HUMAN VACCINES & IMMUNOTHERAPEUTICS 2016, VOL. 12, NO. 11, 2872–2874 http://dx.doi.org/10.1080/21645515.2016.1208326
SHORT REPORT
HPV vaccine uptake in a school-located vaccination program Amy B. Middlemana, Tiana Wonb, Beth Auslanderc, Sanghamitra Misrad, and Mary Shorte a Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA; bDepartment of Pediatrics, University of Washington, Seattle, WA, USA; cDepartment of Pediatrics, University of Texas Medical Branch at Galveston, Galveston, TX, USA; dDepartment of Pediatrics, Baylor College of Medicine, Houston, TX, USA; eDepartment of Psychology, University of Houston-Clear Lake, Clear Lake, TX, USA
ABSTRACT
ARTICLE HISTORY
Previous research has implied that while parents may be willing to have their adolescents receive some recommended vaccines via school-located vaccination program (SLVP), they were less likely to agree to the HPV vaccine being administered via SLVP. During an SLVP in a large urban area, 86% of those participating in the program received an HPV vaccine.
Received 23 March 2016 Revised 10 June 2016 Accepted 28 June 2016 KEYWORDS
adolescent vaccination; HPV vaccine; school-located vaccination; vaccine adherence
Introduction Since 2005, the number of vaccines the average adolescent is expected to receive from age 11 through 18 y has increased from one injection (tetanus, diphtheria booster at age 11– 12 years) to 14 injections and counting, when including an annual influenza vaccine. Accessing adolescents for vaccine administration requires more complex strategies than those used to immunize younger children; adolescents are engaging in developmentally appropriate after-school activities and are more difficult to get in to a provider’s office for vaccines. It is critical to avoid missed opportunities and vaccinate adolescents whenever they are seen in an office setting; school-located vaccination programs (SLVPs) provide access to vaccination for those adolescents whose parents cannot miss work or other daytime commitments or those who have multiple after-school commitments. Prior work has indicated that while middle school parents are willing to have their adolescents immunized at school,1,2 they may be less likely to have their children vaccinated against human papillomavirus (HPV) in the SLVP setting.3 However, a prior study has shown that parental reported intentions on surveys does not always predict behavior when an SLVP is actually available as a vaccination option.4 This study aims to determine whether parents of middle school students and their children, who are offered all adolescent vaccines in a SLVP setting, will consent/assent to receive the HPV vaccine.
Results Enrollment in the 8 middle schools participating in the program included approximately 8333 students, 80% of whom were Hispanic, 17% African American, 1% white; 93% of students were enrolled in the free lunch program. Because this was CONTACT Amy B. Middleman, MD © 2016 Taylor & Francis
[email protected]
primarily a service project, race/ethnicity data on those receiving vaccines were not collected. Fifty percent of those receiving HPV vaccine were male. Overall program participation rates varied between 3.5% and 10.5% of each school’s population.5 The numbers of vaccines administered through the program are noted in Table 1. Among all of the adolescents utilizing the SLVP, 449/524 participating students (86%) in the fall and 161/ 188 (86%) in the spring received the HPV vaccine. Thus 86% of those utilizing the SLVP received the HPV vaccine. Twentyone of those who received HPV vaccine in the spring, 2013, had also received a vaccine in the fall, 2012 SLVP; 19 of those 21 had received an HPV vaccine in the fall.
Discussion Eighty six percent of parents of VFC-eligible students participating in an SLVP consented to have their children vaccinated against HPV by the SLVP. This finding is surprising given survey data indicating that parents are significantly less likely to report willingness to immunize with HPV versus other routine vaccines provided through an SLVP. One study of a similar study population found that 57% vs. 27% of parents reported willingness to have their child receive an influenza vaccine versus HPV vaccine via SLVP;6 other research supports this difference in parents’ self-reported willingness to vaccinate using influenza (63.5%,67%) vs. HPV vaccine (58%,53%) in the context of an SLVP.7,8 Previous studies have also indicated that parents report greater willingness to consent to having their child receive HPV vaccine in the context of an SLVP that includes multiple adolescent vaccines versus an SLVP that provides HPV vaccine only.9,10 An SLVP conducted among middle schools in Denver also experienced good uptake of HPV vaccine among those participating in the program; other than the flu vaccine, HPV vaccines were administered most
1200 Children's Avenue, Suite 12200, Oklahoma City, OK 73151, USA.
HUMAN VACCINES IMMUNOTHERAPEUTICS
2873
Table 1. Vaccines administered through the SLVP.
Fall, 2012 Spring, 2013
Number of individual participants
Influenza Vaccine
HPV Vaccine
Tdap Vaccine
MCV4 Vaccine
Other Vaccines
TOTAL Vaccines
524 188
472 3
449 161
334 101
331 108
88 159
1674 532
Other vaccines included: Hepatitis A, varicella, and MMR
frequently to participants (the denominator of the proportion was all vaccines administered, not unique recipients).11 The data presented here imply that if participants are already willing to have their child receive vaccines using an SLVP, they will also likely consent for the HPV vaccine through the SLVP. This study does have some limitations. First, this is a descriptive study based on a service project. Data on the vaccination status of all enrolled students were not available to service personnel due to privacy laws, so a true denominator of students who needed various vaccines was not known. The participating schools are in primarily lower income areas, potentially limiting generalizability. Overall, SLVP participation was relatively low despite the fact that most students should have had at least the influenza vaccine indicated, however rates were similar to other SLVPs conducted among middle school participants.9,12 Program personnel and programming changed, making the third visit data very different from the first and second visits, thus rendering it less useful. Finally, with state testing requirements, school priorities clearly change during the school year; the opportunity to have students protected from influenza, which affects attendance rates, is far more incentivizing for a fall visit than follow up vaccination in the spring, and we know from prior study that teacher and administrative support is critical to the success of SLVPs.14,15 SLVPs may be more successful not only when they include all vaccines, but also when conducted in the fall prior to the onset of preparation for high-stakes state testing. Despite these limitations, these data support that parents are willing to utilize SLVPs to provide HPV vaccine to their adolescent children. Parents in lower income settings, who represent those most likely to utilize SLVPs,8 are willing to have their children vaccinated against HPV when participating in schoollocated vaccination. Barriers to use of SLVPs, including parent and school administration unfamiliar with such programming, competing school priorities, and lack of knowledge regarding HPV vaccine in general, require thoughtful solutions.15 These data demonstrate that SLVP providers should offer HPV vaccine in addition to all other recommended vaccines as part of their service to adolescents.
completion of vaccination series. During all 3 visits, packets (cover letter, Vaccine Information Statements, and consent) were distributed to all students to take home to parents. The cover letter described the program and the recommended vaccines for the adolescent age group. The Vaccine Information Sheet for each vaccine offered by the SLVP was included in both English and Spanish. The consent form was the standard form used for inclusion in the state immunization information system, which allowed parents to note Vaccine For Children Program (VFC) eligibility and Medicaid/State Child Health Insurance Program numbers, to respond to immunization screening questions, and to consent for each adolescent vaccine and catch-up vaccine (including the live attenuated influenza vaccine or the inactivated influenza vaccine). Consent forms were returned to teachers/ school nurses and picked up by program personnel, so immunization information system (IIS) reports, when available (reported IIS participation statewide is >95%, per state contact), could be run on participants to confirm vaccination status prior to the visit dates. On visit days a mobile unit from a large, pediatric hospital arrived to each school to immunize. Immunization times occurred either before school hours or after school ended to allow interested parents to be present during immunizations. Mobile unit personnel set up and administered vaccines inside the school in the school nurse’s office, library, gym, or auditorium. Per the guidelines set forth by the mobile unit, participants had to be VFC eligible (per forms sent home in the student packets) to receive vaccines from the program; fewer than 5 participants were unable to receive vaccines from the program due to insurance status. If registry records indicated a need for additional immunizations beyond those for which consent was obtained, personnel would call the parents to discuss and obtain appropriate verbal informed consent. Due to significant personnel changes in year 2 leading to programmatic inconsistencies (principal investigator transitioned out-of-state), the third immunization visit is not included in this analysis.
Disclosure of potential conflicts of interest One author previously received salary support from Merck Pharmaceuticals.
Methods Prior to the academic school year 2012-2013, 8 of approximately 33 free-standing middle schools in a large, urban school district were chosen randomly and were offered participation in an SLVP. These schools were chosen randomly from middle schools where at least 90% of students participated in a free or reduced lunch program. This service project was conducted as part of a larger research project and the selection of schools is described in detail elsewhere.5 Three separate visits (September/October, 2012, March/April, 2013, and September/October, 2013) were scheduled for each school to assure maximum participation and
Acknowledgment Presented in part at the Society of Adolescent Health and Medicine Meeting in Los Angeles, C.A. in March 2015.
Funding Publication of this article was supported by the Society for Adolescent Health and Medicine through a grant from Merck & Co., Inc. The opinions or views expressed in this supplement are those of the authors and do not represent the position of the funder.
2874
A. B. MIDDLEMAN ET AL.
References [1] Clevenger L. Parent’s acceptance of adolescent immunizations outside of the traditional medical home. J Adolesc Health 2011; 49:13340; PMID:21783044; http://dx.doi.org/10.1016/j.jadohealth.2011. 04.012 [2] Middleman A, Tung J. At what sites are parents willing to have their 11 through 14-year-old adolescents immunized? Vaccine 2010; 28:2674-8; PMID:20085835; http://dx.doi.org/10.1016/j.vaccine.2010. 01.006 [3] Middleman A, Tung J. Urban middle school parent perspectives: The vaccines they are willing to have their children receive using schoolbased immunization programs. J Adolesc Health 2010; 47:249-53; PMID:20708563; http://dx.doi.org/10.1016/j.jadohealth.2010.01.009 [4] Middleman A, Tung J. School-located immunization programs: do Parental preferences predict behavior? Vaccine 2011; 29:3513-6; PMID:21414378; http://dx.doi.org/10.1016/j.vaccine.2011.02.101 [5] Won TL, Middleman AB, Auslander BA, Short MB. Trust and a school-located immunization program. J Adolesc Health 2015; 56: S33-39; PMID:25863553; http://dx.doi.org/10.1016/j.jadohealth. 2014.09.018 [6] Middleman A, Tung J. Parent’s Willingness to Get Vaccines in Schools. J Adolesc Health 2010; 46:S69-S70; http://dx.doi.org/ 10.1016/j.jadohealth.2009.11.168 [7] Gargano L, Weiss P, Underwood N. School-located vacination clinics for adolescents: correlates of acceptance among parents. J Community Health 2015; 40:660-9; PMID:25528325; http://dx.doi.org/ 10.1007/s10900-014-9982-z [8] Kelminson K, Saville A, Seewald L, Stokley S, Dickinson LM, Daley MF, Suh C, Kempe A. Parental views of school-located delivery of
[9]
[10]
[11]
[12]
[13]
[14]
[15]
adolescent vaccines. J Adolesc Health 2012; 51:190-6; PMID:22824451; http://dx.doi.org/10.1016/j.jadohealth.2011.11.016 Hayes K, Entzel P, Berger W, Caskey RN, Shlay JC, Stubbs BW, Smith JS, Brewer NT. Early lessons learned from extramural school programs that offer HPV vaccine. J Sch Health 2013; 83:119-26; PMID:23331272; http://dx.doi.org/10.1111/josh.12007 Reiter P, McRee AL, Pepper J, Brewer NT. Default Policies and Parents’ consent for School-Located HPV Vaccination. J Behav Med 2012; 35:651-7; PMID:22271328; http://dx.doi.org/10.1007/s10865012-9397-1 Shlay JC, Rodgers S, Lyons J, Romero S, Vogt TM, McCormic EV. Implementing a school-located vaccination program in denver public schools. J Sch Health 2015; 85(8):536-43; PMID:26149309; http://dx. doi.org/10.1111/josh.12281 Stubbs BW, Panozzo CA, Moss JL, Reiter PL, Whitesell DH, Brewer NT. Evaluation of an Intervention Providing HPV Vaccine in Schools. Am J Health Behav 2014; 38(1):92-102; PMID:24034684 Lindley MC, Boyer-Chu L, Fishbein DB, Kolasa M, Middleman AB, Wilson T, Wolicki J, Wooley S. The role of schools in strengthening delivery of new adolescent vaccines. Pediatrics 2008; 121(1):S46-S54; PMID:18174320; http://dx.doi.org/10.1542/peds.2007-1115F Tung CS, Middleman AB. An evaluation of school-level factors used in a successful school-based hepatitis B immunization initiative. J Adolesc Health 2005; 37:61-8; PMID:15963908; http://dx.doi.org/ 10.1016/j.jadohealth.2004.07.019 Nodulman JA, Starling R, Kong AS, Buller DB, Wheeler CM, Woodall WG. Investigating stakeholder attitudes and opinions on schoolbased human papillomavirus vaccination programs. J Sch Health 2015; 85(5):289-98; PMID:25846308; http://dx.doi.org/10.1111/ josh.12253
SHORT REPORT
HPV vaccine uptake in a school-located vaccination program Amy B. Middlemana, Tiana Wonb, Beth Auslanderc, Sanghamitra Misrad, and Mary Shorte a Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA; bDepartment of Pediatrics, University of Washington, Seattle, WA, USA; cDepartment of Pediatrics, University of Texas Medical Branch at Galveston, Galveston, TX, USA; dDepartment of Pediatrics, Baylor College of Medicine, Houston, TX, USA; eDepartment of Psychology, University of Houston-Clear Lake, Clear Lake, TX, USA
ABSTRACT
ARTICLE HISTORY
Previous research has implied that while parents may be willing to have their adolescents receive some recommended vaccines via school-located vaccination program (SLVP), they were less likely to agree to the HPV vaccine being administered via SLVP. During an SLVP in a large urban area, 86% of those participating in the program received an HPV vaccine.
Received 23 March 2016 Revised 10 June 2016 Accepted 28 June 2016 KEYWORDS
adolescent vaccination; HPV vaccine; school-located vaccination; vaccine adherence
Introduction Since 2005, the number of vaccines the average adolescent is expected to receive from age 11 through 18 y has increased from one injection (tetanus, diphtheria booster at age 11– 12 years) to 14 injections and counting, when including an annual influenza vaccine. Accessing adolescents for vaccine administration requires more complex strategies than those used to immunize younger children; adolescents are engaging in developmentally appropriate after-school activities and are more difficult to get in to a provider’s office for vaccines. It is critical to avoid missed opportunities and vaccinate adolescents whenever they are seen in an office setting; school-located vaccination programs (SLVPs) provide access to vaccination for those adolescents whose parents cannot miss work or other daytime commitments or those who have multiple after-school commitments. Prior work has indicated that while middle school parents are willing to have their adolescents immunized at school,1,2 they may be less likely to have their children vaccinated against human papillomavirus (HPV) in the SLVP setting.3 However, a prior study has shown that parental reported intentions on surveys does not always predict behavior when an SLVP is actually available as a vaccination option.4 This study aims to determine whether parents of middle school students and their children, who are offered all adolescent vaccines in a SLVP setting, will consent/assent to receive the HPV vaccine.
Results Enrollment in the 8 middle schools participating in the program included approximately 8333 students, 80% of whom were Hispanic, 17% African American, 1% white; 93% of students were enrolled in the free lunch program. Because this was CONTACT Amy B. Middleman, MD © 2016 Taylor & Francis
[email protected]
primarily a service project, race/ethnicity data on those receiving vaccines were not collected. Fifty percent of those receiving HPV vaccine were male. Overall program participation rates varied between 3.5% and 10.5% of each school’s population.5 The numbers of vaccines administered through the program are noted in Table 1. Among all of the adolescents utilizing the SLVP, 449/524 participating students (86%) in the fall and 161/ 188 (86%) in the spring received the HPV vaccine. Thus 86% of those utilizing the SLVP received the HPV vaccine. Twentyone of those who received HPV vaccine in the spring, 2013, had also received a vaccine in the fall, 2012 SLVP; 19 of those 21 had received an HPV vaccine in the fall.
Discussion Eighty six percent of parents of VFC-eligible students participating in an SLVP consented to have their children vaccinated against HPV by the SLVP. This finding is surprising given survey data indicating that parents are significantly less likely to report willingness to immunize with HPV versus other routine vaccines provided through an SLVP. One study of a similar study population found that 57% vs. 27% of parents reported willingness to have their child receive an influenza vaccine versus HPV vaccine via SLVP;6 other research supports this difference in parents’ self-reported willingness to vaccinate using influenza (63.5%,67%) vs. HPV vaccine (58%,53%) in the context of an SLVP.7,8 Previous studies have also indicated that parents report greater willingness to consent to having their child receive HPV vaccine in the context of an SLVP that includes multiple adolescent vaccines versus an SLVP that provides HPV vaccine only.9,10 An SLVP conducted among middle schools in Denver also experienced good uptake of HPV vaccine among those participating in the program; other than the flu vaccine, HPV vaccines were administered most
1200 Children's Avenue, Suite 12200, Oklahoma City, OK 73151, USA.
HUMAN VACCINES IMMUNOTHERAPEUTICS
2873
Table 1. Vaccines administered through the SLVP.
Fall, 2012 Spring, 2013
Number of individual participants
Influenza Vaccine
HPV Vaccine
Tdap Vaccine
MCV4 Vaccine
Other Vaccines
TOTAL Vaccines
524 188
472 3
449 161
334 101
331 108
88 159
1674 532
Other vaccines included: Hepatitis A, varicella, and MMR
frequently to participants (the denominator of the proportion was all vaccines administered, not unique recipients).11 The data presented here imply that if participants are already willing to have their child receive vaccines using an SLVP, they will also likely consent for the HPV vaccine through the SLVP. This study does have some limitations. First, this is a descriptive study based on a service project. Data on the vaccination status of all enrolled students were not available to service personnel due to privacy laws, so a true denominator of students who needed various vaccines was not known. The participating schools are in primarily lower income areas, potentially limiting generalizability. Overall, SLVP participation was relatively low despite the fact that most students should have had at least the influenza vaccine indicated, however rates were similar to other SLVPs conducted among middle school participants.9,12 Program personnel and programming changed, making the third visit data very different from the first and second visits, thus rendering it less useful. Finally, with state testing requirements, school priorities clearly change during the school year; the opportunity to have students protected from influenza, which affects attendance rates, is far more incentivizing for a fall visit than follow up vaccination in the spring, and we know from prior study that teacher and administrative support is critical to the success of SLVPs.14,15 SLVPs may be more successful not only when they include all vaccines, but also when conducted in the fall prior to the onset of preparation for high-stakes state testing. Despite these limitations, these data support that parents are willing to utilize SLVPs to provide HPV vaccine to their adolescent children. Parents in lower income settings, who represent those most likely to utilize SLVPs,8 are willing to have their children vaccinated against HPV when participating in schoollocated vaccination. Barriers to use of SLVPs, including parent and school administration unfamiliar with such programming, competing school priorities, and lack of knowledge regarding HPV vaccine in general, require thoughtful solutions.15 These data demonstrate that SLVP providers should offer HPV vaccine in addition to all other recommended vaccines as part of their service to adolescents.
completion of vaccination series. During all 3 visits, packets (cover letter, Vaccine Information Statements, and consent) were distributed to all students to take home to parents. The cover letter described the program and the recommended vaccines for the adolescent age group. The Vaccine Information Sheet for each vaccine offered by the SLVP was included in both English and Spanish. The consent form was the standard form used for inclusion in the state immunization information system, which allowed parents to note Vaccine For Children Program (VFC) eligibility and Medicaid/State Child Health Insurance Program numbers, to respond to immunization screening questions, and to consent for each adolescent vaccine and catch-up vaccine (including the live attenuated influenza vaccine or the inactivated influenza vaccine). Consent forms were returned to teachers/ school nurses and picked up by program personnel, so immunization information system (IIS) reports, when available (reported IIS participation statewide is >95%, per state contact), could be run on participants to confirm vaccination status prior to the visit dates. On visit days a mobile unit from a large, pediatric hospital arrived to each school to immunize. Immunization times occurred either before school hours or after school ended to allow interested parents to be present during immunizations. Mobile unit personnel set up and administered vaccines inside the school in the school nurse’s office, library, gym, or auditorium. Per the guidelines set forth by the mobile unit, participants had to be VFC eligible (per forms sent home in the student packets) to receive vaccines from the program; fewer than 5 participants were unable to receive vaccines from the program due to insurance status. If registry records indicated a need for additional immunizations beyond those for which consent was obtained, personnel would call the parents to discuss and obtain appropriate verbal informed consent. Due to significant personnel changes in year 2 leading to programmatic inconsistencies (principal investigator transitioned out-of-state), the third immunization visit is not included in this analysis.
Disclosure of potential conflicts of interest One author previously received salary support from Merck Pharmaceuticals.
Methods Prior to the academic school year 2012-2013, 8 of approximately 33 free-standing middle schools in a large, urban school district were chosen randomly and were offered participation in an SLVP. These schools were chosen randomly from middle schools where at least 90% of students participated in a free or reduced lunch program. This service project was conducted as part of a larger research project and the selection of schools is described in detail elsewhere.5 Three separate visits (September/October, 2012, March/April, 2013, and September/October, 2013) were scheduled for each school to assure maximum participation and
Acknowledgment Presented in part at the Society of Adolescent Health and Medicine Meeting in Los Angeles, C.A. in March 2015.
Funding Publication of this article was supported by the Society for Adolescent Health and Medicine through a grant from Merck & Co., Inc. The opinions or views expressed in this supplement are those of the authors and do not represent the position of the funder.
2874
A. B. MIDDLEMAN ET AL.
References [1] Clevenger L. Parent’s acceptance of adolescent immunizations outside of the traditional medical home. J Adolesc Health 2011; 49:13340; PMID:21783044; http://dx.doi.org/10.1016/j.jadohealth.2011. 04.012 [2] Middleman A, Tung J. At what sites are parents willing to have their 11 through 14-year-old adolescents immunized? Vaccine 2010; 28:2674-8; PMID:20085835; http://dx.doi.org/10.1016/j.vaccine.2010. 01.006 [3] Middleman A, Tung J. Urban middle school parent perspectives: The vaccines they are willing to have their children receive using schoolbased immunization programs. J Adolesc Health 2010; 47:249-53; PMID:20708563; http://dx.doi.org/10.1016/j.jadohealth.2010.01.009 [4] Middleman A, Tung J. School-located immunization programs: do Parental preferences predict behavior? Vaccine 2011; 29:3513-6; PMID:21414378; http://dx.doi.org/10.1016/j.vaccine.2011.02.101 [5] Won TL, Middleman AB, Auslander BA, Short MB. Trust and a school-located immunization program. J Adolesc Health 2015; 56: S33-39; PMID:25863553; http://dx.doi.org/10.1016/j.jadohealth. 2014.09.018 [6] Middleman A, Tung J. Parent’s Willingness to Get Vaccines in Schools. J Adolesc Health 2010; 46:S69-S70; http://dx.doi.org/ 10.1016/j.jadohealth.2009.11.168 [7] Gargano L, Weiss P, Underwood N. School-located vacination clinics for adolescents: correlates of acceptance among parents. J Community Health 2015; 40:660-9; PMID:25528325; http://dx.doi.org/ 10.1007/s10900-014-9982-z [8] Kelminson K, Saville A, Seewald L, Stokley S, Dickinson LM, Daley MF, Suh C, Kempe A. Parental views of school-located delivery of
[9]
[10]
[11]
[12]
[13]
[14]
[15]
adolescent vaccines. J Adolesc Health 2012; 51:190-6; PMID:22824451; http://dx.doi.org/10.1016/j.jadohealth.2011.11.016 Hayes K, Entzel P, Berger W, Caskey RN, Shlay JC, Stubbs BW, Smith JS, Brewer NT. Early lessons learned from extramural school programs that offer HPV vaccine. J Sch Health 2013; 83:119-26; PMID:23331272; http://dx.doi.org/10.1111/josh.12007 Reiter P, McRee AL, Pepper J, Brewer NT. Default Policies and Parents’ consent for School-Located HPV Vaccination. J Behav Med 2012; 35:651-7; PMID:22271328; http://dx.doi.org/10.1007/s10865012-9397-1 Shlay JC, Rodgers S, Lyons J, Romero S, Vogt TM, McCormic EV. Implementing a school-located vaccination program in denver public schools. J Sch Health 2015; 85(8):536-43; PMID:26149309; http://dx. doi.org/10.1111/josh.12281 Stubbs BW, Panozzo CA, Moss JL, Reiter PL, Whitesell DH, Brewer NT. Evaluation of an Intervention Providing HPV Vaccine in Schools. Am J Health Behav 2014; 38(1):92-102; PMID:24034684 Lindley MC, Boyer-Chu L, Fishbein DB, Kolasa M, Middleman AB, Wilson T, Wolicki J, Wooley S. The role of schools in strengthening delivery of new adolescent vaccines. Pediatrics 2008; 121(1):S46-S54; PMID:18174320; http://dx.doi.org/10.1542/peds.2007-1115F Tung CS, Middleman AB. An evaluation of school-level factors used in a successful school-based hepatitis B immunization initiative. J Adolesc Health 2005; 37:61-8; PMID:15963908; http://dx.doi.org/ 10.1016/j.jadohealth.2004.07.019 Nodulman JA, Starling R, Kong AS, Buller DB, Wheeler CM, Woodall WG. Investigating stakeholder attitudes and opinions on schoolbased human papillomavirus vaccination programs. J Sch Health 2015; 85(5):289-98; PMID:25846308; http://dx.doi.org/10.1111/ josh.12253
