COMMENTARY

School-Located Influenza Vaccination: Can Collaborative

Efforts Go the Distance?Sharon G. Humiston, MD, MPH; Katherine A. Poehling, MD, MPH;Peter G. Szilagyi, MD, MPH

From the Department of Pediatrics (Dr Humiston), Children’s Mercy Hospital and Clinics, Kansas City, MO; Department of Pediatrics(Dr Poehling), Wake Forest School of Medicine, Winston Salem, NC; and Department of Pediatrics (Dr Szilagyi), University of RochesterSchool of Medicine and Dentistry, Rochester, NYDr Poehling reports research funding from NIH, Medimmune, and BD Diagnostics. Drs Humiston and Szilagyi have no conflicts of interestto disclose.Address correspondence to Sharon G. Humiston, MD, MPH, Department of Pediatrics, Children’s Mercy Hospital and Clinics, 2401 GillhamRoad, Kansas City, MO 64108 (e-mail: sghumiston@cmh.edu).Received for publication March 10, 2014; accepted March 10, 2014.

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DESPITE A LARGE amount of publicity about universalpediatric influenza vaccination, nationally, influenzavaccination rates among school-aged children remainlow. Only 59% of 5- to 12-year-old children and 43%of 13- to 17-year-old adolescents were vaccinated duringthe 2012 to 2103 flu vaccination season.1 It is time toconsider new paradigms to complement traditional influ-enza vaccinations in primary care. One “new” paradigminvolves school-located influenza vaccination (SLIV),about which there is a great deal of confusion.

There are 3 general types of SLIV: 1) influenza vaccina-tion that is part of existing school-based health center activ-ities, 2) programs that take place before or after schoolhours and use the schools as sites for vaccinations (oftenvaccinating school personnel and parents, and potentiallychildren who accompany parents, and 3) programs thatvaccinate children during the school day without parentsbeing present at the time of vaccination. The first modelinvolves school-based health centers, which delivercomprehensive health services so the licensing, staffing,and billing issues are dictated by the general health centeractivities. Because there are only approximately 2000 suchcenters,2 a relatively small proportion of US children oradolescents have access to them and SLIV must includemany more models to have a meaningful effect on influ-enza immunization coverage. The second model mirrorsinfluenza vaccination programs that exist at malls, airports,and other locations. These often focus on adult vaccinationand are no more convenient for parents than vaccination inmedical offices. The third model, which occurs during theschool day without parents being present, is the mostintriguing yet challenging to implement because it involvesissues of parental consent, billing a variety of insurers, esti-mating the number of vaccines to order for SLIV wellbefore the season, practical challenges of vaccinating chil-dren during school hours, and communications with pri-mary health care providers.

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The concept of SLIV should be kept distinct from vacci-nation against other diseases or at other sites in the commu-nity. During discussions of SLIV, the topic should belimited to influenza vaccination. Many experts who believethere is a place for SLIV in the array of strategies toincrease national influenza vaccination coverage wouldnot be comfortable with uncoupling other vaccinationsfrom the medical home. All other childhood and adolescentimmunizations are given at any time of the year rather thanduring influenza vaccination’s relatively short fall to winterflu vaccination window. This commentary, therefore,focuses on the third model of SLIV—influenza vaccina-tions during the school day.Vaccinating during the school day—when parents are

not present—allows parents to keep working (on the jobor in the home) rather than taking time out to accompanytheir child. Because only a small percentage of school-aged children make a visit to primary care during influ-enza vaccination season,3 SLIV can save parents time,prevent children from missing school to attend a medicalvisit, and potentially save the health care system money.A recent randomized clinical trial of this SLIV modelnoted greater immunization rates in SLIV than in controlschools.4 The logistic challenges are notable: SLIV dur-ing school hours creates the need to develop a communi-cation process to inform parents, a parental consentprocess, a mechanism for the vaccine clinics, and commu-nication with primary care providers. Offering injectableand intranasal spray vaccine allows choice of vaccinefor parents and the sizable proportion of children with acontraindication to the intranasal spray (eg, 9% of chil-dren have asthma5) to be vaccinated. It also increasesthe complexity of parent education, consent, and manyaspects of the SLIV clinics’ organization. Most SLIV pro-grams use nonschool personnel (eg, health departmentstaff or commercial community vaccinators), to deliverthe vaccine and run the “Vaccine Day,” which limits the

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burden on the school nurse, but also limits the number ofopportunities a child has to be vaccinated at school.Models that use school nurses are able to vaccinate chil-dren who might have been absent on “Vaccine Day.” Mostpreviously described models of SLIV required financialsupport in the form of free vaccine, free labor, or both.The work of Kempe et al, detailed in this issue,6 describesan SLIV model in which billing for vaccine and vaccineadministration was part of the team’s activities. This pio-neering demonstration project has led the Centers for Dis-ease Control and Prevention to further explore relatedmodels in several states.

All models of SLIV require collaboration between“silos” that are rarely brought together. The Denver SLIVprogram demonstrated this clearly. For this school-dayvaccination program, the school personnel helped to gatherparental consent through communication from the class-room teacher and, in the second year, by adding the consentpackage to other school registration materials. Schoolpersonnel followed up on missing information from con-sent forms, set up the vaccination clinics, and escorted stu-dents. Community vaccinators attended school registrationand other back-to-school activities to answer parents’ ques-tions; they also administered the vaccinations and carriedout the multistep billing process. The public sector’smost notable contribution—maintaining the infrastructureto provide the Vaccine For Children vaccines—is easy tooverlook, but is crucial. This study was not designed toevaluate how much the SLIV program improved the vacci-nation rates, but it is notable that 30% of these elementaryschool students received influenza vaccine in schools inwhich 87% of the students were eligible for the Free andReduced Lunch program. Presumably, many of these chil-dren would not have received an influenza vaccination thatyear if it were not for the SLIV program.

What do parents think of SLIV? In this issue, Kempeet al describe the results of a survey of parents of elemen-tary school children from schools that participated in theSLIV program.7 Most parents of children in these schoolswere very strongly positive about the SLIV program, butmost had not had their child participate. Perhaps not sur-prisingly, parents who perceived the vaccine as efficaciousand the SLIV program as convenient were more likely to bepositive about the program and to have had their childparticipate in it. Despite efforts to advertise the program,approximately 1 of 4 parents who responded to the surveyhad not heard previously about the SLIV program in their

school. Interestingly, among parents who usually paid acopay for their child’s vaccination, approximately a thirdwere somewhat or not at all willing to pay the same copayfor a vaccine given in a SLIV program. Overall, parentsviewed SLIV favorably.Primary care providers have done a remarkable job of

embracing and realizing the universal influenza vaccina-tion recommendation of the Centers for Disease Controland Prevention8 and the American Academy of Pediatrics.Nonetheless, it seems likely that to increase influenzavaccination rates will require vaccinating “outside thebox,” that is, in sites other than the medical home. Becauseinfluenza immunization rates tend to decrease from infancythrough adolescence1 and the difficulty of getting patientsinto the office tends to increase with the child’s age, itseems important to utilize a site in which school-agedyouth already tend to congregate (ie, schools).

ACKNOWLEDGMENTS

Drs. Humiston and Szilagyi were funded in part by a grant from

the Agency for Healthcare Research and Quality (R18HS021163 PI –

Szilagyi).

REFERENCES

1. Centers for Disease Control and Prevention. Flu vaccination coverage,

United States, 2012-13 influenza season. Available at: http://www.

cdc.gov/flu/fluvaxview/coverage-1213estimates.htm. Accessed March

9, 2014.

2. Council on School Health. School-based health centers and pediatric

practice. Pediatrics. 2012;129:387–393.

3. Rand CM, Szilagyi PG, Yoo BK, et al. Additional visit burden for uni-

versal influenza vaccination of US school-aged children and adoles-

cents. Arch Pediatr Adolesc Med. 2008;162:1048–1055.

4. Humiston SG, Schaffer SJ, Szilagyi PG, et al. Seasonal influenza vacci-

nation at school: a randomized controlled trial. Am J Prev Med. 2014;

46:1–9.

5. U.S. Department of Health and Human Services. Centers for Disease

Control and Prevention. Vital and Health Statistics; Summary Health

Statistics for U.S. Children: National Health Interview Survey, 2012.

Available at: http://www.cdc.gov/nchs/data/series/sr_10/sr10_258.pdf.

Accessed March 9, 2014.

6. Kempe A, Daley MF, Pyrzanowski J, et al. School-located influenza

vaccination with third party billing: outcomes, cost and reimburse-

ment. Acad Pediatr. 2014;14:234–240.

7. Kempe A, Daley MF, Pyrzanowski J, et al. School-located influenza

vaccination with third-party billing: what do parents think? Acad

Pediatr. 2014;14:241–248.

8. Fiore AE, Shay DK, Broder K, et al. Prevention and control of influ-

enza: recommendations of the Advisory Committee on Immuniza-

tion Practices (ACIP), 2008. MMWR Recomm Rep. 2008;57(RR-7):

1–60.