COMMENTARY
School-Located Influenza Vaccination: Can Collaborative Efforts Go the Distance? Sharon G. Humiston, MD, MPH; Katherine A. Poehling, MD, MPH; Peter G. Szilagyi, MD, MPH From the Department of Pediatrics (Dr Humiston), Children’s Mercy Hospital and Clinics, Kansas City, MO; Department of Pediatrics (Dr Poehling), Wake Forest School of Medicine, Winston Salem, NC; and Department of Pediatrics (Dr Szilagyi), University of Rochester School of Medicine and Dentistry, Rochester, NY Dr Poehling reports research funding from NIH, Medimmune, and BD Diagnostics. Drs Humiston and Szilagyi have no conflicts of interest to disclose. Address correspondence to Sharon G. Humiston, MD, MPH, Department of Pediatrics, Children’s Mercy Hospital and Clinics, 2401 Gillham Road, Kansas City, MO 64108 (e-mail: [email protected]). Received for publication March 10, 2014; accepted March 10, 2014.
ACADEMIC PEDIATRICS 2014;14:219–220
DESPITE A LARGE amount of publicity about universal pediatric influenza vaccination, nationally, influenza vaccination rates among school-aged children remain low. Only 59% of 5- to 12-year-old children and 43% of 13- to 17-year-old adolescents were vaccinated during the 2012 to 2103 flu vaccination season.1 It is time to consider new paradigms to complement traditional influenza vaccinations in primary care. One “new” paradigm involves school-located influenza vaccination (SLIV), about which there is a great deal of confusion. There are 3 general types of SLIV: 1) influenza vaccination that is part of existing school-based health center activities, 2) programs that take place before or after school hours and use the schools as sites for vaccinations (often vaccinating school personnel and parents, and potentially children who accompany parents, and 3) programs that vaccinate children during the school day without parents being present at the time of vaccination. The first model involves school-based health centers, which deliver comprehensive health services so the licensing, staffing, and billing issues are dictated by the general health center activities. Because there are only approximately 2000 such centers,2 a relatively small proportion of US children or adolescents have access to them and SLIV must include many more models to have a meaningful effect on influenza immunization coverage. The second model mirrors influenza vaccination programs that exist at malls, airports, and other locations. These often focus on adult vaccination and are no more convenient for parents than vaccination in medical offices. The third model, which occurs during the school day without parents being present, is the most intriguing yet challenging to implement because it involves issues of parental consent, billing a variety of insurers, estimating the number of vaccines to order for SLIV well before the season, practical challenges of vaccinating children during school hours, and communications with primary health care providers. ACADEMIC PEDIATRICS Copyright ª 2014 by Academic Pediatric Association
The concept of SLIV should be kept distinct from vaccination against other diseases or at other sites in the community. During discussions of SLIV, the topic should be limited to influenza vaccination. Many experts who believe there is a place for SLIV in the array of strategies to increase national influenza vaccination coverage would not be comfortable with uncoupling other vaccinations from the medical home. All other childhood and adolescent immunizations are given at any time of the year rather than during influenza vaccination’s relatively short fall to winter flu vaccination window. This commentary, therefore, focuses on the third model of SLIV—influenza vaccinations during the school day. Vaccinating during the school day—when parents are not present—allows parents to keep working (on the job or in the home) rather than taking time out to accompany their child. Because only a small percentage of schoolaged children make a visit to primary care during influenza vaccination season,3 SLIV can save parents time, prevent children from missing school to attend a medical visit, and potentially save the health care system money. A recent randomized clinical trial of this SLIV model noted greater immunization rates in SLIV than in control schools.4 The logistic challenges are notable: SLIV during school hours creates the need to develop a communication process to inform parents, a parental consent process, a mechanism for the vaccine clinics, and communication with primary care providers. Offering injectable and intranasal spray vaccine allows choice of vaccine for parents and the sizable proportion of children with a contraindication to the intranasal spray (eg, 9% of children have asthma5) to be vaccinated. It also increases the complexity of parent education, consent, and many aspects of the SLIV clinics’ organization. Most SLIV programs use nonschool personnel (eg, health department staff or commercial community vaccinators), to deliver the vaccine and run the “Vaccine Day,” which limits the
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burden on the school nurse, but also limits the number of opportunities a child has to be vaccinated at school. Models that use school nurses are able to vaccinate children who might have been absent on “Vaccine Day.” Most previously described models of SLIV required financial support in the form of free vaccine, free labor, or both. The work of Kempe et al, detailed in this issue,6 describes an SLIV model in which billing for vaccine and vaccine administration was part of the team’s activities. This pioneering demonstration project has led the Centers for Disease Control and Prevention to further explore related models in several states. All models of SLIV require collaboration between “silos” that are rarely brought together. The Denver SLIV program demonstrated this clearly. For this school-day vaccination program, the school personnel helped to gather parental consent through communication from the classroom teacher and, in the second year, by adding the consent package to other school registration materials. School personnel followed up on missing information from consent forms, set up the vaccination clinics, and escorted students. Community vaccinators attended school registration and other back-to-school activities to answer parents’ questions; they also administered the vaccinations and carried out the multistep billing process. The public sector’s most notable contribution—maintaining the infrastructure to provide the Vaccine For Children vaccines—is easy to overlook, but is crucial. This study was not designed to evaluate how much the SLIV program improved the vaccination rates, but it is notable that 30% of these elementary school students received influenza vaccine in schools in which 87% of the students were eligible for the Free and Reduced Lunch program. Presumably, many of these children would not have received an influenza vaccination that year if it were not for the SLIV program. What do parents think of SLIV? In this issue, Kempe et al describe the results of a survey of parents of elementary school children from schools that participated in the SLIV program.7 Most parents of children in these schools were very strongly positive about the SLIV program, but most had not had their child participate. Perhaps not surprisingly, parents who perceived the vaccine as efficacious and the SLIV program as convenient were more likely to be positive about the program and to have had their child participate in it. Despite efforts to advertise the program, approximately 1 of 4 parents who responded to the survey had not heard previously about the SLIV program in their
ACADEMIC PEDIATRICS
school. Interestingly, among parents who usually paid a copay for their child’s vaccination, approximately a third were somewhat or not at all willing to pay the same copay for a vaccine given in a SLIV program. Overall, parents viewed SLIV favorably. Primary care providers have done a remarkable job of embracing and realizing the universal influenza vaccination recommendation of the Centers for Disease Control and Prevention8 and the American Academy of Pediatrics. Nonetheless, it seems likely that to increase influenza vaccination rates will require vaccinating “outside the box,” that is, in sites other than the medical home. Because influenza immunization rates tend to decrease from infancy through adolescence1 and the difficulty of getting patients into the office tends to increase with the child’s age, it seems important to utilize a site in which school-aged youth already tend to congregate (ie, schools).
ACKNOWLEDGMENTS Drs. Humiston and Szilagyi were funded in part by a grant from the Agency for Healthcare Research and Quality (R18HS021163 PI – Szilagyi).
REFERENCES 1. Centers for Disease Control and Prevention. Flu vaccination coverage, United States, 2012-13 influenza season. Available at: http://www. cdc.gov/flu/fluvaxview/coverage-1213estimates.htm. Accessed March 9, 2014. 2. Council on School Health. School-based health centers and pediatric practice. Pediatrics. 2012;129:387–393. 3. Rand CM, Szilagyi PG, Yoo BK, et al. Additional visit burden for universal influenza vaccination of US school-aged children and adolescents. Arch Pediatr Adolesc Med. 2008;162:1048–1055. 4. Humiston SG, Schaffer SJ, Szilagyi PG, et al. Seasonal influenza vaccination at school: a randomized controlled trial. Am J Prev Med. 2014; 46:1–9. 5. U.S. Department of Health and Human Services. Centers for Disease Control and Prevention. Vital and Health Statistics; Summary Health Statistics for U.S. Children: National Health Interview Survey, 2012. Available at: http://www.cdc.gov/nchs/data/series/sr_10/sr10_258.pdf. Accessed March 9, 2014. 6. Kempe A, Daley MF, Pyrzanowski J, et al. School-located influenza vaccination with third party billing: outcomes, cost and reimbursement. Acad Pediatr. 2014;14:234–240. 7. Kempe A, Daley MF, Pyrzanowski J, et al. School-located influenza vaccination with third-party billing: what do parents think? Acad Pediatr. 2014;14:241–248. 8. Fiore AE, Shay DK, Broder K, et al. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2008. MMWR Recomm Rep. 2008;57(RR-7): 1–60.
School-Located Influenza Vaccination: Can Collaborative Efforts Go the Distance? Sharon G. Humiston, MD, MPH; Katherine A. Poehling, MD, MPH; Peter G. Szilagyi, MD, MPH From the Department of Pediatrics (Dr Humiston), Children’s Mercy Hospital and Clinics, Kansas City, MO; Department of Pediatrics (Dr Poehling), Wake Forest School of Medicine, Winston Salem, NC; and Department of Pediatrics (Dr Szilagyi), University of Rochester School of Medicine and Dentistry, Rochester, NY Dr Poehling reports research funding from NIH, Medimmune, and BD Diagnostics. Drs Humiston and Szilagyi have no conflicts of interest to disclose. Address correspondence to Sharon G. Humiston, MD, MPH, Department of Pediatrics, Children’s Mercy Hospital and Clinics, 2401 Gillham Road, Kansas City, MO 64108 (e-mail: [email protected]). Received for publication March 10, 2014; accepted March 10, 2014.
ACADEMIC PEDIATRICS 2014;14:219–220
DESPITE A LARGE amount of publicity about universal pediatric influenza vaccination, nationally, influenza vaccination rates among school-aged children remain low. Only 59% of 5- to 12-year-old children and 43% of 13- to 17-year-old adolescents were vaccinated during the 2012 to 2103 flu vaccination season.1 It is time to consider new paradigms to complement traditional influenza vaccinations in primary care. One “new” paradigm involves school-located influenza vaccination (SLIV), about which there is a great deal of confusion. There are 3 general types of SLIV: 1) influenza vaccination that is part of existing school-based health center activities, 2) programs that take place before or after school hours and use the schools as sites for vaccinations (often vaccinating school personnel and parents, and potentially children who accompany parents, and 3) programs that vaccinate children during the school day without parents being present at the time of vaccination. The first model involves school-based health centers, which deliver comprehensive health services so the licensing, staffing, and billing issues are dictated by the general health center activities. Because there are only approximately 2000 such centers,2 a relatively small proportion of US children or adolescents have access to them and SLIV must include many more models to have a meaningful effect on influenza immunization coverage. The second model mirrors influenza vaccination programs that exist at malls, airports, and other locations. These often focus on adult vaccination and are no more convenient for parents than vaccination in medical offices. The third model, which occurs during the school day without parents being present, is the most intriguing yet challenging to implement because it involves issues of parental consent, billing a variety of insurers, estimating the number of vaccines to order for SLIV well before the season, practical challenges of vaccinating children during school hours, and communications with primary health care providers. ACADEMIC PEDIATRICS Copyright ª 2014 by Academic Pediatric Association
The concept of SLIV should be kept distinct from vaccination against other diseases or at other sites in the community. During discussions of SLIV, the topic should be limited to influenza vaccination. Many experts who believe there is a place for SLIV in the array of strategies to increase national influenza vaccination coverage would not be comfortable with uncoupling other vaccinations from the medical home. All other childhood and adolescent immunizations are given at any time of the year rather than during influenza vaccination’s relatively short fall to winter flu vaccination window. This commentary, therefore, focuses on the third model of SLIV—influenza vaccinations during the school day. Vaccinating during the school day—when parents are not present—allows parents to keep working (on the job or in the home) rather than taking time out to accompany their child. Because only a small percentage of schoolaged children make a visit to primary care during influenza vaccination season,3 SLIV can save parents time, prevent children from missing school to attend a medical visit, and potentially save the health care system money. A recent randomized clinical trial of this SLIV model noted greater immunization rates in SLIV than in control schools.4 The logistic challenges are notable: SLIV during school hours creates the need to develop a communication process to inform parents, a parental consent process, a mechanism for the vaccine clinics, and communication with primary care providers. Offering injectable and intranasal spray vaccine allows choice of vaccine for parents and the sizable proportion of children with a contraindication to the intranasal spray (eg, 9% of children have asthma5) to be vaccinated. It also increases the complexity of parent education, consent, and many aspects of the SLIV clinics’ organization. Most SLIV programs use nonschool personnel (eg, health department staff or commercial community vaccinators), to deliver the vaccine and run the “Vaccine Day,” which limits the
219
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burden on the school nurse, but also limits the number of opportunities a child has to be vaccinated at school. Models that use school nurses are able to vaccinate children who might have been absent on “Vaccine Day.” Most previously described models of SLIV required financial support in the form of free vaccine, free labor, or both. The work of Kempe et al, detailed in this issue,6 describes an SLIV model in which billing for vaccine and vaccine administration was part of the team’s activities. This pioneering demonstration project has led the Centers for Disease Control and Prevention to further explore related models in several states. All models of SLIV require collaboration between “silos” that are rarely brought together. The Denver SLIV program demonstrated this clearly. For this school-day vaccination program, the school personnel helped to gather parental consent through communication from the classroom teacher and, in the second year, by adding the consent package to other school registration materials. School personnel followed up on missing information from consent forms, set up the vaccination clinics, and escorted students. Community vaccinators attended school registration and other back-to-school activities to answer parents’ questions; they also administered the vaccinations and carried out the multistep billing process. The public sector’s most notable contribution—maintaining the infrastructure to provide the Vaccine For Children vaccines—is easy to overlook, but is crucial. This study was not designed to evaluate how much the SLIV program improved the vaccination rates, but it is notable that 30% of these elementary school students received influenza vaccine in schools in which 87% of the students were eligible for the Free and Reduced Lunch program. Presumably, many of these children would not have received an influenza vaccination that year if it were not for the SLIV program. What do parents think of SLIV? In this issue, Kempe et al describe the results of a survey of parents of elementary school children from schools that participated in the SLIV program.7 Most parents of children in these schools were very strongly positive about the SLIV program, but most had not had their child participate. Perhaps not surprisingly, parents who perceived the vaccine as efficacious and the SLIV program as convenient were more likely to be positive about the program and to have had their child participate in it. Despite efforts to advertise the program, approximately 1 of 4 parents who responded to the survey had not heard previously about the SLIV program in their
ACADEMIC PEDIATRICS
school. Interestingly, among parents who usually paid a copay for their child’s vaccination, approximately a third were somewhat or not at all willing to pay the same copay for a vaccine given in a SLIV program. Overall, parents viewed SLIV favorably. Primary care providers have done a remarkable job of embracing and realizing the universal influenza vaccination recommendation of the Centers for Disease Control and Prevention8 and the American Academy of Pediatrics. Nonetheless, it seems likely that to increase influenza vaccination rates will require vaccinating “outside the box,” that is, in sites other than the medical home. Because influenza immunization rates tend to decrease from infancy through adolescence1 and the difficulty of getting patients into the office tends to increase with the child’s age, it seems important to utilize a site in which school-aged youth already tend to congregate (ie, schools).
ACKNOWLEDGMENTS Drs. Humiston and Szilagyi were funded in part by a grant from the Agency for Healthcare Research and Quality (R18HS021163 PI – Szilagyi).
REFERENCES 1. Centers for Disease Control and Prevention. Flu vaccination coverage, United States, 2012-13 influenza season. Available at: http://www. cdc.gov/flu/fluvaxview/coverage-1213estimates.htm. Accessed March 9, 2014. 2. Council on School Health. School-based health centers and pediatric practice. Pediatrics. 2012;129:387–393. 3. Rand CM, Szilagyi PG, Yoo BK, et al. Additional visit burden for universal influenza vaccination of US school-aged children and adolescents. Arch Pediatr Adolesc Med. 2008;162:1048–1055. 4. Humiston SG, Schaffer SJ, Szilagyi PG, et al. Seasonal influenza vaccination at school: a randomized controlled trial. Am J Prev Med. 2014; 46:1–9. 5. U.S. Department of Health and Human Services. Centers for Disease Control and Prevention. Vital and Health Statistics; Summary Health Statistics for U.S. Children: National Health Interview Survey, 2012. Available at: http://www.cdc.gov/nchs/data/series/sr_10/sr10_258.pdf. Accessed March 9, 2014. 6. Kempe A, Daley MF, Pyrzanowski J, et al. School-located influenza vaccination with third party billing: outcomes, cost and reimbursement. Acad Pediatr. 2014;14:234–240. 7. Kempe A, Daley MF, Pyrzanowski J, et al. School-located influenza vaccination with third-party billing: what do parents think? Acad Pediatr. 2014;14:241–248. 8. Fiore AE, Shay DK, Broder K, et al. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2008. MMWR Recomm Rep. 2008;57(RR-7): 1–60.
