Date of Award


Document Type

Open Access Thesis

Degree Name

Master of Public Health (MPH)


School of Public Health

First Advisor

Linda M. Niccolai


Background: The wide-ranging nature of state vaccination requirements for school entry allows for suboptimal coverage of adolescent vaccination as well as missed opportunities where some adolescent vaccinations are received but not all of them. Variation exists both in the types of exemptions that are allowed and the process that is required to obtain an exemption. State-level policies have been shown to be associated with childhood vaccination coverage, but far fewer studies have examined adolescent vaccine coverage.

Methods: HPV, MenACWY, and Tdap vaccine receipt and demographic data from the 2017 National Immunization Survey-Teen (NIS-Teen) Public Use Dataset were combined with data on school entry requirements and allowable exemptions from the Immunization Action Coalition. Ease of exemption was determined through ranking of exemption criteria collected from state immunization websites. Univariate logistic regressions and multivariable logistic regressions adjusting for demographic variables associated with vaccine outcomes were run to determine the relationship of missed opportunities and vaccine initiation with state vaccine policies.

Results: Having a vaccine requirement for a specific adolescent vaccine was associated with higher odds of initiating vaccination for that specific vaccine and lower odds of having a missed opportunity for that vaccine. However, there was no association between requirements for an adolescent vaccine and coverage for other non-targeted vaccines. While there were significant associations between the ease of exemption requirement outcomes and the number of mechanisms to obtain a non-medical exemption with some vaccination outcomes, there was not a consistent trend in the results.

Conclusions: The ease of obtaining a vaccine exemption seems to have less of an impact on adolescent vaccination than the presence of a school entry requirement does. Future research that seeks to understand the limited association between exemption policies and adolescent vaccination will be important to determine optimal state policies. School entry requirements still remain the strongest policy means for increasing coverage although their spillover effects are limited.

Open Access

This Article is Open Access

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