Experts weigh advisability of school-based flu shots

Nov 19, 2008 (CIDRAP News) – Earlier this year the US Centers for Disease Control and Prevention (CDC) broadened its flu vaccine recommendation to include all school-age children, prompting some health officials to eye school-based immunization programs as an efficient way to improve vaccination rates in young people.

Federal health officials have said children bear a significant burden of seasonal flu and that reducing flu transmission among children may limit virus spread among household contacts and in the community. Also, they point out that vaccinating school-age children could reduce the need for medical care and curb school absenteeism.

The new recommendation, which includes children from ages 5 through 18 years, adds 30 million children to the CDC's target group, poses a big challenge for the healthcare system because the vaccine season is limited and many young people don’t regularly visit doctor's offices, where many people typically get their yearly flu shots. Some experts question whether school-based flu vaccination programs lower healthcare costs. Though research findings on the costs and benefits have been mixed, a multistate trial earlier this year that factored in household protection benefits suggested that such programs were cost-effective.

A snapshot of school-based efforts
Over the past few years, a variety of schools and districts have hosted immunization programs—some as pilot projects and some working toward more permanent programs.

Last year Hawaii became the first state in the nation to offer free flu vaccines to its children in elementary and middle schools, vaccinating 60,000 students and 9,000 faculty and staff at 340 public and private schools, according to an Aug 6 Hawaii Department of Health press release. That state's "Stop Flu at School" program includes a long list of partners, including state agencies, professional groups, university departments, healthcare organizations, and vaccine companies.

In early November, the East Baton Rouge (Louisiana) Parish school district launched its first influenza vaccine program, a state pilot program that hopes to vaccinate close to 40% of the student population, according to a Nov 6 statement from the district. Vaccines will be administered by a contractor that provides medical care at the schools as well as volunteers from Southeastern Louisiana University's school of nursing. The cost of immunizations for qualifying students is covered through the CDC's Vaccines for Children (VFC) program, with the remainder covered by a donation from a local hospital foundation.

In Aurora, Colo., hospitals in the Anschutz Medical Campus' Adopt-a-School program recently offered free flu shots to students and staff at two local elementary schools, according to a Nov 13 report from the Aurora Sentinel.

One district's experience
In 2005, MedImmune, maker of FluMist, approached more than a dozen US sites to test the feasibility of school-based immunizations, said John Lott, director of nursing at the Knox County (Tennessee) Department of Health, who supervises the area's school immunization programs. Local schools are keenly aware of how severely flu can impact schools, he said. In 2004, the area experienced school closures due to the illness.

In 2005 Knox County's pilot program included 81 public schools with a goal of immunizing 54,000 children over a 4-week period. "We were their (MedImmune's) largest project, and our vaccination rate was 46%," he said, adding that the company challenged the county to exceed that number in 2006.

Last year, the county continued the school-based immunizations on its own by cobbling together some vaccine from the VFC program, funding for staffing and vaccine purchase from the county, and assistance from school nurses. However, the vaccination rates were difficult to sustain because of the extra burden on schools and their nurses. "It's a challenge trying to find a sustainable model," he said.

Despite the difficulties, Lott says he has seen other benefits for schools beyond just improved vaccination rates. Over the past 4 years, Knox County hasn't had to close any of its schools, even though surrounding areas have. Financial support for schools is often based on daily attendance, he said, so healthy students can have bottom-line benefits for their schools, he said.

Lott said he and his colleagues have learned useful lessons from their experiences with school-based immunization. For example, he said it's easier to exceed 60% vaccination rates in K-5 elementary schools because the paperwork channels for items such as vaccine consent forms are more reliable with this age-group. Rates drop to about 45% in middle schools, then fall off to about 25% to 30% in high schools. With limited resources for school-based vaccination drives, healthcare officials have to make tough decisions about what age-groups to target.

Realistic expectations for schools
Diane Peterson, an editor for the National Influenza Vaccine Summit's Web site and associate director for immunization projects at the Immunization Action Coalition, based in St Paul, said it’s a tall order to expect schools to help host immunization clinics during school hours. "From my experience, schools are just stretched beyond compare with staffing and tight budgets," she said.

Schools are also feeling pressured to pass No Child Left Behind testing requirements, so many of them aren't too eager to take time away from learning activities, Peterson said.

Strategizing how to meet the CDC's flu vaccine recommendation for school-age kids is difficult, she said. "The best way would be to make it part of a mandate, but schools are up to their ears with mandates."

One option might be to have schools serve more simply as convenient sites for flu shot clinics, Peterson said, adding that school nurses have suggested that public health officials hold after-school immunization clinics at schools. "Then it would be a family program that could vaccinate parents, too. Schools like that," she said. "We have to think of different models for getting this done."

Peterson said she was part of a National Association of County and City Health Officials (NACCHO) group that recently met to discuss options relating to school-based immunization programs. She said NACCHO hopes to develop some model programs to help local groups navigate the issues and implement immunization programs for school-age children.

See also:

Mar 5 CIDRAP News story "Flu immunizations for children will pose big challenge"

Jan 31 CIDRAP News story "Study: school-based immunizations save money"

Aug 6 Hawaii Department of Health press release

Nov 6 East Baton Rouge Parish School System press release

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