School surveillance and prior vaccination clinics strengthen H1N1 response

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Hawaii's existing school surveillance alerted health officials of changing disease patterns early during the outbreak. This, combined with its established school-located vaccination clinics, significantly aided its H1N1 response effort.

The first two identified cases of H1N1 in Hawaii were confirmed by the Hawaii Department of Health (HDOH) on May 12, 2009. Both cases were from the same K-12 school; a charter school that has students from across the island. This suggested that the outbreak was probably not limited to only one local community. An investigation was initiated to determine the extent of transmission at the school and among household contacts of school students and staff. The goal of the investigation was to help establish appropriate control strategies to mitigate any further spread of the disease. The school outbreak continued for three weeks with a total of 16 confirmed cases.

In response to this outbreak, HDOH, the school, and the Hawaii Department of Education (HDOE) launched an educational campaign asking students and staff to stay home if sick. Together, these organizations conveyed unified advice for schools to immediately send home students and staff experiencing influenza-like illness (ILI). Dr. Sarah Park, the state epidemiologist, believes this cohesive voice might have helped contain the outbreak. HDOH feels that clear, ongoing communication between education and public health authorities is especially important because guidance on school closures and other policies are routinely updated and revised.

HDOH also reviewed student absenteeism rates both before and during the outbreak. Schools are required to report when absentee rates attributable to any illness exceed 10% of the student body to the state department of health. During the H1N1 outbreak, overall absenteeism rates exceeded 10% on seven occasions during the 2 weeks prior to the confirmation of the first case. In fact, the median daily absenteeism rate from April 23 through May 13 was 13% for the entire school. This illustrates how routine monitoring of influenza activity in schools can alert public health officials of changing disease patterns early during an epidemic, possibly even prior to official case confirmation. Absenteeism increased to 35% during the two weeks after the school-wide outbreak notification. Based on anecdotal reports from the school, Dr. Park attributes a significant portion of this spike in absenteeism to fearful parents temporarily pulling their kids of out school.

The 2009-2010 influenza season was HDOH's third year for operating a voluntary statewide seasonal vaccination campaign within its elementary and middle schools. Each school is able to decide yearly if it wants to participate in this program. In addition to students, the free vaccine is also offered to school staff; a decision that HDOH believes has increased program buy-in. To operate the school-located clinics, HDOH recruits and trains mobile vaccination teams that consists of contract nurses, public health nurses, MRC volunteers, local nursing school students, and other volunteers. These teams can set-up, vaccinate, and break down a school-located clinic in approximately four hours with minimal disruption to the school. Consent forms signed by parents are pre-screened prior to the clinic date to save time and reduce potential errors. HDOH utilized this system to distribute both seasonal and H1N1 vaccine in 2009.

This initiative costs approximately $1.8 million each year; $1.2 million for the vaccine and $600,000 for operational cost - excluding HDOH staff time. During the first two years of operation, 42-43% of Hawaii's 5-13 year-olds who attended school received a seasonal flu vaccine. This rate increased in 2009 to 50% of the state's 5-13 year-olds receiving the seasonal vaccine. A total of 342 schools, 91% of the public and private schools in the state, participated in the 2009 seasonal vaccination program. Of those schools, 327 also participated in the H1N1 vaccination program. Data are still being compiled, but preliminarily, up to 40% of children ages 5-13 years received H1N1 vaccination. Hawaii didn't experience a second wave of H1N1, which HDOH feels may be in part because of this program.

HDOH credits its H1N1 vaccination success to having a school-located vaccination program previously in place. Parents and school staff were already familiar with this process and a community expectation had formed over its three years of operation. During this time, HDOH's mobile vaccination teams also reported a change in the children. Receiving the vaccine seemed to lead to a sense of proud accomplishment, creating a peer pressure of sorts and resulting in children asking their parents if they too could be vaccinated.

In preparation for next year's vaccination program, HDOH is working with schools to encourage better illness reporting practices and is piloting an online vaccine consent form. HDOH also plans to explore options such as funding agreements with the major insurance carriers in the region to reduce the program's operating expenses. In the future, the department will seek to develop a better system for capturing and analyzing vaccination data by utilizing the state's nascent immunization registry to determine who is being vaccinated and who is not. Also, if funding allows, the state would eventually like to expand the program to include high school students.

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