School-based influenza vaccinations: a good option?

Some argue that implementing the CDC’s vaccination recommendation will be an overwhelming challenge for pediatricians.

Faced with the recent CDC recommendation that by 2010 all children aged 6 months to 18 years be given an annual influenza vaccination, pediatricians question how they will be able to vaccinate an additional 30 million children in their offices every year. Vaccinating school-aged children during school hours is one option being considered.

“We are looking at schools as a good setting to successfully vaccinate adolescents,” Lance Rodewald, MD, pediatrician and director of the Immunization Services Division of the CDC, said in an interview. “The idea behind this is not so much that schools will have to hire the staff and burden the expense, but that there will be a partnership between a health department clinic and a community vaccinator like the visiting nurses or the commercial vaccinators. I believe this has the potential to be a viable model for adolescent vaccination.”

Stan L. Block, MD, speaking for many pediatricians and family practitioners, said that implementing the vaccination recommendation will be an overwhelming challenge. “We do not see school-aged children often enough and well enough in the office during the typical three to five month pre-influenza window. Even if we did, we currently don’t have the nursing staff or the time to vaccinate several hundred children day in and day out. It would be overwhelming for our offices.”

“School-based programs are going to be critical in aiding in the influenza vaccination of all U.S. children and teens. Pediatricians will likely be in favor of this program, but can we vaccinate perhaps 10,000 patients in our pediatrician offices within this short period?” said Block, a member of the Infectious Diseases in Children Editorial Board.

James C. King Jr., MD, of the department of pediatrics at the University of Maryland School of Medicine, said that “both physicians and parents are overwhelmed by all the vaccines that are required for school entry.”

King agrees with recommending influenza vaccine for virtually all children over the age of 6 months and older if there are no contraindications to receiving the vaccine. However, he disagrees with the concept that influenza vaccination be required by the school systems annually.

“Parents should be able to choose whether or not their children receive the vaccine,” King said. “The conflict of recommendation vs. requirement results from the enormous practical problem of enforcing annual influenza vaccination by school systems.”

Bonnie L. Fass-Offit, MD, attending physician at Kid’s First primary care office of the Children’s Hospital of Philadelphia, said that because the influenza vaccine is required every year, influenza vaccinations will require a tremendous amount of organization, manpower, office space and nursing staff.

“I support the pediatrician’s office as the place where children are vaccinated, but we certainly know from the AAP that the medical home model — at least in my practice — makes great sense and there are so many areas that this works well. However, the influenza vaccine is the one vaccine where a school or other public venue is a better fit because it is a yearly vaccine,” Fass-Offit said.

“Over the last few years most pediatric offices have geared up and are now better equipped to handle this vaccine, but I still think there is a place for school-based programs as another option to administer the annual vaccine,” she said.

Models of school-based programs

Recent programs have looked at the cost, benefits and challenges that would be associated with a school-based approach.

Lisa Swank, BSN, RN, coordinator of the Public Health Emergency Preparedness and Response and Cities Readiness Initiative, Harford County Health Department in Maryland, led a 2006 emergency preparedness plan to vaccinate all elementary school children in that county with the influenza vaccine (Flumist, MedImmune).

Funded by the state of Maryland, the CDC’s Vaccines for Children program and MedImmune, the program vaccinated more than 8,000 students in more than 30 schools in a 16-hour period, utilizing 160 people working on 16 teams.

“Much planning and coordination are required to determine the size of the population to be vaccinated,” Swank said. “Staffing may consist of retired nurses, public health or school nurses, local nursing schools, staffing agencies, parent volunteers and nonmedical staff at the school. Following the 2006 vaccination project, we discovered that each team only required one team leader, one or two assistants and one nurse for every 100 students vaccinated in a two and a half hour period. In 2007, we were able to staff the teams using only health department personnel.”

Funding for vaccinations, including school-based programs, is a challenge “due to the lack of knowledge regarding the economic impact of influenza on a community,” Swank said.

The Vaccines for Children program can purchase vaccine for about 48% of the eligible population in an average community. However, it takes more than vaccine to vaccinate a group of school children.

There are expenses associated with the infrastructure, the administration of the vaccine and coordination with the school-based clinics, Rodewald said. “There are currently few additional resources to help fund this supporting infrastructure … right now, we mainly have only vaccine to offer.”

Medicaid can be billed an administration fee for children enrolled in the program, so this will offset some costs. However, there is no government-supported administration fee for children not enrolled in Medicaid, Rodewald added.

In a local school-based program that Fass-Offit helps direct in Montgomery County, Penn., the county uses MAXIM Health Systems, an access company that offers vaccination services for places such as colleges/universities, public health facilities and retail-based locations, such as pharmacies and grocery stores across the United States.

“This company supplied the staff to administer the vaccine in our schools because the school nurses were too busy,” Fass-Offit said. “Even though the school nurses were excited about this program, they still had to be at their offices for when children were coming in with hyperventilation and fevers, etc, so the school nurses won’t work; this is why I think this medical company is the best way to go.

“The only down-side is that they charge about $35 per child for Flumist, whereas Flumist is normally around $16 to $18. The interesting thing about this vaccine and many other vaccines is that we are actually protecting others, so there is an inherit value here.”

Outbreak shortened

One school-based program in Philadelphia in 1998 and 1999 successfully curtailed a varicella outbreak in two elementary schools: one public and one private. Vaccinations were administered with written parent consent to susceptible children.

Vaccination coverage of susceptible children increased from 52.9% to 92.2% in the public school and from 68.8% to 85.3% in the private school. The intervention was effective in “increasing varicella vaccine coverage, decreasing disease susceptibility and shortening the outbreak,” the researchers reported in Pediatrics. “Additionally, vaccination may have protected unvaccinated susceptible children indirectly by interrupting transmission.”

King and colleagues demonstrated the effect of a community-based influenza vaccine intervention on student absenteeism in Carroll County, Md., from 2005 to 2006.

“The county public school system and the county health department put together a volunteer effort where they were able to vaccinate all children whose parents signed a consent form and were eligible for the vaccine in all 21 elementary schools,” King said.

The live-attenuated influenza vaccine was administered to 5,319 of the 12,090 students enrolled in public elementary schools in Carroll County. The control group included students in Carroll County from 2001 to 2005 and nearby Frederick County from 2001 to 2006.

“Using an analysis model that includes adjusting for an effect of county, there was a 1% higher increase in all-cause absenteeism above baseline in the control elementary schools when compared with the intervention school (P=.029, 95% CI=0.1-1.9%). For high schools, this difference was 0.9 (P=.028, 95% CI=0.1%-1.7%).

“This was a very positive experience,” King said. “The health department nurses served as the generals or chiefs and we had volunteers to carry out the effort. Pediatricians will struggle with the execution of the influenza mandate in their practice alone, so we will have to think outside of the box for alternative ways to vaccinate this large number of children, such as school-based clinics.”

Purchasing the right number of doses

Another concern that plagues office-based pediatricians is determining the right amount of influenza vaccine doses to purchase.

“Deciding on which vaccine and what certain volume of different vaccines to order and pay for boggles my mind,” said Block. “The logistics for sending a large group back for a second dose is scary. Who pays for unused surplus? The continued unreliable, disrupted influenza supply issues this year again have been awful for both Vaccines for Children and insurance patients in our office. I am very wary of the economics and logistics of this recommendation.”

Joseph F. Hagan, MD, is a practicing pediatrician in Vermont where the state has a public-private partnership for vaccine funding for all primary care offices.

“Whenever a new vaccine is added in Vermont, pediatricians are faced with this incredible decision of whether or not to stock the vaccine and bill people for it,” he said.

“The problems with stocking and billing the vaccine ourselves is that there is a huge cash outlay, there is no guarantee that the insurance company will reimburse us for cost, and if Vermont decides they are going to provide the vaccine that year and the pediatrician has already bought a shipment of 20 doses, the insurance company is not going to pay for it since the state just gave it out for free.”

Hagan said it is important to look at all venues for increasing vaccination rates and is in favor of the implementation of school-based influenza vaccination programs.

“From a public health perspective, if this is the way a community or state wants to go about this, then there are some real advantages to vaccinate children in school,” Hagan said. “However, everyone needs to agree that this is the way to improve the health of the children in the community.” –by Jennifer Southall

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For more information:

• Davis M, King JC, Moag L, Cummings G, et al. County-wide school-based influenza immunization: direct and indirect impact on student absenteeism. Pediatrics. 2008;122:e260-e265.
• Bernstein A and Swank L. Mass vaccination of a target population. Presented at the 42 National Immunization Conference; held in Atlanta; March 17-20, 2008.
• Hall S, Galil K, Watson B and Seward J. The Use of School-Based Vaccination Clinics to Control Varicella Outbreaks in Two Schools. Pediatrics. 2000; 105: p. e17.
• National Conference of State Legislatures: www.ncsl.org/programs/health/hpvvaccine.htm. Last accessed 9/24/2008.
• WSJ.com/Harris Interactive Study: www.harrisinteractive.com/news