The use of school-based vaccination clinics to control varicella outbreaks in two schools

School-based human papillomavirus vaccination program for increasing vaccine uptake in an underserved area in Texas

Objective

Compare the effectiveness of community-based HPV-related education and onsite school-based vaccination versus community-based education only for increasing HPV vaccine uptake in a rural, medically underserved area.

Methods

Our cohort included 2307 Rio Grande City Consolidated Independent School District (RGCISD) middle school students from 3 schools enrolled in August 2016 and followed until April 2018. Using a quasi-experimental design, this study implemented an onsite school-based vaccination program and physician-led education on HPV and HPV vaccines for parents/guardians, school nurses/staff, and pediatric/family providers in the surrounding community (15-mile radius of RGCCISD) at 1 middle school (“intervention school”), and education-only for the remaining 2 schools (“comparison schools”). The Centers for Disease Control and Prevention's HPV-related educational materials supplemented the education. HPV vaccine status was obtained from school immunization records and the project's contracted vaccine vendor. HPV vaccine initiation and completion rates were compared pre and post intervention and between the intervention and comparison schools. Logistic regression was used to compare the odds of newly initiating/completing vaccination between the intervention and comparison schools.

Results

At baseline, the intervention school had lower HPV vaccine initiation and completion rates than the comparison schools (20.00% and 8.70% vs 28.97% and 14.56%). Post intervention, the intervention school had higher initiation and completion rates than the comparison schools (53.67% and 28.36% vs 41.56% and 20.53%). Students from the intervention school were over 3.6-times more likely to newly initiate/complete the HPV vaccinations than students from the comparison schools.

Conclusion

The school with on-site vaccination events and community-based education had a higher adolescent HPV vaccination rate compared to schools that received community-based education only.

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Our study implemented the first school-based vaccination program in a rural, medically underserved area in Texas.

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School-based vaccinations and community education increased the HPV vaccination rate at a greater rate than education only.

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Our work demonstrates that middle schools provide feasible and effective settings for increasing HPV vaccination rates.

Opportunities for increasing human papillomavirus vaccine provision in school health centers

BACKGROUND

Uptake of human papillomavirus (HPV) vaccine remains low among adolescents in the United States. We sought to assess barriers to HPV vaccine provision in school health centers to inform subsequent interventions.

METHODS

We conducted structured interviews in the fall of 2010 with staff from all 33 school health centers in North Carolina that stocked HPV vaccine.

RESULTS

Centers had heterogeneous policies and procedures. Out-of-pocket costs for children and youth to receive privately purchased HPV vaccine were a key barrier to providing HPV vaccine within school health centers. Other barriers included students not returning consent forms, costs to clinics of ordering and stocking privately purchased HPV vaccine, and difficulty using the statewide immunization registry. Most (82%) school health centers were interested in hosting interventions to increase HPV vaccine uptake, especially those that the centers could implement themselves, but many had limited staff to support such efforts. Activities rated as more likely to raise HPV vaccine uptake were student incentives, parent reminders, and obtaining consent from parents while they are at school (all ps < .05).

CONCLUSIONS

Although school health centers reported facing several key barriers to providing HPV vaccine, many were interested in partnering with outside organizations on low-cost interventions to increase HPV vaccine uptake among adolescents.

Varicella-zoster vaccine in the USA: success for control of disease severity, but what next?

In the period from 1990 to 1994, before the introduction of a varicella vaccine to the USA, approximately 100 deaths in otherwise healthy individuals, children and adolescents under 20 years of age, were attributable to varicella complications. The administration of a single-dose vaccine has now been widespread in the USA for nearly 10 years; however, since the effectiveness of a single dose in children under 13 years of age in an outbreak situation is approximately 80%, consideration of a second booster dose is in progress although not yet recommended. Licensure of a measles-mumps-rubella-varicella vaccine may hasten the recommendation.

Seasonal influenza vaccination at school: a randomized controlled trial

BACKGROUND

Influenza vaccination coverage for U.S. school-aged children is below the 80% national goal. Primary care practices may not have the capacity to vaccinate all children during influenza vaccination season. No real-world models of school-located seasonal influenza (SLV-I) programs have been tested.

PURPOSE

Determine the feasibility, sustainability, and impact of an SLV-I program providing influenza vaccination to elementary school children during the school day.

DESIGN

In this pragmatic randomized controlled trial of SLV-I during two vaccination seasons, schools were randomly assigned to SLV-I versus standard of care. Seasonal influenza vaccine receipt, as recorded in the state immunization information system (IIS), was measured.

SETTING/PARTICIPANTS

Intervention and control schools were located in a single western New York county. Participation (intervention or control) included the sole urban school district and suburban districts (five in Year 1, four in Year 2).

INTERVENTION

After gathering parental consent and insurance information, live attenuated and inactivated seasonal influenza vaccines were offered in elementary schools during the school day.

MAIN OUTCOME MEASURES

Data on receipt of ≥1 seasonal influenza vaccination in Year 1 (2009-2010) and Year 2 (2010-2011) were collected on all student grades K through 5 at intervention and control schools from the IIS in the Spring of 2010 and 2011, respectively. Additionally, coverage achieved through SLV-I was compared to coverage of children vaccinated elsewhere. Preliminary data analysis for Year 1 occurred in Spring 2010; final quantitative analysis for both years was completed in late Fall 2012.

RESULTS

Results are shown for 2009-2010 and 2010-2011, respectively: Children enrolled in suburban SLV-I versus control schools had vaccination coverage of 47% vs 36%, and 52% vs 36% (p<0.0001 both years). In urban areas, coverage was 36% vs 26%, and 31% vs 25% (p<0.001 both years). On multilevel logistic analysis with three nested levels (student, school, school district) during both vaccination seasons, children were more likely to be vaccinated in SLV-I versus control schools; ORs were 1.6 (95% CI=1.4, 1.9; p<0.001) and 1.5 (95% CI=1.3, 1.8; p<0.001).

CONCLUSIONS

Delivering influenza vaccine during school is a promising approach to improving pediatric influenza vaccination coverage.

TRIAL REGISTRY

ClinicalTrials.govNCT01224301.

Physician attitudes regarding school-located vaccination clinics

BACKGROUND

School-located vaccination clinics offer an opportunity to target children for vaccination programs during communicable disease outbreaks. However, children in the United States are primarily vaccinated in the pediatrician's or family physician's office, and the concept of school-located vaccinations may be unfamiliar to some parents and guardians. Physician support could contribute to effective implementation of school-located vaccination clinics during outbreak situations. The primary objective of the study was to assess physician opinion of using school-located vaccination clinics to administer both outbreak-specific and routine vaccines.

METHODS

A statewide mail and Internet survey was administered to 275 pediatricians and 275 family physicians in Oregon during July and August 2010.

RESULTS

Ninety-one percent of physicians supported the use of school-located vaccination clinics as immunization delivery sites during outbreak situations. Sixty percent of physicians supported using school-located vaccination clinics to administer routine vaccinations. Only 57% of physicians had knowledge of school-located vaccination clinic availability to their patients.

CONCLUSIONS

Pediatricians and family physicians expressed strong support of school vaccination clinics as sites for immunization delivery during outbreak situations but significantly less support for administering routine vaccinations. Increasing physician awareness of school-located vaccination clinic availability and establishing partnerships between physician practices and school vaccination clinics may improve access to immunizations for school-aged children and adolescents, particularly during large-scale communicable disease outbreaks.

Successful use of volunteers to conduct school-located mass influenza vaccination clinics

OBJECTIVE

To determine the feasibility of using volunteers to assist in school-located mass vaccination clinics for influenza.

METHODS

A set of elementary school-based mass vaccination clinics was implemented in Carroll County, Maryland by the local health department in the 2005-2006 school year. In addition to using health department personnel, fiscal restraints necessitated using medical volunteers and lay volunteers to assist health professionals. The medical volunteers included physicians, nurses, and pharmacists, and were responsible for administering intranasal vaccine (live, attenuated influenza vaccine [LAIV]). We assessed the performance, as measured by the number of vaccinations administered, and effort expended by these volunteers.

RESULTS

A total of 5319 (44%) of the 12,090 elementary school children in the county received LAIV. Of the estimated 3547 (66%) children eligible and consenting to receive a second dose, 3124 (88%) received it. In total, 8806 doses of LAIV were administered. Health department nurses worked 42 person-days and were assisted by medical and allied health professionals volunteering 87 person-days without compensation, totaling 581 person-hours spent in this effort.

CONCLUSIONS

A mass school-located influenza vaccination program using medical and lay volunteers guided by health department nurses is feasible. Several issues were identified to improve future clinics and help make the program sustainable.

Default policies and parents' consent for school-located HPV vaccination

While defaults may encourage some health behaviors, how defaults influence controversial behaviors is not well understood. We examined the effect of two default policies on parents' consent to have their adolescent sons hypothetically receive HPV vaccine at school. A national sample of 404 parents of adolescent sons participated in an online 3 × 2 between-subjects factorial experiment. Factors varied the default consent policy (opt-in, opt-out, or neutral) and the number of vaccines sons would receive (HPV vaccine alone or along with two other recommended adolescent vaccines). Among parents wanting to get their sons HPV vaccine in the next year, consent was higher in the opt-in condition (compared to the opt-out condition) or if other recommended adolescent vaccines would be included. Default policies had no effect among parents undecided about HPV vaccination. Parents' consent for school-located HPV vaccination may be higher when presented as an opt-in decision and other vaccines are included.

Using the North Dakota Immunization Information System to determine adolescent vaccination rates and uptake

OBJECTIVES

We described the uptake and coverage rates of meningococcal conjugate vaccine (MCV4); tetanus-diphtheria-acellular pertussis vaccine (Tdap); and quadrivalent human papillomavirus vaccine (HPV4) in North Dakota using the North Dakota Immunization Information System (NDIIS).

METHODS

We analyzed all available MCV4, Tdap, and HPV4 doses given after vaccine licensure and through December 31, 2009, obtained from the NDIIS to identify trends and patterns in vaccine administration. We analyzed all data by administration date, age group, and health-care provider type. We also calculated missed opportunities to complete all recommended vaccines among vaccinated adolescents.

RESULTS

For adolescents aged 13-17 years, 69.2% had > or = 1 dose of Tdap and 62.8% had > or = 1 dose of MCV4. Of females aged 13-17 years, 42.8% initiated the HPV4 vaccination series and 24.9% received > or = 3 HPV4 doses. Only 48.7% of males aged 13-17 years received both Tdap and MCV4 at the same visit, and only 11.5% of females aged 13-17 years received Tdap, MCV4, and HPV4 doses at the first visit.

CONCLUSIONS

The NDIIS is useful in tracking adolescent vaccine uptake. The immunization rates for all three routinely recommended adolescent vaccines are rising in North Dakota, although at different paces. Providers should be educated about the importance of not missing opportunities to vaccinate, and school-based vaccination clinics should be used to reach adolescents who are less likely to have preventive care visits.

Incremental effectiveness of second dose varicella vaccination for outbreak control at an elementary school in Philadelphia, pennsylvania, 2006

BACKGROUND

In 2006, the Philadelphia Department of Public Health conducted an investigation of a varicella outbreak at an elementary school in which second-dose vaccination for outbreak control (VOC) was implemented. We evaluated the effectiveness of this intervention.

METHODS

Self-administered questionnaires collected varicella disease and vaccination information. Students eligible for second-dose VOC were 1-dose vaccine recipients without prior varicella disease. A breakthrough varicella case was defined as a maculopapulovesicular rash in a student with onset >42 days after 1-dose vaccination without other apparent cause. Vaccine effectiveness was evaluated using survival analysis techniques and analyzed by vaccine status (first dose versus second dose). Multivariable Cox proportional hazard models were used to identify statistical interactions and adjust for confounders.

RESULTS

The questionnaire response rate was 92% (342/370). Of the 286 eligible students, 187 (65%) received a second-dose VOC. The crude attack rate was 9/187 (5%) among second-dose VOC recipients; 43/99 (43%) among 1-dose recipients, and 5/6 (83%) among unvaccinated students. Second-dose VOC recipients had milder rashes, compared with 1-dose or unvaccinated students. The adjusted incremental second-dose vaccine effectiveness was 76% (95% confidence interval: 44%-90%) for students with classroom exposure. Incremental effectiveness was similar (79%) when we extended the immune response time from 4 days to 7 days after second-dose VOC.

CONCLUSIONS

Second-dose VOC resulted in a substantial reduction in varicella incidence for students with classroom exposure. Until high rates of routine second-dose vaccine coverage are achieved, clinicians should consider second-dose VOC an appropriate intervention to reduce disease transmission in institution-based outbreaks.

School-Located Vaccination Clinics: Then and Now

School-located vaccination has a long history in the United States. The 2008 Advisory Committee on Immunization Practices (ACIP) recommendation for annual influenza vaccination of all children 6 months through 18 years of age adds approximately 30 million individuals to the overall cohort recommended to have a yearly vaccination. Th\e ability to administer this vast number of vaccinations may be beyond the capacity of primary care providers, leaving schools as an attractive venue for mass immunization clinics.

'It's a logistical nightmare!' Recommendations for optimising human papillomavirus school-based vaccination experience

Introduction: To date, no published studies examine procedural factors of the school-based human papillomavirus (HPV) vaccination program from the perspective of those involved. This study examines the factors that were perceived to impact optimal vaccination experience. Methods: Schools across Sydney were selected to reflect a range of vaccination coverage at the school level and different school types to ensure a range of experiences. Semi-structured focus groups were conducted with girls; and one-on-one interviews were undertaken with parents, teachers and nurses until saturation of data in all emergent themes was reached. Focus groups and interviews explored participants’ experiences in school-based HPV vaccination. Transcripts were analysed, letting themes emerge. Results: Themes related to participants’ experience of the organisational, logistical and procedural aspects of the vaccination program and their perceptions of an optimal process were organised into two categories: (1) preparation for the vaccination program and (2) vaccination day strategies. In (1), themes emerged regarding commitment to the process from those involved, planning time and space for vaccinations, communication within and between agencies, and flexibility. In (2), themes included vaccinating the most anxious girls first, facilitating peer support, use of distraction techniques, minimising waiting time girls, and support staff. Discussion: A range of views exists on what constitutes an optimal school-based program. Several findings were identified that should be considered in the development of guidelines for implementing school-based programs. Future research should evaluate how different approaches to acquiring parental consent, and the use of anxiety and fear reduction strategies impact experience and uptake in the school-based setting.

The role of schools in strengthening delivery of new adolescent vaccinations

Schools offer an opportunity to deliver new vaccines to adolescents who may not receive them in their medical home. However, school budgets and health priorities are set at the local level; consequently resources devoted to health-related activities vary widely. Partnering with schools requires soliciting buy-in from stakeholders at district and school levels and providing added value to schools. With appropriate resources and partnerships, schools could carry out vaccination-related activities from educating students, parents, and communities to developing policies supporting vaccination, providing vaccines, or serving as the site at which partners administer vaccines. Activities will vary among schools, but every school has the potential to use some strategies that promote adolescent vaccination.

A pilot study of the effectiveness of a school-based influenza vaccination program

OBJECTIVE

The objective of this study was to evaluate the feasibility of a school-based influenza immunization program.

METHODS

Pupils and their families from 3 demographically similar elementary schools participated in this pilot, unblinded, controlled intervention study. Live attenuated influenza vaccine (FluMist) was made available to all eligible pupils in 1 target school during regular school hours. Two schools where vaccine was not offered served as control schools. All families from the 3 study schools were sent an anonymous questionnaire requesting 7-day recall data on fever or respiratory illness (FRI)-related medical visits, medications purchased, and days of school or paid work lost during the peak influenza week. Changes in weekly pupil absenteeism were also examined.

RESULTS

One hundred eighty-five (40%) of the target school pupils received vaccine, of whom >50% were vaccinated < or =3 weeks before the influenza outbreak period. Questionnaires were returned by 43% to 51% of households. Significant (45-70%) relative reductions in FRI-related outcomes, including doctor visits by adults or children, prescription or other medicines purchased, and family schooldays or workdays missed, were observed for target school households, compared with control school households. The increases in absenteeism rates during the influenza outbreak period, compared with baseline rates earlier in the fall, were not significantly different between target and control schools. Within the target school, however, the increase in absenteeism rates was significantly smaller for the FluMist-vaccinated pupils, compared with the non-FluMist-vaccinated pupils.

CONCLUSIONS

This school-based influenza immunization program was associated with significant reductions in FRI-related outcomes in households of pupils attending an intervention school. These results might have underestimated the potential impact of FluMist, because the majority of children received intraepidemic vaccination.

Varicella: a vaccine preventable disease?

OBJECTIVES

To present a review of varicella disease, vaccine development and implementation of universal vaccination, discuss common questions about the vaccine and the epidemiology of the disease since licensure of the varicella vaccine.

METHODS

Review the incidence of complications from varicella disease prior to vaccine licensure, safety of the varicella vaccine from clinical trials and post-marketing surveillance data, the impact of the vaccine on disease incidence where high vaccine coverage has been achieved, and address some barriers to vaccination. Raise issues that developed since 1995.

RESULTS

The safety data gathered during the 20-year-gestation period of this vaccine prior to licensure has been confirmed. The vaccine works-in areas where vaccine coverage is over 70%, there has been a decline in disease, most marked in the age group with the best vaccine coverage (the 1-4-year olds), leading to a concern that unexposed susceptible children may reach adulthood and remain susceptible unless better practice of universal vaccination of ALL susceptible is practiced.

CONCLUSIONS

Varicella disease has declined in areas with moderate vaccine coverage. Continued implementation of existing vaccine policies will lead to further reductions of varicella morbidity and mortality throughout the USA.