The Journal of School Nursing2023, Vol. 39(6) 456–462© The Author(s) 2021Article reuse guidelines:sagepub.com/journals-permissionsDOI:10.1177/10598405211038598journals.sagepub.com/home/jsn
The purpose of this study was to determine the amount of time elementary and middle-school students spend away from the classroom and clinic time required to administer vaccines in school-located vaccination (SLV) clinics. We conducted a time study and estimated average time away from class and time to administer vaccine by health department (HD), student grade level, vaccine type, and vaccination process for SLV clinics during the 2012–2013 school year. Average time away from classroom was 10 min (sample: 688 students, 15 schools, three participating HD districts). Overall, time to administer intranasally administered influenza vaccine was nearly half the time to administer injected vaccine (52.5 vs. 101.7 s) (sample: 330 students, two HDs). SLV administration requires minimal time outside of class for elementary and middle-school students. SLV clinics may be an efficient way to administer catch-up vaccines to children who missed routine vaccinations during the coronavirus disease-2019 pandemic.
Keywordsinfluenza, vaccination, administration, time evaluation, school-located vaccination
During the coronavirus disease-2019 (COVID-19) pandemic, there has been a sharp drop in routine vaccinations for children in the United States, leading to a large gap in vaccination coverage for key vaccine-preventable diseases such as measles (Bode et al., 2021; Bramer et al., 2020; Santoli, 2020). It is a public health imperative to close this gap in vaccination coverage but doing so is challenging because medical practices may be operating at reduced capacity and some parents/guardians have limited capacity or desire to visit a medical practice (O’Leary et al., 2021; Vogt et al., 2020). Therefore, it is essential to identify alternative vaccination venues that minimize the burden on parents/guardians and medical practices. Similar concerns have been raised in the past for child influenza vaccination (Fiore et al., 2012; Srivastav et al., 2015).
School-located vaccination (SLV) programs have been considered one of the most promising alternative vaccination settings for school-aged children (Fiore et al., 2012), based on strong evidence of effectiveness in increasing vaccination rates and in decreasing rates of vaccine-preventable disease and associated morbidity and mortality (Benjamin-Chung et al., 2020; Humiston et al., 2014; Szilagyi et al., 2016, 2019). SLV may serve to efficiently vaccinate children against COVID-19, as was the case during the 2009–2010 H1N1 influenza pandemic, during which over one-third of school-aged children aged 5–17 years old received H1N1 vaccination in a school setting (Vogt & Wortley, 2012). However, school staff may be concerned about students spending time away from the classroom for these clinics because of disruption to students and teachers and limited information is available to inform the school’s or school district’s decisions on SLV. Published assessments on the topic currently consist of interview findings that SLV programs do not unduly disturb school activities and that students are generally vaccinated in a timely fashion within SLV clinics (Christensen et al., 2012; Williams et al., 2012), but no quantitative information is available to support this.
In summary, there is a need for alternative vaccination sites, especially for COVID-19 vaccination and catch-up for routine vaccinations. SLV has been shown to be an effective alternative vaccination site for increasing vaccination rates but the disruption costs of SLV are unknown and may discourage schools from implementation. Therefore, the objective of our study was to answer two questions: (a) how much time do students spend away from the classroom to participate in an SLV clinic? and (b) how much clinic time is required to administer injected trivalent-inactivated vaccine (TIV) for influenza and intranasally administered live attenuated influenza vaccine (LAIV)?
This study is part of a larger study called the School-Located Vaccination Evaluation (SoLVE), which assessed whether administering influenza vaccination to school-aged children in a school setting is a viable and acceptable supplement to influenza vaccination delivery in a health care provider setting. The objectives of SoLVE were to (a) assess contextual factors, clinic approaches, and school principal and health professional attitudes associated with student vaccination in school-located vaccination for influenza (SLV-I) clinics; (b) understand SLV-I-related knowledge, attitudes, and roles among school principals and health professionals in a randomly selected, national sample of schools; (c) determine the costs to conduct SLV-I, processes used to bill thirdparty payers for SLV-I services provided, success of SLV-I billing efforts, and resources available to health departments (HDs) to help with billing; (d) assess teacher beliefs, attitudes, and roles, if any, that are associated with classroom-level student participation in SLV-I clinics; and (e) determine the average amount of time students spend away from the classroom to attend an influenza vaccination clinic and the average time required to administer TIV and LAIV. Here we present the components of the study related to objective “e.” RTI International’s Institutional Review Board provided human subjects approval for the project.
For the SoLVE Study, we solicited HD participation via a National Association of County and City Health Officials’ newsletter. The eight HDs that volunteered and participated in SoLVE during 2011–2012 and that planned to continue implementing SLV during the 2012–2013 school year were eligible to participate in the SoLVE Time Tracking Study. All study HDs were local HDs that had experience conducting SLV programs.
To recruit HDs for the Time Tracking Study, we conducted teleconferences with the eight HD representatives to describe the planned study and determine their interest in participating. Four of the eight HDs volunteered to participate; each HD subsequently identified five elementary and middle schools in which they would implement the study. Participating HDs received an incentive of $1,000 at study completion.
Data collection at all schools was the sole responsibility of the HDs. Each HD identified a data collection supervisor to oversee data collection at all schools and serve as a liaison to the study team. We provided data collection materials to each HD, including a HD-specific protocol (i.e., tailored to address the clinic approaches used), time tracking forms, and stopwatches. During data collection, we provided technical guidance to the HDs and helped resolve any unforeseen issues.
Data collection took place during the first SLV clinic of the year offered at the schools selected for participation. To determine the amount of time students spent away from the classroom to attend an SLV clinic, data collectors first positioned themselves in front of the classrooms and then started the stopwatch as the first student left the classroom. When students returned to the classroom, the data collector recorded the elapsed time on the stopwatch in minutes and seconds for the last student to return. If students left the classroom in groups, the data collector also recorded the number of students in a group. Students that left in groups all retuned in the same group. Data collectors also recorded student grade levels on the tracking sheets. Finally, data collectors recorded in the notes of each observation any items of interest such as unforeseen delays.
Two HDs did not follow the data collection protocol exactly in all cases. In HD A, data collectors did not track the number of students attending the clinic in groups (versus individually) for two schools, so we excluded these schools’ data from analysis and only used the data from five schools in HD A. In HD B, data collectors did not use the stopwatch provided for data collection and instead used their personal watches. Therefore, data collectors recorded the amount of time away from the classroom in minutes instead of in minutes and seconds, as per the protocol instructions. We used this data in minutes for analysis. Each of the HDs had five schools included in the final analysis.
To determine the amount of clinic time required to administer the influenza vaccine, data collectors positioned themselves at a location in the clinic that would allow them to observe students from the time they arrived at the vaccination station until they stood up to leave the vaccination station (immediately postvaccination). This included time to provide students with instruction and reassurance. Data collectors identified students to track and used the stopwatches to capture the vaccination time in seconds. They then recorded the vaccination time, the type of vaccine administered (LAIV or TIV), and grade level of each student. They also recorded in the notes of each observation any items of interest such as the need to provide additional instruction or reassurance to the student. Data collection of clinic time took place at a different time than data collection of time away from class; so, the samples of the two study components include different students.
Three of the four HDs completed data collection and submitted final data on time away from class for analysis. Of these, HD C did not collect data on the types of vaccine administered or the time required to vaccinate a child. For all three of these HDs, data collection began in October 2012; we received completed tracking sheets from the last HD in December 2012. We were unable to determine whether data collection was completed for the fourth HD; after 4 months of extensive follow-up with the HD contact, we made the decision to drop this HD from the study.
Across the three HDs, a total of 688 students were tracked in 15 schools. We used data on these students to estimate the average amount of time a student spends away from the classroom to attend an SLV clinic. Of the 688 students tracked, 88% were in elementary school (pre-K to 5) and 92% attended the SLV clinic in a group. The average group size across HDs and grade levels was 7.3 students. Table 1 provides detailed summary statistics of the sample by HD and grade level.
Table 2 displays the average amount of time a student spent away from the classroom to attend an SLV clinic by HD and grade level. The average time a student spent away from class was 10 min. However, the times varied by HD. The average time a student spent away from class was 5.4 min in HD A, 11.3 min in HD B, and 13.1 min in HD C. Differences between these three means were all statistically significant (p < .01), but differences across HDs by grade level were not. Elementary school students spent an average of 10 min to attend the SLV clinic, whereas middle-school students spent 10.2 min. However, in HD C, elementary school students spent significantly less time attending the clinic than middle-school students: 12.7 and 22.8 min (p < .01), respectively. Because there were some extreme values in the time away from classroom data, we also report the median time away from class. As shown in Table 2, the median time away from class across all HDs and grades was 8.0 min. However, there was still variation across the HDs. The median time was 5.1 min in HD A, 10.3 min in HD B, and 12.0 min in HD C. The median time away from class for elementary school students (8.0 min) and middle-school students (7.2 min) was very similar across HDs. Variation within each HD was low as shown by standard deviations that were approximately 50% of the average.
Table 3 shows the average time students spent away from class by grade level for all students that attended the SLV clinic as a group and for those who attended individually. Across all HDs and grades, students who attended the clinic in a group spent more time on average away from class than those who attended the clinic individually, 10.5 and 5.5 min, respectively (p < .10). Across the HDs, there was no significant difference in times away from class between elementary school students (10.4 min) and middle-school students (11.3 min) for students who attended the clinic as a group. Similarly, for students tracked individually, we found no significant difference in means between elementary school students (5.5 min) and middle-school students (4.7 min).
Across all HDs and grade levels, the median time away from class for groups of students was 8.6 min. For students tracked individually, the median time away from class was 4.2 min. Elementary school students were more likely to be escorted to the clinic in groups than middle-school students.
To estimate the amount of clinic time required to administer LAIV and TIV, we tracked 330 students across two HDs (A and B). Across both HDs, 85.2% of the students received LAIV, and 14.9% received TIV. Students in middle school were nearly twice as likely to receive TIV (24.9%) than students in elementary school (13.3%). This difference was nearly identical across the two HDs. Table 1 provides detailed summary statistics by HD and vaccine type.
Table 4 shows the average time in seconds required to administer the influenza vaccine by HD, grade level, and vaccine type. Across all grade levels and HDs, the average time to administer LAIV (52.5 s) was nearly half the time to administer TIV (101.7 s). The difference in means is statistically significant (p < .01). We also found statistically significant differences in most of the grade-level means across and within HDs.
The mean time to administer the LAIV vaccine to elementary students (52.4 s) was similar to the average time to administer the LAIV vaccine to middle-school students (52.7 s). Across both HDs, the average time for TIV vaccination of elementary school students (106.9 s) was 28% higher than the average time for TIV vaccination of middle-school students (83.8 s). Because of the relatively small number of students vaccinated with TIV in our sample, it is unclear whether this trend would be observed in a larger sample.
Our study findings suggest that when elementary and middle-school students participate in an SLV clinic, they spend an average of 10 min outside of the classroom. These findings demonstrate that SLV clinics can cause minimal school-day disruption for teachers and require little time outside of the class for children, corroborating existing interview assessments of attitudes on SLV programs (Christensen et al., 2012; Williams et al., 2012). SLV may be an efficient method for vaccinating children when vaccination in the medical home is not feasible or unlikely.
Most of the students tracked in this study attended the clinic as a group. However, the data show that students who attended the clinic individually spent nearly half as much time obtaining a vaccination in the clinic as students who attended in groups: 5.4 min versus 10.5 min, respectively. During clinic data collection, data collectors observed that younger students were escorted to the clinic in groups, and as a result, were often required to wait in the clinic for everyone in the group to be vaccinated before they could return to the classroom, which explains this time difference.
The data indicate that the amount of time for students to participate in an SLV clinic may also differ substantially across HDs. However, differences in data-collection procedures across HDs may have contributed to the differences in mean times away from the classroom. In HD A, staff members did not track the number of students attending the clinic in groups (versus individually) for two schools, so for analysis purposes, we excluded these schools’ data. In HD B, data collectors did not use the stopwatch provided for data collection and instead used their personal watches. Therefore, data collectors recorded the amount of time away from the classroom in minutes instead of in minutes and seconds, as per the protocol instructions.
Our study findings also show the time required to administer LAIV (52.5 s) is significantly less than the time required to administer TIV (101.7 s). According to school staff comments, this difference is mostly due to clinic staff spending more time to help students, especially younger students, relax and prepare for receiving the injection (TIV). Our SLV administration time data are consistent with this comment; TIV administration for elementary school students required 28% more time than TIV administration for middle-school students. These data also agree with qualitative assessments of SLV programs elsewhere in the literature, which have noted the frequent need for staff to calm and prepare elementary-aged students prior to injection (Christensen et al., 2012). This suggests that it may be beneficial for school nurses to play a larger role in preparing students for the clinic and escorting them to the clinic.
Our study had several limitations. Participants in this study were from only three HD SLV programs and represent SLV programs that are well-established, and therefore may be run more efficiently than less-established SLV programs. Future research should examine a larger sample that includes differences in school and student demographics. We did not capture student or school demographics as part of this study. This is important to include in future research to examine differences by demographic characteristics. In addition, due to the sample included in this study, we were unable to assess the time required to administer vaccine to high-school students, which is another population that would be useful to assess, especially given their lower influenza vaccination rates in comparison to other children (Centers for Disease Control and Prevention, 2014). Future research should examine clinics in high schools. Additionally, as discussed above, there were differences in data-collection procedures across HDs that limited comparison across HDs. In future research, it is recommended to provide a trained data collector for all sites. Finally, because data collection of clinic time took place at a different time than data collection of time away from class, the samples are different and not comparable.
Our study contributes to an understanding of the time required to administer vaccines to students during SLV programs. Across the elementary and middle schools in three HD program areas that had both LAIV and TIV vaccine available, vaccination activities only required an average of 10 min out of class per student. While students were in the SLV clinics, administration of the LAIV and TIV vaccines required just under 1 and 2 min per student, respectively. These findings demonstrate that SLV clinics can cause minimal school-day disruption for teachers and require little time outside of class for children. Results also suggest that increasing the role of school nurses in preparing students for the clinic and escorting them to the clinic may help to reduce time and disruption. This aligns with the community public health and care coordination components of the Framework for 21st Century School Nursing Practice™ (Maughan et al., 2015). This indicates that SLV clinics may be a minimally disruptive way to offer influenza or COVID-19 vaccination to school-aged children. However, it is important to note that there are important differences in COVID-19 vaccination such as a minimum 15-min postvaccination observation period that need to be considered in planning. SLV may also be useful for catch-up vaccination of children who have fallen behind during the COVID-19 pandemic when vaccination at their medical home cannot occur or is unlikely to occur. Catch-up vaccination may also present different challenges and considerations than influenza vaccination, all of which should be considered in planning. More research is needed to provide newer data, examine demographic differences, and examine clinics in high schools.
We would like to acknowledge H.G. and N.P. for their roles in conceptualizing and designing the study and supervising implementation, data collection, analysis, and providing review of earlier drafts; Y.K. for her review of draft manuscripts; and S.M. for excellent editorial support. Finally, we acknowledge Drs G.B.A., B.-H.C, S.P., and M.M. for their contributions to study design.
The content is solely the responsibility of the authors and does not necessarily represent the official views of RTI International or the Centers for Disease Control and Prevention.
he authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the National Center for Immunization and Respiratory Diseases (Grant no. 200-2010-F-37187).
Ben Yarnoff https://orcid.org/0000-0002-5147-1588
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Ben Yarnoff, PhD, is part of the Health Economics Program at RTI International, Durham, NC, USA.
Laura Danielle Wagner, MPH, is part of the Global Public Health Impact Centerat RTI International, Durham, NC, USA.
Amanda A. Honeycutt, PhD, is part of the Health Economics Program at RTI International, Durham, NC, USA.
Tara M. Vogt, PhD, MPH, is part of the National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
1 Health Economics Program, RTI International, Durham, NC, USA
2 National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
3 Global Public Health Impact Center, RTI International, Durham, NC, USA
Corresponding Author:Ben Yarnoff, Health Economics Program, RTI International, 3040 Cornwallis Road, Research Triangle Park, NC 27709, USA.Email: byarnoff@rti.org
