School-based Vaccination Clinics Research Articles

Evidence-Based Storytelling for a Strategic Roadmap to Promote Cancer Prevention via Adolescent HPV Vaccination in Northern New England.

Vaccination rates for the human papillomavirus (HPV) among rural youth in northern New England lag those of more urbanized areas. Reasons include a lack of available medical offices, time constraints, perceptions of vaccines and HPV, and, to a smaller degree, delays caused by the COVID-19 pandemic. We have a responsibility to increase vaccinations in these communities. To do so, vaccination experts recommend addressing the three C's of vaccination hesitation: confidence, complacency, and convenience. With this framework as our foundation, in this article we detail a plan to address these important elements, and we add several more C's: clinics, communication, collaboration, community, capacity, and commitment to the list as we discuss the essential pieces-human, infrastructural, and perceptual-needed to create and promote successful, community-supported, school-based HPV vaccination clinics to serve youths aged nine to 18. We then integrate research and storytelling science into an innovative Persuasion Playbook, a guide for local opinion leaders to use in creating evidence-based, pro-vaccine messages on the community level to promote the clinics via evidence-based, pro-vaccination messages.

Lessons Learned from All for Them: Best Practices for a Cross-Collaboration Approach to HPV Vaccination in Public Schools.

The Community Preventive Services Task Force endorses vaccination programs in schools to increase access to vaccinations. However, implementing a school-based approach requires substantial coordination, planning, and resources. All for Them (AFT) is a multilevel, multicomponent approach to increase HPV vaccination among adolescents attending public schools in medically underserved areas in Texas. AFT comprised a social marketing campaign, school-based vaccination clinics, and school nurse continuing education. Process evaluation metrics and key informant interviews to understand experiences with AFT program implementation informed lessons learned. Lessons emerged in six domains: strong champion, school-level support, tailored and cost-effective marketing approaches, mobile provider collaboration, community presence, and crisis management. Strong support at district and school levels is vital for gaining principal and school nurse buy-in. Social marketing strategies are integral to program implementation and should be adjusted to maximize their effectiveness in motivating parents to vaccinate children against HPV, which also can be achieved through increased community presence of the project team. Preparing contingency plans and flexibility within the program can facilitate appropriate responses to provider restrictions in mobile clinics or in the event of unforeseen crises. These important lessons can offer useful guidelines for the development of prospective school-based vaccination programs.

Raising the HPV Vaccination Rate in Rural Northern New England Using Local Opinion Leaders.

The human papillomavirus is associated with a range of cancers. A vaccine introduced in 2006 has dramatically decreased the incidence of these cancers, but Americans still experience over 47,000 new cases of HPV-related cancers each year. The situation is worse in rural areas, where vaccination rates lag the national average, making HPV a significant health disparity issue. This article lays out an evidence-based HPV vaccine-promotion strategy that will serve as part of a campaign to improve health equity in rural northern New England in a process that is repeatable and sustainable. The campaign includes the following elements: partnerships with state departments of health and trusted community opinion leaders, evidence-based storytelling, local social media, traditional media, and school-based pop-up vaccination clinics. Borrowing from marketing and social marketing frameworks and guided by public health perspectives, we begin with psychographic and geodemographic information about our target audience, followed by a discussion about relevant models, frameworks, and research related to persuasive storytelling. We conclude with the outline of a guidebook to foster the creation of persuasive stories as part of a sustainable, replicable HPV vaccination campaign.

659. Mumps Outbreak in a High School: Uptake and Parental Perceptions of Third Dose MMR Recommendations, Dallas County, Texas, 2017

BackgroundIn February 2017, a mumps outbreak was identified in a large Dallas high school among students who had previously completed the two-dose MMR vaccination series. Early notification of recommendations for third dose MMR and free vaccination clinics provided an opportunity to assess vaccine uptake, efficacy, and parental perceptions of third dose MMR recommendations.MethodsMumps illnesses were classified as probable or confirmed cases using 2012 CSTE case definitions. Information about vaccination status, exposure history, and illness characteristics was collected from case interviews and medical records. A third MMR vaccine was recommended to all noncase students and offered without charge at school-based vaccination clinics. Supplemental questionnaires assessing parental knowledge and attitudes regarding this third MMR recommendation were administered to guardians of a randomly selected sample of 20 students who received third dose MMR and 50 students who did not receive the vaccine. Fishers exact tests and chi-square were used to compare responses. Data analysis was performed using SAS 9.4.ResultsFrom February to May 2017, 28 PCR-confirmed and 12 probable mumps cases were identified in students attending one high school campus (24.3 cases per 1,000 students). Of the 1,646 enrolled students, 99.8% had documentation of at least two doses of MMR prior to the outbreak, including all mumps cases. Three undervaccinated students who declined to receive one dose of MMR were excluded from school during the outbreak. Following public health recommendations for a voluntary third MMR dose, 291 students (17.6%) elected to receive a third MMR. No mumps cases occurred in students who received a third vaccine dose. Parental perception of protective benefit of an additional third dose of MMR was significantly associated with decisions to receive third dose MMR (OR: 4.9; 95% CI = 1.6–15.3).ConclusionResponsiveness to health department recommendations for third MMR vaccination in this outbreak setting was limited, even with broad educational communications and free school-based vaccine clinics. The challenges in achieving robust voluntary uptake of a third MMR dose may not improve substantially despite recent ACIP recommendations, in the absence of school mandates requiring third dose of MMR during outbreaks.Disclosures All authors: No reported disclosures.

Billing and Volunteers Substantially Reduced School-Located Influenza Vaccination Costs, 2 Oregon Counties, 2010-2011.

After the 2009 pandemic influenza seasons, the financial sustainability of school-located vaccination (SLV) clinics drew much attention. This study estimated and compared the labor costs of SLV clinics and reimbursements for influenza vaccinations for students attending 5 schools in 2 Oregon counties during 2010-2011. Using a biweekly, Web-based survey, staff and volunteers prospectively tracked the time they spent on SLV clinic planning, implementation, and billing. They also tracked claims submitted and reimbursements by payment source. We report labor hours and associated costs for implementing school-based vaccination clinics; number of claims submitted and the reimbursement rate; and total and net costs. In county A, 260 doses were administered at a total cost of $5009 and received $3620 in payment. For county B, 165 doses were administered at a cost of $5598 and received $3807 in payments. With billing, the net cost per dose decreased from $19.74 to $8.57 and $38.08 to $16.17, for county A and county B, respectively. Reimbursements reduced cost per dose by 48% across SLV clinics across both Oregon counties. Local health departments can bill local health insurers to offset costs for implementing school-based vaccination clinics. Efforts to set up billing processes require dedicated billing staff who can effectively manage claims submission processes with multiple health insurers.

School-based influenza vaccination clinics and school absenteeism

School-based influenza vaccination clinics and school absenteeism

Learning From Successful School‐Based Vaccination Clinics During 2009 pH1N1

The 2009 H1N1 vaccination campaign was the largest in US history. State health departments received vaccines from the federal government and sent them to local health departments (LHDs) who were responsible for getting vaccines to the public. Many LHD's used school-based clinics to ensure children were the first to receive limited vaccine supplies, but the success of school-based distribution strategies varied in different locations. The goal of this project was to identify and learn from high-performing school-based vaccination clinics in order to share successes and improve performance in future school-based vaccination campaigns. We used a combination of process mapping and comparative analysis to identify and derive lessons from positive outlier cases observed during 2009 H1N1 school-based vaccination clinic implementation. We created process maps to identify the activities of LHDs conducting school-based vaccinations and used them as the basis for in-depth interviews of LHD staff. We asked interviewees to describe their activities during the 2009 H1N1 pandemic (pH1N1) school-based vaccination campaign with a focus on successful processes. We identified positive deviants, that is, those that performed better than expected, and categorized qualitative data from in-depth interviews with 13 successful LHDs according to the process maps. Key mechanisms for school-based vaccination success included having a relationship with local school authorities, communicating effectively with parents, and ensuring clinic logistics allowed for an easy flow of students through the vaccination process. Utilizing rigorous methodology, we defined and learned lessons from successful LHDs when conducting school-based vaccination clinics, which can be applied to future school-based vaccination campaigns.

Understanding reasons for participating in a school-based influenza vaccination program and decision-making dynamics among adolescents and parents

Influenza remains a significant cause of morbidity and mortality in the United States. Vaccinating school-aged children has been demonstrated to be beneficial to the child and in reducing viral transmission to vulnerable groups such as the elderly. This qualitative study sought to identify reasons parents and students participated in a school-based influenza vaccination clinic and to characterize the decision-making process for vaccination. Eight focus groups were conducted with parents and students. Parents and students who participated in the influenza vaccination clinic stated the educational brochure mailed to their home influenced participation in the program. Parents of non-participating students mentioned barriers, such as the lengthy and complicated consent process and suspicions about the vaccine clinic, as contributing to their decision not to vaccinate their child. Vaccinated students reported initiating influenza vaccine discussion with their parents. Parental attitudes and the educational material influenced parents' decision to allow their child to receive influenza vaccine. This novel study explored reasons for participating in a school-based vaccination clinic and the decision-making process between parents and child(ren). Persons running future school-based vaccination clinics may consider hosting an 'information session with a question and answer session' to address parental concerns and assist with the consent process.

HPV Knowledge, Attitudes, and Beliefs Among Northern Plains American Indian Adolescents, Parents, Young Adults, and Health Professionals

Native American women in the Northern Plains have a high prevalence of human papillomavirus (HPV) and high incidence of cervical disease and cervical cancer. HPV vaccination coverage is shown to be lower among nonwhite populations and disparity populations. We assessed HPV knowledge, attitudes, and beliefs towards HPV and HPV vaccination during a community-based participatory research project among tribal youth, young adults, parents, and health professionals. In 2009, we recruited a total of 73 individuals to participate in four tribal focus groups: tribal health providers, (n=10), Indian Health Service providers (n=7), young adult women ages 19-26 (n=22), girls (14-18) (n=18), and parents (n=16). Of these, 62 (84.93 %) completed a survey, which included 10 healthcare providers, 22 young adults, 14 teens, and 16 parents. We employed a qualitative thematic analysis of focus group transcript data and conducted frequency analysis of survey data, which were both reviewed and triangulated by a Community Advisory Board. Based on the results of this study, the tribal community advisory board identified local tribal settings for interventions to increase HPV vaccination coverage through health education classes and a school-based vaccination clinic. In addition to tribal community-wide education events to increase awareness of HPV disease, the HPV vaccine, provider-specific training was identified as a potential intervention. These community-based focus group findings underscore the importance of locally and cultural tailored educational interventions to further increase HPV knowledge and HPV vaccination among disparate populations like American Indian adolescent and young adult women.

27. Understanding Reasons for Participating in a School-Based Influenza Vaccine Clinic Program and Decision Making Dynamics Between Parent and Child

Influenza remains a public health burden and is a significant source of morbidity and mortality in the United States. Vaccinating school-aged children has been demonstrated to be beneficial to the child as well as reducing viral transmission to other vulnerable groups such as the elderly. This qualitative study sought to identify reasons parents allowed their middle or high school child(ren) to participate in a school-based vaccination clinic. The school-based vaccine program, which consisted of a structural component (school-based vaccine clinic) and an educational component (a brochure mailed home to parents and an informational skit performed in school for students) was conducted during two consecutive years.

Successful Use of Volunteers to Conduct School-located Mass Influenza Vaccination Clinics

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

HPV and HPV Vaccine Education Intervention: Effects on Parents, Healthcare Staff, and School Staff

Increasing knowledge about human papillomavirus (HPV) and HPV vaccine is a potentially important way to increase vaccination rates, yet few education interventions have addressed these topics. We report the results of an education intervention targeting three key groups who have contact with adolescent females. We conducted HPV education intervention sessions during 2008 and 2009 in Guilford County, North Carolina. Parents (n = 376), healthcare staff (n = 118), and school staff (n = 456) attended the one-time sessions and completed self-administered surveys. Analyses used mixed regression models to examine the intervention's effects on participants' self-rated HPV knowledge, objectively assessed HPV and HPV vaccine knowledge, and beliefs about HPV vaccine. Participants had relatively low levels of objectively assessed HPV and HPV vaccine knowledge prior to the intervention. The education intervention increased self-rated HPV knowledge among all three key groups (all P < 0.001), and objectively assessed knowledge about many aspects of HPV and HPV vaccine among healthcare and school staff members (all P < 0.05). Following the intervention, more than 90% of school staff members believed HPV and HPV vaccine education is worthwhile for school personnel and that middle schools are an appropriate venue for this education. Most parents (97%) and school staff members (85%) indicated they would be supportive of school-based vaccination clinics. Our education intervention greatly increased HPV and HPV vaccine knowledge among groups influential to the HPV vaccination behaviors of adolescent females. Education interventions represent a simple yet potentially effective strategy for increasing HPV vaccination and garnering stronger support for school-based vaccination clinics.

Abstract A20: HPV and HPV vaccine education intervention: Effects on parents, healthcare staff, and school staff

Abstract Background: Increasing knowledge about HPV and HPV vaccine is a potentially important way to increase vaccination rates, yet few education interventions have addressed these topics. We report the results of an education intervention targeting three key groups who have contact with adolescent females. Methods: We conducted HPV education intervention sessions during 2008 and 2009 in Guilford County, North Carolina. Guilford County has a higher proportion of African American residents compared to North Carolina as a whole, as well as one of the highest cervical cancer mortality rates in the state. Parents (n=376), healthcare staff (n=118), and school staff (n=456) attended the one-time education sessions and completed self-administered surveys. Analyses used mixed regression models. Results: Participants had relatively low levels of objectively assessed HPV and HPV vaccine knowledge prior to the intervention. The education intervention increased self-rated HPV knowledge among all three key groups (all p&amp;lt;0.001), as well as objectively assessed knowledge about many aspects of HPV and HPV vaccine among healthcare and school staff members (all p&amp;lt;0.05). Although all groups experienced an increase in their self-rated knowledge, the largest increase was seen among parents, with healthcare and school staff experiencing smaller increases (p&amp;lt;0.05). Following the intervention, over 90% of school staff members believed HPV and HPV vaccine education is worthwhile for school personnel and that middle schools are an appropriate venue for this education. Most parents (97%) and school staff members (85%) indicated they would be supportive of school-based vaccination clinics. Discussion: An important first step in increasing HPV vaccination rates among adolescent females in the US is to improve knowledge levels among key groups influential to adolescents’ vaccination behaviors. In this study, we demonstrated that a simple education intervention greatly improved objectively assessed and self-rated HPV and HPV vaccine knowledge levels among parents, healthcare staff, and school staff members. Such interventions offer a relatively low effort and potentially effective strategy for increasing HPV vaccination. Citation Information: Cancer Epidemiol Biomarkers Prev 2011;20(10 Suppl):A20.

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

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). 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. 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. 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.

Use of Mass Tdap Vaccination to Control an Outbreak of Pertussis in a High School—Cook County, Illinois, September 2006–January 2007

On September 6, 2006, the Cook County Department of Public Health (CCDPH) was notified that a local high school student aged 17 years had pertussis. During September 2006-January 2007, 36 pertussis cases directly linked to the high school were identified. Because Bordetella pertussis immunity from childhood vaccinations wanes over time, outbreaks of pertussis can periodically occur among students and staff at middle and high schools. School settings facilitate transmission of pertussis, disrupting school and community activities and putting vulnerable populations, such as unvaccinated infants, at risk. A pertussis booster vaccine suitable for adolescents and adults became available in the United States in 2005, when two new tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccines were licensed for persons aged 10-18 years and 11-64 years, respectively. In 2006, the Advisory Committee on Immunization Practices (ACIP) recommended that all adolescents and adults receive a one-time Tdap booster vaccination. This report summarizes strategies used to control the pertussis outbreak in Cook County, Illinois, including efforts to increase Tdap vaccination coverage. Despite multiple communications recommending Tdap vaccination and implementation of a cough exclusion policy during the pertussis outbreak, student vaccination rates did not increase substantially until a school-based Tdap vaccination clinic was implemented. Because persons at risk for pertussis might not seek vaccination from their usual health-care provider, even during an outbreak, local health departments might consider early implementation of a cough exclusion policy and on-site Tdap vaccination clinic as control measures.

Challenges to Implementing Second‐Dose Varicella Vaccination during an Outbreak in the Absence of a Routine 2‐Dose Vaccination Requirement—Maine, 2006

In June 2005, the Advisory Committee on Immunization Practices (ACIP) recommended administering a second dose of varicella vaccine during outbreaks, supplementing the routine 1-dose requirement. From October 2005 to January 2006, a varicella outbreak occurred in Maine in a highly vaccinated elementary school population. We investigated the outbreak, held a school-based vaccination clinic, and assessed costs in implementing ACIP's outbreak-response recommendation. Parents completed questionnaires and case investigation interviews. Personnel at the Maine Center for Disease Control and Prevention, the school in which the outbreak occurred ("school A"), and physician offices completed economic surveys. Forty-eight cases occurred, with no hospitalizations or deaths. Vaccine effectiveness was 86.6% (95% confidence interval, 82.0%-90.1%). Of 240 eligible students, 132 (55.0%) received second-dose vaccination. Implementing ACIP's outbreak-response recommendation was challenging and cost approximately $26,875. Additionally, the routine 1-dose varicella vaccination policy did not confer adequate population immunity to prevent this outbreak. These findings support ACIP's June 2007 recommendation for a routine 2-dose varicella vaccination program.

Parental Vaccine Beliefs and Child's School Type

Journal of School HealthVolume 75, Issue 7 p. 276-280 Free Access Parental Vaccine Beliefs and Child's School Type Allison M. Kennedy, Allison M. KennedySearch for more papers by this authorDeborah A. Gust, Deborah A. GustSearch for more papers by this author Allison M. Kennedy, Allison M. KennedySearch for more papers by this authorDeborah A. Gust, Deborah A. GustSearch for more papers by this author First published: 11 August 2005 https://doi.org/10.1111/j.1746-1561.2005.00037.xCitations: 28 Allison M. Kennedy, MPH, Epidemiologist, (ark2@cdc.gov); and 2Deborah A. Gust, PhD, MPH, Health Scientist, (dgg6@cdc.gov), Centers for Disease Control and Prevention, 1600 Clifton Road, NE, Mailstop E-61, Atlanta, GA 30333. AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat References 1 Hall S, Galil K, Watson B, Seward J. The use of school-based vaccination clinics to control varicella outbreaks in two schools. Pediatrics. 2000; 105(1): e17. 2 Murphy TV, Pastor P, Turner SB, et al. Estimating immunization coverage from school-based childhood immunization records. Pediatr Infect Dis J. 1995; 14(7): 561– 567. 3 Robbins KB, Brandling-Bennett AD, Hinman AR. Low measles incidence: association with enforcement of school immunization laws. Am J Public Health. 1981; 71(3): 270– 274. 4 Gerald DE, Hussar WJ. Projections of Education Statistics to 2012 (NCES 2002–030). Washington, DC: US Department of Education, National Center for Education Statistics; 2002. 5 Linton LS, Peddecord KM, Seidman RL, et al. Implementing a seventh grade vaccination law: school factors associated with completion of required immunizations. Prev Med. 2003; 36: 510– 517. 6 Fredrickson DD, Kies KM, Burbach CA. Immunization compliance among public and private school children. J Sch Health. 1997; 67(2): 75– 77. 7 Pollard W. Use of consumer panel survey data for public health communication planning: an evaluation of survey results. Proceedings of the Annual Meeting of the American Statistical Association, August 11–15, 2002; New York, NY. 8 Glanz K, Basil M, Maibach E, Goldberg J, Snyder D. Why Americans eat what they do: taste, nutrition, cost, convenience, and weight control concerns as influences on food consumption. J Am Diet Assoc. 1998; 98(10): 1118– 1126. 9 Centers for Disease Control and Prevention. Knowledge about cases of peptic ulcer disease—United States, March-April 1997. MMWR Morb Mortal Wkly Rep. 1997; 46(42): 985– 987. 10 Weir MR, Maibach EW, Bakris GL, et al. Implications of a health lifestyle and medication analysis for improving hypertension control. Arch Intern Med. 2000; 160: 481– 490. 11 Slater MD, Basil MD, Maibach EW. A cluster analysis of alcohol-related attitudes and behaviors in the general population. J Stud Alcohol. 1999; 60: 667– 674. 12 Wang SS, Fridinger F, Sheedy KM, Khoury MJ. Public attitudes regarding the donation and storage of blood specimens for genetic research. Community Genet. 2001; 4: 18– 26. 13 Maibach EW, Maxfield A, Ladin K, Slater M. Translating health psychology into effective health communication: The American Healthstyles audience segmentation project. J Health Psychol. 1996; 1(3): 261– 277. 14 Bielick S, Chandler K, Broughman SP. Homeschooling in the United States: 1999 (NCES 2001-033). Washington, DC: US Department of Education, National Center for Education Statistics; 2001. 15 Stevens M. Kingdom of Children: Culture and Controversy in the Homeschooling Movement. Princeton, NJ: Princeton University Press; 2001. 16 Houston RG, Toma EF. Home schooling: an alternative school choice. South Econ J. 2003; 69(4): 920– 935. 17 Rota JS, Salmon DA, Rodewald LE, Chen RT, Hibbs BF, Gangarosa EJ. Processes for obtaining nonmedical exemptions to state immunization laws. Am J Public Health. 2001; 91(4): 645– 648. 18 Gellin BG, Maibach EW, Marcuse EK. Do parents understand immunizations? A national telephone survey. Pediatrics. 2000; 106(5): 1097– 1102. Citing Literature Volume75, Issue7September 2005Pages 276-280 ReferencesRelatedInformation

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

School-based vaccination clinics were offered in 2 schools experiencing varicella outbreaks. The clinics raised coverage of susceptible children from 52.9% to 92.2% and from 68.8% to 85.3% in the 2 schools, respectively. Although routine immunization and school-entry requirements are the best strategies for preventing outbreaks, school-based vaccination clinics may greatly increase coverage and shorten outbreaks.