Background: In June 2015 California passed Senate Bill 277 (SB277) which eliminated nonmedical exemptions from state-mandated immunizations for school-entry. As the first state in nearly 35 years to eliminate nonmedical exemptions, and with 18 states considering 46 bills to change to exemptions laws in 2017, the implementation and effects of SB277 have important implications for other states. The objective of this study was to describe lessons learned from the first year of SB277 implementation. Methods:Thirty-four semi-structured telephone interviews were conducted between August and September 2017 with 41 health officers and county-level immunization staff representing 35 of the 61 county/city jurisdictions in California. Interviews were audio-recorded, coded, and analyzed. Results: We identified two major themes: 1) the vagueness of SB277’s legislative and regulatory language left it open to interpretation, leading to considerable variation in implementation of the law, and 2) the lack of centralized state-level review of medical exemptions has allowed a “black market” for medically-questionable exemptions to flourish. According to SB277, certain students (individualized education program, special education, independent study programs, homeschooling) are exempt from immunizations requirements; however, there was confusion on how to interpret these clauses which led to participants using their subjective judgment to determine how much classroom time warrants immunization requirements. Without centralized review of medical exemptions, participants reported a wide variation in the types of physicians who write medical exemptions, the conditions that constitute a valid contraindication for immunization, and the process for reporting medically-questionable exemptions. The lack of central review has allowed some physicians to take advantage of the law to write medical exemptions that study participants considered questionable. Conclusion: Due to the legislative and regulatory language of SB277, there was confusion about certain clauses which led to variation in the implementation of this state law at the county and school district level. Public health implications: The implementation and effects of SB277 have important implications for other states considering similar legislation. Other states can use California’s experience as a guide when drafting similar exemption policy.

background: The federal program, Vaccines for Children (VFC), provides free vaccines for Medicaid-eligible, Alaska Native, American Indian, and uninsured populations. While it has succeeded in increasing immunization rates, there are still barriers to access for non-VFC eligible patients. To address this gap, some states have adopted universal purchase policies that cover recommended vaccines for all children, regardless of VFC eligibility. We hypothesized that states with such programs have higher immunization rates. methods: Between October and December 2017, information on each state’s childhood vaccine funding structure was collected from publicly available sources. Immunization Information Systems (IIS) representatives from each state were contacted by email and phone to verify collected information. We categorized state programs as 1) Universal (covering all ACIP recommended childhood vaccines regardless of VFC eligibility), 2) Universal Select (augmenting VFC coverage populations but not universal), or 3) Traditional VFC. State vaccination rates were collected from the 2015 National Immunization Survey. One-way ANOVA and t-tests were used to compare immunization rates for 7 categories of childhood vaccines by type of state funding program. results: In 2017, 8 states participated in Universal Purchase, 7 Universal-Select, and 35 Traditional VFC. Rates for all vaccine categories were higher in Universal states compared with Traditional VFC, with Universal-Select states performing in between. However these differences were not statistically significant. For example, MMR vaccination rates were: Traditional 90.95%(SD2.58), Universal-Select 91.99(4.47), and Universal 93.06(2.12), p=.147. HPV rates for females were 63.73(8.51), 65.04(9.44), and 68.91(11.01) respectively (p=.346), and for males 54.73(8.55), 55.97(10.45), and 62.61(14.77), p=.139. When Universal and Universal-Select states were combined, the differences were still not statistically significant. conclusions: Our analysis showed higher vaccination rates for all vaccines, in states with Universal Purchase Programs when compared with Traditional VFC states. While these differences were not statistically significant, this could be due to the small sample size of the universal purchase groups. Further studies are indicated to determine the cost-effectiveness and differences in impact of various Universal Purchase models. public health implications: This study contributes ideas for increasing pediatric vaccination rates, cost savings in the US healthcare system, centralizing vaccine purchasing, and decreasing public health disease burden.

◦background In the 2014-2015 flu season, 97 deaths occurred in San Diego County. Influenza vaccinations are the primary source of protection from the illness. Some areas of the County have higher vaccination rates than others, possibly leading to increased deaths as the County population grows. ◦methods: Using San Diego Immunization Registry (SDIR) vaccination data patient zip codes, rates of influenza vaccination per 10,000 people were calculated for each SRA. Rates of influenza hospitalizations and emergency department encounters were calculated and mapped by SRA using 2015 data from the California Office of Statewide Health Planning and Development (OSHPD). Data was mapped and spatially analyzed using ArcMap 10.5.1 with an added layer of hospital locations to better understand this relationship. ◦results Several SRA’s with the highest vaccination rates also have the highest medical encounter rate. With vaccination rates of 1406 per 10,000 and 1350 per 10,000 respectively, Southeastern San Diego and National City have some of the highest vaccination rates. They also have the highest medical encounter rates at 42 per 10,000 and 32 per 10,000 respectively. Areas with higher densities of hospitals tended to have both higher vaccination rates and higher medical encounter rates. However, urban SRA’s with higher socioeconomic status (SES) such as Coastal and University have multiple hospitals, low vaccination rates (479 and 501 per 10,000 respectively), and low medical encounter rates (8.8 and 8.9 per 10,000 respectively). In contrast, rural SRA’s of low SES including Anza-Borrego Springs have high rates of vaccinations (1,000 per 10,000) and lowest rates of medical encounters (0 per 10,000 respectively), but are far from coastal hospitals. ◦conclusions While it is expected that SRA’s within close distance of a hospital have higher vaccination rates and medical encounter rates, disparities between these rates are seen between urban, high SES areas and rural, low SES areas. Spatial access to hospitals may influence both vaccinations and medical encounters. ◦public health implications Examining where influenza vaccination rates are low and medical encounters are high may help improve future vaccination campaign locations. Improving hospital access to rural SRA’s may impact the number of medical encounters seen in those areas.

Background Ever since 1995 when immunization privileges were expanded to pharmacists, pharmacies have offered the promise of further expanding and accelerating vaccination coverage. This can be particularly important during an epidemic when getting as much of the population protected as soon as possible is crucial. Objectives To estimate the epidemiologic and economic impact of adding pharmacies as vaccination locations during a novel influenza epidemic. Methods We enhanced and utilized an agent-based model, Public Health Influenza Laboratory (PHIL) of the United States that includes representations of each person, household, workplace, and school in the country to simulate the spread of influenza under various conditions. This model included geographically explicit representations of 61,939 traditional vaccination locations (i.e., hospitals, clinic and physician offices, and urgent care clinics) and 61,202 pharmacies. Different scenarios evaluated the economic and epidemiologic impact of distributing vaccines through various combinations of traditional locations and pharmacy locations under different influenza epidemic settings. Results A mild influenza epidemic would result in 87,008,275 symptomatic infections when only vaccinating in traditional locations. Expanding to include all pharmacies would lead to 30,595,952 additional immunizations, resulting in 11,898,502 fewer symptomatic cases, 25,020 fewer deaths and avert the loss of 354,965 quality-adjusted life years (QALYs). This in turn would save $1.7 billion and $5.5 billion from the third-party payer and societal perspectives respectively. Thus, adding pharmacies would be economically dominant (i.e., saves costs and provides health benefits) compared to vaccination in only traditional locations. Benefits increased with a more severe epidemic, where distributing vaccines through all pharmacies would result in 30,925,064 additional vaccinations, averting 16,013,791 symptomatic cases, 33,880 deaths, and 450,117 QALYs lost. This would save $2.4 billion and $8.1 billion from the third-party payer and societal perspectives, respectively. Conclusion Pharmacies have the potential to expand the reach and capacity of vaccination, thereby mitigating cases, saving costs, and providing health benefits in the event of an epidemic. Public health implications In the event of an influenza epidemic, vaccines should be distributed through pharmacies in addition to traditional locations when vaccines become available.