Promising practices for school-located vaccination clinics-- part II: clinic operations and program sustainability

A school-located mass vaccination program can enable rapid vaccination of a large number of students while minimizing disruption of their school activities. During 3 consecutive influenza seasons beginning in 2005, the Knox County Health Department conducted school-located mass vaccination clinics using live attenuated influenza vaccine. Overall, the proportion of elementary schoolchildren vaccinated with live attenuated influenza vaccine exceeded 40% each year. We describe key lessons learned in clinic operations, including obtaining informed consent, defining the organizational structure and roles, preparing the school, staffing, training, supplies, vaccine management, team communication, and data management. We conclude by discussing program costs and sustainability.     

Promising practices for school-located vaccination clinics--part I: preparation

A school-located mass vaccination clinic approach can enable rapid vaccination of a large number of students while minimizing disruption of their school activities and potentially reducing missed work hours by parents. During 3 consecutive influenza seasons beginning in 2005, the Knox County Health Department conducted school-located mass vaccination clinics using live attenuated influenza vaccine. Clinics were held each year throughout the county over 4 weeks in more than 100 public and private schools for more than 65, 000 students in Grades K to 12. Overall, the proportion of all students vaccinated at school each year exceeded 40%. Our experience indicated that careful and thorough planning was essential to program success. Critical planning elements included (1) initial planning with extensive lead time to find the proper lead agency and project leader and to develop sound comprehensive vaccine clinic planning; (2) developing partnerships, especially with schools; (3) communicating successfully with parents, children, school administrators and teachers, medical providers, and the community at large; and (4) educating these groups successfully, using good timing, through local media, school events, direct mailings (including parents receiving information and consent packets), and partners. We review here the details of these key planning elements.     

Pediatricians' attitudes about collaborations with other community vaccinators in the delivery of seasonal influenza vaccine

ObjectiveAchieving universal influenza vaccination among children may necessitate collaborative delivery involving both practices and community vaccinators. We assessed among pediatricians nationally their preferences regarding location of influenza vaccination for patient subgroups and their attitudes about collaborative delivery methods.MethodsThe design/setting was a national survey conducted from July 2009 to October 2009. Participants included a representative sample of pediatricians from the American Academy of Pediatrics.ResultsThe response rate was 79% (330 of 416). Physicians felt strongly that vaccination should occur in their practice for children with chronic conditions (52%) and healthy 6–24-month-old infants (48%), but few felt strongly about healthy 5–18-year-olds (17%). Most (78%) thought having multiple delivery sites increased vaccination rates, and 86% thought that influenza vaccine should be available at school. Physicians reported being very/somewhat willing to hold joint community clinics with public health entities (76%) and to suggest to patient subgroups that they receive vaccine at community sites, including public clinics or pharmacies (76%). The most frequently reported barriers to collaborative delivery with community sites or school-located delivery included concerns about the following: estimating the amount of vaccine to order if children are vaccinated elsewhere (community 56%; school 80%); transfer of vaccine records (community 57%; school 78%); and reluctance of families to go outside of the office (community 45%; school 74%).ConclusionsMost physicians are in favor of school-located or collaborative influenza vaccine delivery with community vaccinators, especially for healthy school-aged children. Collaborative approaches will require planning to ensure transfer of records, effective targeting of subgroups, and provisions to protect providers from being left with extra influenza supply.     

Using Reminder/Recall Systems to Improve Influenza Immunization Rates in Children With Asthma

IntroductionAsthma is a major public health concern in the U.S. pediatric population. Children with asthma tend to fare worse when they acquire respiratory illnesses such as influenza, requiring more episodic office visits and hospitalizations than do healthy children with the same illnesses. Despite the American Academy of Pediatrics recommendation that children with chronic diseases be immunized for seasonal influenza annually, influenza immunization rates in this population peaks at < 30%. The purpose of this literature review was to examine the effectiveness of reminder/recall systems in improving influenza immunization rates among children with asthma.MethodThis literature review was conducted using PubMed, CINAHL, EMBASE, and Cochrane. Of the 178 articles found, 12 met criteria for inclusion. Articles were included if they addressed influenza vaccination in asthmatic children and “high-risk” children and considered asthmatics in the definition of “high risk.” Additionally, inclusion criteria required discussion of at least one mode of reminder method or recall method that was used to influence the rate of influenza vaccination in children with asthma. For the purposes of this review, “reminders” is defined as any action performed by health provider or representative of the health provider that was aimed at informing and/or reiterating to patients the importance of influenza vaccination for asthmatic children and/or the potential for increased morbidity with acquisition of the flu and/or availability of the vaccine. “Recall” methods included all efforts made by the health provider or his/her representative to encourage patients to return to clinics for vaccination during the influenza season. Articles were excluded if they focused on improving influenza vaccination rates in healthy children and if they used reminder/recall systems to influence vaccination against diseases other than influenza. No systematic review was found on this particular topic.ResultsProviders have used reminder and recall systems that alert patients of the need for vaccination and encourage compliance with this recommendation. Implemented techniques included verbal and mailed reminders, electronically generated alerts, and year-round scheduling of flu vaccination appointments.DiscussionImprovements have been seen in influenza immunization rates with the implementation of reminder/recall systems; however, most have been modest. Enhancements in patient education and access to vaccination are other areas of needed improvement.     

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.     

Teaching inner-city mothers about family planning and prenatal and pediatric services

One hundred thirty-five young, black, inner-city, pregnant women assessed the usefulness of a videotape designed by community health nurses to increase the self-care practices of low-income minority women with regard to their prenatal, pediatric, and family planning health needs. Seventy percent of the women rated as very useful information on the availability of health care and the protocols of public health clinics. The women also stated that they would tell others about public health care services and intended to make use of these services themselves as a result of viewing the videotape. The viewers' responses help clarify the preferred modality, content, and length of patient education for medically and socioeconomically high-risk pregnant women who tend to underuse preventive and primary health care.     

Changing immunization referral patterns among pediatricians and family practice physicians, Dallas County, Texas, 1988

Family practice physicians and pediatricians in Dallas County, Texas, were surveyed to determine how recent vaccine price increases have changed immunization referral patterns. A total of 73% of responding physicians referred some pediatric patients for immunization in 1988. Public health clinics were the largest referral source with more responding pediatricians (84.4%) referring patients than did responding family practitioners (66.5%). Referrals to the clinics were most often made when patients were unable to afford immunizations in a private practice setting. Between 1979 and 1988, the number of responding pediatricians and family practitioners making immunization referrals increased by 193% and 391%, respectively. The percentages of children referred for immunization increased by 693% during the same decade. It was suggested by our survey of Dallas County physicians that a new influx of patients are using public sector immunizations, potentially creating additional financial stress for public health programs. In addition, this shift to the public sector may undermine the health departments' ability to provide new vaccines or protect greater numbers of children with immunization.     

Vaccination practices, policies, and management factors associated with high vaccination coverage levels in Georgia public clinics. Georgia Immunization Program Evaluation Team

BACKGROUND: Controlling vaccine-preventable diseases by achieving high childhood vaccination coverage levels is a national priority. However, there are few, if any, comprehensive evaluations of state immunization programs in the United States, and little attention has been given to the importance of vaccination clinic management style and staff motivation. OBJECTIVE: To evaluate the factors associated with the increase in childhood vaccination coverage levels from 53% in 1988 to 89% in 1994 in Georgia's public health clinics. DESIGN: A 1994 mail survey obtaining information on clinic vaccination policies and practices and management practices. SETTING: All 227 public health clinics in Georgia. PARTICIPANTS: Clinic nurses responsible for vaccination services. OUTCOME MEASURE: The 1994 clinic-specific coverage level for 21- to 23-month-old children for 4 doses of diphtheria and tetanus toxoids and pertussis vaccine, 3 doses of polio vaccine, and 1 dose of a measles-containing vaccine as determined by an independent state assessment of clinic coverage levels. RESULTS: Univariate analysis showed that higher coverage levels were significantly (P<.05) associated with smaller clinic size, higher proportions of clientele enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), being a nonurban clinic, and numerous vaccination practices and policies. Multivariable analysis showed that only 8 of greater than 150 factors remained associated with higher coverage levels, including having no waiting time to be seen, having telephone reminder systems, conducting home visits for defaulters, and restricting WIC vouchers when a child was undervaccinated. Motivational factors related to higher coverage included clinic lead nurses receiving an incentive to raise coverage and lead nurses participating in assessments of clinic coverage levels by state immunization staff. CONCLUSIONS: No single factor is responsible for raising vaccination coverage levels. Efforts to improve coverage should include local assessment to provide feedback on performance and identify appropriate local solutions. Coordinating with WIC, conducting recall and reminder activities, motivating clinic staff, and having staff participate in decisions are important in raising vaccination levels.     

New vaccines for old diseases: trivalent cold-adapted influenza vaccine

Schoolchildren regularly have the highest influenza attack rates. Schoolchildren also are accessible for vaccination; school-based vaccine clinics can facilitate delivery of vaccine to a high proportion of children in a short period of time. CAIV-T has advantages for immunization of this group due to the effectiveness of a single dose, ease of administration, and ready acceptance by children. Modeling of control for an influenza epidemic by Longini et al. has shown vaccination of 70% of school children would dampen epidemics and significantly reduce the exposure of vulnerable people in the community. The goal of the central Texas trial is to demonstrate this effect in the field. Universal childhood immunization could be an important supplement to current control efforts. Vaccine coverage with TIV has leveled off since 1997; no progress toward the Healthy People 2010 goals of 90% coverage has been made after 4 years in the new decade. The number of excess deaths is expected to double within the next 25 years if control methods are not intensified. CAIV-T may become an important adjunct to control measures and can facilitate influenza pandemic preparedness.     

Influenza burden of illness, diagnosis, treatment, and prevention: what is the evidence in children and where are the gaps?

Influenza is a disease of global public health significance. Traditionally the emphasis has been on adult disease because of the impact of influenza related mortality in the elderly and other high risk groups. However, it is becoming increasingly better recognised that young children suffer considerable morbidity from influenza. There are also potential consequences for siblings, parents, other carers, and extended family members in terms of secondary infections and carer leave. Influenza infection in childhood could be effectively prevented through vaccination. However, the United States is the only industrialised country currently recommending universal influenza vaccination for young children (between the ages of 6 and 23 months), as opposed to vaccinating only those with high risk conditions.     

2009 H1N1 Influenza Pandemic

The 2009 H1N1 influenza pandemic took health care workers worldwide by surprise. Early in the course of the pandemic it was determined that children and pregnant women were at high risk of increased morbidity and mortality from the novel influenza virus. The Centers for Disease Control and Prevention and state and local public health officials quickly rallied to develop treatment guidelines for the new strain of influenza A, including emergency approvals for off-label use of some antiviral drugs. Prevention of the spread of influenza via vaccination and environmental controls is critical to the health of children. The 2009 H1N1 influenza virus emerged too late to be included in the 2009/2010 seasonal influenza vaccine, so production of a monovalent vaccine was set in motion. Five months from when the first cases of novel H1N1 appeared in Mexico and the United States, a vaccine was being distributed to high-risk patients. Looking ahead to the 2010/2011 influenza season, it is difficult to predict 2009 H1N1 activity. The 2010/2011 seasonal influenza vaccine will include the 2009 H1N1 strain, so it is critical to get all children vaccinated early in the flu season.     

Delivering oral health services to children in the past: the rise and fall of children's dental clinics.

As a contribution to the current discourse on improving the oral health of impoverished children by increasing their access to oral health services, this essay describes and examines an earlier attempt to accomplish a very similar goal: the philanthropically and publicly funded children's dental clinics that were responsible for close to half of all oral health services delivered to US children during the first half of the 20th century. As an explanation of why these clinics were established and why they proliferated, the essay argues they met 4 criteria essential to successful public health programs aimed at children: they had a clearly understood and largely accepted fiscal and social utility; they provided services that parents could easily understand as benefiting their children; they serviced a broad enough segment of the population to earn them significant social and political support; and, by meeting a variety of the professional needs of oral health care providers, they established a relationship of enlightened self interest with a group whose support or, at least, lack of opposition was crucial to their survival.     

Time spent by primary care practices on pediatric influenza vaccination visits: implications for universal influenza vaccination

OBJECTIVE: To measure the time currently spent by primary care practice personnel, and the examination room occupancy time for childhood influenza vaccination visits, to assess the practicality of annual influenza vaccination of all preschool children. SETTING: Seven primary care practices serving one fourth of the children living in Rochester, NY. PATIENTS: Ninety-two children seen for influenza vaccination visits in the 2000-2001 vaccination season. METHODS: Using a standardized protocol, practice staff measured the time spent on check-in, nurse or physician examination, and the actual influenza vaccination process. Waiting and "hands-on" times were determined, as well as total visit and room occupancy times. Nonparametric tests and multivariable models were used to analyze the time spent for components of the visits and to compare time spent by different age groups and practice types (suburban or urban). RESULTS: The median duration of the influenza vaccination visit was 14 minutes (25th to 75th percentiles range, 9-25 minutes) across the 7 practices, with visits to urban practices being longer (22 minutes) than visits to suburban practices (9 minutes). Eighty percent of patient time involved waiting, primarily in examination rooms. The major components of influenza vaccination visits included waiting room time (4 minutes in suburban practices vs 8 minutes in urban practices; P<.01), and time in the examination room (5 minutes vs 14 minutes, respectively; P<.001), during which only 1 to 2 minutes (for both suburban and urban practices) were for hands-on vaccinations. Only 5% of visits were examined by a physician or nurse practitioner. Visit times did not vary by age. CONCLUSIONS: Although the personnel time for influenza vaccination visits was short, there was substantial patient waiting and long occupancy of examination rooms. If universal influenza vaccination is to be efficiently managed in primary care practices, it may be necessary to implement "vaccination clinics" or sessions in which large numbers of children are scheduled for influenza vaccinations at times when adequate rooms and dedicated nursing staff are available.     

Influenza in children

Excess mortality associated with annual influenza epidemics is highest among persons over 65 y of age, and therefore influenza is often regarded as an illness of the elderly population. Ample evidence indicates, however, that the burden of influenza is also substantial in children, and that children have a central role in the spread of influenza in the community during epidemics. Vaccination of children against influenza could bring about substantial health benefits not only to children themselves but also to persons in other age groups.

Conclusion: General awareness about the total impact of influenza in children should be increased among both healthcare personnel and the parents of children. More widespread vaccination of children should be considered to decrease the burden of influenza on children and wider society.     

New opportunity for vaccinating older people: Well‐child clinic visits

Background: Streptococcus pneumoniae causes considerable morbidity and mortality in the elderly. As aging of the population is making the health of the elderly a universal priority, preventive measures, such as vaccination, will become increasingly important. Methods: We designed a prospective interventional study to determine whether recommendations to vaccinate grandparents of children attending well‐child clinics would increase the pneumococcal vaccination rate in the elderly. Children younger than 5 years of age, attending a university well‐child clinic from 1 May to 31 September 2008 who had grandparents over 65 years of age were eligible. A survey including the questions about the demographic characteristics of children, their parents and grandparents over 65 was carried out by face‐to‐face interview with the parents. High‐risk medical conditions and vaccination history of grandparents was also noted and the benefits and necessity of pneumococcal vaccination (23vPPV) for the elderly was emphasized. Four months later these families were contacted to determine whether this intervention had increased the pneumococcal vaccination rates of the elderly. Results: Information was obtained from 938 grandparents of 545 children. Before the interview, among all grandparents, only 0.9% were vaccinated with 23vPPV. Four months after this intervention, immunization coverage increased to 19.1%. The sex of the grandchild (OR: 1.99) and previous hepatitis B or influenza immunization of the grandparents (OR: 2.73) were the significant parameters accounting for higher immunization rates. Conclusion: Reminding elderly grandparents about vaccines in well‐child clinics could be an opportunity in this field.     

ARSH 5: Reproductive Health Needs Assessment of Adolescents and Young People (15–24 y): A Qualitative Study on ‘Perceptions of Community Stakeholders’

Objective

To explore the perceived reproductive health problems, health seeking behaviors, knowledge about available services and barriers to reach services among adolescents in order to improve reproductive health services for adolescents.

Methods

The study was conducted in three districts of Kerala and need assessment was done qualitatively using focus group discussions (FGDs), five each from all the three districts among junior public health nurses (JPHNs), anganwadi workers (AWWs), non-government organizations (NGOs), community leaders and adolescents.

Results

Majority of community stakeholders expressed that adolescents get knowledge regarding personal hygiene from their family itself and that they have poor knowledge about genital hygiene. Pain and associated problems are the most important difficulties faced by adolescent girls during menstrual periods. Most of the adolescents believed that excessive masturbation is a very dangerous practice. Most of the community stakeholders pointed out that though our adolescents know about HIV, they have very poor knowledge about other STIs and that parental ignorance increases vulnerability for sexual abuse among adolescents. They also suggested family life education sessions at schools and colleges for younger ones and premarital counseling for older ones, apart from counseling services and adolescent clinics. The important barriers in the utilization of services for adolescents are lack of awareness of parents, stigma to utilize services, economic factors, facility available at faraway places, and non-availability of services.

Conclusions

The need for adolescent friendly health services and premarital counseling services in the community attached to health facilities, has been highlighted.

     

Potential Strategies to Achieve Universal Influenza Vaccination for Children: Provider Attitudes in Two States

Objective

Childhood influenza vaccination rates remain suboptimal. Provider perceptions on strategies to achieve universal vaccination are needed. We assessed the perceptions and attitudes of primary care providers across 2 states regarding 2 strategies to potentially bolster rates: centralized reminder/recall (C-R/R), such as reminder/recall (R/R) notices from state immunization registries, and influenza vaccination by complementary community vaccinators (CCVs), such as retail pharmacies, schools, and health departments.

Does influenza vaccination prevent asthma exacerbations in children?

OBJECTIVE: Influenza can exacerbate asthma, particularly in children. The effectiveness of influenza vaccine in preventing influenza-related asthma exacerbations, however, is not known. We evaluated influenza vaccine effectiveness in protecting children against influenza-related asthma exacerbations. STUDY DESIGN: We conducted a population-based retrospective cohort study with medical and vaccination records in 4 large health maintenance organizations in the United States during the 1993-1994, 1994-1995, and 1995-1996 influenza seasons. We studied children with asthma who were 1 through 6 years of age and who were identified by search of computerized databases of medical encounters and pharmacy dispensings. Main outcome measures were exacerbations of asthma evaluated in the emergency department or hospital. RESULTS: Unadjusted rates of asthma exacerbations were higher after influenza vaccination than before vaccination. After adjustment was done for asthma severity by means of a self-control method, however, the incidence rate ratios of asthma exacerbations after vaccination were 0.78 (95% CI: 0.55 to 1.10), 0.59 (0.43 to 0.81), and 0.65 (0.52 to 0.80) compared with the period before vaccination during the 3 influenza seasons. CONCLUSIONS: After controlling for asthma severity, we found that influenza vaccination protects against acute asthma exacerbations in children.