Evaluating Variability in Immunization Requirements and Policy Among U.S. Colleges and Universities

Perceptions of vaccine requirements among students at four Pennsylvania universities

BACKGROUND

University students have a unique perspective on vaccination because of their recent or perhaps newly acquired autonomy and ability to make health-related decisions. The development of the COVID-19 vaccine in 2020 and its implementation over the past few years was accompanied by much information and communication about vaccination requirements and safety, which may have affected students' perspectives on vaccination and vaccine requirements more broadly. This analysis describes current vaccine policies at several universities and evaluates student respondents' perceptions of and agreement with university vaccine requirements.

METHODS

A 32-question survey was administered to undergraduate, graduate, and professional students attending four Pennsylvania universities in March-May 2023; 2,223 students responded to the survey. The survey included questions about vaccine requirements, agreement with vaccine requirements, and knowledge of selected vaccines. These responses were compared with the actual vaccine requirements and recommendations of the four universities.

RESULTS

Most respondents agreed with university vaccine requirements, though knowledge of those requirements varied, with many unaware of which were required. University requirement of the COVID-19 vaccine was not associated with being vaccinated for COVID-19. However, while the requirement itself was not related to vaccine uptake, respondents' perception of a requirement was. Respondents were more likely to report COVID-19 vaccination and influenza vaccination if they believed their university required those vaccines. Respondents were more likely to approve of a vaccine requirement if their perception was that their university required that vaccine.

CONCLUSIONS

Overall, student respondents were supportive of their institution's vaccine requirements, but many lacked information about those requirements. Clear messaging using multiple modes of communication about vaccines and vaccine requirements may improve students' knowledge of vaccines and result in a corresponding increase in vaccine uptake.

COVID-19 vaccine perspectives and uptake among university students three years into the pandemic

BACKGROUND

University students have been uniquely impacted by the COVID-19 pandemic for the past three years (2020-2023). Understanding their COVID-19 perspectives, beliefs, and vaccine uptake may help to improve future vaccine initiatives and education.

METHODS

A cross sectional, confidential, online survey was conducted at four universities in Pennsylvania in spring 2023 to assess undergraduate, graduate, and professional students' perspectives regarding their knowledge of COVID-19 vaccines, importance of COVID-19 vaccines and mandates, number of doses of COVID-19 vaccine received including the recent BA.4/BA.5 bivalent booster, where they were vaccinated, receipt of influenza vaccine, and sources of information used to make decisions about COVID-19 vaccine.

RESULTS

Vaccination for COVID-19 was considered important by 75 % of 2223 students surveyed; 68 % agreed with mandating COVID-19 vaccine. Over 89 % were fully COVID-19 vaccinated (≥2 doses), 65 % were up-to-date (≥3 doses), but only 35 % had received the BA.4/BA.5 booster. Students who considered COVID-19 vaccine important were generally older, female, and non-business majors. Higher rates of up-to-date COVID-19 vaccination were found in those who received influenza vaccine in 2022-2023, females, Asians, doctoral or professional students, those attending larger universities, non-US residents, and those interested in learning more about COVID-19 vaccines. Most trusted sources of information on COVID-19 vaccines were the Centers for Disease Control and Prevention, healthcare providers, and parents; the least trusted sources were social media, television, and the internet.

CONCLUSIONS

The majority of university students agreed that COVID-19 vaccination is important and supported COVID-19 mandates. While the rate of fully vaccinated and up-to-date students was similar to the US adult population, the latter rate needs improvement. Receipt of the BA.4/BA.5 booster was particularly low. Further education is needed to improve vaccine knowledge, especially as we move to periodic boosters. Business majors, males, and younger students may benefit from increased on-campus vaccine education initiatives.

U.S. public support and opposition to vaccination mandates in K-12 education in light of the COVID-19 pandemic

BACKGROUND

Vaccination mandates have long been an effective tool in increasing vaccination rates and reducing the potential for disease outbreaks. In the wake of COVID-19, opposition to mandates in the K-12 setting has garnered more attention, and policymakers opposed to them have become more active. This study sought to assess whether these efforts are supported by the U.S. public.

METHODS

We fielded a large, national survey (N = 16,461) from January to April of 2022 to assess U.S. public opinion about seven specific vaccination mandates (diphtheria, tetanus, & pertussis (DTaP); polio; chickenpox; measles, mumps, and rubella (MMR); hepatitis; human papillomavirus (HPV); and COVID-19) in K-12 educational settings.

RESULTS

We found that Americans are overwhelmingly supportive of all vaccination mandates with support ranging from a high 90 percent of respondents for DTaP, polio, chickenpox, and MMR to a low of 68 percent for COVID-19. Individuals who deemed vaccines safe and important, those with trust in the National Institutes of Health and the Food and Drug Administration, urban residents, and ethnic and racial minorities tended to be consistently more supportive. Perceptions about vaccine effectiveness were positively associated with mandate support in most cases, as was trust in medical doctors. Respondents who believed that vaccines cause autism, those with better health and more trust in religious leaders tended to be consistently more opposed. Women were generally more supportive of mandates except for HPV and COVID-19. Ideology and partisanship affected opinion for COVID-19 as did trust in the Centers for Disease Control and Prevention. We found no effects for income or education.

CONCLUSION

Vaccination mandates in K-12 have broad support among the American public, even in more controversial cases such as HPV and COVID-19. Vocal opposition and growing interest by policymakers to limit or undo vaccination mandates are not supported by the broader public.

An immunization quality improvement learning collaborative in the college health setting

OBJECTIVE

To increase administration of influenza (flu), human papillomavirus (HPV) and meningococcal serogroup B (MenB) vaccinations to students at college student health centers (SHCs).

PARTICIPANTS

Improvement teams from 45 US-based SHCs.

METHODS

Teams participated in a 7-month virtual learning collaborative to implement immunization delivery best practices at their SHCs. A pre-post-intervention design was used to compare vaccination coverage in May 2017 to May 2018 among students who were unvaccinated at the start of the academic year.

RESULTS

Data were compared from 29 SHCs and 152,648 students (2017) and from 18 SHCs and 122,315 students (2018). Percent of newly vaccinated students increased for ≥1 dose of flu vaccine by 14.3 percentage points to 32.3% (p < .01), ≥1 dose of HPV vaccine by 3.9 points to 7.8% (p < .05) and ≥3 doses of HPV vaccine by 0.7 points to 1.5% (p < .05).

CONCLUSIONS

Participating in a learning collaborative may help SHCs improve vaccination delivery.

College health administrator's perceptions of the impacts of COVID-19 on college immunization programs

College immunization policies vary. To evaluate the landscape of college immunization programs, we distributed a 45-item survey to college health administrators between July and September 2021. Items measured perceptions of institutionally recommended and required vaccines, enforcement strategies, barriers to vaccine uptake, and the impact of the COVID-19 pandemic. Of 566 invitations sent, only 66 college health administrators completed the survey (11.7% response rate). The majority of participating institutions (89%) required at least one vaccine, with measles-mumps-rubella (MMR) being the most commonly required (83%). Geographic region, school type, or size was not significantly correlated with immunization policies but state-level political leanings were. Common barriers to vaccine program implementation identified by respondents included student-based and institutional concerns. The COVID-19 pandemic was described as both exacerbating existing immunization program barriers and providing opportunities to strengthen programs. Future work will evaluate identified themes in a larger study population and monitor change in perceptions over time.

National and regional differences in meningococcal vaccine recommendations for individuals at an increased risk of meningococcal disease

INTRODUCTION

Invasive meningococcal disease (IMD) is a severe, life-threatening condition caused by infection with Neisseria meningitidis. Currently available vaccines offer protection against the five most common meningococcal disease-causing serogroups and include monovalent and quadrivalent conjugate vaccines (MenA, MenC, MenACWY vaccines) and outer membrane vesicle- and/or recombinant protein-based vaccines (MenB vaccines).

AREAS COVERED

Country and regional immunization programs target populations susceptible to IMD and typically emphasize the highest-risk age groups (i.e., infants, adolescents/young adults, and the elderly); however, additional groups are also considered at an elevated risk and are the focus of the current review. Specific increased-risk groups include individuals with underlying immunocompromising medical conditions, university/college students, Indigenous people, laboratory workers, military personnel, men who have sex with men, and travelers to areas with hyperendemic IMD. This review compares established meningococcal vaccination recommendations for these vulnerable groups in Europe, the United States, Australia, New Zealand, Israel, Brazil, and Turkey.

EXPERT OPINION

Recommendations should be standardized to cover all groups at increased risk of IMD.

Surveillance and risk assessment of health screening for vaccine-preventable diseases among international students in Japan: A cross-sectional study in 2020

We conducted a cross-sectional study using a structured questionnaire in three major Japanese cities from August 03 to 24, 2020 to clarify the current situation of health checkups, including vaccine-preventable diseases (VPDs), among international students at Japanese universities (JUs) and Japanese language schools (JLSs). The total response rate was 36%: 69 JUs (31%) and 137 JLSs (39%). Over 90% of these institutions conducted chest X-ray screening for tuberculosis among their students, whereas only 24.6% of JUs and 15.3% of JLSs performed general blood tests for health screening. Only 14.5% and 2.2% of the JUs and JLSs, respectively, required the submission of vaccination or antibody certificates for admission. The difficulties in requesting vaccination certificates from international students are due to poor legal requirements and concerns about rising costs for schools. From 2017 to 2019, 183 international students, principally from East Asia and Southeast Asia, were infected with VPDs, particularly tuberculosis (99 cases) and varicella (71 cases). Whereas the majority of Japanese educational institutions screen international students for tuberculosis (TB) at admission, only a few institutions request proof of antibody testing relating to other VPDs or of vaccination. These findings will help formulate guidelines for checkups related to vaccination for international students required to protect the educational institutions in Japan from the spread of VPDs. In addition, providing multifaceted social support, including financial compensation for institutions and enhanced international students' health issues, would be helpful.

Psychological Reactance Theory and COVID-19 Vaccine Mandates: The Roles of Threat Magnitude and Direction of Threat

The current study examines psychological reactance theory (PRT), focusing on the role of threat directness and threat magnitude in the context of a COVID-19 vaccine mandate. Students on two college campuses in the United States (N = 374) were informed that their university or the other university (i.e., threat directness manipulation) was considering a vaccinate mandate for the following semester that would or would not include sanctions for noncompliance (i.e., threat magnitude manipulation). Participants experienced significantly greater freedom threat perceptions when the mandate included sanctions compared to when it did not, but freedom threat perception did not differ when the mandate was on their own campus as to the other campus. An interaction effect was also observed in which perceived freedom threat and reactance was greatest among participants receiving an indirect (as opposed to direct) threat with sanctions. Findings are discussed with an emphasis on the theoretical contribution to PRT along with the practical implications for vaccine mandates.

How colleges intervene to increase student body vaccination coverage

OBJECTIVE

The interventions colleges use to help students be compliant with vaccinations is unknown. This study describes colleges' use of practices consistent with Centers for Disease Control and Prevention (CDC) recommendations to encourage student body vaccination.

PARTICIPANTS

Participants were a convenience sample of 136 student health center (SHC) administrators from colleges across the U.S.

METHODS

An online survey assessed SHCs' use of various practices, policies and services to improve student body vaccination coverage.

RESULTS

There was wide variability in use of evidence-based interventions overall and with respect to specific vaccinations. While most SHCs (92.7%) coordinated vaccination outreach events on campus, only half (50%) accessed an immunization registry to verify vaccination histories. While 88.6% requested student vaccination histories for MMR, only 39.7% requested it for human papillomavirus (HPV).

CONCLUSIONS

The discrepancies in SHC implementation of interventions to increase coverage of the recommended vaccinations for students suggest that helping colleges expand their capacity to intervene may decrease coverage rate disparities.

COVID-19 vaccine acceptance among adults in four major US metropolitan areas and nationwide

This study assesses attitudes towards COVID-19 vaccination and the predictive value of COVID-VAC, a novel scale, among adults in the four largest US metropolitan areas and nationally. A 36-item survey of 6037 Americans was conducted in mid-April 2021. The study reports factors for COVID-19 vaccine acceptance among: (1) already vaccinated; (2) unvaccinated but willing to accept a vaccine; and (3) unvaccinated and unwilling to vaccinate. More than 20% were unwilling to vaccinate, expressing concerns about vaccine efficacy and safety and questioning the disease's severity. Poverty, working outside of the home and conservative political views are predictors of unwillingness. Conversely, those who either personally tested positive for COVID-19, or had a family member who did so, were more likely to accept vaccination. Majorities of all respondents supported vaccination mandates for employees and university students. Respondents preferred to receive vaccines in their doctor´s office. Lower income and conservative ideology, but not race, were strongly associated with vaccine unwillingness. The predictive value of COVID-VAC was demonstrated. While vaccination mandates are likely to be accepted, additional effective, targeted interventions to increase vaccine uptake are needed urgently.

Meningococcal disease and vaccination in college students

Neisseria meningitidis is a bacterial pathogen capable of causing rapidly progressing illness from nonspecific symptoms to end-organ failure or death in a matter of hours to days. Despite the availability of meningococcal vaccines, there remains a notable disease incidence peak among individuals aged 18-19 years, with college students at increased risk for disease relative to non-college students. Between 2007 and 2017, as many as one in five colleges in the United States experienced an outbreak of meningococcal disease at their own or a nearby institution. Evidence-based strategies to promote meningococcal vaccination among students can be adapted for the college setting, but barriers exist that limit widespread implementation of these strategies by colleges. In this article, we review meningococcal disease characteristics and epidemiology among US college students, vaccination indications and coverage levels among US college students, as well as college vaccination policies and practices that can impact students' vaccine uptake.

Evaluation of meningococcal vaccination policies among colleges and universities - United States, 2017

ObjectiveQuadrivalent meningococcal conjugate vaccines (MenACWY) have been recommended routinely for adolescents since 2005; in 2015, serogroup B meningococcal (MenB) vaccines were recommended for persons aged 16-23 years based on individual clinical decision making. We surveyed college health providers or administrators to understand current meningococcal vaccine policies. Methods/Participants: In January 2017, we distributed a survey to 985 institutions in partnership with the American College Health Association to assess vaccination policies and outbreak response plans. Results: Overall, 352 (36%) institutions completed the survey. Most either required (N = 186, 53%) or recommended (N = 148, 42%) a meningococcal vaccine; only half (N = 167) had a policy specifically addressing MenB vaccines. Few institutions with a MenB vaccine policy required vaccination (N = 7, 4%); most recommended vaccination (N = 160, 96%). Conclusion: Most institutions have a meningococcal vaccination policy; however, there is substantial diversity in policies. Fewer schools have policies specifically addressing MenB vaccines.

Joining the herd? U.S. public opinion and vaccination requirements across educational settings during the COVID-19 pandemic

With effective and safe COVID-19 vaccines beginning to be distributed across the United States, questions about who should receive the vaccine first have been the focus of public discussions. Yet, over the long-term, questions about the order of distribution will be displaced by questions about how to achieve high levels of vaccination rates. Historically, absent incentives or mandates, Americans have shown ambivalence, if not general antipathy, towards vaccinations, and vaccination rates have generally been low for many vaccines. There is evidence that vaccination requirements across educational settings are an effective policy instrument to increase vaccination rates. We administered a large national survey to assess American's attitudes towards vaccination requirements across three educational settings (daycare, K-12 schools, and universities) in general and for COVID-19 specifically. Partisanship, gender, race, rurality, and perceptions about the appropriate role schools should play in providing health services are substantive predictors of public opinion. While Americans generally support vaccination mandates across all three settings for both types of requirements, support is consistently and significantly lower for COVID19 requirements. The effect of partisanship is accentuated for COVID-19 requirements as compared to general requirements. Drop off in support between general and COVID-19 specific requirements are driven by partisanship, gender, political knowledge, rurality, and having children in the household. Nonetheless, mandates are supported by a majority of Americans. Assessing Americans' opinions of vaccination requirements in educational settings offers an important opportunity to explore the potential of mandates as policy instrument in the government's arsenal against COVID-19 and guide public policy on the issues.

Suboptimal uptake of meningococcal vaccines among older adolescents: Barriers, solutions, and future research directions

Over the past 15 y, several vaccines have been added to the recommended immunization schedule for adolescents in the United States. In addition to annual influenza vaccination, the Advisory Committee on Immunization Practices recommends tetanus, diphtheria, and pertussis (Tdap), meningococcal conjugate (MenACWY), and human papillomavirus (HPV) vaccine for routine administration at ages 11-12 y, and a second dose of MenACWY at age 16. A vaccine against meningococcal disease caused by serogroup B (MenB) is also available and recommended for shared clinical decision-making. Though notable gains in uptake have been achieved for some adolescent vaccines, coverage varies considerably with lower rates for HPV vaccine and second dose of MenACWY. Coverage for MenB is especially low. While extensive research has focused on barriers to and solutions for higher uptake of HPV vaccine, limited attention has been given to the reasons for lower uptake of meningococcal vaccines among older adolescents. This purpose of this commentary is to discuss barriers to and solutions for higher uptake of meningococcal vaccines among older adolescents, and to identify gaps in knowledge that can inform research efforts going forward.

Understanding vaccine knowledge, attitudes, and decision-making through college student interviews

Objective: We aimed to explore knowledge, attitudes, and beliefs about vaccines required for college-entry and vaccine-related behaviors among college students. Participants: Thirty-three full-time undergraduate students, ≥ 18 years old, enrolled at public (2) and private (3) colleges and universities in metropolitan Philadelphia in fall 2016. Methods: We conducted semistructured interviews, which were double-coded with 5,015 comments overall and 99.3% intercoder reliability (κ = 0.779) using NVivo 11 software. Results: Six key themes emerged: (1) low knowledge about vaccines and requirements; (2) mixed attitudes about required vs. recommended vaccines; (3) high trust in medical professionals; (4) low perceived risk for vaccine-preventable disease outbreaks; (5) substantial parental influence on students' decision-making; and (6) low utilization of Student Health Services. Conclusions: This study revealed lack of knowledge about and low prioritization of vaccination despite overall positive attitudes towards vaccines. Prematriculation education of college students is critical to increasing vaccine knowledge and use.

Student health administrator perspectives on college vaccine policy development and implementation

BACKGROUND

Immunization policies at colleges and universities differ greatly for many reasons, including prior experience with disease outbreaks and state immunization requirements. Few studies comprehensively explore the range of factors that influence the development of college vaccine policies or facilitators and barriers to their implementation.

OBJECTIVE

To explore the perceptions and decision-making process that influence college vaccine policy development and implementation from the perspective of student health administrators.

METHODS

This qualitative study used semi-structured interviews with student health administrators (N = 10) from ten U.S. colleges and universities purposefully sampled by school type (public vs. private) and geographic region. A descriptive codebook was developed from the interview guide, and each interview was double-coded using NVivo 11 software (κ = 0.87; inter-observer reliability = 99.4%).

RESULTS

We coded 5785 phrases. Administrators positively viewed their institutions' vaccine requirements, but some expressed concerns about the acceptance of philosophical and religious exemptions. They noted that students were generally ambivalent towards vaccine requirements, and while students recognized the benefits of vaccination, they did not prioritize immunizations. All administrators cited reliance on governmental and professional organizations as well as state regulations for decisions regarding vaccine requirements and recommendations at their institutions. Partnerships with other school departments, pharmaceutical companies, immunization coalitions, and healthcare providers were frequently cited as facilitators of college vaccine programs. Costs of purchasing, storing, and tracking vaccines were identified as major barriers.

CONCLUSIONS

We identified key themes that can be evaluated in subsequent studies to identify factors associated with successful implementation of university immunization programs and inform initiatives to increase vaccine acceptance and optimize immunization rates on college and university campuses.