Struggling to resume childhood vaccination during war in Myanmar: evaluation of a pilot program.

BACKGROUND: After the military coup in Myanmar in February 2021, the health system began to disintegrate when staff who called for the restoration of the democratic government resigned and fled to states controlled by ethnic minorities. The military retaliated by blocking the shipment of humanitarian aid, including vaccines, and attacked the ethnic states. After two years without vaccines for their children, parents urged a nurse-led civil society organization in an ethnic state to find a way to resume vaccination. The nurses developed a vaccination program, which we evaluated. METHODS: A retrospective cohort study and participatory evaluation were conducted. We interviewed the healthcare workers about vaccine acquisition, transportation, and administration and assessed compliance with WHO-recommended practices. We analyzed the participating children's characteristics. We calculated the proportion of children vaccinated before and after the program. We calculated the probability children would become up-to-date after the program using inverse survival. RESULTS: Since United Nations agencies could not assist, private donations were raised to purchase, smuggle into Myanmar, and administer five vaccines. Cold chain standards were maintained. Compliance with other WHO-recommended vaccination practices was 74%. Of the 184 participating children, 145 (79%, median age five months [IQR 6.5]) were previously unvaccinated, and 71 (41%) were internally displaced. During five monthly sessions, the probability that age-eligible zero-dose children would receive the recommended number of doses of MMR was 92% (95% confidence interval [CI] 83-100%), Penta 87% (95% CI 80%-94%); BCG 76% (95% CI 69%-83%); and OPV 68% (95% CI 59%-78%). Migration of internally displaced children and stockouts of vaccines were the primary factors responsible for decreased coverage. CONCLUSIONS: This is the first study to describe the situation, barriers, and outcomes of a childhood vaccination program in one of the many conflict-affected states since the coup in Myanmar. Even though the proportion of previously unvaccinated children was large, the program was successful. While the target population was necessarily small, the program's success led to a donor-funded expansion to 2,000 children. Without renewed efforts, the proportion of unvaccinated children in other parts of Myanmar will approach 100%.

Swine flu in college: early campus response to outbreak control measures.

OBJECTIVES: To describe student and faculty attitudes towards and adherence to nonpharmaceutical control measures during the first-known university outbreak of 2009 pandemic influenza A (H1N1). METHODS: Preferred information sources, control measure adherence and likelihood of adherence during future out-breaks, and perceived illness risk, were explored through focus groups and patient interviews. RESULTS: We conducted 7 focus groups (N=48) and 9 patient inter- views. Measures (eg, hand hygiene, self-isolation while ill) were initially heeded. Limited information regarding A(H1N1) pdm09, insufficient understanding of university decisions, and perceived university alert overuse led to reports that future outbreaks would be regarded less seriously. CONCLUSIONS: Reported concern and commitment to recommendations decreased rapidly. Initial university messaging and response was critical in shaping participants' later perceptions.

Knowledge, attitudes, and practices among border crossers during temporary enforcement of a formal entry requirement for Mexican-style soft cheeses, 2009.

Mexican-style soft cheese known as queso fresco (QF), which is often unpasteurized, has been implicated in outbreaks of foodborne illness in the United States. The U.S. Food and Drug Administration (FDA) exercises discretion in enforcement of noncommercial importation of cheese. To test control measures aimed at decreasing unlawful QF importation, in 2009 the FDA temporarily enforced a requirement for formal commercial entry for all cheeses over 5 lb (2.3 kg) at the San Diego-Tijuana border. Enforcement was combined with educational outreach. Border crossers importing cheese and those not importing cheese were surveyed at the beginning and end of the temporary enforcement period. Data collected included participant demographic information, knowledge of QF-associated health risks, and attitudes and practices regarding QF consumption and importation. We surveyed 306 importers and 381 nonimporters. Compared with nonimporters, importers had a lower level of knowledge regarding QF-associated health risks (P < 0.0001). Border crossers carrying cheese were more likely to have less education, be U.S. or dual residents, consume QF more frequently, and cross the border less often. Importation and consumption of unpasteurized QF remained prevalent among border crossers during the temporary enforcement period, and the level of knowledge regarding QF-associated risks remained low among these crossers. More vigorous, sustained messaging targeted at high-risk groups is needed to change behaviors. Definition and consistent enforcement of limits will likely be needed to reduce QF importation and the risk of QF-associated diseases along the U.S.-Mexico border; however, public health benefits will need to be balanced against the cost of enforcement.

Influenza A(H1N1)pdm09 during air travel.

The global spread of the influenza A(H1N1)pdm09 virus (pH1N1) associated with travelers from North America during the onset of the 2009 pandemic demonstrates the central role of international air travel in virus migration. To characterize risk factors for pH1N1 transmission during air travel, we investigated travelers and airline employees from four North American flights carrying ill travelers with confirmed pH1N1 infection. Of 392 passengers and crew identified, information was available for 290 (74%) passengers were interviewed. Overall attack rates for acute respiratory infection and influenza-like illness 1-7 days after travel were 5.2% and 2.4% respectively. Of 43 individuals that provided sera, 4 (9.3%) tested positive for pH1N1 antibodies, including 3 with serologic evidence of asymptomatic infection. Investigation of novel influenza aboard aircraft may be instructive. However, beyond the initial outbreak phase, it may compete with community-based mitigation activities, and interpretation of findings will be difficult in the context of established community transmission.

Mass screening for fever in children: a comparison of 3 infrared thermal detection systems.

OBJECTIVES: Infrared thermal detection systems (ITDSs) have been used with limited success outside the United States to screen for fever during recent outbreaks of novel infectious diseases. Although ITDSs are fairly accurate in detecting fever in adults, there is little information about their utility in children. METHODS: In a pediatric emergency department, we compared temperatures of children (<18 years old) measured using 3 ITDSs (OptoTherm Thermoscreen, FLIR ThermoVision 360, and Thermofocus 0800H3) to standard, age-appropriate temperature measurements (confirmed fever defined as ≥38.0°C [oral or rectal], ≥37.0°C [axillary]). Measured temperatures were compared with parental reports of fever using descriptive, multivariate, and receiver operating characteristic analyses. RESULTS: Of 855 patients, 400 (46.8%) had parent-reported fever, and 306 (35.8%) had confirmed fever. At optimal fever thresholds, OptoTherm and FLIR had sensitivity (83.0% and 83.7%, respectively) approximately equal to parental report (83.9%) and greater than Thermofocus (76.8%), and specificity (86.3% and 85.7%) greater than parental report (70.8%) and Thermofocus (79.4%). Correlation coefficients between traditional thermometry and ITDSs were 0.78 (OptoTherm), 0.75 (FLIR), and 0.66 (Thermofocus). CONCLUSIONS: Compared with traditional thermometry, FLIR and OptoTherm were reasonably accurate in detecting fever in children and better predictors of fever than parental report. These findings suggest that ITDSs could be a useful noninvasive screening tool for fever in the pediatric age group.

Effectiveness of a school district closure for pandemic influenza A (H1N1) on acute respiratory illnesses in the community: a natural experiment.

BACKGROUND: Following detection of pandemic influenza A H1N1 (pH1N1) in Dallas/Fort Worth, Texas, a school district (intervention community, [IC]) closed all public schools for 8 days to reduce transmission. Nearby school districts (control community [CC]) mostly remained open. METHODS: We collected household data to measure self-reported acute respiratory illness (ARI), before, during, and after school closures. We also collected influenza-related visits to emergency departments (ED(flu)). RESULTS: In both communities, self-reported ARIs and ED(flu) visits increased from before to during the school closure, but the increase in ARI rates was 45% lower in the IC (0.6% before to 1.2% during) than in the CC (0.4% before to 1.5% during) (RRR(During)(/Before) = 0.55, P < .001; adjusted OR(During/Before) = 0.49, P < .03). For households with school-aged children only (no children 0-5 years), IC had even lower increases in adjusted ARI than in the CC (adjusted OR(During/Before) = 0.28, P < .001). The relative increase of total ED(flu) visits in the IC was 27% lower (2.8% before to 4.4% during) compared with the CC (2.9% before to 6.2% during). Among children aged 6-18 years, the percentage of ED(flu) in IC remained constant (5.1% before vs 5.2% during), whereas in the CC it more than doubled (5.2% before vs 10.9% during). After schools reopened, ARI rates and ED(flu) visits decreased in both communities. CONCLUSIONS: Our study documents a reduction in ARI and ED(flu) visits in the intervention community. Our findings can be used to assess the potential benefit of school closures during pandemics.

Emergency health risk communication during the 2007 San Diego wildfires: comprehension, compliance, and recall.

In October 2007, wildfires burned nearly 300,000 acres in San Diego County, California. Emergency risk communication messages were broadcast to reduce community exposure to air pollution caused by the fires. The objective of this investigation was to determine residents' exposure to, understanding of, and compliance with these messages. From March to June 2008, the authors surveyed San Diego County residents using a 40-question instrument and random digit dialing. The 1,802 respondents sampled were predominantly 35-64 years old (65.9%), White (65.5%), and educated past high school (79.0%). Most (82.5%) lived more than 1 mile away from the fires, although many were exposed to smoky air for 5-7 days (60.7%) inside and outside their homes. Most persons surveyed reported hearing fire-related health messages (87.9%) and nearly all (97.9%) understood the messages they heard. Respondents complied with most to all of the nontechnical health messages, including staying inside the home (58.7%), avoiding outdoor exercise (88.4%), keeping windows and doors closed (75.8%), and wetting ash before cleanup (75.6%). In contrast, few (<5%) recalled hearing technical messages to place air conditioners on recirculate, use High-Efficiency Particulate Air filters, or use N-95 respirators during ash cleanup, and less than 10% of all respondents followed these specific recommendations. The authors found that nontechnical message recall, understanding, and compliance were high during the wildfires, and reported recall and compliance with technical messages were much lower. Future disaster health communication should further explore barriers to recall and compliance with technical recommendations.

Non-pharmaceutical interventions during an outbreak of 2009 pandemic influenza A (H1N1) virus infection at a large public university, April-May 2009.

Nonpharmaceutical interventions (NPIs), such as home isolation, social distancing, and infection control measures, are recommended by public health agencies as strategies to mitigate transmission during influenza pandemics. However, NPI implementation has rarely been studied in large populations. During an outbreak of 2009 Pandemic Influenza A (H1N1) virus infection at a large public university in April 2009, an online survey was conducted among students, faculty, and staff to assess knowledge of and adherence to university-recommended NPI. Although 3924 (65%) of 6049 student respondents and 1057 (74%) of 1401 faculty respondents reported increased use of self-protective NPI, such as hand washing, only 27 (6.4%) of 423 students and 5 (8.6%) of 58 faculty with acute respiratory infection (ARI) reported staying home while ill. Nearly one-half (46%) of student respondents, including 44.7% of those with ARI, attended social events. Results indicate a need for efforts to increase compliance with home isolation and social distancing measures.

Comparison of 3 infrared thermal detection systems and self-report for mass fever screening.

Despite limited evidence regarding their utility, infrared thermal detection systems (ITDS) are increasingly being used for mass fever detection. We compared temperature measurements for 3 ITDS (FLIR ThermoVision A20M [FLIR Systems Inc., Boston, MA, USA], OptoTherm Thermoscreen [OptoTherm Thermal Imaging Systems and Infrared Cameras Inc., Sewickley, PA, USA], and Wahl Fever Alert Imager HSI2000S [Wahl Instruments Inc., Asheville, NC, USA]) with oral temperatures (≥ 100 °F = confirmed fever) and self-reported fever. Of 2,873 patients enrolled, 476 (16.6%) reported a fever, and 64 (2.2%) had a confirmed fever. Self-reported fever had a sensitivity of 75.0%, specificity 84.7%, and positive predictive value 10.1%. At optimal cutoff values for detecting fever, temperature measurements by OptoTherm and FLIR had greater sensitivity (91.0% and 90.0%, respectively) and specificity (86.0% and 80.0%, respectively) than did self-reports. Correlations between ITDS and oral temperatures were similar for OptoTherm (ρ = 0.43) and FLIR (ρ = 0.42) but significantly lower for Wahl (ρ = 0.14; p < 0.001). When compared with oral temperatures, 2 systems (OptoTherm and FLIR) were reasonably accurate for detecting fever and predicted fever better than self-reports.

Estimating the risk of rabies transmission to humans in the U.S.: a Delphi analysis.

BACKGROUND: In the United States, the risk of rabies transmission to humans in most situations of possible exposure is unknown. Controlled studies on rabies are clearly not possible. Thus, the limited data on risk has led to the frequent administration of rabies post-exposure prophylaxis (PEP), often in inappropriate circumstances. METHODS: We used the Delphi method to obtain an expert group consensus estimate of the risk of rabies transmission to humans in seven scenarios of potential rabies exposure. We also surveyed and discussed the merits of recommending rabies PEP for each scenario. RESULTS: The median risk of rabies transmission without rabies PEP for a bite exposure by a skunk, bat, cat, and dog was estimated to be 0.05, 0.001, 0.001, and 0.00001, respectively. Rabies PEP was unanimously recommended in these scenarios. However, rabies PEP was overwhelmingly not recommended for non-bite exposures (e.g. dog licking hand but unavailable for subsequent testing), estimated to have less than 1 in 1,000,000 (0.000001) risk of transmission. CONCLUSIONS: Our results suggest that there are many common situations in which the risk of rabies transmission is so low that rabies PEP should not be recommended. These risk estimates also provide a key parameter for cost-effective models of human rabies prevention and can be used to educate health professionals about situation-specific administration of rabies PEP.

Likely transmission of norovirus on an airplane, October 2008.

BACKGROUND: On 8 October 2008, members of a tour group experienced diarrhea and vomiting throughout an airplane flight from Boston, Massachusetts, to Los Angeles, California, resulting in an emergency diversion 3 h after takeoff. An investigation was conducted to determine the cause of the outbreak, assess whether transmission occurred on the airplane, and describe risk factors for transmission. METHODS: Passengers and crew were contacted to obtain information about demographics, symptoms, locations on the airplane, and possible risk factors for transmission. Case patients were defined as passengers with vomiting or diarrhea (> or =3 loose stools in 24 h) and were asked to submit stool samples for norovirus testing by real-time reverse-transcription polymerase chain reaction. RESULTS: Thirty-six (88%) of 41 tour group members were interviewed, and 15 (41%) met the case definition (peak date of illness onset, 8 October 2008). Of 106 passengers who were not tour group members, 85 (80%) were interviewed, and 7 (8%) met the case definition after the flight (peak date of illness onset, 10 October 2008). Multivariate logistic regression analysis showed that sitting in an aisle seat (adjusted relative risk, 11.0; 95% confidence interval, 1.4-84.9) and sitting near any tour group member (adjusted relative risk, 7.5; 95% confidence interval, 1.7-33.6) were associated with the development of illness. Norovirus genotype II was detected by reverse-transcription polymerase chain reaction in stool samples from case patients in both groups. CONCLUSIONS: Despite the short duration, transmission of norovirus likely occurred during the flight.

Reporting patterns and characteristics of tuberculosis among international travelers, United States, June 2006 to May 2008.

BACKGROUND: As part of efforts to prevent the introduction of communicable diseases into the United States, the Centers for Disease Control and Prevention (CDC) conducts surveillance for selected diseases in international travelers. One of these diseases, tuberculosis (TB), received substantial attention in May 2007 when the CDC issued travel restrictions and a federal isolation order for a person with drug-resistant TB who traveled internationally against public health recommendations. METHODS: Reports of TB in international travelers in the CDC's Quarantine Activity Reporting System (QARS) from 1 June 2006 through 31 May 2007 (year 1) were compared with reports from 1 June 2007 through 31 May 2008 (year 2). These reports were classified using the CDC and American Thoracic Society guidelines and analyzed for epidemiologic characteristics and trends. RESULTS: Among QARS reports, 4.6% were classified as active TB disease and 1.7% as no TB disease. Active TB disease reports increased from 2.5% of QARS reports in year 1 to 6.4% in year 2 (p < .001). The proportion of active TB disease reports leading to a federal travel restriction increased from 6.8% in year 1 to 15.4% in year 2 (p = .08). CONCLUSIONS: The significant increase in reports of international travelers with TB disease likely represents more attention to and a higher index of suspicion for TB. The increased use of federal travel restrictions was associated with the development of new procedures to limit travel for public health reasons. Continued efforts are needed to decrease the number of persons with TB who travel while potentially contagious.

A new paradigm for quarantine and public health activities at land borders: opportunities and challenges.

The Institute of Medicine (IOM) report Quarantine Stations at Ports of Entry: Protecting the Public's Health focused almost exclusively on U.S. airports and seaports, which served 106 million entries in 2005. IOM concluded that the primary function of these quarantine stations (QSs) should shift from providing inspection to providing strategic national public health leadership. The large expanse of our national borders, large number of crossings, sparse federal resources, and decreased regulation regarding conveyances crossing these borders make land borders more permeable to a variety of threats. To address the health challenges related to land borders, the QSs serving such borders must assume unique roles and partnerships to achieve the strategic leadership and public health research roles envisioned by the IOM. In this article, we examine how the IOM recommendations apply to the QSs that serve the land borders through which more than 319 million travelers, immigrants, and refugees entered the U.S. in 2005.

Adolescent vaccination: coverage achieved by ages 13-15 years, and vaccinations received as recommended during ages 11-12 years, National Health Interview Survey 1997-2003.

PURPOSE: To present progress toward Healthy People 2010 vaccination objectives for adolescents aged 13-15 years, and to determine how much catch-up and routine vaccination was administered at the recommended ages of 11-12 years. METHODS: Data from the 1997-2003 National Health Interview Survey were evaluated. In the first analysis, vaccination coverage levels for adolescents aged 13-15 years were determined for each survey year. Main outcome measures include the percent of adolescents who had received the three-dose hepatitis B vaccine (Hep B) series, the two-dose measles/mumps/rubella vaccine (MMR) series, the tetanus and diphtheria toxoids (Td) booster, and one dose of varicella vaccine. In the second analysis, data from all survey years were combined and vaccination dates were analyzed to determine the percentage of adolescents who were missing any vaccines at ages 11-12 and received them at that age. Data for varicella vaccine were sufficient only for the first analysis. RESULTS: Among the approximately 15%-20% of respondents who reported vaccination history from records in the home and who were reporting on a 13-15-year-old, coverage with three doses of Hep B increased significantly during 1997-2001, from 15.2% to 55.0%. Coverage with MMR and Td fluctuated, with no significant increase; highs were 76.7% for MMR in 2003 and 36.2% for Td in 2002. Examination of vaccination dates for all surveyed adolescents showed that among 11-12-year-olds who needed catch-up vaccine, 0.6%-31.3% were brought up to date for Hep B and 22.1%-31.8% were brought up to date for MMR. For Td, 2.6%-15.4% of 11-12-year-olds who had not previously received Td received the vaccine. CONCLUSION: Vaccination coverage among adolescents aged 13-15 years was below the Healthy People 2010 goals of 90%, but generally increased over the survey years. However, the suboptimal delivery of needed vaccines during ages 11 and 12 is concerning in light of recent vaccine recommendations targeted at this age. Continuing to focus on strategies to make adolescent preventive care, including vaccination, a new norm is essential.

School-based influenza immunization.

Annual influenza vaccination of schoolchildren will protect individual vaccines and, with high coverage, may protect entire communities. Because schoolchildren are more difficult to reach than preschoolers, school-based immunization programs may be needed to reach a high percentage of children. We offered free live, attenuated influenza vaccine to all healthy schoolchildren (K-12) in three Minnesota counties. Counties vaccinated from 33% to 58% of students. Overall, 41% of enrolled children were vaccinated. Elementary students were vaccinated at higher rates than older students. Administrative costs averaged $9.78 per dose delivered. School-based immunization programs offer the potential to achieve higher vaccination coverage of schoolchildren at modest cost.

Adolescent immunizations and other clinical preventive services: a needle and a hook?

Advances in technology have led to development of new vaccines for adolescents, but these vaccines will be added to a crowded schedule of recommended adolescent clinical preventive services. We reviewed adolescent clinical preventive health care guidelines and patterns of adolescent clinical preventive service delivery and assessed how new adolescent vaccines might affect health care visits and the delivery of other clinical preventive services. Our analysis suggests that new adolescent immunization recommendations are likely to improve adolescent health, both as a "needle" and a "hook." As a needle, the immunization will enhance an adolescent's health by preventing vaccine-preventable diseases during adolescence and adulthood. It also will likely be a hook to bring adolescents (and their parents) into the clinic for adolescent health care visits, during which other clinical preventive services can be provided. We also speculate that new adolescent immunization recommendations might increase the proportion and quality of other clinical preventive services delivered during health care visits. The factor most likely to diminish the positive influence of immunizations on delivery of other clinical preventive services is the additional visit time required for vaccine counseling and administration. Immunizations may "crowd out" delivery of other clinical preventive services during visits or reduce the quality of the clinical preventive service delivery. Complementary strategies to mitigate these effects might include prioritizing clinical preventive services with a strong evidence base for effectiveness, spreading clinical preventive services out over several visits, and withholding selected clinical preventive services during a visit if the prevention activity is effectively covered at the community level. Studies are needed to evaluate the effect of new immunizations on adolescent preventive health care visits, delivery of clinical preventive services, and health outcomes.

The role of schools in strengthening delivery of new adolescent vaccinations.

Schools offer an opportunity to deliver new vaccines to adolescents who may not receive them in their medical home. However, school budgets and health priorities are set at the local level; consequently resources devoted to health-related activities vary widely. Partnering with schools requires soliciting buy-in from stakeholders at district and school levels and providing added value to schools. With appropriate resources and partnerships, schools could carry out vaccination-related activities from educating students, parents, and communities to developing policies supporting vaccination, providing vaccines, or serving as the site at which partners administer vaccines. Activities will vary among schools, but every school has the potential to use some strategies that promote adolescent vaccination.

New, and some not-so-new, vaccines for adolescents and diseases they prevent.

Adolescents in the United States now have the opportunity to receive new vaccines that prevent invasive meningococcal infections, pertussis (whooping cough), and cervical cancer. Except for their potential to cause serious illness, these infections could not be more different. Their incidence ranges from extremely low to quite high. Early clinical manifestations of infection range from none to life-threatening illness. Two of the vaccines are similar to those already in use, whereas 1 is completely new. In conjunction with the 4 vaccines previously recommended for adolescents (the tetanus and diphtheria booster, hepatitis B, measles-mumps-rubella, and varicella), the 3 new vaccines (meningococcal, human papillomavirus, and the tetanus-diphtheria-pertussis booster [which replaced the tetanus-diphtheria booster]) bring the number recommended for adolescents to 6. In this article, we describe key characteristics of the 3 new vaccines and infections they were designed to prevent. We also briefly discuss other vaccines recommended for all adolescents who have not already received them and new vaccines that are still under development.

Vaccinating adolescents in high-risk settings: lessons learned from experiences with hepatitis B vaccine.

Meeting the health needs of adolescents who live in high-risk settings such as homeless shelters, migrant camps, juvenile detention centers, prisons, and other types of residential facilities presents many challenges. Although there is no doubt that adolescents in many high-risk settings are at increased risk for hepatitis B and human papillomavirus, acute medical and psychological problems may consume all of the provider's time and resources. Potential health threats such as vaccine-preventable diseases must necessarily be given lower priority. Lack of vaccination expertise, supplies, and access to records further complicate delivery of vaccines. Since the 1990s, a number of approaches have been used to deliver hepatitis B vaccine to adolescents in many high-risk settings. Close collaboration among state and federal programs, local health departments, and community-based organizations has been necessary to introduce and sustain the delivery of vaccines to these young people. Medicaid, Statute 317 of the Public Health Service Act, the Vaccines for Children program, and State Children's Health Insurance Program have been used to finance vaccinations for adolescents 18 years or younger, and the expanded Medicaid option in the Foster Care Independence Act of 1999 has been used for adolescents older than 18 years of age. A number of states allow adolescents under age 18 to consent to their own hepatitis B vaccination under laws passed to allow treatment of sexually transmitted infections without parental consent. In this article, we present the experiences of several model programs that developed successful hepatitis B vaccination programs in venues that serve adolescents at risk, the important role of state laws and state agencies in funding immunization and other preventive health services for adolescents in high-risk situations, and discuss barriers and means to resolve them.

Delivering new vaccines to adolescents: the role of school-entry laws.

In the United States, state-based school-entry vaccination laws have been used effectively to rapidly increase vaccination rates among adolescents, in particular, for hepatitis B vaccine. New vaccines for adolescents raise the question of whether and under what circumstances school-entry laws may be used to increase coverage rates with these vaccines. The new vaccines differ somewhat from their predecessors and raise policy and legal issues. For example, some of the new vaccines prevent diseases for which the primary mode of transmission is sexual contact. Mandating these vaccines before school entry has been met with concern by those who believe that mandates for this type of vaccine not only intrude on parental decision-making rights but might also lead to sexual promiscuity among youth. In this article we explore (1) the possible utility of school-entry requirements to increase the delivery of the new vaccines for adolescents, including the legal basis for US school-entry laws, (2) arguments in favor and concerns about the adoption of laws for adolescent vaccination, and (3) the importance of including diverse stakeholders in the deliberative process and formulating and implementing laws in a way that maximizes their acceptance and effectiveness.