It is the position of the National Association of School Nurses (NASN) that reaching high vaccination coverage of school-age children and their families, as outlined in Healthy People 2020 (U. S. Department of Health and Human Services [USDHHS], 2017), is an important public health objective. NASN further recognizes that challenges still remain in meeting this goal and schools can play a key role in the deterrence of vaccine preventable diseases (VPD).
The National Vaccine Plan, 2015-2016 Mid-Course Review, states that there are still opportunities to eliminate financial and system barriers for providers and consumers to facilitate access to routine, recommended vaccines. Highlighted in Goal #4, Health care providers must continue to improve access to and acceptance of vaccination providers in nontraditional healthcare settings. School-located vaccination (SLV) can augment other emerging alternative vaccination sites (USDHHS, 2016).
The registered professional school nurse (hereinafter referred to as the school nurse) is in a critical position to create awareness, influence action, and provide leadership in the development of SLV programs. School nurses are trusted professionals within the school and community settings and can play a pivotal role in the success of SLV. They are ideally placed to identify students who have missed vaccines (Swallow & Roberts, 2016). Studies also show that SLV is key for adolescents who have significantly lower rates of vaccination due to lower rates of office-based visits (Bernstein & Bocchini, 2017).
Historically, SLV has been shown to enhance vaccination rates. In 1875, New York City used schools to deliver the smallpox vaccine. Schools were again utilized in the 1950s to deliver the Salk polio vaccine. In 1969, schools held vaccine clinics to administer the rubella vaccine, in the 1990s to conduct hepatitis B catch-up clinics, and again in 2009 for varicella and H1N1 vaccines (Mazyck, 2009; Lambert & Merkel, 2000; Hodge & Gostin, 2002). In the 2012-13 school year, an SLV project in rural Kentucky administered the HPV vaccine, significantly improving vaccination rates (Vanderpool et al., 2015).
However, broad adoption of SLV has been slow. Reasons for this are varied, but a major reason is that the beliefs of widespread morbidity and mortality caused by vaccine-preventable diseases have faded from memory. VPDs in a variety of locations remind us that they have not been completely eradicated and that there is continued vulnerability of VPDs. Other factors that may be influencing SLV are informed consent, privacy and confidentiality, and harm from fear and anxiety (Braunack-Mayer et al., 2015). The shift to the use of SLV in administering routinely recommended vaccines will require careful planning to implement known strategies designed to assure appropriate reimbursement for cost-effective services. SLV provides an important opportunity to immunize youth with limited access to healthcare services in the community at large (Middleman, 2016).
In November 2010, a cross-sector, interdisciplinary meeting was co-hosted by NASN, the National Association of City and County Health Officials, and the Association of State and Territorial Health Officials in Washington DC. Participants were drawn from organizations representing public health, education, medical practice, government agencies, patient advocacy, and industry. The group identified two key challenges to developing, sustaining, and expanding SLV: 1) funding and 2) documentation (Bobo, Etkind, & Talkington, 2010). These challenges still exist today.
In a recent study, Illinois Medicaid managed care providers and billing personnel lacked clarity in how to obtain coverage for immunizations that are administered outside of the medical home (Limper & Caskey, 2016).
SLV has a long history in the United States and has successfully contributed to lower morbidity and mortality due to vaccine-preventable diseases (Limper et al., 2014). The school is an ideal place to reach 52 million children from all cultures, socioeconomic groups, and age groups that attend each day; and the school is conveniently located in a familiar and trusted community environment. SLV also offers a convenient option for parents to have their children receive needed vaccinations without having to arrange for a healthcare provider visit or take off time from work (Shlay et al., 2015).
One strategy to improve immunization rates in the United States is to capitalize on the trusted position of schools and school nurses to establish SLV. The school nurse can play a critical role in planning SLV because of understanding both the needs of the community and the school. For example, school nurses
- have experience collaborating with community partners, including local and state public health departments, school officials, other nurses, teachers, emergency planning authorities, child health agencies, families, community leaders, and local healthcare providers. The school and public health partnership is a familiar model for the delivery of health care in many communities. This collaboration is key to successful SLV.
- are considered a trusted source of health information by school boards and school officials. They can educate these groups on the impact of vaccination on school attendance.
- can provide accurate information and dispel myths about vaccines.
- are familiar with the health status of students and thus able to mitigate potential contraindications for vaccines.
- understand the implications of Family Educational Rights and Privacy Act (FERPA) and Health Insurance Portability and Accountability Act (HIPAA) related to recording and sharing immunization records.
In addition, schools and school nurses can provide significant logistical assistance in implementing SLV. Some of these include the following:
- Schools have the space and capacity to host SLV (e.g. gymnasium, library, cafeteria). Schools can also provide a space for safe storage of vaccines in a controlled environment.
- School start and dismissal times provide the framework for scheduling SLV with the least disruption of the school day.
- Schools can assist with securing volunteers such as parents, nursing students and other community partners to participate with SLV.
- School nurses understand mandated and recommended vaccination schedules and the complexities of vaccine administration.
- School nurse relationships with parents/families can be critical in obtaining consent for vaccination.
- School nurses can create SLV as the norm to enhance community-wide emergency preparedness.
SLV can reach children in the school environment and can complement the work of office-based healthcare providers. School nurses are well-versed in the importance of deterring and eradicating vaccine preventable diseases and the issues that are unique to their school community. NASN supports the continued efforts of school nurses and their community partners in developing SLV opportunities when it is appropriate for the health and well-being of their students and the community at large.
Bernstein, H. H., & Bocchini, J. A. (2017). Practical approaches to optimize adolescent immunization. Pediatrics, 139(3), e1-e14. Retrieved from http://pediatrics.aappublications.org/content/pediatrics/early/2017/02/02/peds.2016-4187.full.pdf
Bobo, N., Etkind, P., & Talkington, K. (2010) School-located vaccination clinics. NASN, NACCHO, ASTHO Summit November 16-17, 2010. Retrieved from http://www/nasn.org/portals/0/2011_11_21_nasn_naccho_astho_pdf
Braunack-Mayer, A, Skinner, S. R., Collins, J., Tooher, R., Proeve, C., O’Keefe, M., Marshall, H. (2015). Ethical challenges in school-based immunization programs for adolescents: A qualitative study. American Journal of Public Health, 105(7), 1399-1403. doi:10.2105/AJPH.2014.302280
Hodge, J., & Gostin, O. (2002). School vaccination requirements: Historical, social, and legal requirements. Baltimore, MD: Johns Hopkins and Georgetown University’s School of Public Health Center for Law and the Public’s Health.
Lambert, S., & Markel, H. (2000, May). Making history: Thomas Francis, Jr. MD and the 1954 Salk poliomyelitis vaccine field study. Archives of Pediatric and Adolescent Medicine, 154, 512-517.
Limper, H., & Caskey, R. (2016). Medicaid managed care. Unanswered impact on school-located immunization services. NASN School Nurse, 31(6), 328-330. doi: 10.1177/1942602X16638929
Limper, H., Burnes, J., Lloyd, L., Atilano, J., Alexander, K., & Caskey, R. (2014). Challenges to school-located vaccination: Lessons learned. Pediatrics, 134(4), 803-808. doi:10.1542/peds.2014-1339
Mazyck, D. (2009). School-located vaccination clinics: Then and now. Journal of School Nursing, 26(Supp 1), 3S-6S. doi: 10.1177/1059840510369231
Middleman, A., (2016). School-located vaccination for adolescents: Past, present, and future and implications for HPV vaccine delivery. Journal of Human Vaccines & Immunotherapeutics, 12, 1599-1606. doi: 10.1080/21645515.2016.1168953
Shlay, J., Rodgers, S., Lyons, J., Romero, S., Vogt, T., & McCormick, E. (2015). Implementing a school-located vaccination program in Denver public schools. Journal of School Health, 85, 536-543. doi: 10.1111/josh.12281
Swallow, W., & Roberts, J. C. (2016). An evidence-based project demonstrating increased school immunization compliance following a school nurse-initiated vaccine compliance strategy. The Journal of School Nursing, 32(6), 385-389. doi:10.1177/1059840516665216
U.S. Department of Health and Human Services. (2016). 2015-2016 National vaccine mid-course review. Retrieved from https://www.hhs.gov/sites/default/files/nvpo-midcourse-review-final.pdf
U. S. Department of Health and Human Services. (2017). Healthy people 2020. Washington, DC: U.S. Government Printing Office. Retrieved from https://www.healthypeople.gov/
Vanderpool, R. C., Breheny, P. J., Tiller, P. A., Huckelby, C. A., Edwards, A. D., Upchurch, K. D., ...Weyman, C. F. (2015). Implementation and evaluation of a school-based human papillomavirus vaccination program in rural Kentucky. American Journal of Preventative Medicine,49(2), 317-323. doi: 10.1016/j.amepre.2015.05.001
Acknowledgment of Authors:
Megan Fioravanti, BSN, RN, NCSN
Carol Ward, MSN, RN
Adopted: January 2013
Revised: January 2018
Suggested citation: National Association of School Nurses. (2017). School-located vaccination (Position Statement). Silver Spring, MD: Author.
All position statements from the National Association of School Nurses will automatically expire five years after publication unless reaffirmed, revised, or retired at or before that time.