School-located Influenza Vaccination Programs Research Articles

Parents and teachers’ perspectives on a school-located influenza vaccination program: A pilot study in the Region of Murcia, Spain

ABSTRACT During the 2022–2023 season, the Region of Murcia (an autonomous community of Spain) introduced the influenza vaccination campaign in children aged 24–59 months with the live-attenuated influenza nasal spray vaccine. To expand coverage, a pilot study was conducted to include the 3- to 4-year population in 24 public schools. The aim of the study was to assess the experiences of parents and teachers involved in the project. This was a psychosocial qualitative study in which information was collected from a cohort of 23 parents and 17 teachers who attended three and two focus group sessions, respectively. A high degree of satisfaction with the school-located influenza vaccination program was consistently reported. The teachers reported creating a friendly environment and acting as companions to support children in the absence of their parents. They also considered the intranasal route, which avoids intramuscular puncture, as a facilitating element that turned the vaccination process into a kind of game. Parents emphasized the importance of vaccination to protect their children, and secondarily, to ensure protection of the family nucleus. Some parents who had their children already vaccinated in the health care center reported preference for the school setting, probably selecting this option in the future. The availability of school-based influenza vaccination promoted greater equity in accessing the vaccine and facilitated family reconciliation. To optimize coverage and minimize potential reluctance, providing the necessary information to parents both before and after vaccination was considered. School-located influenza vaccination was feasible and is a valuable strategy to be implemented in future campaigns.

Identifying implementation strategies to address barriers of implementing a school-located influenza vaccination program in Beijing

BackgroundThe school-located influenza vaccinations (SLIV) can increase influenza vaccination and reduce influenza infections among school-aged children. However, the vaccination rate has remained low and varied widely among schools in Beijing, China. This study aimed to ascertain barriers and facilitators of implementing SLIV and to identify implementation strategies for SLIV quality improvement programs in this context.MethodsSemi-structured interviews were conducted with diverse stakeholders (i.e., representatives of both the Department of Health and the Department of Education, school physicians, class headteachers, and parents) involved in SLIV implementation. Participants were identified by purposive and snowball sampling. The Consolidated Framework for Implementation Research was adopted to facilitate data collection and analysis. Themes and subthemes regarding barriers and facilitators were generated using deductive and inductive approaches. Based on the Consolidated Framework for Implementation Research—Expert Recommendations for Implementing Change (CFIR-ERIC) matching tool, practical implementation strategies were proposed to address the identified barriers of SLIV delivery.ResultsTwenty-four participants were interviewed. Facilitators included easy access to SLIV, clear responsibilities and close collaboration among government sectors, top-down authority, integrating SLIV into the routine of schools, and priority given to SLIV. The main barriers were parents’ misconception, inefficient coordination for vaccine supply and vaccination dates, the lack of planning, and inadequate access to knowledge and information about the SLIV. CFIR-ERIC Matching tool suggested implementation strategies at the system (i.e., developing an implementation blueprint, and promoting network weaving), school (i.e., training and educating school implementers), and consumer (i.e., engaging students and parents) levels to improve SLIV implementation.ConclusionsThere were substantial barriers to the delivery of the SLIV program. Theory-driven implementation strategies developed in this pre-implementation study should be considered to address those identified determinants for successful SLIV implementation.

Evaluation of a city-wide school-located influenza vaccination program in Oakland, California with respect to race and ethnicity: A matched cohort study

BackgroundIncreasing influenza vaccination coverage in school-aged children may substantially reduce community transmission. School-located influenza vaccinations (SLIV) aim to promote vaccinations by increasing accessibility, which may be especially beneficial to race/ethnicity groups that face high barriers to preventative care. Here, we evaluate the effectiveness of a city-wide SLIV program by race/ethnicity from 2014 to 2018. MethodsWe used multivariate matching to pair schools in the intervention district in Oakland, CA with schools in a comparison district in West Contra Costa County, CA. We distributed cross-sectional surveys to measure caregiver-reported student vaccination status and estimated differences in vaccination coverage levels and reasons for non-vaccination between districts stratifying by race/ethnicity. We estimated difference-in-differences (DID) of laboratory confirmed influenza hospitalization incidence between districts stratified by race/ethnicity using surveillance data. ResultsDifferences in influenza vaccination coverage in the intervention vs. comparison district were larger among White (2017–18: 21.0% difference [95% CI: 9.7%, 32.3%]) and Hispanic/Latino (13.4% [8.8%, 18.0%]) students than Asian/Pacific Islander (API) (8.9% [1.3%, 16.5%]), Black (5.9% [−2.2%, 14.0%]), and multiracial (6.3% [−1.8%, 14.3%)) students. Concerns about vaccine effectiveness or safety were more common among Black and multiracial caregivers. Logistical barriers were less common in the intervention vs. comparison district, with the largest difference among White students. In both districts, hospitalizations in 2017–18 were higher in Blacks (Intervention: 111.5 hospitalizations per 100,00; Comparison: 134.1 per 100,000) vs. other races/ethnicities. All-age influenza hospitalization incidence was lower in the intervention site vs. comparison site among White/API individuals in 2016–17 (DID −25.14 per 100,000 [95% CI: −40.14, −10.14]) and 2017–18 (−36.6 per 100,000 [−52.7, −20.5]) and Black older adults in 2017–18 (−282.2 per 100,000 (−508.4, −56.1]), but not in other groups. ConclusionsSLIV was associated with higher vaccination coverage and lower influenza hospitalization, but associations varied by race/ethnicity. SLIV alone may be insufficient to ensure equitable influenza outcomes.

A Mixed-Methods Study to Evaluate Elementary School Staff's Acceptability, Delivery Challenges, and Communication Regarding the Implementation of School-Located Influenza Vaccination Program in Hong Kong.

This was a mixed-methods study comprising a questionnaire-based survey, a qualitative study, and analysis of school newsletters to evaluate elementary school staff’s acceptability, delivery challenges and communication about school-located influenza vaccination program (SIVP) in Hong Kong. We found that school staff with lower intention to implement SIVP perceived greater logistical difficulties in arranging SIVP. Challenges regarding program delivery included schools’ limited infrastructure, the burden of paperwork, the fear of being overwhelmed by multiple school-based vaccination schedules, lacking confidence in communicating with parents about influenza vaccines, and the difficulties in managing vaccination-related anxiety among children with intellectual disability. School staff were generally passive in communicating with parents and students about influenza vaccines. We also found that schools may use the school newsletters as a substitute of the formal informed consent forms. Good partnerships among government, service providers and schools should be established to minimize the burden of paperwork for school staff, facilitate early planning of SIVP, and support schools with limited infrastructure and the vaccination of children with intellectual disabilities. Training is needed to enhance school staff’s confidence in communicating with parents and students about influenza vaccines and improve information delivery to support parents’ informed decisions for children’s vaccination.

City-wide school-located influenza vaccination: A retrospective cohort study

BackgroundWe measured the effectiveness of a city-wide school-located influenza vaccination (SLIV) program implemented in over 102 elementary schools in Oakland, California. MethodsWe conducted a retrospective cohort study among Kaiser Permanente Northern California (KPNC) members of all ages residing in either the intervention or a multivariate-matched comparison site from September 2011 - August 2017. Outcomes included medically attended acute respiratory illness (MAARI), influenza hospitalization, and Oseltamivir prescriptions. We estimated difference-in-differences (DIDs) in 2014–15, 2015–16, and 2016–17 using generalized linear models and adjusted for race, ethnicity, age, sex, health plan, and language. ResultsPre-intervention member characteristics were similar between sites. The proportion of KPNC members vaccinated for influenza by KPNC or the SLIV program was 8–11% higher in the intervention site than the comparison site during the intervention period. Among school-aged children, SLIV was associated with lower Oseltamivir prescriptions per 1,000 (DIDs: −3.5 (95% CI −5.5, −1.5) in 2015–16; −4.0 (95% CI −6.5, −1.6) in 2016–17) but not with other outcomes. SLIV was associated with lower MAARI per 1,000 in adults 65 + years (2014–15: −13.2, 95% CI –23.2, −3.2; 2015–16: −21.5, 95% CI −31.1, −11.9; 2016–17: −13.0, 95% CI –23.2, −2.9). There were few significant associations with other outcomes among adults. ConclusionsA city-wide SLIV intervention was associated with higher influenza vaccination coverage, lower Oseltamivir prescriptions in school-aged children, and lower MAARI among people over 65 years, suggesting possible indirect effects of SLIV among older adults.

Evaluation of a city-wide school-located influenza vaccination program in Oakland, California, with respect to vaccination coverage, school absences, and laboratory-confirmed influenza: A matched cohort study.

It is estimated that vaccinating 50%-70% of school-aged children for influenza can produce population-wide indirect effects. We evaluated a city-wide school-located influenza vaccination (SLIV) intervention that aimed to increase influenza vaccination coverage. The intervention was implemented in ≥95 preschools and elementary schools in northern California from 2014 to 2018. Using a matched cohort design, we estimated intervention impacts on student influenza vaccination coverage, school absenteeism, and community-wide indirect effects on laboratory-confirmed influenza hospitalizations. We used a multivariate matching algorithm to identify a nearby comparison school district with pre-intervention characteristics similar to those of the intervention school district and matched schools in each district. To measure student influenza vaccination, we conducted cross-sectional surveys of student caregivers in 22 school pairs (2017 survey, N = 6,070; 2018 survey, N = 6,507). We estimated the incidence of laboratory-confirmed influenza hospitalization from 2011 to 2018 using surveillance data from school district zip codes. We analyzed student absenteeism data from 2011 to 2018 from each district (N = 42,487,816 student-days). To account for pre-intervention differences between districts, we estimated difference-in-differences (DID) in influenza hospitalization incidence and absenteeism rates using generalized linear and log-linear models with a population offset for incidence outcomes. Prior to the SLIV intervention, the median household income was $51,849 in the intervention site and $61,596 in the comparison site. The population in each site was predominately white (41% in the intervention site, 48% in the comparison site) and/or of Hispanic or Latino ethnicity (26% in the intervention site, 33% in the comparison site). The number of students vaccinated by the SLIV intervention ranged from 7,502 to 10,106 (22%-28% of eligible students) each year. During the intervention, influenza vaccination coverage among elementary students was 53%-66% in the comparison district. Coverage was similar between the intervention and comparison districts in influenza seasons 2014-2015 and 2015-2016 and was significantly higher in the intervention site in seasons 2016-2017 (7%; 95% CI 4, 11; p < 0.001) and 2017-2018 (11%; 95% CI 7, 15; p < 0.001). During seasons when vaccination coverage was higher among intervention schools and the vaccine was moderately effective, there was evidence of statistically significant indirect effects: The DID in the incidence of influenza hospitalization per 100,000 in the intervention versus comparison site was -17 (95% CI -30, -4; p = 0.008) in 2016-2017 and -37 (95% CI -54, -19; p < 0.001) in 2017-2018 among non-elementary-school-aged individuals and -73 (95% CI -147, 1; p = 0.054) in 2016-2017 and -160 (95% CI -267, -53; p = 0.004) in 2017-2018 among adults 65 years or older. The DID in illness-related school absences per 100 school days during the influenza season was -0.63 (95% CI -1.14, -0.13; p = 0.014) in 2016-2017 and -0.80 (95% CI -1.28, -0.31; p = 0.001) in 2017-2018. Limitations of this study include the use of an observational design, which may be subject to unmeasured confounding, and caregiver-reported vaccination status, which is subject to poor recall and low response rates. A city-wide SLIV intervention in a large, diverse urban population was associated with a decrease in the incidence of laboratory-confirmed influenza hospitalization in all age groups and a decrease in illness-specific school absence rate among students in 2016-2017 and 2017-2018, seasons when the vaccine was moderately effective, suggesting that the intervention produced indirect effects. Our findings suggest that in populations with moderately high background levels of influenza vaccination coverage, SLIV programs are associated with further increases in coverage and reduced influenza across the community.

Nontraditional Uses of Live Attenuated Influenza Vaccine: School-Located Influenza Vaccination.

Immunization against influenza continues to be the best method of preventing influenza infection in children, and additionally, indirectly helping to lower disease in adults, given the role of children as "spreaders" of influenza to the community at large. An increasing evidence base exists for the use of school-located influenza vaccination (SLIV) programs to increase the influenza vaccination rates among children. Live, attenuated influenza vaccine (LAIV) has unique characteristics that make it useful for SLIV programs, including ease of immunization without needles, faster delivery, and in many (but not all) years, good vaccine effectiveness. Reviewed herein are results of selected published trials as well as guidance on planning a successful SLIV program.

Cost effectiveness of school-located influenza vaccination programs for elementary and secondary school children

BackgroundStudies have noted variations in the cost-effectiveness of school-located influenza vaccination (SLIV), but little is known about how SLIV’s cost-effectiveness may vary by targeted age group (e.g., elementary or secondary school students), or vaccine consent process (paper-based or web-based). Further, SLIV’s cost-effectiveness may be impacted by its spillover effect on practice-based vaccination; prior studies have not addressed this issue.MethodsWe performed a cost-effectiveness analysis on two SLIV programs in upstate New York in 2015–2016: (a) elementary school SLIV using a stepped wedge design with schools as clusters (24 suburban and 18 urban schools) and (b) secondary school SLIV using a cluster randomized trial (16 suburban and 4 urban schools). The cost-per-additionally-vaccinated child (i.e., incremental cost-effectiveness ratio (ICER)) was estimated by dividing the incremental SLIV intervention cost by the incremental effectiveness (i.e., the additional number of vaccinated students in intervention schools compared to control schools). We performed deterministic analyses, one-way sensitivity analyses, and probabilistic analyses.ResultsThe overall effectiveness measure (proportion of children vaccinated) was 5.7 and 5.5 percentage points higher, respectively, in intervention elementary (52.8%) and secondary schools (48.2%) than grade-matched control schools. SLIV programs vaccinated a small proportion of children in intervention elementary (5.2%) and secondary schools (2.5%). In elementary and secondary schools, the ICER excluding vaccine purchase was $85.71 and $86.51 per-additionally-vaccinated-child, respectively. When additionally accounting for observed spillover impact on practice-based vaccination, the ICER decreased to $80.53 in elementary schools -- decreasing substantially in secondary schools. (to $53.40). These estimates were higher than the published practice-based vaccination cost (median = $25.50, mean = $45.48). Also, these estimates were higher than our 2009–2011 urban SLIV program mean costs ($65) due to additional costs for use of a new web-based consent system ($12.97 per-additionally-vaccinated-child) and higher project coordination costs in 2015–2016. One-way sensitivity analyses showed that ICER estimates were most sensitive to the SLIV effectiveness.ConclusionsSLIV raises vaccination rates and may increase practice-based vaccination in primary care practices. While these SLIV programs are effective, to be as cost-effective as practice-based vaccination our SLIV programs would need to vaccinate more students and/or lower the costs for consent systems and project coordination.Trial RegistrationClinicalTrials.govNCT02227186 (August 25, 2014), updated NCT03137667 (May 2, 2017).

Sustainability of school-located influenza vaccination programs in Florida

BackgroundSchool-located influenza vaccination (SLIV) programs are a promising strategy for increasing vaccination coverage among schoolchildren. However, questions of economic sustainability have dampened enthusiasm for this approach in the United States. We evaluated SLIV sustainability of a health department led, county-wide SLIV program in Alachua County, Florida. Based on Alachua's outcome data, we modeled the sustainability of SLIV programs statewide using two different implementation costs and at different vaccination rates, reimbursement amount, and Vaccines for Children (VFC) coverage. MethodsMass vaccination clinics were conducted at 69 Alachua County schools in 2013 using VFC (for Medicaid and uninsured children) and non-VFC vaccines. Claims were processed after each clinic and submitted to insurance providers for reimbursement ($5 Medicaid and $47.04 from private insurers). We collected programmatic expenditures and volunteer hours to calculate fixed and variable costs for two different implementation costs (with or without in-kind costs included). We project program sustainability for Florida using publicly available county-specific student populations and health insurance enrollment data. ResultsApproximately 42% (n=12,853) of pre-kindergarten – 12th grade students participated in the SLIV program in Alachua. Of the 13,815 doses provided, 58% (8042) were non-VFC vaccine. Total implementation cost was $14.95/dose or $7.93/dose if “in-kind” costs were not included. The program generated a net surplus of $24,221, despite losing $4.68 on every VFC dose provided to Medicaid and uninsured children. With volunteers, 99% of Florida counties would be sustainable at a 50% vaccination rate and average reimbursement amount of $3.25 VFC and $37 non-VFC. Without volunteers, 69% of counties would be sustainable at 50% vaccination rate if all VFC recipients were on Medicaid and its reimbursement increased from $5 to $10 (amount private practices receive). Conclusions and relevanceKey factors that contributed to the sustainability and success of an SLIV program are: targeting privately insured children and reducing administration cost through volunteers. Counties with a high proportion of VFC eligible children may not be sustainable without subsidies at $5 Medicaid reimbursement.

Cost effectiveness analysis of Year 2 of an elementary school-located influenza vaccination program-Results from a randomized controlled trial.

BackgroundSchool-located vaccination against influenza (SLV-I) has the potential to improve current suboptimal influenza immunization coverage for U.S. school-aged children. However, little is known about SLV-I’s cost-effectiveness. The objective of this study is to establish the cost-effectiveness of SLV-I based on a two-year community-based randomized controlled trial (Year 1: 2009–2010 vaccination season, an unusual H1N1 pandemic influenza season, and Year 2: 2010–2011, a more typical influenza season).MethodsWe performed a cost-effectiveness analysis on a two-year randomized controlled trial of a Western New York SLV-I program. SLV-I clinics were offered in 21 intervention elementary schools (Year 1 n = 9,027; Year 2 n = 9,145 children) with standard-of-care (no SLV-I) in control schools (Year 1 n = 4,534 (10 schools); Year 2 n = 4,796 children (11 schools)). We estimated the cost-per-vaccinated child, by dividing the incremental cost of the intervention by the incremental effectiveness (i.e., the number of additionally vaccinated students in intervention schools compared to control schools).ResultsIn Years 1 and 2, respectively, the effectiveness measure (proportion of children vaccinated) was 11.2 and 12.0 percentage points higher in intervention (40.7 % and 40.4 %) than control schools. In year 2, the cost-per-vaccinated child excluding vaccine purchase ($59.88 in 2010 US $) consisted of three component costs: (A) the school costs ($8.25); (B) the project coordination costs ($32.33); and (C) the vendor costs excluding vaccine purchase ($16.68), summed through Monte Carlo simulation. Compared to Year 1, the two component costs (A) and (C) decreased, while the component cost (B) increased in Year 2. The cost-per-vaccinated child, excluding vaccine purchase, was $59.73 (Year 1) and $59.88 (Year 2, statistically indistinguishable from Year 1), higher than the published cost of providing influenza vaccination in medical practices ($39.54). However, taking indirect costs (e.g., averted parental costs to visit medical practices) into account, vaccination was less costly in SLV-I ($23.96 in Year 1, $24.07 in Year 2) than in medical practices.ConclusionsOur two-year trial’s findings reinforced the evidence to support SLV-I as a potentially favorable system to increase childhood influenza vaccination rates in a cost-efficient way. Increased efficiencies in SLV-I are needed for a sustainable and scalable SLV-I program.

School-Located Influenza Vaccination With Third-Party Billing: Outcomes, Cost, and Reimbursement

ObjectiveTo assess rates of immunization; costs of conducting clinics; and reimbursements for a school-located influenza vaccination (SLIV) program that billed third-party payers. MethodsSLIV clinics were conducted in 19 elementary schools in the Denver Public School district (September 2010 to February 2011). School personnel obtained parental consent, and a community vaccinator conducted clinics and performed billing. Vaccines For Children vaccine was available for eligible students. Parents were not billed for any fees. Data were collected regarding implementation costs and vaccine cost was calculated using published private sector prices. Reimbursement amounts were compared to costs. ResultsOverall, 30% of students (2784 of 9295) received ≥1 influenza vaccine; 39% (1079 of 2784) needed 2 doses and 80% received both. Excluding vaccine costs, implementation costs were $24.69 per vaccination. The percentage of vaccine costs reimbursed was 62% overall (82% from State Child Health Insurance Program (SCHIP), 50% from private insurance). The percentage of implementation costs reimbursed was 19% overall (23% from private, 27% from Medicaid, 29% from SCHIP and 0% among uninsured). Overall, 25% of total costs (implementation plus vaccine) were reimbursed. ConclusionsA SLIV program resulted in vaccination of nearly one third of elementary students. Reimbursement rates were limited by 1) school restrictions on charging parents fees, 2) low payments for vaccine administration from public payers and 3) high rates of denials from private insurers. Some of these problems might be reduced by provisions in the Affordable Care Act.

Implementing and Sustaining School-Located Influenza Vaccination Programs

Local health departments have typically led school-located influenza vaccination (SLIV) programs, assuming resource-intensive roles in design, coordination, and vaccination. This level of involvement is often not financially sustainable over time. Five diverse school districts in Los Angeles County designed, implemented, refined, and institutionalized their own SLIV programs over 3 years by identifying and maximizing their existing resources. School district nurses and other staff served as project leaders, designing their own vaccination administration process, parental consent, and clinic promotional models. Two districts expanded their existing school immunization clinics and three developed their vaccination capacity with community partnerships. Each district tailored its program in creative resource-minimum ways, sometimes abandoning or adopting new methods/technologies based on the effectiveness in previous seasons. The shared experiences and strategies between district nurses and the local health department described in this article illustrate a district's ability to develop a tailor-made SLIV program, often in less than ideal conditions.

School-Located Influenza Vaccination and Absenteeism Among Elementary School Students in a Hispanic Community

Seasonal influenza is recognized as a significant health burden to children and is a cause of excess school absenteeism in children. In 2008, the Advisory Committee on Immunization Practices recommended annual influenza vaccination for all children 6 months to 18 years of age. School nurses influence participation in this recommendation by conducting school-located influenza vaccination (SLIV) programs at their campuses. Knowing the effect of SLIV programs on student absenteeism may motivate school nurses and district administrators to conduct such vaccination programs. This study examines the impact of an SLIV program on elementary school absenteeism in an inner city school district with a predominantly Hispanic population. Using Poisson regression models with robust standard errors, we analyzed data from 3,775 records obtained by stratified random sampling. Results of the study indicate that students vaccinated through an SLIV program have fewer absences than unvaccinated students. A surprising result of the study shows that students vaccinated through an SLIV program had fewer absences than students vaccinated elsewhere. These results are of particular importance to school nurses who work with large Hispanic populations. Our study illustrates one way that a school nurse can assess the effect of an SLIV program on absenteeism.

Assessing the Acceptability and Feasibility of a School-Located Influenza Vaccination Program With Third-Party Billing in Elementary Schools

This study qualitatively assesses the acceptability and feasibility of a school-located vaccination for influenza (SLIV) project that was conducted in New York State in 2009-2011, from the perspectives of project participants with different roles. Fourteen in-depth semistructured interviews with participating schools' personnel and the mass vaccinator were tape-recorded and transcribed. Interviewees were randomly selected from stratified lists and included five principals, five school nurses, two school administrators, and two lead personnel from the mass vaccinator. A content analysis of transcripts from the interviews was completed and several themes emerged. All participants generally found the SLIV project acceptable. School personnel and the vaccinator viewed the SLIV project process as feasible and beneficial. However, the vaccinator identified difficulties with third-party billing as a potential threat to sustainability.

Elementary School–Located Influenza Vaccine Programs

This study examined the initiation and logistics, funding, perceived barriers and benefits, and disruption of school activities by school-located influenza vaccination (SLIV) programs conducted during the 2008-2009 influenza season. Seventy-two interviews using a structured protocol were conducted with 26 teachers, 16 school administrators, and 30 health care professionals from 34 schools in 8 school districts. SLIV programs used a variety of locations, scheduling and staffing options, and methods for receiving parental consent and screening children. Health care professionals were primarily responsible for implementing SLIV programs, and most administrators and health care professionals considered programs easy to initiate. Health care professionals identified successful programs as requiring adequate planning/coordination, a dedicated program coordinator, and a consistent funding source. Most respondents (96%) reported minimal school-day disruptions. The perception of most stakeholders is that SLIV programs can be relatively easy to initiate, minimally disruptive and can become more efficient with experience, especially with feedback from all stakeholders.

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.

Pediatrician Attitudes Concerning School-located Vaccination Clinics for Seasonal Influenza

Vaccinating all children aged 6 months to 18 years every year has potentially large ramifications for office-based primary care pediatricians. We determined the degree to which pediatricians support routine annual influenza vaccination outside the medical home, especially in school-located mass influenza vaccination clinics. Internet-based survey sent in May and June 2009 to all 623 currently practicing primary care general pediatricians who were members of the Maryland Chapter of the American Academy of Pediatrics. Of those surveyed, 193 (31%) responded. Approximately 67% reported they vaccinated more than half the children in their practice with at least one dose in the 2008-2009 influenza season, and about half anticipated that, in their office, they would not attain ≥75% coverage of all patients older than 5 months of age. Approximately 27% of respondents predicted they would likely have difficulty obtaining sufficient vaccine to cover commercially insured patients, and 32% were likely to have difficulty getting sufficient vaccine to cover Medicaid, underinsured, and uninsured patients because of ordering or distribution problems. Approximately 78% of respondents cited borderline or poor reimbursement for influenza vaccinations, and 53% had unused vaccine at the end of the 2008-2009 influenza season. Ninety-six percent of respondents supported school-located influenza vaccination programs in their community for their patients. These results indicate awareness by primary care pediatricians in Maryland of the potential difficulties involved in implementing universal influenza vaccinations in their practice and their support of school-located vaccination programs managed by the local health department in their community.

Factors associated with increased vaccination in 2009 H1N1 school-located influenza vaccination programs

In the United States, school-located influenza vaccination (SLIV) programs have increased significantly in recent years. In June 2010, the Office of Inspector General issued a report regarding 38 elementary school H1N1 SLIV programs conducted in 6 localities in November/December 2009. By locality, there was a mean of 14 to 46 first doses of vaccine administered per 100 students. The locality that conducted programs in early November had a higher uptake rate than localities with later programs (46 vs 21 per 100 students; P

The Impact of School-Located Influenza Vaccination Programs on Student Absenteeism

A literature review was conducted to summarize the impact of school-located influenza vaccination (SLIV) programs on school absenteeism. Seven studies were identified: six peer-reviewed articles and one conference presentation. The number of students vaccinated ranged from 185 to 5,315, representing 35-86% of enrolled students. Six studies compared absenteeism for students in SLIV schools and control schools; all found absenteeism decreased in SLIV schools. Three studies compared absenteeism for vaccinated and unvaccinated students in SLIV schools; all found that absenteeism was reduced for vaccinated students. Benefits were also reported to extend beyond the vaccinated children; one study found that absenteeism was significantly reduced among high school students when elementary school students were vaccinated. The available evidence indicates that SLIV programs reduce student absenteeism during the influenza season. Additional research into sustainable funding sources and the comprehensive effects of SLIV programs on students, families, staff, and the community is warranted.

Statewide School-located Influenza Vaccination Program for Children 5–13 Years of Age, Hawaii, USA

New guidance recommends annual influenza vaccination for all children 5-18 years of age in the United States. During 2007-2008, Hawaii offered inactivated and live attenuated influenza vaccine at school-located clinics for grades kindergarten through 8. Most (90%) public and private schools participated, and 622 clinics were conducted at 340 schools. Of 132,775 children 5-13 years of age, 60,760 (46%) were vaccinated. The proportion vaccinated peaked at 54% for those 6 years of age and declined for older cohorts. More than 90% of schoolchildren transited the clinic in <10 minutes. A total of 16,920 staff-hours were expended; estimated cost per dose administered was $27 and included vaccine purchase and administration, health staffing resources, printing costs, data management, and promotion. This program demonstrates the feasibility of conducting mass school-located influenza vaccination programs in public and private schools statewide, as might be indicated to respond to pandemic influenza.