8 months to 5 days: what happened when Pennsylvania changed the vaccination regulations for provisional enrollment?

Abstract

In March 2017, the Pennsylvania Department of Health reduced the time allowed to demonstrate compliance with school-entry vaccination requirements from eight months to five days. We describe changes in provisional enrollment, vaccine exemptions, and vaccine coverage rates before and after the new regulation. Across Pennsylvania, provisional enrollment decreased from 11.1% in 2016/17 to 2.5% in 2017/18 (77% relative decrease). Personal belief exemptions continued a modest upward trend, similar to previous years, and medical exemptions remained steady. Among kindergartners, coverage with ≥ 2 doses of MMR vaccine and 2 doses of Varicella vaccine increased; similar increases were seen for the MCV and Tdap vaccines among 7th graders. However, improvements in coverage and reductions in provisional enrollment were not consistent across counties. Provisional enrollment in Philadelphia County during the 2017/18 school year (10.4%) did not substantially decrease. The statewide reduction in provisional enrollment suggests that the new regulations accomplished the goal of increasing the proportion of students who are up-to-date on required vaccines at the beginning of the school year without a significant increase in vaccine exemptions. However, the persistence of high provisional enrollment in some counties points to additional barriers to this goal in some schools and regions.

Impact of school-entry vaccination requirement changes on clinical practice implementation and adolescent vaccination rates in metropolitan Philadelphia

“…The findings of increases in vaccination coverage of Tdap and MCV4 vaccines in 7th graders were similarly reflected in other analyses performed by the Pennsylvania Department of Health. 21 We observed concurrent increases among New Jersey practices, suggesting that our results may reflect general trends in adolescent vaccination rates, or that the Pennsylvania new school-entry requirements influenced recommendation practices across the entire primary care network.…”

Students Provisionally Enrolled Due to Vaccination Requirements: Variation in State Laws and Rates

“…While this provides accountability, it also requires resources, which may not be readily available or may be overwhelmed by many provisional enrollments requiring follow-up. Provisional enrollment leads to more immunization plans and records to review 1. Despite the importance of following up to ensuring provisional entrants become up to date on vaccination, only 5 states provide any type of follow-up procedure in the law itself.…”

“…The reduction of provisional entrants as an alternative intervention to increase vaccination remains largely untested. Efforts in California and Pennsylvania appear to have been successful in quickly reducing provisional entrants and boosting up-to-date rates 1,3,4. Furthermore, focusing on provisional enrollment may be a more effective and less controversial avenue for increasing students entering school fully up-to-date than efforts to restrict or eliminate nonmedical exemptions.…”

“…In the United States, all states provide medical exemptions to vaccination requirements and some allow exemptions for religious and/or philosophical reasons. Nearly all states have an additional entry pathway for children who have started, but not completed, a multiple-dose vaccination series to attend school while completing their required vaccinations1; these children are known as “provisional” or “conditional” enrollees (heretofore referred to as provisional). The rationale for provisional status is to balance the need for public health protection and access to education, ensuring that students are protected from vaccine-preventable diseases while not excluding them from school due to incomplete vaccination status.…”

“…At least 2 states have considered reducing the number of provisional entrants as an opportunity to increase coverage at the time of school entry. Pennsylvania shortened the grace period for provisionally enrolled students to become up to date, which led to a substantial decrease in provisionally enrolled kindergarteners and corresponding increase in the number who were up to date on required vaccinations 1,3. California addressed high rates of provisional enrollment via an educational campaign 4…”