See-Ya-Later Fluagator School-Based Influenza Vaccination Program

State: VA Type: Model Practice Year: 2011

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To address the impact of seasonal influenza on the communities served by the Cumberland Plateau Health District, the health district is currently in its fourth year (in 2010) of offering influenza vaccine to school students and staff in school-based clinics in close partnership with local school districts. The Flu-a-gator program was conceived by a team of health district and local hospital employees as a school assignment to write a business plan in the Management Academy for Public Health through the University of North Carolina. The business plan won their 2003 “Blue Ribbon.” While the project was later revised when taken on by the health department and delayed because of vaccine supply issues, it has been considered a success by both the school districts and the health department.

The goal of the Flu-a-gator program is to decrease the impact of seasonal influenza in our communities by providing flu vaccines to school children and staff. While the overall goal is very difficult to measure, the program’s yearly objectives of 1) increasing the total number of seasonal flu vaccines provided and 2) increasing the percentage of the district’s student body being vaccinated each year have been met each year to date, although the numbers for the first year were not as high as the program hoped or expected. Published research has shown a correlation between higher student vaccination rates with lower rates of illness in the students’ families/communities.

Each year the program has vaccinated a larger percent of the student population. In the first year (October-December 2007), the health department piloted the program in elementary schools in two counties and vaccinated over 10% of the school students. In the second year, the program expanded to elementary and middle schools in all four counties and vaccinated over 15% of the student body. Two years of previous experience with in-school vaccination proved very beneficial for the 2009/2010 season, with the addition of 2009 pandemic H1N1 influenza vaccine. The district vaccinated nearly 20% of the entire K-12 student population with seasonal vaccine, even with the added task of providing pandemic flu vaccine in schools as well. The health district receives reimbursement from Medicaid, private insurers, and from individuals, being able to lower fees charged to individuals over the past three years. While the reimbursement does not cover the entire cost of providing the service, it does provide income (in the first year of the program, for 334 vaccines provided in one county, the total reimbursement equaled $10,436).

Some of the most important factors that have contributed to the success of this program include:
1) strong relationships and partnerships with schools,
2) schools that are strongly committed to the health of their students and staff,
3) highly dedicated health district staff members, including clerical and administrative staff, nursing staff, and management staff,
4) convenience of receiving vaccines in the school setting,
5) current events and media coverage of influenza activity, and
6) strong leadership combined with a team approach in all phases of planning and implementation.

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Cumberland Plateau Health District
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See-Ya-Later Fluagator School-Based Influenza Vaccination Program
To address the impact of seasonal influenza on the communities served by the Cumberland Plateau Health District, the health district is currently in its fourth year (in 2010) of offering influenza vaccine to school students and staff in school-based clinics in close partnership with local school districts. The Flu-a-gator program was conceived by a team of health district and local hospital employees as a school assignment to write a business plan in the Management Academy for Public Health through the University of North Carolina. The business plan won their 2003 “Blue Ribbon.” While the project was later revised when taken on by the health department and delayed because of vaccine supply issues, it has been considered a success by both the school districts and the health department. The goal of the Flu-a-gator program is to decrease the impact of seasonal influenza in our communities by providing flu vaccines to school children and staff. While the overall goal is very difficult to measure, the program’s yearly objectives of 1) increasing the total number of seasonal flu vaccines provided and 2) increasing the percentage of the district’s student body being vaccinated each year have been met each year to date, although the numbers for the first year were not as high as the program hoped or expected. Published research has shown a correlation between higher student vaccination rates with lower rates of illness in the students’ families/communities. Each year the program has vaccinated a larger percent of the student population. In the first year (October-December 2007), the health department piloted the program in elementary schools in two counties and vaccinated over 10% of the school students. In the second year, the program expanded to elementary and middle schools in all four counties and vaccinated over 15% of the student body. Two years of previous experience with in-school vaccination proved very beneficial for the 2009/2010 season, with the addition of 2009 pandemic H1N1 influenza vaccine. The district vaccinated nearly 20% of the entire K-12 student population with seasonal vaccine, even with the added task of providing pandemic flu vaccine in schools as well. The health district receives reimbursement from Medicaid, private insurers, and from individuals, being able to lower fees charged to individuals over the past three years. While the reimbursement does not cover the entire cost of providing the service, it does provide income (in the first year of the program, for 334 vaccines provided in one county, the total reimbursement equaled $10,436). Some of the most important factors that have contributed to the success of this program include: 1) strong relationships and partnerships with schools, 2) schools that are strongly committed to the health of their students and staff, 3) highly dedicated health district staff members, including clerical and administrative staff, nursing staff, and management staff, 4) convenience of receiving vaccines in the school setting, 5) current events and media coverage of influenza activity, and 6) strong leadership combined with a team approach in all phases of planning and implementation.
Influenza annually causes a large impact on the health district’s rural communities. The school setting was selected based upon the large health burden among students and staff, the interest in and need for vaccination, and the fact that there are currently few opportunities for children in this age group to be vaccinated unless their primary care physician sees them. This is also a rural and medically underserved district (a designated health professional shortage area, HPSA), many children do not have medical homes and the population generally is hard to reach both in terms of physical locations and low trust in such interventions, making the school-based platform particularly useful and repeated application of the program increasingly beneficial in terms of participation and acceptance. Research found that for every 100 school children followed through one flu season (37 school days), there were a total of 68 missed days of school, parents missed an estimated 20 days of work, and 22 cases of secondary illness occurred among family members (Neuzil, K. M., Hohlbein, C., Zhu, Y. [2002]. Illness Among Schoolchildren During Influenza Season: Effect on School Absenteeism, Parental Absenteeism From Work, and Secondary Illness in Families. Arch Pediatr Adolesc Med 156: 986-991). Modeling studies have indicated that in a mild influenza season, between 19 – 100 million influenza cases could be prevented by vaccinating a large number of children, depending on the proportion of children vaccinated and the transmission intensity (Am. J. Epidemiol. (2009) 170 (6): 679-686). Another program goal is to improve public health and school system procedural familiarity with mass vaccination to foster enhanced community emergency preparedness. The emergency preparedness goal proved to be a particular success, in that this mountainous, rural and geographically isolated health district was recognized as the third most prolific vaccinator out of 35 Virginia health districts during the 2009 H1N1 influenza pandemic (led only by two more affluent and populous districts) due to the experience gained in the previous two years of the program by staff and partners.
Agency Community RolesThe Cumberland Plateau Health District is the primary agency responsible for conducting the school-based influenza vaccination program, with school districts providing strong partnership. Costs and ExpendituresTo address the impact of seasonal influenza on the communities served by the Cumberland Plateau Health District, the health district is currently in its fourth year (in 2010) of offering influenza vaccine to school students and staff in school-based clinics in close partnership with local school districts. The Flu-a-gator program was conceived by a team of health district and local hospital employees as a school assignment to write a business plan in the Management Academy for Public Health through the University of North Carolina. The business plan won their 2003 “Blue Ribbon.” While the project was later revised when taken on by the health department and delayed because of vaccine supply issues, it has been considered a success by both the school districts and the health department. The goal of the Flu-a-gator program is to decrease the impact of seasonal influenza in our communities by providing flu vaccines to school children and staff. While the overall goal is very difficult to measure, the program’s yearly objectives of 1) increasing the total number of seasonal flu vaccines provided and 2) increasing the percentage of the district’s student body being vaccinated each year have been met each year to date, although the numbers for the first year were not as high as the program hoped or expected. Published research has shown a correlation between higher student vaccination rates with lower rates of illness in the students’ families/communities.  Each year the program has vaccinated a larger percent of the student population. In the first year (October-December 2007), the health department piloted the program in elementary schools in two counties and vaccinated over 10% of the school students. In the second year, the program expanded to elementary and middle schools in all four counties and vaccinated over 15% of the student body. Two years of previous experience with in-school vaccination proved very beneficial for the 2009/2010 season, with the addition of 2009 pandemic H1N1 influenza vaccine. The district vaccinated nearly 20% of the entire K-12 student population with seasonal vaccine, even with the added task of providing pandemic flu vaccine in schools as well. Some of the most important factors that have contributed to the success of this program include: 1) strong relationships and partnerships with schools, 2) schools that are strongly committed to the health of their students and staff, 3) highly dedicated health district staff members, including clerical and administrative staff, nursing staff, and management staff, 4) convenience of receiving vaccines in the school setting, 5) current events and media coverage of influenza activity, and 6) strong leadership combined with a team approach in all phases of planning and implementation. ImplementationCombined answer for both questions: Goal: Decrease the impact of seasonal influenza in our communities by providing flu vaccines to school children and staff and improve public health and school system procedural familiarity with mass dispensing annually to foster enhanced community emergency preparedness, relationships, confidence and trust. Objective 1: Increase the total number of seasonal flu vaccines provided every year. Objective 2: Increase the percentage of the district’s student body being vaccinated each year. Action steps: January/February: District epidemiologist analyzes past season’s data, calculating total number of vaccines given by vaccine type, by student/adult, by school, by county and by district (four-county jurisdiction). District team leaders meet to decide on the number of vaccines to order for the coming year using analysis. March/April: District team leaders meet to plan upcoming year’s program, after evaluating successes and challenges of the previous year’s program. The team makes decisions on vaccine charges and updates and revises program documents including: Memoranda of Agreement (MOAs), Director’s letter to school Superintendent, Director’s letter to parents/guardians, program overview description. May: The district sends MOAs to school superintendents. July/August: District team leaders meet after ACIP recommendations for vaccination are made for upcoming season to adjust consent forms (student form, students needing second dose form, and adult form). Finalized forms are sent to school Superintendents. August: Public Health Nurses are assigned schools for which they will serve as lead and the schools primary point of contact. These nurses distribute all forms to the school nurses and administrative staff in those schools for which they are responsible. On availability of vaccine: Public Health Nurses work with school staff to schedule vaccination clinics.
Objective 1: Increase the total number of influenza vaccinations provided through the Fluagator program by at least 20% in each of the first five years of the program. The performance measure for objective 1 is a tally of the total number of vaccinations given each year. Raw data are collected by clerks or nurses going to school clinics, by simply counting consent forms on return from clinics. These data are then compiled by the epidemiologist. Results: 2007: 584 2008: 2,530 (430% increase over 2007) 2009: 4,584 (180% increase over 2008) 2010: 5,486 season to date, as of 10/31/2010 At the conclusion of the season’s activities, the health department provides each school district with a program summary which includes information about number of students and adults vaccinated, by type of vaccine and school. The analysis helps to inform the health department’s decision about the quantity of vaccine to be ordered for the coming year. An example of this is that the percentage of TIV and LAIV used each year has remained relatively constant between 68-74% (TIV) and 26-32% (LAIV), even though LAIV use was expected to increase each year. Objective 2: Increase the percentage of the student population vaccinated through the Fluagator program (with at least one dose of influenza vaccine) by 20% in each of the first five years of the program. The performance measure for objective 2 is a simple calculation of the percent of student population vaccinated through the Fluagator program. As above, raw numbers are collected by clerks or nurses, counting individuals vaccinated (not vaccine doses given). After all clinics are complete, the epidemiologist calculates the percentage using Dept. of Education fall membership as the denominator. Results: 2007: 10.3% 2008: 15.2% (48% increase over 2007) 2009: 19.6% (29% increase over 2008) 2010: TBD At the conclusion of the season’s activities, the health department provides each school district with a program summary which includes information about number of students and adults vaccinated, by type of vaccine and school. Objective 3: By year five of the Fluagator program all forty-seven public schools (K-12) will participate in the Fluagator program. The performance measure for objective 3 is a simple tally of all schools participating, counted by health department staff as clinics are completed. Results: 2007: 10 2008: 36 2009: 49 (reached the objective in year 3) 2010: 49 The Fluagator program reached the objective in its third year, and the health district decided to further expand the program by reaching out to private schools and local colleges. In large part the 2009 H1N1 influenza pandemic helped drive the expansion of the program, but the health department and these new partners are continuing the program in 2010 because of its success. We are providing vaccination opportunities in private schools, Head Start Programs, home school programs, the local community college, the four year college, and two professional schools (law and pharmacy).
The school systems have demonstrated a high level of commitment to continue this program. Some of the reasons for a high level of commitment from the school system that will continue into the future include: o The school systems are strongly committed to the health of their students and staff, recognizing the importance of flu immunization in decreased absenteeism and improved learning. o The program offers a choice of vaccine (both injectable and nasal spray forms are offered), at competitive prices, and the cost is generally covered in part or fully by the primary insurance providers in the area. o The in-school vaccination clinics are convenient to staff, students and parents. o The health department staff members work diligently to keep the level of school learning time disruption to a minimum. After the vaccination clinics, the health department shares vaccination information with the school nurse. o A well-defined and comprehensive Memorandum of Agreement (MOA) ensures all stakeholders know their roles and responsibilities. o With each year of the program, it becomes a little more of a tradition. Families know that the flu vaccine will be offered in schools, and they know what to expect. The parents/guardians of school children are also developing a commitment to yearly flu vaccination of their children, sharing many of the reasons above. Each year of the program, the percent of students receiving the vaccine through the in school program has increased. This past season, about 22% of all students received the vaccine. With each year of the program, it becomes a little more of a tradition. Families know that the flu vaccine will be offered in schools, and they know what to expect. The health department will continue the Flu a gator program if possible into the foreseeable future. The health district receives reimbursement from Medicaid, private insurers and from individuals. While the reimbursement does not cover the entire cost of providing the service, it does provide revenue, while much of the expenditures would exist anyway in the time and effort of employees even if the service were not provided; therefore, there is a net revenue gain. Schools have committed substantial resources as well: even in tough budgetary climates, the schools have printed packets for all their students (the packets contain a letter to parents/guardians, an informational program overview, consent form, TIV and LAIV VIS documents, and reminder slips). School nurses and administrative staff spend time and effort printing forms, distributing materials to students, collecting forms, organizing vaccination clinic set up, etc. Even though the fixed cost inherent in staff time is not fully costed out, the health department achieves a net revenue gain. While fiscal resources will fluctuate over time, both agencies are committed to continuing the program
 
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