Influenza Vaccination Compliance in Preschool Settings

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PETER CORREALE
Influenza Vaccination Compliance in Preschool Settings
What’s On Your Mind?: 

WHY EVERY HEALTH DEPARTMENT SHOULD HAVE A COPY OF THIS IMMUNIZATION TOOLKIT: Public health nurses have to audit childcare centers every year, for influenza and other age- appropriate required immunizations. This toolkit has everything you need to be prepared to go into an immunization audit and follow up documentation to increase compliance and success rate.

THE ISSUE:
Newly adopted regulations required preschoolers to receive influenza vaccinations prior to years end. During annual immunization audits in 2010, public health nurses observed many children without documentation of their seasonal influenza vaccine in Childcare Centers and Preschools.

The New Jersey state mandated influenza vaccinations in Daycare and preschool settings in the 2008-2009 influenza season. Just one year later, during the 2009-2010 influenza season, that mandate was lifted. This was due to shortages of seasonal influenza vaccine and actions to prevent the spread of pandemic H1N1. Another contributing factor may have been that the yellow immunization cards did not include influenza until the 2008 printing. Therefore, schools were continuing to add immunizations on to old cards and did not have the visual trigger to follow up on influenza vaccinations.

Influenza is highly contagious. It can cause high fever, pneumonia and can make existing medical conditions (e.g. asthma) worse. It can cause diarrhea and seizures in children. Each year, thousands of people die from seasonal influenza and even more require hospitalization. Each year, 20,000 children are hospitalized with complications from influenza.

To date, no plans were in place to consistently encourage the immunization of children against the flu. The goal is to increase documentation rates of seasonal influenza vaccination among children six to fifty-nine months of age in Childcare Centers and Preschools.

THE OPPORTUNITY:
No consistent data existed prior to this project. Therefore, we needed to understand why seasonal influenza was not being documented. In collecting data to understand supports and barriers, we explored potential reasons through a two part process:

• Hypothesized barriers and supports using a fishbone diagram. Several key factors were identified in terms of infrastructure (Childcare and Preschool facilities), customers (parents), policy, law and regulations as well as materials (vaccine availability).

• Developed a sub-committee to gather data and develop a project to address findings and design an intervention.

DO
Survey of Childcare and Preschool Personnel.
The goal was to identify the barriers and their relative importance.
We developed a survey, piloted, revised and fielded it via telephone. 64 of 64 centers participated. (The final survey is available at MLC3 website.)

Some of the key barriers to documentation identified in the survey were:
• Uncertainty of state mandate requiring flu vaccine for children.
• Parents did not routinely submit documentation of vaccination, even when the child may have received it.
• The final survey found that 66% of Childcare Centers said parents are concerned about the vaccine’s safety and 47% stated the vaccine was unnecessary.
• 64% cited access/availability of vaccine and 25% cited inconvenient to schedule.
• 56% stated that ‘parents not submitting’ documentation was a large barrier.

Another important finding of this survey was that 85% of the respondents indicated that their local Health Department was a source of guidance and information regarding influenza immunization. 100% were satisfied.

While the main focus of this effort was to increase documentation rates, it was important to address some of the early findings which were identified as barriers:
• Lack of understanding of the state mandate and their legal responsibility.
• Lack of availability of childhood flu vaccine in fall 2009. For fall 2010, local health departments participating in this effort agreed to offer the flu vaccine to children.
• Childcare staff is not knowledgeable about antigens.

Based on the survey data obtained, a Tool Kit format was decided on and developed for Childcare Directors.
• Sample IMM-8 as they should correctly be completed for each age group.
• Charts demonstrating the brand names and the antigens they contain. A separate chart listed the specific diseases and the brand names that covered them.
• Sample parent letters.
• Vaccine resources. Science-based information to address concerns of vaccine hesitant parents and to empower Childcare Directors to answer questions.
• New Jersey Communicable Disease Reporting Requirement.
• Orientation to Tool Kit provided.

THE IMPROVEMENT:
Based on results of the survey and 2011 annual immunization audits the rate of documentation increased to 94% and the following changes were recommended

• Send out reminder of State mandated influenza vaccine
• Include a statement of the fines for non-compliance within the Tool Kit.
• Continue to conduct pre-audits in November to encourage Childcare and Preschool Directors to document influenza.

PROMISING PRACTICES:
Staff realized the benefit of a structured process to evaluate and enhance program development and outcome. In addition, the process engaged all levels of staff and stakeholders motivated all to a higher level of performance.

The Multi-State Learning Collaborative provided the platform for the Department to work with four additional local health agencies in Morris County and the County of Morris to acquired skills in quality improvement.