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Abstract
Washington State has some of the highest percentages of school immunization exemptions in the country. We compared
school immunization records in a rural school district in Pierce County, Washington, to immunization records in the state
immunization information system (IIS) and parent-held records. Correcting school immunization records resulted in an
increase in the number of students classified as fully immunized from 1,189 to 1,564 (p < .0001). We conducted schoolbased immunization clinics that increased the number of fully immunized students to 1,624 (p .013). Immunized students
with certificates of exemption on file suggest exemptions of convenience. Strategies to improve school immunization services
include assigning IIS access to school administrative staff and educating school staff and parents on the importance of
immunization.
Keywords
immunizations, documentation, legal/ethical issues, health education, elementary, policies/procedures, middle/junior/high
school, administration/management
Washington State has some of the highest percentages of
school-aged children exempted from immunizations in the
country. During the 2009-2010 school year, 5.7% of kindergarten students in Washington State were exempted from
immunizations (Centers for Disease Control and Prevention
[CDC], 2011b). The CDC (2011a) estimated that between
2007 and 2008, 62.6% of children ages 19 to 35 months in
Pierce County, Washington, were fully vaccinated, well
below the Healthy People 2020 objective of 80% (U.S.
Department of Health and Humans Services [DHHS],
2012). Data from Pierce County school districts for the
2010-2011 school year showed that 5.4% of children in
kindergarten and 4.74% of kindergarten through Grade 12
students (K-12) were exempted from immunizations, with
higher exemptions in rural districts than urban school
districts (Tacoma-Pierce County Health Department
[TPCHD], 2011).
Several factors contribute to high exemption rates. Parental misconceptions or lack of knowledge about immunizations and concerns about vaccine safety increase the
likelihood of immunization exemption (Gust et al., 2004;
Kennedy, Brown, & Gust, 2005; Salmon et al., 2004).
Salmon et al. (2004) found that misperceptions about vaccine safety and efficacy, susceptibility and severity of
Corresponding Author:
Matthew P. Rollosson, Tacoma-Pierce County Health Department, 3629
South D Street, Tacoma, WA 98418, USA
Email: mrollosson@tpchd.org
Peterson et al.
353
Methodology
We selected a geographically large, rural school district in
Pierce County with low immunization coverage and high
percentages of immunization exemptions. This study was
conducted in two phases: a review of immunization records
and school-based immunization clinics. Baseline data were
collected on February 18, 2010, from school records. Postintervention data for the two phases were collected on May 3
and May 27, 2010. We collected only aggregate data at each
point of data collection and therefore could not evaluate
longitudinal changes for individual students. We used Pearson w2 to statistically evaluate changes in immunization
status.
We also identified students who had not received hepatitis A and human papillomavirus (HPV) vaccines, which are
recommended by the CDCs Advisory Committee on Immunization Practice (ACIP) but not required by Washington
State (CDC, 2010; DOH, 2009b).
We compared students school immunization records to
their records in the Washington State Immunization Information System (IIS). Parents of students who were exempted
from immunizations, admitted under conditional status, or
were out of compliance were contacted by telephone by the
I3 nurses or the school nurse who requested immunization
records held by the parents, offered information about
immunizations, and informed the parents of school-based
immunization clinics that were conducted during the second
phase of this study. We provided records of vaccine doses
missing from students school immunization records to
school administrative staff who corrected the school immunization records.
Results
At baseline, the proportion of completely immunized students in the five schools in the district ranged from 7.8%
to 82.2%. Out of a total of 2,052 students in the district,
1,189 (57.9%) were fully immunized (Table 1). The largest
proportion of students whose records did not reflect completely immunized status was out of compliance (24.8%).
By reconciling the school immunization records with IIS and
parent-held immunization records, the proportion of students classified as completely immunized increased from
57.9% to 76.2% (p < .0001). The proportion of students who
were classified as out of compliance decreased from 24.8%
of the total to 13.6%, immunization exemptions decreased
from 10.5% to 7.9% (p .005), and the proportion of students attending class under conditional status decreased
from 6.8% to 2.2%. An additional 60 students achieved completely immunized status during our school-based immunization clinics, increasing the percentage of fully
immunized students from 76.2% to 79.4% (p .013).
Peterson et al.
353
Methodology
We selected a geographically large, rural school district in
Pierce County with low immunization coverage and high
percentages of immunization exemptions. This study was
conducted in two phases: a review of immunization records
and school-based immunization clinics. Baseline data were
collected on February 18, 2010, from school records. Postintervention data for the two phases were collected on May 3
and May 27, 2010. We collected only aggregate data at each
point of data collection and therefore could not evaluate
longitudinal changes for individual students. We used Pearson w2 to statistically evaluate changes in immunization
status.
We also identified students who had not received hepatitis A and human papillomavirus (HPV) vaccines, which are
recommended by the CDCs Advisory Committee on Immunization Practice (ACIP) but not required by Washington
State (CDC, 2010; DOH, 2009b).
We compared students school immunization records to
their records in the Washington State Immunization Information System (IIS). Parents of students who were exempted
from immunizations, admitted under conditional status, or
were out of compliance were contacted by telephone by the
I3 nurses or the school nurse who requested immunization
records held by the parents, offered information about
immunizations, and informed the parents of school-based
immunization clinics that were conducted during the second
phase of this study. We provided records of vaccine doses
missing from students school immunization records to
school administrative staff who corrected the school immunization records.
Results
At baseline, the proportion of completely immunized students in the five schools in the district ranged from 7.8%
to 82.2%. Out of a total of 2,052 students in the district,
1,189 (57.9%) were fully immunized (Table 1). The largest
proportion of students whose records did not reflect completely immunized status was out of compliance (24.8%).
By reconciling the school immunization records with IIS and
parent-held immunization records, the proportion of students classified as completely immunized increased from
57.9% to 76.2% (p < .0001). The proportion of students who
were classified as out of compliance decreased from 24.8%
of the total to 13.6%, immunization exemptions decreased
from 10.5% to 7.9% (p .005), and the proportion of students attending class under conditional status decreased
from 6.8% to 2.2%. An additional 60 students achieved completely immunized status during our school-based immunization clinics, increasing the percentage of fully
immunized students from 76.2% to 79.4% (p .013).
354
Table 1. Changes in Students Immunization Status, Totals for All Schools in the District
Baseline
Record review
Immunization clinic
Immunization status
n 2,052
n 2,053
n 2,045
Complete
Exempt
Conditional
Out of compliance
1189
215
139
509
57.9
10.5
6.8
24.8
1564
163
46
280
76.2***
7.9**
2.2
13.6
1624
151
38
232
79.4*
7.4
1.9
11.3
Discussion
Immunization coverage for students in this district was
underrepresented in the schools records. While the increase
in the percentage of completely immunized students from
our school-based immunization clinics reached statistical
significance, reconciling the schools immunization records
with IIS and parent-held records had the greatest impact on
the immunization status of students in the district. In our
study, school administrative staff made student immunization records available to the I3 nurses who then reviewed
those records. As part of a program to improve immunization coverage in Cincinnati, school health clerks conducted
biannual audits of immunization records to identify students
whose immunization status was not in compliance with state
immunization laws (Toole & Perry, 2004).
In Washington State, school nurses may assign access to
the IIS to school staff who are responsible for verifying
and documenting students immunizations (DOH, 2011b).
School staff may then retrieve students immunization
records from the IIS and print CISs, which can then be
signed by parents and placed on file. The administrative staff
at the schools in this district reported that they had not been
granted access to the IIS. We believe that assigning access to
the IIS to school staff would improve the completeness of
school immunization records and reduce the workload of
school nurses.
Peterson et al.
355
Conclusions
A large proportion of immunizations received by students in
the district were not captured in the schools immunization
database. Reconciling the schools immunization database
with IIS and parent-held immunization records resulted in
significant improvement in the proportion of students documented as fully immunized. Although Washington State law
permits school nurses to delegate access to the IIS to school
staff, none of the staff at the schools in this district had been
granted access to the system. School staff may use the IIS to
generate CISs which can be signed by parents and placed in
students records, reducing the number of errors of the types
that we found. Although we did not collect data on the reasons for exemptions, data collected from the district at the
end of the 2010-2011 school year indicated that 93% of
immunization exemptions were for philosophical reasons
(TPCHD, 2011). Reports of school staff directing parents
to complete COEs rather than submit immunization records,
the ease with which philosophical exemptions could be
obtained in Washington State, and the observation that
reconciling the schools immunization records with IIS and
parent-held immunization records resulted in a significant
decrease in the number of exemption suggest that a substantial proportion of philosophical exemptions are convenience
exemptions. These findings were used to successfully support a revision of immunization requirements in Washington
State in 2011. Beginning July 2011, parents who wish to
exempt their children from immunization for philosophical
reasons are required to have a COE signed by a health care
professional, documenting receipt of information on the benefits and risks of vaccines (DOH, 2011a).
The percentage of immunization exemptions in this
school district remains greater than that for Pierce County
and Washington State even after our district-wide interventions. This suggests that other factors such as vaccine hesitancy and broader access issues may still be a factor for
many parents. Further study is warranted to assess the nature
of these factors; however, our work in this district suggests
that providing training to school administrative staff and
ensuring access to IIS and educating parents and school staff
on the importance of immunizations can result in a substantial decrease in the number of philosophical exemptions to
immunizations required for school entry.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article: This
study was funded by a grant from the Group Health Foundation.
Carolyn Cook thanks Denise Stinson for her contribution to this
work. Carolyn Cook, Robin Peterson, and Mary Yerxa thank the
Pierce County Immunization Coalition for its support of their work.
356
Matthew Rollosson thanks Gini Gobeske and Nigel Turner for their
review of this manuscript.
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Bios
Robin M. Peterson, MSN, RN, is a coordinator at MultiCare
Mobile Health Services, Tacoma, WA, USA.
Carolyn Cook, MSN, RN, is a clinic nurse at Mary Bridge Mobile
Immunization Clinic, MultiCare Health System, Tacoma, WA,
USA.