Meeting the Preteen Vaccine Law: A Pilot Program in Urban Middle Schools
Boyer-Chuanroong, Lynda, Deaver, Paul, Journal of School Health
Including vaccinations as part of the requirements for school entry or moving into the next grade level provides one of the most effective ways of achieving widespread vaccination coverage.[1,2] School entry requirements are based on recommendations by the Advisory Committee on Immunization Practices (ACIP), a group of physicians that establishes national recommendations about immunizations.
In 1989, the ACIP recommended a second measles dose (MMR #2) for all students, kindergarten through university-level, to protect individuals who may not have developed immunity after the first dose. In 1991, the ACIP recommended Hepatitis B vaccination for infants. In 1996, the ACIP recommended varicella (chickenpox) vaccination for children age 12 months or older who had not been previously infected. In that same year the ACIP, with many other national health organizations, wrote a landmark statement recommending seven different vaccines for adolescents including hepatitis B, measles, and varicella vaccines. The recommendations for hepatitis B, measles. and varicella are "catch-up" strategies to assure protection of youth overlooked or past the age-group for the 1989 MMR #2 recommendation, the 1991 infant hepatitis B recommendation, and the 1996 varicella recommendation.
California is one of 23 states with legislation or regulations regarding adolescent hepatitis B vaccination.[2,7] Requirements for each state may differ by which vaccines are required, the targeted age group, and the applicable grade level. According to a recent survey conducted by the Immunization Action Coalition (St. Paul, Minn., 612/647-9009), 23 states (including Washington DC) have legislated/regulated hepatitis B vaccinations for preteens. These states are California, Colorado, Delaware, Washington, DC. Florida, Idaho, Illinois, Massachusetts, Minnesota (9/01). Missouri, Nebraska (7/00), New Mexico, New York (9/00), North Carolina, Oklahoma, Oregon (9/00), Rhode Island (8/00), South Carolina, Texas (8/00), Vermont (7/01), Virginia (7/01), Wisconsin, and Wyoming. Unless otherwise noted in parentheses (month, year), all these states have already implemented the requirement or are implementing it this school year (1999-2000).
California's requirement was established through California Law AB 381. Effective July 1, 1999, students entering seventh grade were required to have three doses of hepatitis B, a second dose of measles-containing vaccine, and a recommended tetanus-diphtheria booster (Td). Because AB 381 was signed by the governor in October 1997, schools and school health personnel had an entire school year (1998-99) to inform sixth graders and their parents. This article describes the efforts, outcomes, and resulting recommendations from an urban school district pilot program.
Diverse School District
The school district under discussion has an enrollment of 64,000 students attending 110 school sites scattered throughout the city. Of these 110 sites, 17 are middle schools (grades 6-8). The profile of this district is similar to that of other urban school districts: it is ethnically, culturally, and economically diverse. The largest ethnic groups include Chinese (28%), Latinos (21%), African-Americans (16%), Caucasians/"Other White" (12%), and Filipinos (7%). The remaining 16% include many other groups, including Southeast Asians, Middle-Easterners, and other Asians. A notable feature of this district is the home language diversity: eight languages are specifically enumerated and dozens more are included in the "other" category.
Limited Health Care Staffing
The district has its own department responsible for health-related programs. Largely grant-supported, the staff consists of nurses, health workers, health educators, and others. The department has received sizable grants designating nurses, among others, to support youth development services. All 17 middle schools have a nurse on-site for one or two days a week. While school nurses are traditionally viewed as providers of acute, chronic, episodic, and emergency health care, they are also communicators, planners, coordinators, health educators, and researchers. In this district, because nurses are at school sites on a limited basis, emphasis has been placed on planning, coordination, and health care management. Due to limited funding, no clerical health workers support the multifaceted activities of middle school nurses.
In this context of limited health care staffing and multitasking school nurses, AB 381 became law. The law, albeit a positive public health measure, was viewed across the state as a challenge for school districts and school nurses. Nurses wondered how they could add to their already extensive role, new responsibilities of initiating a documentation and follow-up program for preteen vaccinations. This concern was especially acute in schools where nurses were assigned on a part-time basis.
Having experience with adolescent immunization efforts, one of the authors, [LBC, a project director of the CDC-funded middle school immunization program (1992-95), and author of two manual-video kits on school health strategies for protecting adolescents in schools, titled Roll Up Your Sleeves! (1995) and Roll Up BOTH Sleeves! (1998)], conducted a pilot program at two middle schools by creating strategies affecting and/or involving school staff, students, parents, and the health department. Her schools, X and Y, are described in Table 1, rows 1-9. In this same table, results from the pilot program are provided in rows 10-13.
Description of Pilot Schools and Results of Program
Variable School X School Enrollment 1,300 39% Chinese, 22% Caucasian, 10% Black 9% Latino, 4% Filipino Ethnic Composition 16% Other % on Free/Reduced Lunch 26% Limited/Non-English Proficiency 17% Educationally Disadvantaged Youth (reflects economic status and school performance) 32% 1 day/week (fall); Nurse Availability 2 days/week (spring) # of sixth graders 410 15 (includes one special education class with fewer # of sixth grade home rooms than eight students) Yes, at both schools. "Core" group of about 30 students has the same teacher for five out of eight periods. (The other three are Physical Education, an elective, sixth graders "cored?" and lunch/recess.) # of students vaccinated at school 16 Compliance rate(*) by Jan. 1999 43% (175/403) Compliance rate(*) by May 1999 69% (273/393) Students who had not submitted any shot record by May 1999 3 Variable School Y School Enrollment 810 44% Chinese 11% Caucasian, 17% Black 10% Latino, 4% Filipino Ethnic Composition 14% Other % on Free/Reduced Lunch 41% Limited/Non-English Proficiency 24% Educationally Disadvantaged Youth (reflects economic status and school performance) 41% Nurse Availability 2 days a week (all year) # of sixth graders 280 14 (includes four special education classes with fewer # of sixth grade home rooms than eight students each) Yes, at both schools. "Core" group of about 30 students has the same teacher for five out of eight periods. (The other three are Physical Education, an elective, sixth graders "cored?" and lunch/recess.) # of students vaccinated at school 14 Compliance rate(*) by Jan. 1999 48% (136/281) Compliance rate(*) by May ]999 73% (204/283) Students who had not submitted any shot record by May 1999 7 Variable X+Y School Enrollment 2,100 Ethnic Composition % on Free/Reduced Lunch Limited/Non-English Proficiency Educationally Disadvantaged Youth (reflects economic status and school performance) Nurse Availability # of sixth graders 690 # of sixth grade home rooms sixth graders "cored?" # of students vaccinated at school 30 Compliance rate(*) by Jan. 1999 45% (311/684) Compliance rate(*) by May 1999 71% (477/676) Students who had not submitted any shot record by May 1999 10
Among variables "School Enrollment" and "# of sixth graders," enrollment figures have been rounded to the nearest 10s. All percentage figures have been rounded to the nearest 1s.
(*) Compliance rate refers to the number of students who submitted a record confirming MMR#2 and all three doses of hepatitis B series, divided by the number of sixth grade students enrolled in that month.
BARRIERS AND STRATEGIES
School Staff: "Freshmen" in Vaccination Law Procedures
An immunization law targeting preteens, or 11-12 year olds, affects for the most part, middle schools. But, in contrast with preschool or elementary levels, this infrastructure level is unfamiliar with enforcing compulsory vaccination laws. The school staff's lack of experience, limited inservice time, and limited preparation time are just three of several important barriers in implementing a new vaccination law.
It is critical to have site administrator support for new programs. (In this article, "site administrator" will be used when referring to individuals who are principals or assistant principals.) Site administrators at these middle schools already were supportive of health services for students. They were receptive, therefore, to discussing the immunization law and the activities that would be necessary to achieve reasonable compliance. Eliciting administrator feedback about implementation strategies engaged them in the planning process and resulted in improved procedures.
Due to the limited nursing staff time of one to two days. per week at each school, the sixth grade faculty was seen as crucial partners to facilitate implementation of the law Because the law requires compliance of all students entering the seventh grade, the sixth grade faculty's help was needed in notifying students and parents about the new law and to compel parents to promptly submit copies of their children's shot records. The experiences of CDC demonstration projects regarding hepatitis B vaccination of middle school students in the early 1990s revealed the vital role of faculty in educating and motivating students to be vaccinated. Fortunately, because of the practice of "coring," sixth grade faculty at the two schools develop strong rapport with students. "Coring" refers to the practice of having one teacher teach the core academic subjects -- language arts, social studies, math and science -- to the same group of students. It was believed that this close faculty-student relationship would enhance compliance because faculty could work with nurses to motivate students.
At both schools, grade-level team meetings are scheduled at least monthly. The nurse requested and received agenda time at each school's sixth grade meetings. At these meetings, a memo explaining the new law was distributed and discussed, followed by a viewing of the educational video The Case of the Missing Shots. This 22-minute video is an "X-Files"-like spoof, following the escapades of two FBI (the "Federal Bureau of Immunizations," of course, a fictitious agency) agents on a mission to find out why preteens aren't getting their shots. Unlike many videos that focus on hepatitis B only, this program covers measles and tetanus, and mentions varicella (chickenpox), rubella, and mumps. While the humor targets preteens, adults and younger children can also enjoy and learn from the video. The program is included in the videocassette tape that comes with the Roll Up BOTH Sleeves/Kit. As a result of the California State Dept. of Health Services (DHS)'s program of distributing this video at no charge to school nurses in the state, the school district received multiple copies of the video. Teachers were asked to show the video to their students and to elicit response through a student video review guide. To facilitate prompt viewing of the video by students, three copies were made available to each school. To be able to address programmatic snags during the year, nurse encouraged teachers to provide suggestions and feedback.
Core teachers were asked to educate and motivate students about hepatitis B and measles shots. Yet, asking teachers to provide a lesson on a new health-related topic would require preparatory time beyond what they normally spend. It was important that an educational intervention be nearly effortless for teachers, but at the same time appeal to students and take a reasonably brief time to teach -- one or two class periods. Perhaps because the video fulfilled all these criteria, a teacher survey revealed that The Case of the Missing Shots was shown to nearly every sixth grade class. Another resource from DHS was a colorful and eye-catching poster promoting preteen shots. These posters were laminated for display at the schools.
Because the preteen vaccination law was not accompanied by funding for implementation, the state was compelled to limit expenditures on public education and to limit media events to public service announcements. The message had to convey that hepatitis B vaccination requires three doses for full protection and the series takes at least four to six months to complete. The ACIP, the AAP, and the AMA have stated that, for children and adolescents, a minimum of four months is adequate to complete the series -- eg, using a 0-1-4 or 0-2-4 month schedule -- but most providers are adhering to the schedule recommended in the pharmaceutical insert, ie, the 0-1-6 month schedule. The use of 0-1-6 month schedule results in a lower compliance level for parents who delay the first dose. Memos from DHS to school superintendents and administrators sought school cooperation in notifying parents at the beginning of the 1998-1999 school year so that their children could obtain all three hepatitis B doses and MMR #2 before August 1999. The challenge for schools was creating a minimally disruptive procedure for submitting vaccination records and to provide clear instructions to parents about this paperwork.
To enforce compulsory vaccination requirements, schools are obligated to obtain a copy of each sixth grader's shot record, to assess each record, and to enforce completion by excluding any students with incomplete records. As noted earlier, middle schools were inexperienced with these activities. An informational flier from DHS reads, "The school will ask to see your child's Immunization Record as proof of immunization." But the DHS cannot specify to which department/personnel the proof should be sent, whether photocopies and/or faxes are acceptable, a deadline date, and the name and telephone number of a specific contact person at the school site. (The flier reads, "For further information, contact your physician or the school nurse or your local health department.")
Immunization record review, in general, is time-consuming for a number of reasons, among them variations in legibility in record forms, inconsistent recording style (some clinicians note the brand name of the vaccine instead of the actual vaccine name), that some vaccinations require multiple doses given over minimal intervals for adequate protection, and the requirement of two or more vaccines. In California, for example, because both the measles #2 and hepatitis B vaccines are required, when parents submit records, if anything is missing, such as the measles #2 or one of the hepatitis B series, then that student needs to be reassessed at a later time to assure completion. When there are hundreds of records, it can take several days, several times a year, to assess and re-evaluate them.
A further challenge is the tendency of parents to lose shot records. Studies of childhood immunizations showed that only about one-half of households could produce an immunization card despite being interviewed in their own homes.[11,12] One could surmise that, by the time a child reaches adolescence, an even lower proportion of parents can locate their child's record.
A set of forms, described as the green, yellow, and red fliers -- to suggest traffic lights -- was created to address nearly all the barriers noted. Fliers were sent in September, January, and April. Descriptions of the three fliers and the consent form for school-based shots are provided in The Roll Up BOTH Sleeves! Kit, second printing.
September: The "Green" Flier
The green flier was given to students by their core teachers, and students were asked to take them home to their parents. Teachers were asked to show the educational video prior to distributing the fliers to motivate students about the importance of vaccinations.
This first flier communicated several points:
* The specifics of the new law;
* The minimum time period needed to complete the hepatitis B series is 4-6 months, so start now;
* A copy of the current shot record of the child must be sent, even if the child is not finished with the shots;
* Forms are to be directed to the school nurse;
* Forms can be sent by fax;
* There is an option to obtain shots at school for free, if the child does not have health insurance and is of low income. To obtain additional forms for shots, the parent must sign at a designated space (parents who signed the designated space were sent a consent form and, as required by the CDC, Vaccine Information Statements (VIS) for offered vaccines); and
* The 24-hour voice mail of the nurse, as well as the names of site administrators.
A Simple Tracking System: Three Highlighters
School districts vary in their database capabilities. For example, this school district does not yet allow vaccination data to be entered at school sites into the district's database. Therefore, a hand-tracking system was created. A master list of sixth graders was produced by copying the attendance strips for every sixth grade home room, and home room teachers were asked to collect and turn in shot records to the nurse. After a large batch of records was compiled, each student's completion status was noted by highlighting the student's name according to a color code:
1. in complete compliance: pink
2. in process (missing any hepatitis B shot or MMR #2 shot): yellow
3. has submitted record, but has not started the required shots: clear (no color)
4. no record submitted: clear (no color)
5. receiving shots at school (with parent-signed consent form): blue
When students achieved a different completion status, their names were re-highlighted with the appropriate color to indicate their new status.
January: The "Yellow" Flier
This flier was individualized for every sixth grader by placing a computer-generated name and address sticker and sent to parents in January. The form confirmed the vaccination status of their child, ie, complete, incomplete -- and if so, for which doses of hepatitis B or for MMR #2, or no record received. If parents had not returned a consent form for school-based shots, a deadline was provided as a reminder. This flier repeated many of the same items of information as in the green flier and, as a convenience, provided spaces for the health care provider to note the dates of each dose.
April: The "Red" Flier
This warning flier, sent only to parents whose children were still incomplete for either or both vaccines, repeated many items of information in the previous fliers. The new feature was in providing a firm deadline date to submit a record. This letter, reproduced on pink paper, received a positive response. Most parents submitted copies of complete or "in process" shot records.
To convey vaccination requirements to parents, forms should be provided in appropriate home languages. The DHS created and distributed to every school district, sets of attractive and friendly fliers for parents, titled "Your Preteen Needs Some More Immunizations," in English and in eight other languages: Cambodian, Chinese, Hmong, Korean, Laotian, Russian, Spanish, and Vietnamese. (Readers may request this set of forms and the poster described earlier, from the California Dept. of Health Services; limited quantities are available.)
Fliers sent in September, January, and April were translated into Chinese because of the high proportion (39%-44%) of students at these pilot schools who were of Chinese ethnicity. Brochures about vaccinations were provided in English, Chinese, Spanish, and Vietnamese. (Brochures, titled "Are your child's shots up-to-date?," were produced by Children Now, an organization with offices in Oakland, Calif; Los Angeles, and New York City.) For parents requesting school-based vaccinations, consent forms and Vaccine Information Statements were made available in English, Chinese and Spanish.
Vaccinations at School
Thirty students (Table 1, row 10) returned a consent form signed by their parents, making them eligible for receiving vaccines from the school nurse. Most of these students were eligible for the free vaccine from the federal Vaccines for Children (VFC) program due to low family income. The procedure involved "pulling" students from class in small groups, vaccinating them in the school nurse office, and returning them to class after an observation period. Students tolerated the vaccinations well. At both schools the Biojector[R] and traditional syringes were used on an alternating basis. No serious adverse reactions were observed or reported. All students but two of the original 30 completed their Hepatitis B series and the MMR #2.
By the end of April, a "hard core" list was created, consisting of students who were incomplete with at least two hepatitis B doses or had not even started either of the required vaccines. School X had fewer than 40 in this category and School Y had fewer than 70. Individualized follow-up was provided: the nurse and the sixth grade counselor met with each student; the nurse sent a "final warning" form to and made telephone contacts with parents; and telephone calls were made to providers. At school X, students who had not turned in a shot record by mid-April were threatened with being excluded from a popular field trip. Because many of these students responded to this threat by submitting shot records, only three students actually had to be excluded from the trip. While all these activities were time-consuming, by the end of the year, the "hard core" category dwindled to just 10 students (Table 1, row 13).
Computerized Tracking: Work In Progress
As in most urban school districts, vaccination and TB data are entered into the district-wide database as part of the initial assessments for kindergarten and first-grade students. When students enter the district beyond these grade levels, data may not be entered into the district's database. Given the recent updating of this district's database system, it may take just a few more years before nurses and other personnel will be able to enter, read, and prepare printouts of vaccination data at school sites. Computerized tracking should dramatically reduce the paperwork currently required to conduct immunization compliance activities.
While parental lack of awareness and attitudes, provider attitudes, and limited access to primary care providers are often cited as barriers to immunization, a review of research studies disclosed that a relatively low association existed between these factors and under-immunization of infants and children. Results of the pilot program in this school district appear to confirm this finding. When reminded, almost all parents responded by taking their child for at least one vaccination, and more than 70% of students (Table 1, row 12) achieved full compliance with the requirements by the end of the school year.
Vaccination follow-up and enforcement have traditionally been the responsibilities of preschool and elementary schools. Despite very limited health care personnel and limited resources, it was possible for greater than 70% of sixth graders in middle school settings to achieve full compliance in the first year of a preteen vaccination law.
Despite a healthy economy at both the state and national levels, some school districts may face financial constraints that prohibit full-time nursing and health clerical staff. Even with limited personnel, it still appears possible to initiate a program to enforce a preteen vaccination law. The following eight recommendations may help to develop a successful program:
1. Collaborate: Prepare a plan that you feel is do-able. Collaborate with the health department at the state and local levels, get acquainted with the immunization coalition in your area, and invite the private sector to help.
2. Educate: Educate school administrators about the law and elicit their feedback and input. Ask them in advance to review and approve forms to be used. Similarly, educate and involve the teachers. They can be your best allies. Educate and involve parent organizations. Use existing written materials and adapt them to your situation.
3. Motivate: Motivate the students through using effective educational materials and free or low-cost incentives if possible.
4. Translate: Obtain translations of written materials. This can be a time-consuming process but necessary in communities with diverse home languages.
5. Vaccinate: Consider offering vaccinations at school, targeting VFC-eligible students, such as low-income families with limited or no health insurance.
6. "Exclud-iate:" Exclude students from school who do not meet state requirements despite reminders and other follow-up activities. While exclusions should be used judiciously, a well-publicized exclusion process may motivate those students and families who do not appear to respond to other interventions.
7. Tabulate and Evaluate: Tally your students' status by completion levels at least twice: at midyear and at the end of the year. Evaluate your program and develop your next year's plan. Support registry-development activities at the school and health department.
8. Celebrate: Celebrate your progress by thanking administrators, teachers, colleagues, and organizations that supported the vaccination campaign. In the context of the first year of a new program being usually the most difficult, the school community should feel proud of trying to protect its students from vaccine-preventable diseases.
The pilot program described in this article indicates that it is possible to achieve a reasonably high level of compliance even in the first year of a new preteen vaccination law. While it is important to be aware of the barriers, by trying the strategies recommended, these barriers may be mitigated so that students are protected against serious vaccine-preventable diseases. Ultimately, by meeting reasonable objectives, your program may motivate others in the school and in the larger community to comply with this worthwhile public health law.
Sources of Free, Up-to-Date Information About Immunizations
National Immunization Hotline
English: 800/232-2522; Spanish: 800/232-0233 e-mail: firstname.lastname@example.org
National Immunization Program Resource Request List 888/232-3299
NIP Home Page http://www.cdc.gov/nip
CDC Home Page
A bulletin by the non-profit Immunization Action Coalition, sent to your e-mail address with late-breaking information. Subscribe by sending an e-mail to email@example.com, and writing SUBSCRIBE in the subject field.
A three times-a-week bulletin sent to your e-mail address. Subscribe by sending an e-mail to firstname.lastname@example.org and request a subscription.
[1.] Managing a Hepatitis B Prevention Program: A Guide to Life as a Program Coordinator. Centers for Disease Control and Prevention-US Dept. of Health and Human Services; September 1996;33.
[2.] Centers for Disease Control and Prevention. Effectiveness of a seventh-grade school entry vaccination requirement -- statewide and Orange County, Florida, 1997-98. MMWR. 1998;47(no.34):711-715.
[3.] Centers for Disease Control. Measles prevention: recommendations of the Advisory Committee on Immunization Practices. MMWR. 1989;38(S-9).
[4.] Centers for Disease Control and Prevention. Hepatitis B virus infection: a comprehensive strategy for eliminating transmission in the United States through universal childhood vaccination. Recommendations of the Advisory Committee on Immunization Practices. MMWR. 1995:44(30): 574-575.
[5.] Centers for Disease Control and Prevention. Prevention of varicella: recommendations of the Advisory Committee on Immunization Practices. MMWR. 1996;45:(RR-11).
[6.] Centers for Disease Control and Prevention. Immunization of adolescents: recommendations of the Advisory Committee on Immunization Practices, the American Academy of Pediatrics, the American Academy of Family Physicians, and the American Medical Association. MMWR. 1996;45:(RR-13).
[7.] Immunization Action Coalition. 23 states have legislated/regulated hepatitis B vaccinations for preteens. Needle Tips. Fall/Winter; 1999.
[8.] Allensworth DD, Bradley B. Guidelines for adolescent preventive services: a role for the school nurse. J Sch Health. 1996;66(8):281-285.
[9.] Unti L, Coyle KK, Woodruff BA, Boyer-Chuanroong L. Incentives and motivators in school-based hepatitis B vaccination programs. J Sch Health. 1997;67(7):265-268.
[10.] Roll Up BOTH Sleeves! 1998. Distributed by American School Health Association; Kent, OH.
[11.] Morrow AL, Rosenthal K, Lakkis HD, Bowers JC, Butterfoss FD, Crews C, Sirotkin B. A population-based study of access to immunization among urban Virginia children served by public, private, and military health care systems. Pediatrics. 1988. Available at: http://www.pediatrics.org/cgi/contents/full/101/2/e5.
[12.] Centers for Disease Control and Prevention. Vaccination coverage for 2-year-old children -- United States. Third Quarter, 1993. MMWR. 1994;43:556-559.
[13.] Santoli JM, Szilagyi PG, Rodewald LE. Barriers to immunization and missed opportunities. Pediatr Ann. 1998;27(6):366-374.
Lynda Boyer-Chuanroong, RN, MPH, School District Nurse, San Francisco Unified School District, Marina Middle School, 3500 Fillmore St., San Francisco, CA 94123; or
Questia, a part of Gale, Cengage Learning. www.questia.com
Publication information: Article title: Meeting the Preteen Vaccine Law: A Pilot Program in Urban Middle Schools. Contributors: Boyer-Chuanroong, Lynda - Author, Deaver, Paul - Author. Journal title: Journal of School Health. Volume: 70. Issue: 2 Publication date: February 2000. Page number: 39. © 1999 American School Health Association. COPYRIGHT 2000 Gale Group.