1. Jennifer Rittenhouse Cope, MD EIS Officer North Dakota Department of Health Factors Associated with Tdap and Meningococcal Vaccination Coverage Among Middle School Students — North Dakota, 2010 Office of Surveillance, Epidemiology, and Laboratory Services Scientific Education and Professional Development Program Office

2. BACKGROUND

3. Meningitis, Pertussis, Diphtheria, and Tetanus – Serious But Preventable Diseases  Meningococcal meningitis case-fatality rate 10-14%, morbidity among survivors 11-19%  Increasing numbers of pertussis cases with 17,000 reported in the US in 2009  10-19 years  Infants < 6 months  Tetanus and diphtheria – serious but now rare  Vaccine preventable  Tetanus toxoid, reduced diphtheria toxoid, acellular pertussis vaccine (Tdap)  Quadrivalent meningococcal conjugate vaccine (MCV4)

4. Adolescent Immunizations in North Dakota Schools  ACIP recommends for pre-adolescents aged 11–12 yrs:  MCV4 in 2005  Tdap in 2006  Required for ND middle school entry starting in 2008– 2009 school year  ND state law: “Any child not adhering to the recommended schedule shall provide proof of immunization or a certificate of immunization within thirty days of enrollment or be excluded from school.”

5. Rationale for Study  Vaccine coverage in ND among persons aged 13–17 years in 2009:  72% for Tdap  66% for MCV4  Vaccine coverage for kindergarten vaccines in 2009:  85-96%

6. Objectives  To assess whether ND middle school immunization policies are compliant with the state law  To determine what factors are associated with high (≥ 90%) Tdap and MCV4 coverage among ND 7 th grade students

7. METHODS

8. School Immunization Survey  Annual web-based survey of all ND public and private schools  Link sent to school administrators  May be completed by  Nurse  Administrative assistant  Principal

9. School Immunization Survey  3 additional questions added to 2010 survey  “Who determines which students are up-to-date with their immunizations?”  Administrative Assistant  Local public health (LPH) nurse  Principal  School nurse  Other  “Do you have a school nurse assigned to your school?”  “What is your school’s policy regarding students who are not up-to-date with required immunizations?”

10. Methods  Middle school = school with 7 th grade enrollment greater than zero  State-law–compliant immunization policy = policies that exclude students from school who have not received required immunizations or have not provided a valid exemption  High Tdap and MCV4 coverage defined as ≥ 90% of 7 th grade students  Bivariate analysis using SAS® 9.2

11. RESULTS

12. School Survey Respondents 377 Schools Responded (88% response rate) 175 Schools with 7 th grade199 Other Schools 428 Total ND Schools 15% Grades 6-8 85% K-12, K-8, 8-12

13. North Dakota Schools with 7 th Grade Schools(%) Public154/175 (88) Rural location118/175 (67) State law compliant policy82/164 (50) School nurse assigned49/173 (28)

14. Personnel Who Determine Immunization Status PersonnelSchools (N=175) n(%) Local Public Health Nurse70 (40) Administrative Assistant51 (29) School Nurse29 (17) Principal9 (5) Other16 (9)

15. Factors Associated with High (≥90%) Tdap Coverage among ND 7 th Grade Students Schools%P value High Tdap Coverage 98/17556 State law compliant policy Yes56/8268<0.01 No33/8240 School nurse assigned Yes28/49570.93 No70/12456

16. Factors Associated with High (≥90%) Tdap Coverage among ND 7 th Grade Students Schools%P value Nurse determines up-to-date status Yes63/99640.02 No35/7646 Rural location Yes73/118620.02 No25/5744

17. Factors Associated with High (≥90%) MCV4 Coverage among ND 7 th Grade Students Schools%P value High MCV4 Coverage 92/17553 State law compliant policy Yes50/82610.02 No35/8243 School nurse assigned Yes26/49530.98 No66/12453

18. Factors Associated with High (≥90%) MCV4 Coverage among ND 7 th Grade Students Schools%P value Nurse determines up-to-date status Yes58/99590.07 No34/7645 Rural location Yes68/118580.05 No24/5742

19. CONCLUSIONS

20. Summary  High Tdap coverage was associated with schools that have:  state-law–compliant policy  nurse determine immunization status  rural location  High MCV4 coverage was associated with schools that have:  state-law–compliant policy  Having a school nurse assigned was not associated with high Tdap or MCV4 coverage

21. Discussion  Suboptimal Tdap and MCV4 coverage not explained by any one factor  Not all schools have a policy to exclude students who are not up-to-date with required immunizations  Lack of association with school nursing  Association of high Tdap coverage with rural schools  Rural health units go into schools to immunize

22. Limitations  School-reported data but validation with records supports results  Misclassification  School nurse question  School policy question

23. Recommendations  Investigate barriers to implementing an exclusion policy for middle school students not up-to-date with Tdap and MCV4  Explore reasons why having a school nurse was not associated with high Tdap and MCV4 coverage  Pilot intervention: Link middle school and LPH unit in an area where this is not currently occurring

24. For more information please contact Centers for Disease Control and Prevention 1600 Clifton Road NE, Atlanta, GA 30333 Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348 E-mail: cdcinfo@cdc.gov Web: www.cdc.gov The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Acknowledgments Office of Surveillance, Epidemiology, and Laboratory Services Scientific Education and Professional Development Program Office North Dakota Department of Health - Immunization Program Molly Sander, MPH Abbi Pierce, MPH Keith LoMurray North Dakota Department of Health Steve Pickard, MD North Dakota Department of Health – Division of Community Health Becky Bailey, RN, BNSc CDC – EIS Field Assignments Branch Eddie Weiss, MD Betsy Gunnels, MSPH

25. North Dakota Schools Middle schools (%)All schools (%) Public154/175 (88)337/377 (89) Rural location118/175 (67)197/377 (52) State law compliant policy 82/164 (50)184/362 (49) School nurse assigned49/173 (28)155/372 (42)

26. Personnel Who Determine Up-to-date Status of Immunizations PersonnelMiddle Schools (N=175) n(%) All Schools (N=376) n(%) Administrative Assistant51 (29)108 (29) Local Public Health Nurse70 (40)104 (28) Principal9 (5)19 (5) School Nurse29 (17)115 (31) Other16 (9)30 (8)

27. Full Policy Question with Answer Choices  “What is your school’s policy regarding students who are not up-to-date with required immunizations?”  Students that are missing required immunizations or without a valid exemption may not attend school.  Students with no documented immunization record may not attend school.  Students who are not-up-to date may attend school but must provide proof that they are in the process of completing required immunizations within 30 days.  Students are encouraged to receive all required immunizations, but school entry is not denied for missing or incomplete immunizations.  School collects immunization records but does not review for up-to-date status.  I don't know.

28. North Dakota Urban Counties

29. North Dakota “Middle” Schools (n=175) School Type% of “Middle” Schools K-1251 Elementary (have Kindergarten)17 Middle15 High (have 12 th grade)17

30. Validation Results for 12 Middle Schools SurveyRecords Mean Tdap Rate % (95% CI) 72 (51-92) 75 (61-89) Mean MCV4 Rate % (95% CI) 71 (50-91) 74 (60-88)