Expanding Access to Influenza Vaccine: Importance of School- Located Vaccination Susan M. Kansagra, MD, MBA 1, Vikki Papadouka, PhD, MPH 1, Anita Geevarughese, MD, MPH 1, Michael A. Hansen, MPH 1, Jane R. Zucker, MD, MSc 2. Author Affiliations: 1. New York City Department of Health and Mental Hygiene, 2. CDC, National Center for Immunization and Respiratory Diseases, Immunization Services Division, assigned to the NYC DOHMH, Bureau of Immunization

New York City Population: 8.3 million Population: 8.3 million Annual birth cohort of ~127,000 Annual birth cohort of ~127, million school-age children (K-12) 1.4 million school-age children (K-12) 1.1 million public school children 1.1 million public school children 300,000 private school children 300,000 private school children More than 1,500 public school buildings More than 1,500 public school buildings School nurses are present in nearly all elementary schools with >200 students School nurses are present in nearly all elementary schools with >200 students

NYC and pH1N1 1. Balter S, Gupta LS, Lim S, Fu J, Perlman SE; New York City 2009 H1N1 Flu Investigation Team. Pandemic (H1N1) 2009 surveillance for severe illness and response, New York, New York, USA, April–July Emerg Infect Dis [serial on the Internet] Aug [date cited]. Available from Hadler JL, Konty K, McVeigh, Katharine H. et al. Case fatality and hospitalization rates based on population estimates of influenza-like illness due to novel H1N1 influenza during the first wave: New York City, May-June In publication. April School outbreak of respiratory illness April School outbreak of respiratory illness Discovered to be pH1N1 Discovered to be pH1N1 First major outbreak of pH1N1 in the US 1 First major outbreak of pH1N1 in the US 1 April –June Over 50 NYC schools closed April –June Over 50 NYC schools closed June 2009 Survey June 2009 Survey 12% (~1M) New Yorkers report ILI in past 30 days 2 12% (~1M) New Yorkers report ILI in past 30 days 2 ILI in 20% of 0-17 year olds ILI in 20% of 0-17 year olds

NYCDOHMH Response to H1N1 Agency response structure Agency response structure Vaccination branch H1N1 monovalent vaccine available through: H1N1 monovalent vaccine available through: Provider offices Provider offices Point-of-Dispensing Operations (PODs) Point-of-Dispensing Operations (PODs) Mass vaccination clinics conducted in boroughs Mass vaccination clinics conducted in boroughs ~ 50,000 vaccines administered Schools Schools

School Vaccination Campaign H1N1 vaccination in elementary schools H1N1 vaccination in elementary schools October January 2010 October January 2010 Goals: Goals: Mitigate the severity of the H1N1 in NYC Mitigate the severity of the H1N1 in NYC Prevent transmission of H1N1 and reduce the rate of infection in schools Prevent transmission of H1N1 and reduce the rate of infection in schools Providing greater protection to the general public Providing greater protection to the general public

School Participation Over 1200 elementary schools in NYC Over 1200 elementary schools in NYC Partnership with NYC Dept of Education Partnership with NYC Dept of Education Majority public schools participated Majority public schools participated Almost half of private elementary schools Almost half of private elementary schools Completed two rounds of vaccination Completed two rounds of vaccination 208,887 doses administered 208,887 doses administered 128,228 children vaccinated 128,228 children vaccinated

School Vaccination Campaign Program successful at vaccinating large numbers of children Program successful at vaccinating large numbers of children Does school-located vaccination (SLV) successfully reach children who otherwise may go unvaccinated? Does school-located vaccination (SLV) successfully reach children who otherwise may go unvaccinated?

Objective Determine efficacy of the school-located vaccination program versus provider offices in reaching children who had never previously received influenza vaccine Determine efficacy of the school-located vaccination program versus provider offices in reaching children who had never previously received influenza vaccine Compare characteristics of children vaccinated through both settings Compare characteristics of children vaccinated through both settings

Methods NYC’s Citywide Immunization Registry (CIR) - a mature Immunization Information System (IIS): NYC’s Citywide Immunization Registry (CIR) - a mature Immunization Information System (IIS): Population based, began in 1996 Population based, began in 1996 Populated with vital records twice a week Populated with vital records twice a week Mandatory reporting of immunizations of children 0-18 years of age Mandatory reporting of immunizations of children 0-18 years of age 1815 child-immunizing sites 1815 child-immunizing sites 90% of providers report regularly 90% of providers report regularly 4.4 million patient records; 51 million immunizations 4.4 million patient records; 51 million immunizations

Methods: Data Capture for H1N1 Two data entry methods for CIR Two data entry methods for CIR School vaccination data School vaccination data Scannable paper form Scannable paper form Completed by parents (demographics and consent) and school nurses (immunization date, type) Completed by parents (demographics and consent) and school nurses (immunization date, type) Scanned by vendor and loaded in the CIR Scanned by vendor and loaded in the CIR Provider vaccination data Provider vaccination data Processed as other immunization data Processed as other immunization data Electronic batch file, extracted from EHRs Electronic batch file, extracted from EHRs Direct entry through CIR’s web based application Direct entry through CIR’s web based application

Methods Methods Inclusion Criteria: Inclusion Criteria: Children vaccinated at school or providers between October 1, 2009 to March 31, 2010 Children vaccinated at school or providers between October 1, 2009 to March 31, 2010 Children age 4-10 at time of first H1N1 vaccination Children age 4-10 at time of first H1N1 vaccination Children with at least one other vaccination in CIR Children with at least one other vaccination in CIR Exclusion Criteria: Exclusion Criteria: Children receiving H1N1 at more than one setting Children receiving H1N1 at more than one setting Children vaccinated at PODs Children vaccinated at PODs

Outcome Measures Main outcome measure Main outcome measure History of seasonal influenza vaccination History of seasonal influenza vaccination Additional comparisons Additional comparisons Mean number of immunizations Mean number of immunizations Up-to-date status of childhood immunizations Up-to-date status of childhood immunizations H1N1 second dose completion rate H1N1 second dose completion rate Age and sex Age and sex Vaccines for Children (VFC)/SCHIP history Vaccines for Children (VFC)/SCHIP history *Up-to-date on immunizations was defined as receiving 4 doses of DTaP, 3 doses IPV, 1 MMR, 3 doses Hib, 3 doses Hepatitis B vaccine, and 1 dose of varicella vaccine by 35 months of age.

Results: History of Seasonal Influenza Vaccination School-located vaccination Provider offices Total children age 4-10 immunized with pH1N1 and one additional immunization in the registry 84,412100%125,430100% Immunized with seasonal flu before 55,17865%113,61191% *Significant for p <

Influenza Immunization History Of Children Vaccinated With Influenza A (H1N1) 2009 Vaccine (pH1N1) By Setting* School-located vaccination Provider offices Total children age 4-10 immunized with pH1N1 and one additional immunization in the registry 84,412100%125,430100% Immunized with seasonal flu season 26,55731%95,04576% Received seasonal vaccine at same visitN/A 47,62138% Immunized with seasonal flu season 26,85932%60,93749% *All comparisons between school-located vaccination and provider offices were significant for p <

Coverage Provider offices Provider offices Increase in seasonal influenza vaccination coverage between and (49%  76%) Increase in seasonal influenza vaccination coverage between and (49%  76%) SLV group, no significant change (32%  31%) SLV group, no significant change (32%  31%) Greater media attention regarding H1N1 did not seem to affect behaviors in SLV group Greater media attention regarding H1N1 did not seem to affect behaviors in SLV group School-located vaccination Provider offices Immunized with seasonal flu season 26,55731%95,04576% Immunized with seasonal flu season 26,85932%60,93749%

Demographic Characteristics Of Children Vaccinated With Influenza A (H1N1) 2009 Vaccine (pH1N1) By Setting* School-located vaccination Provider offices Total children age 4-10 immunized with pH1N1 and one additional immunization in the registry 84,412100%125,430100% 4-6 year olds32,92039%63,97451% 7-10 year olds51,49261%61,45649% Male41,74849%64,92552% * *All comparisons between school-located vaccination and provider offices were significant for p <

School-located vaccination Provider offices Total children age 4-10 immunized with pH1N1 and one additional immunization in the registry 84,412100%125,430100% Mean number of immunization records in registry 22N/A25N/A Up-to-date on childhood immunizations (4:3:1:3:3:1 by age 35 mo) 35,87742%62,67250% At least one vaccine given through Vaccines for Children or State Children’s Health Insurance Program 55,34966%96,30977% * * All comparisons between school-located vaccination and provider offices were significant for p < *4:3:1:3:3:1 = 4 doses of DTaP, 3 doses IPV, 1 MMR, 3 doses Hib, 3 doses Hepatitis B vaccine, and 1 dose of varicella vaccine by 35 months of age. Immunization History Of Children Vaccinated With Influenza A (H1N1) 2009 Vaccine (pH1N1) By Setting*

Second Dose Completion Rate With Influenza A (H1N1) 2009 Vaccine (pH1N1) By Setting* School-located vaccination Provider offices Total children age 4-9 immunized with pH1N1 and one additional immunization in the registry 73,009100%114,467100% Completed second dose of pH1N1 † 58,95981%50,36444% *Significant for p <

Summary of Results SLV children less likely to have been immunized in past with a seasonal influenza vaccine SLV children less likely to have been immunized in past with a seasonal influenza vaccine 65% SLV vs. 91% Provider Offices 65% SLV vs. 91% Provider Offices SLV group had distinct characteristics SLV group had distinct characteristics Older Older Less likely to be UTD by 35 months Less likely to be UTD by 35 months Lower mean number of vaccinations in CIR Lower mean number of vaccinations in CIR Less likely to have history of VFC/SCHIP vaccination Less likely to have history of VFC/SCHIP vaccination

Discussion SLV Group SLV Group Greater barriers to care? Greater barriers to care? May not access care as frequently or as timely May not access care as frequently or as timely Provider Office group Provider Office group Overall, better immunized Overall, better immunized Greater access to vaccine through VFC program? Greater access to vaccine through VFC program?

Considerations History of VFC or SCHIP vaccination History of VFC or SCHIP vaccination Proxy for current eligibility Proxy for current eligibility Cannot draw firm conclusions based on this alone Cannot draw firm conclusions based on this alone VFC vaccines are more likely to be reported VFC vaccines are more likely to be reported Provider office group - Higher % children with VFC vaccinations Provider office group - Higher % children with VFC vaccinations Seasonal flu vaccination history may be more complete Seasonal flu vaccination history may be more complete Older children may not have been covered by ACIP recommendations in the past, which may be why SLV vaccination history rates are lower Older children may not have been covered by ACIP recommendations in the past, which may be why SLV vaccination history rates are lower

Considerations Pandemic year Pandemic year Overall vaccination rates may be higher Overall vaccination rates may be higher Second dose vaccination coverage may be higher Second dose vaccination coverage may be higher SLV children may have been vaccinated elsewhere in this pandemic year SLV children may have been vaccinated elsewhere in this pandemic year May have directed them to a medical provider May have directed them to a medical provider Seasonal influenza vaccination - 31% SLV vs. 76% provider Seasonal influenza vaccination - 31% SLV vs. 76% provider

: Next Steps 2009 H1N1 Results - 35% students received influenza vaccine for the first time 2009 H1N1 Results - 35% students received influenza vaccine for the first time Were these children vaccinated again this year? Were these children vaccinated again this year? If so, in which setting? If so, in which setting? Second dose completion rates of SLV children Second dose completion rates of SLV children One round of vaccination offered in schools One round of vaccination offered in schools

Conclusions School-located vaccination serves as an important supplement to the medical home School-located vaccination serves as an important supplement to the medical home Expansion of ACIP influenza recommendation to universal vaccination places additional burdens on the medical system Expansion of ACIP influenza recommendation to universal vaccination places additional burdens on the medical system Levels the playing field for access to life-saving preventive services Levels the playing field for access to life-saving preventive services

Conclusions SLV may be an effective approach if two dose vaccination is required SLV may be an effective approach if two dose vaccination is required SLV kids more likely to complete second dose SLV kids more likely to complete second dose Ensuring that health departments have the capacity to deliver such programs will help support public health infrastructure and emergency preparedness Ensuring that health departments have the capacity to deliver such programs will help support public health infrastructure and emergency preparedness

Acknowledgments Kevin Konty Kevin Konty Linda May Linda May Beth Maldin Beth Maldin Allison Scaccia Allison Scaccia Carmen Jones Carmen Jones Anna-Isabella Caffarelli Anna-Isabella Caffarelli Kristen Swedish, MD Kristen Swedish, MD Preeti Pathela, PhD Preeti Pathela, PhD Department of Education Department of Education All participants in the 2009 and 2010 School Based Vaccination Programs All participants in the 2009 and 2010 School Based Vaccination Programs

Questions? Anita Geevarughese, MD, MPH New York City Department of Mental Hygiene Bureau of Immunization