The Journal of School Nursing

http://jsn.sagepub.com/ The Impact of Mass School Immunization on School Attendance
Kathleen S. Wiggs-Stayner, Teresa R. Purdy, Gailya N. Go, Natalie C. McLaughlin, Penny S. Tryzynka, Joyce R. Sines and Thein Hlaing The Journal of School Nursing 2006 22: 219 DOI: 10.1177/10598405050220040601 The online version of this article can be found at: http://jsn.sagepub.com/content/22/4/219

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Title 1 is a federal entitlement program allocated on the basis of student enrollment and census poverty data. is a school nurse. Purdy.6% attendance rate. Penny S. is a trauma epidemiologist for Parkview Hospital. Hohlbein. IN. Fort Wayne. Go. Gailya N. Fort Wayne. A comparison was done of total days absent versus total days enrolled between schools receiving FluMist and schools not receiving the vaccine. Department of Education disburses funds to state education agencies. RN. Attendance rates for the year also were compared with the previous year for all 4 schools. on-site influenza immunization program could have on attendance in Title 1 schools. Joyce R. which then distribute these funds to local school districts. 2002). RN. BSN. BSN.7%. Documentation on the reason for absences at all 4 schools included self.or parentreported influenza absences were not significant. Parkview Community Health Improvement Program. RN. is a school nurse. MSN. McLaughlin. Teresa R. the difference in days absent between individual vaccinated and nonvaccinated schools was statistically significant. The differences in self. on-site influenza immunization program could have on attendance in Title 1 schools. IN. MS Ed PH. Previously. The intent is to ensure that all children have an opportunity to obtain a high quality education and to reach grade-level proficiency (No Child Left Behind Act. Thein Hlaing. Previous research has shown that school absentee rates increase during influenza season (Neuzil. IN. RN. RN. MSN. McLaughlin. BC. attendance. RN. The U. Members of the group observed that influenza and absences due to influenza were challenges each winter. Parkview Community Health Improvement Program. and students at 2 control schools were not. MBBS. is director of Community Nursing. Tryzynka. FACE ABSTRACT: The purpose of this study was to assess the impact a free.Research Article The Impact of Mass School Immunization on School Attendance Kathleen S. Wiggs-Stayner. RN. The benchmark Kathleen S. Penny S. RN.sagepub. 2001). KEY WORDS: absenteeism. FRCP. IN.8%. immunization.8%.or parent-reported influenza. is a school nurse. Tryzynka. BSN.3% and 93. influenza. FluMist . 2012 . BC. RN. The 2 schools receiving FluMist increased their attendance rates from 95. Pediatric Specialty Clinics. is a school nurse. Natalie C. Purdy. and Thein Hlaing. RN. Parkview Hospital. Go. Gailya N. IN. attendance rate for the state of Indiana in the 95th percentile would be 97. Fort Wayne. RN. Wiggs-Stayner. BSN.com at FLORIDA INTL UNIV on November 11.4% and the other rose very slightly to 94. BSN.9% to 96. one fell to 94. However. particularly in schools with a high population of children with a low socioThe Journal of School Nursing 219 Volume 22. Natalie C. Fort Wayne. Fort Wayne.S. Title 1 schools INTRODUCTION This study was undertaken to assess the impact a free. the comparison schools each had a 94. & Zhu. IN. Parkview Community Health Improvement Program. Parkview Community Health Improvement Program. 57% of those medically eligible to receive it had parental permission and received the vaccine. Fort Wayne. MBBS. Four Title 1 elementary schools participated in the study. BSN. Students at 2 schools were offered free FluMist immunizations on site. Teresa R. RN. Compliance on receiving FluMist was measured on the percentage of students participating after evaluating for medical exclusions. BSN. FACE. Sines. MS Ed PH. Despite the fact that FluMist is a new vaccine and is not required for children. FRCP. Pediatrics. Sines. Fort Wayne. Joyce R.1% and 95. School nurses noted that none of the local Title 1 schools met this benchmark. is a pediatric clinical nurse specialist. BSN. IN. Number 4 August 2006 Downloaded from jsn. Pediatric Intensive Care. The goal of the Parkview Community Nursing Research Group was to increase school attendance rates. Parkview Hospital.

. School Characteristics 2003/2004 Vaccine Schools School 1 control schools. double-blind.297 healthy children 5–17 years of age. medications purchased.com at FLORIDA INTL UNIV on November 11. As the day of vaccination approached. children to evaluate the efficacy of FluMist against confirmed influenza over two successive seasons. Staff and students who had no such documentation were given an educational sheet explaining the FluMist study and a permission slip in either English or Spanish. The population that was evaluated included 10. smaller increase in absenteeism rates in the FluMist recipients compared with the non-FluMist recipients (King et al.economic status. school nurses called parents to encourage them to return forms Nonvaccine Schools 2 1 2 Number of students % free/reduced lunch White Black Hispanic Asian Multirace Attendance 2003/2004 264 92% 35% 38% 20% 2% 7% 95.S. trivalent. The Pediatric Efficacy Study was a multicenter. nasally-administered vaccine intended for active immunization to prevent disease caused by influenza A and B viruses in healthy children and adolescents 5–17 years of age and healthy adults 18–49 years of age (MedImmune Vaccines. The SchoolMist Study Group recently examined the effect of FluMist on elementary school children on several influenza-related outcomes in families. However. The Parkview Community Nursing Research Group compared four Title 1 elementary schools in a large urban school system. a situation that increased person-to-person contact and promoted the spread of bacteria and viruses. Institutional Review Board approval was obtained from both Parkview Hospital and the local school system. these families often did not have the funds or transportation to receive preventive health care.. The increases in absentee rates from baseline to the peak influenza outbreak period were not significant between the target and the Table 1. Three schools participated in the study. 40% of the children received the FluMist vaccine. The schools were comparable in size. The overall efficacy of FluMist against culture confirmed wild-type influenza was 86. A pediatrician was available for any screening questions the nurses might have. Many of these school families lived in multifamily dwellings. but their medical condition prevented them from obtaining FluMist . with one school receiving the vaccine. intranasal (FluMist ) is a live.3% 287 87% 34% 33% 24% 0% 6% 93.6% 349 89% 53% 34% 6% 0% 6% 94. Number 4 . within the target school. All families from the three schools were sent an anonymous questionnaire asking for a 7-day recall of ‘‘fever or respiratory illness (FRI)-related’’ medical visits. Inc. In that school.6% 220 The Journal of School Nursing August 2006 Downloaded from jsn. placebo-controlled trial performed on healthy U. METHODOLOGY Funding for the vaccine cost of the study was obtained from the Parkview Hospital Community Health Improvement Program. Staff and students who had prior documentation of medical conditions that excluded them from the study were sent a letter explaining that free flu immunizations were being offered. and socioeconomic status. 2005). 2012 Volume 22. or days of school or paid work lost during the peak influenza week. Free vaccinations were offered to all staff and students who were medically eligible at the elementary schools designated to receive vaccines.9%.9% 392 82% 35% 37% 20% 0% 7% 94. as determined by the percentage of children qualifying for free or reduced lunch (Table 1). Influenza virus vaccine live. there was a statistically significant. 2000) described a study in which FluMist was administered to 20. There were significant reductions in the FRI-related outcomes between the target school and the comparison schools. Although influenza vaccines were available in the community. randomized. 2005).sagepub. race. Free vaccinations were offered to all staff and students who were medically eligible at the elementary schools designated to receive vaccines. They were referred to other sources to obtain an inactivated influenza vaccine. 2005). School nurses and a Spanish-speaking social worker were available to answer questions from parents. School nurses evaluated current medical histories and checked for immediate medical exclusions. Belshe and colleagues (1998.228 subjects in clinical studies. LITERATURE REVIEW The Centers for Disease Control and Prevention (CDC) stated that the primary option for reducing the number of influenza cases is immunoprophylaxis with vaccine (CDC.

001 0.372 40.269 42. Of those who were medically eligible.575 165. Attendance Rates and Influenza Absences of Vaccine Schools and Nonvaccine Schools Vaccine Schools 1 2 Nonvaccine Schools 1 2 large number of staff were medically excluded.763 3. Teachers and school staff also were offered free FluMist .878 51. The parental response rate was 60%.897 1.25 ml was administered into each nostril while the recipient was in an upright position.975 0. Statistical Comparison of Individual Vaccine and Nonvaccine Schools (School 1 in Vaccine vs. RESULTS There were 273 students enrolled in Vaccine School 1.982 47.3% 96. Herd immunity happens when a part of a population has been vaccinated and then has antibodies that neutralize a virus.or parent-reported influenza absences were not significant (Table 2). Piedra and others (2005) found that vaccination of approximately 20–25% of children 1.and permission slips. DISCUSSION The 57% vaccination rate for medically eligible children may have created some ‘‘herd immunity’’ and protected a larger number of children than those immunized. and phone calls.001 0.975 0. School 1 in Nonvaccine.303 2.933 97.930 217. The proportion of children vaccinated that is required to control the spread of influenza is unknown. A total of 277 children were vaccinated. Children and adults age 9– 49 received one dose.665 47.590 217. the parental response rate (i..878 45.396 91.e.660 School 1 School 2 Total 54. Due to initial letters.5– 18 years of age resulted in protection of 8–18% in adults older than 35 years of age.956 97. Volume 22. whereas the nonvaccine schools had a decrease in overall attendance.001 * Either one.8% 56 94.633 88.or two-tailed. Of those who were medically eligible.005 1.933 45.896 102. School 1 in Nonvaccine) Vaccine Group Nonvaccine Group Statistical Test School Days Enrolled Days Present Days Absent School Days Enrolled Days Present Days Absent Chi Square p Value* School 1 School 2 Total 49.6% 94. whereas the nonvaccine schools had a decrease in overall attendance. 143 students (64%) obtained the vaccine. The attendance rates at the two schools receiving FluMist increased. Children age 5–8 years who had not been vaccinated previously with FluMist received two doses of FluMist 60 days apart.372 40.6% 94. School 2 in Vaccine vs. There were 323 students enrolled in Vaccine School 2. Number 4 August 2006 Downloaded from jsn.370 51.005 1.001 (School 1 in Vaccine vs. The attendance rates at the two schools receiving FluMist increased.sagepub.or parent-reported influenza absence days 95.001 0.665 47. Twenty-two staff members from each school obtained FluMist . On the day of the vaccinations. 2012 The Journal of School Nursing 221 .9% 95.633 88. whether agreeing or not agreeing to have child participate) was 78%.001 (Table 3). 50 students were medically excluded. 222 students were eligible to obtain FluMist . Differences in the self.896 54. Attendance was calculated by dividing total days in attendance by membership days (number of student enrolled per day). School 2 in Nonvaccine.12 61. Due to age and other medical conditions.526 5. difference in days absent between individual vaccinated and nonvaccinated schools was statistically significant with a chi-square p value of .575 112. Approximately 0.049 2. a Table 2.396 91. However. 134 students (49%) obtained the free FluMist vaccine. a nurse went into each classroom and called all the children who had signed permission slips from parents and whose medical eligibility had been reconfirmed.370 97. Although 51 students were medically excluded. School 2 in Nonvaccine) Vaccine Group Nonvaccine Group Days Absent School Days Enrolled Days Present Days Absent Statistical Test Chi Square p Value* School Days Enrolled Days Present School 1 School 2 Total 49.660 School 2 School 1 Total 47.526 3.1% 39 93.763 3.269 42.982 102. of which 273 were eligible to obtain FluMist . School 2 in Vaccine vs.897 1. follow-up letters.com at FLORIDA INTL UNIV on November 11.049 5. making vaccinated individuals less likely to transmit a virus to the unvaccinated population.7% 84 Table 3.4% 61 94. returning a completed form to school.001 0.303 3. Hurwitz and colleagues (2000) gave inactivated vaccine to children in day care and found infection rates of older siblings reduced by 80% compared with siblings of unvacci- Attendance rate 2003/2004 Attendance rate 2004/2005 Self.

Strategy for distribution of influenza vaccine to high risk groups of children. J. M. Pediatrics. multiple staff taking calls. Cummings. C.. Herd immunity in adults against influenza-related illnesses with use of the trivalent-live attenuated influenza vaccine (CAIV-T) in children. MedImmune Vaccines. G. Yan.. Effectiveness of influenza vaccination of daycare children in reducing influenza-related morbidity among household contacts. A pilot study of the effectiveness of a school-based influenza vaccination program. 303–306. H. The efficacy of live attenuated. Hessel.. Y. 1133–1137. B. on-site. trivalent. M. P. Readmond. I. K. The attendance rate increases at the FluMist schools and decreases at the control schools were significant. (2005). P. 1677–1682. a message with no reason for absence. Prevention and control of influenza: Recommendations of the Advisory Committee on Immunization Practices (ACIP). intranasal influenza virus vaccine in children. Rubin. C. L. Magder. Retrieved April 4.. 1540–1548. Ginsberg. Zangwill.. Watts. (2005). although if only 50% of the schoolchildren are vaccinated. K. Haber. M. (1998). M. T.. 248. C. S. Hurwitz. Iacuzio. G. Journal of Infectious Disease. Riggs.com at FLORIDA INTL UNIV on November 11. E. Many schools. J. B.. Cordova. E. King. Archives of Pediatric and Adolescent Medicine. This can be facilitated by ensuring that all students are immunized. F. Hayden. attenuated. P. (2000). M.. W. M.. X. [Product/prescribing information]. Tsai.. M. Waecker. Herschler. Kotloff. school nurses can work with community organizations to provide free. community-wide transmission would be reduced. Bernstein. Chang. (2005).html Piedra. the goal should be to vaccinate 70% of schoolchildren.. Piedra. Piedra. Longini and Halloran (2005) stated the goal should be to vaccinate 70% of schoolchildren.. D. J. Morbidity and Mortality Weekly Report.. K. particularly Title 1 schools. 116. (2005). S. M.. One of the goals of the National Association of School Nurses is to promote the health and academic success of children. Zangwill. School nurses may want to consider recommending mass influenza immunization programs to increase school attendance. K. Reisinger.. Journal of the American Medical Association. P.gov/policy/elsec/leg/ esea02/index. Mendelman. community-wide transmission would be reduced. Kozinetz.. Gaglani. B.. Inc. Hohlbein. W.. J. although if only 50% of the schoolchildren are vaccinated...... By reducing the incidence of influenza in the school setting. King. M. Number 4 .. C. M. K. J. T. & Halloran. 181. Hoffmaster. 338. REFERENCES Belshe. on-site immunizations. Vaccine. L. P.. King. 2006.. Gruber. M. N.. 222 The Journal of School Nursing August 2006 Downloaded from jsn. Public law print of PL 107–110. Fewlass. Hayden. (2002). A. & Glezen. Teo. 986–991.. Such data validate the effectiveness that mass immunization clinics have on increasing attendance.sagepub.. A.. cold-adapted intranasal influenza virus vaccine. B. from http://www.. Correlates of immune protection induced by live. struggle to maintain statemandated attendance rates. It also is essential that school nurses keep data on how such immunization programs affect illness and attendance By reducing the incidence of influenza in the school setting. J. & Wolff. American Journal of Epidemiology.. FluMist (influenza virus vaccine live. Mahmood. D. S... Stong. If this study were replicated. 1–40. mass immunization with FluMist had a positive impact on school attendance. M.. R. J. A. 1405–1412. 54(RR-8). coldadapted.. 23.. M.. intranasal) 2005–2006 formula.. & Zhu. Treanor. (2005. G. D.nated day care attendees.. N. No Child Left Behind Act. 2012 Volume 22. Neuzil.. E. In areas where immunization rates are low and parents do not have the resources for immunization services. and lack of education of parents on what constitutes influenza... . we would recommend that ‘‘self-reports’’ of influenza be discouraged and that a study on a larger number of schools would assess only the overall attendance rate changes... absentee rates can be reduced so that students can remain in school ready to learn.. Illness among schoolchildren during influenza season.. S. ... C. 868–873. 161. F. Kotloff. & Wolff. Gruber.ed. J.. Longini. Mehta. New England Journal of Medicine. August). K. J. C. R.. rates. Centers for Disease Control and Prevention (CDC). L. Stoddard. A. K. Bernstein.. M. IMPLICATIONS FOR SCHOOL NURSING PRACTICE This study found that a free. J. Treanor. including no parent call.. Griffith. & Cox. C. 156. Shope. I. Block. It was difficult to track the ‘‘self-reports’’ of absence from influenza (Table 2) due to several factors. I. & Ruff. W. E. (2001).. G. . (2000). Mendelman. M.. absentee rates can be reduced so that students can remain in school ready to learn. P. Belshe.

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