Dissertations and Theses

Date of Degree


Document Type


Degree Name

Doctor of Public Health (DPH)


Community Health and Social Sciences


Betty Wolder Levin

Committee Members

Mary Clare Lennon

William T Gallo

Jane R Zucker

Subject Categories

Public Affairs, Public Policy and Public Administration | Public Health


vaccine mandate effectiveness, vaccine mandate ethics


Background. In 2014, New York City (NYC) became the third jurisdiction in the United States (US) to enact a childcare influenza vaccine mandate, after the states of New Jersey and Connecticut. The mandate was enacted by the NYC Board of Health by amending the NYC Health Code. The mandate’s goal was to increase vaccination rates among 6-59-month-olds attending city-regulated public and private childcare programs, including prekindergarten, to protect children, families, and the community against influenza. Children younger than 5 years are at high risk for severe illness and complications from influenza. Children are also known to be a major source of influenza transmission in communities. The mandate covered an estimated 122,430 children, representing approximately 24% (122,430/508,112) of all 6-59-month-olds in NYC. Five mothers brought a lawsuit against the mandate in November, 2015. In response, the New York State Supreme Court suspended the mandate in mid-December, 2015, in a ruling stating the NYC Board of Health did not have the authority to require a vaccine not authorized under state law. NYC appealed, but the suspension was upheld by the State Supreme Court, Appellate Division, in October, 2016. This court ruled that the NYC Board of Health had the authority to require the vaccine, but upheld the suspension because the mandate applied to city-regulated childcare, not all childcare in NYC, and, in their opinion, it wrongly allowed childcare programs to opt out of excluding noncompliant children by paying fines. NYC is preparing a second appeal and is also continuing to advocate for the New York State Legislature to add the childcare influenza vaccine requirement by changing state law.

Objectives. This study had two aims. Aim 1 was to analyze the rationale and ethics of the mandate. The decision to mandate a childhood vaccine requires careful consideration because it infringes upon parental autonomy and can generate controversy that may undermine public acceptance of vaccines in general. Aim 2 was to assess the mandate’s effect on influenza vaccination rates among 6-59-month-olds citywide. The findings were intended to guide future decisions to enact childhood vaccine mandates.

Methods. This research followed a convergent mixed methods study design in which qualitative and quantitative methods were used complementarily. A single-case study with record review was used to achieve Aim 1, along with an application of the Kass, and Field and Caplan conceptual frameworks to analyze the mandate’s ethics. For Aim 2, a short, interrupted time-series method was used to examine influenza vaccination rates among 6-59-month-olds as of December 31 in 8 annual influenza seasons before the mandate (2006-07 through 2013-14), 2 seasons during the mandate (2014-15 through 2015-16), and one season after the mandate’s suspension (2016-17). Vaccination rates were also assessed among a control group of 5-8-year-olds and among the aggregate groups of 6-59-month-olds and 5-8- year-olds stratified by one-year age groups.

Results. NYC gathered and analyzed scientific evidence, reached out to community partners, and deliberated for nearly one year before deciding to seek enactment of the mandate by the NYC Board of Health. The decision was reached only after advocacy to add the childcare influenza vaccine requirement by changing state law was unsuccessful. The time-series analysis of vaccination rates showed the mandate had little impact on rates among the aggregate group of 6-59-month-olds. Among 4-year-olds, however, vaccination rates increased 11.4 percentage points, by far the largest increase among all age groups. The vaccination rate dropped by 12.1 percentage points among 4-year-olds after the mandate was suspended.

Conclusions. The rationale for the mandate was strong based on evidence of the health and economic burden of influenza, increased vaccination rates reported by New Jersey and Connecticut, and the support of pediatricians, nurses, and pro-vaccine parents. Application of the Kass framework found the mandate ethical because it was enacted through a democratic process, applied to all 6-59-month-olds attending city-regulated childcare and prekindergarten, allowed for legitimate medical or religious exemptions, and was effective in raising vaccination rates among 4-year-olds. Based on the Field and Caplan framework, the mandate was ethical because NYC’s obligation for utilitarianism, beneficence, justice and nonmaleficence took precedence over parental autonomy in the context of the potentially severe disease of influenza. Despite the mandate’s suspension and subsequent loss of gains realized in raising vaccination rates, NYC was able to demonstrate the mandate’s success at increasing influenza vaccine uptake among 4-year-olds, the largest age group in childcare and prekindergarten. This evidence offers strong support for a change in state law to implement the childcare influenza vaccine requirement statewide. In the absence of such a change, alternatives to a mandate for increasing influenza vaccination rates among young children in NYC are needed.



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