Limited demand
20.3
33.3
Student responsible
74.7
Vaccination given tracked?
23.6
48.3
37.5
Paper medical record
58.2
40.4
28.6
Electronic medical record
24.1
31.9
School database
27.9
23.4
42.9

14. Results – Bivariate Analysis
No significant differences by public/private status
Hepatitis B less likely to be required in Northeast than all other regions
Small differences in requirements by class size for classes <100 vs students
Likely artifact of multiple comparisons
Osteopathic medical schools less likely to report offering medical exemptions
Deadline for compliance with vaccination requirements significantly later at nursing schools

15. Discussion
First description of immunization policies at nursing and osteopathic medical schools, and first description of medical school policies since 1990.
Nursing schools more likely to wait until clinical work begins to enforce requirements
Clinical work is point of exposure and may begin early in studies
Greatest influence on requirements is policies of institutions where clinical work is performed
Extent to which institutional policies reflect ACIP HCP requirements is unknown
ACIP HCP requirements also important source of information

16. Discussion (2)
For the most part, vaccination requirements at all types of HP schools surveyed are consistent with ACIP recommendations for HCP
Tdap and Td fairly similar
Influenza vaccine not usually required for students
Majority of medical schools offer the vaccine at no cost; others do not
Schools not offering perceive obtaining vaccine as student responsibility
With exception of varicella vaccine, no diff by school type

17. Limitations Respondents may not be representative of all schools
High response rate with follow-up
Ambiguity in question about vaccination requirements
‘No proof of immunity required’
Analysis presented is conservative estimate
Self-reported data
Policies often available online, but not reviewed

18. Conclusions
Data gathered by this survey will serve as a basis for future actions to improve HCP immunization rates.
Encourage schools to require annual influenza vaccination for HP students
Increase tracking of vaccination in electronic databases, particularly for influenza
Further research is needed on vaccination policies at other allied health professional schools
Conclusions: Add - Improve knowledge about new/changes in ACIP HCP requirements

19. Acknowledgements
American Association of Colleges of Osteopathic Medicine
Tyler Cymet, DO
Stephen Shannon, DO, MPH
Kentucky Dept. for Public Health
Luta M. Garbat-Welch, MPH
Alicia Tindall, RN, BS
CDC
Norma Allred, MSN, PhD
Gary Edgar
Bayo Willis, MPH
Pascale Wortley, MD, MPH
Association of American Medical Colleges
Danielle Gregory
Rika Maeshiro, MD, MPH
Henry Sondheimer, MD
American Association of Colleges of Nursing
Geraldine Bednash, PhD, RN
Suzanne Begeny, MS, RN
Fay Raines, PhD, RN
Robert Rosseter, MS, MBA

20. ACIP Healthcare Personnel Vaccination Recommendations
Hepatitis B
3 doses (0, 1, 6 months)
Anti-HBs testing 1-2 months after 3rd dose
Influenza
One dose of TIV or LAIV annually
MMR
2 doses, 4 weeks apart for HCP born 1957 or later without vaccination or documented immunity
Varicella
2 doses, 4 weeks apart for those without history of vaccination, disease or documented immunity
Tetanus, diphtheria, pertussis
Td booster every 10 years, following completion of primary 3-dose series
1-time Tdap for all HCP <65 years of age with direct patient contact