Disregarding the fact that she is only 15 years old and in 9th grade, Rachel Trail feels a bit out of place among the young children in the waiting room of the state-run health clinic in this Washington suburb. Despite this, when it comes time for Rachel to get her shot, she insists on receiving a treat, just like the other children in the clinic.

Rachel explains, "I’m a bit of a panicky person. So when I get my shot, I want a sucker and a sticker."

To her delight, Rachel returns to the waiting room after receiving her shots to find a Dora the Explorer sticker placed proudly on her chest. She reassures others that the shots were painless, describing them as "just a pinch."

Rachel is just one of the many teenagers in Maryland who recently received vaccinations for hepatitis B and varicella. In 2005, state health officials decided to accelerate the vaccination schedule, leading to thousands of teenagers being immunized through a new device that administers shots through the skin using compressed air. Maryland’s efforts to get middle school students up to date on their vaccinations serves as an example for schools and public-health officials across the country.

Vaccines have been a significant advancement in medicine, eradicating many previously threatening diseases. Ensuring that children are vaccinated has typically been enforced through school attendance requirements. However, implementing changes to immunization policies is not an easy task for school officials.

Debbie Somerville, coordinator of student services for the Baltimore County school system, explains, "We’re responsible for enforcing these policies. It becomes the school’s responsibility to identify who is not compliant."

Several states, including Maryland, are currently considering changes to their immunization requirements to include the new vaccine for human papillomavirus (HPV). Although no state has made the HPV vaccine’s administration mandatory, it is recommended by the Centers for Disease Control and Prevention.

It is essential that children be properly immunized before attending school in all states. While medical exemptions are available in each state, 28 states allow religious exemptions and 20 states allow personal beliefs to be an exemption.

Maryland added the requirement for hepatitis B and varicella vaccination in 2000, slowly implementing it year by year, starting with kindergartners. Accelerating the schedule meant that school districts in the state had to sort through incomplete records to identify older students who had not received the shots. Approximately 55,000 students were found to be non-compliant. These students had to schedule appointments to receive the shots, provide proof of prior vaccination, or risk missing part of the second semester of school.

As of mid-January, some districts reported that they were still attempting to reach the remaining families who had not responded to previous contact efforts.

Implementing immunization policies becomes more challenging when the vaccines are targeted towards adolescents. While parents are generally aware of the vaccines required for babies and toddlers, their knowledge about recommended vaccines for older children is often lacking.

Medical experts recommend certain vaccines specifically for adolescents. However, not all states require these vaccines.

"Even with ongoing outbreaks of measles, some parents are not prioritizing immunization," stated Dr. Walter A. Orenstein, the director of the vaccine policy and development program at Emory University. Dr. Orenstein, who was previously the director of the National Immunization Program, explained that schools play a crucial role in encouraging parents to prioritize vaccination.

To illustrate this point, an outbreak of pertussis (whooping cough) occurred at a large high school in Winnetka, Illinois, in December. Despite receiving pertussis vaccines during childhood, more than 30 cases were reported among sophomores, juniors, and seniors, as the effectiveness of the vaccine had dwindled over time. Although the school took measures to prevent the spread of illness by excluding students with coughing symptoms, the county health department noticed that the rate of booster shots remained low among students, contrary to recommendations. As a result, the health department had to purchase vaccines and administer booster shots on campus.

Dr. Catherine Counard, the assistant medical director for communicable-disease control at the Cook County Department of Public Health, mentioned that some parents encountered difficulties obtaining the vaccine, while others simply did not perceive the need for it. Dr. Counard attributed society’s complacency towards infectious diseases to a lack of firsthand experience.

However, school involvement in immunization efforts is not without its challenges. Ann Hoxie, the administrator for student wellness in the St. Paul district, highlighted how time-consuming it can be for personnel. She recounted a trip to Atlanta where the CDC discussed whether the hepatitis B vaccine should be recommended for children. During the discussion, someone suggested passing a law to make it mandatory, to which Ms. Hoxie responded by questioning the resources required for such an initiative.

Ms. Somerville, from the Baltimore County school system, shared that extensive preparations were made to implement Maryland’s revised immunization policy. Although the policy was initially planned to be enforced in the 2006-07 school year, schools were granted a one-semester extension. Weeks were dedicated to engaging with parents and addressing their concerns. Rhonda C. Gill, the director of student services in Anne Arundel County, Maryland, echoed Ms. Somerville’s experience, emphasizing that the focus has shifted to working with school personnel who handle truancy. Families that the district has been unable to reach likely have children facing chronic attendance issues.

According to Ms. Gill, difficulties in ensuring children receive necessary vaccinations have always existed. However, the current immunization mandate has garnered more attention and publicity. She believes that once this period passes, vaccination efforts will become routine.