National Center for Immunization & Respiratory Diseases

School Vaccination Assessment Program (SVAP): Methodological Description of the Partnership between State Immunization Programs and Centers for Disease Control and Prevention (CDC) to Monitor

School Vaccination Coverage and Exemptions

Jenelle Mellerson MPH, Erica Street MPH, Cynthia L. Knighton, Kayla Calhoun MS,

Ranee Seither MPH, J. Michael Underwood PhD

American School Health Association Conference Baltimore, MD October 8, 2016

School Vaccination Assessment Program (SVAP)

CDC has tracked school entry vaccination coverage for nearly 20 years – SVAP is the nation’s largest school-based vaccination

surveillance system

Vaccination requirements for school-entry are established by state and local jurisdictions to protect children from vaccine-preventable diseases

States report kindergarten vaccination coverage and exemptions to CDC as part of the immunization program cooperative agreement with CDC

SVAP Impact

Monitor annual trends in kindergarten vaccination coverage and exemption rates

Disseminate data and support applied research

Promote use of state and local-level school vaccination data for program planning

Methodology

Population – Kindergartners in any of the 50 states, District of Columbia (DC),

and territories • First graders in territories where compulsory education

starts with first grade – Enrolled in public, private, and some home schools

Setting – State and local departments of health and education partner to

collect vaccination data from public, private, and home schools with kindergarten students

Vaccination Coverage

Percentage of students who have received state-required number of vaccine doses

Includes students who have history of disease and/or laboratory

evidence of immunity in select states

Not the same as compliance – Students who have all appropriate vaccination or exemption

documentation on file or attend school under a grace period or provisional enrollment

Vaccination Exemption

Legal process for opting out of required vaccination(s) for school entry – Medical – Religious – Philosophical/Personal Belief – Temporary/Annual/Permanent – All vaccine/Vaccine-specific – Other

SVAP Data Collection Process

1. Parents and/or healthcare providers submit student vaccination documentation to schools – Some schools and/or states access student vaccination

documentation from state Immunization Information Systems (IIS)

2. De-identified or aggregated student vaccination data are

submitted to state immunization programs – Census of schools – Random sample of schools

3. State immunization programs aggregate data by school type

– Public – Private – Home

SVAP Data Collection Process

4. Immunization programs submit (de-identified, aggregated) vaccination and exemption data to CDC’s (Program Annual Report and Progress Assessments) online system – CDC provides technical assistance and feedback to reduce

reporting errors and strengthen data collection

5. CDC disseminates findings each school year – National, state, and local reports – Applied research

School Vaccination Assessment Program Data Collection Process

Data submitted to CDC via Program

Annual Report and Progress

Assessments (PAPA)

Data cleaning & feedback

Self-reported census of vaccination

records

Random sample of

schools and/or students collected

by state immunization

programs (may be CDC generated)

Schools receive vaccination &

exemption records (shot cards,

Immunization Information Systems (IIS), parent records)

Data submitted to

state immunization program,

aggregated for state-level reporting

National reports, applied research and assessment,

and programmatic improvements

Local reports, assessment, and

programmatic improvements

from self-reported census data

▪ Schools receive vaccination and exemption records in the form of shot cards, parent records, or documentation is accessed via the IIS ▪ Immunization programs collect vaccination data from a self-reported census or a random sample of schools or students ▪ Immunization programs report state-level vaccination data to the Centers for Disease Control and Prevention (CDC) using the PAPA online tool ▪ CDC disseminates findings via national reports and data are used for applied research and programmatic improvements

State Variations in Data Collection

Data methods – Collected via census, voluntary response, samples (simple

random, stratified cluster sample), and mixed surveys – Provided by school records, parental report, provider report,

Immunization Information Systems (IIS) – Abstracted by school staff, health department staff, school

nurses, or a mix of staff – Validation processes – Assessment date

School type(s) included

Response rates

State Variations in Data Collection

Vaccination data – Vaccine type – Vaccine-specific or “up-to-date” for all vaccines – Number of doses required – Number of doses reported – Method used to count doses (all vs. only valid doses) – Time when required (school entry vs. age)

Exemption data

– Number of exemptions vs. number of children with an exemption (preferred method)

– Exempt-to-all vs. vaccine-specific exemptions

School Vaccination Coverage 2015-16 MMR

Most states require 2 doses of MMR; Alaska, California, New Jersey, and Oregon required 2 doses of measles, 1 dose of mumps, and 1 dose of rubella vaccines. Georgia, New York, New York City, North Carolina, Pennsylvania, and Virginia required 2 doses of measles and mumps, 1 dose of rubella vaccines. Iowa required 2 doses of measles and 2 doses of rubella vaccines.

School Vaccination Coverage 2015-16 MMR

School Vaccination Coverage 2015-16 DTaP

Pertussis vaccination coverage might include some DTP (diphtheria and tetanus toxoids and pertussis vaccine) vaccinations if administered in another country or vaccination provider continued to use after 2000. Most states required 5 doses of DTaP vaccine for school entry; Illinois, Virginia, and Wisconsin required 4 doses; Nebraska required 3 doses . Pennsylvania required 4 doses of diphtheria and tetanus vaccine, but pertussis vaccine was not required. Kentucky required ≥5 but reported ≥4 doses of DTaP.

School Vaccination Coverage 2015-16 Varicella

Seven states do not require 2-dose varicella. Oklahoma did not report varicella coverage for 2015-16.

*Reported exemption data for a sample of schools and/or students. †Some children have both medical and nonmedical exemptions; number of students exempt to any vaccination is less than the sum of medical and nonmedical exemptions. ‡Wyoming could report only the number of students exempt from one or more vaccines, not by type.

Estimated Percentage of Children Enrolled in Kindergarten who were Exempt from One or More Vaccines, Medical vs. Nonmedical - United States, 2015-16 School Year

Source: 2015-2016 MMWR

Grace Period/Provisional Enrollment CDC collected data on kindergartners enrolled under a grace period or

provisional enrollment policy during the 2015-2016 school year Grace period A set period of days, typically applied to all students in a state, during which a student can enroll and attend school without proof of complete vaccination or exemption

Provisional enrollment Allows a student with incomplete vaccinations to attend school while completing a catch-up vaccination schedule. (Also referred to as conditional enrollment, in-progress, in-process, among other state-specific terms)

Source: 2015-2016 MMWR

Estimated Percentage of Children Enrolled in Kindergarten who were Provisionally Enrolled or Within a Grace Period at the Time of Assessment,

Selected States, 2015-16 School Year

School Assessment Outcomes

Surveillance – Monitor state-level kindergarten vaccination coverage and

exemptions

Data Use

– Inform policy and program decisions to improve kindergarten vaccination coverage and exemption activities

• Federal, state, local – Respond to media and public inquiries – Local use of data by immunization programs

• Data shared by 25 states in 2015-16, increase from 21 in 2014-15

Data Sharing by California Department of Public Health

Data Sharing by Washington State Department of Health

School Assessment Lessons Learned

Reporting Inconsistencies – Incomplete vaccination data

– Reporting compliance with documentation requirements

instead of vaccination coverage

– Excluding kindergartners with exemptions from one or more vaccines from coverage estimates of all vaccines

– Reporting the number of vaccines exempted instead of the number of kindergartners with exemptions

– Incomplete or incorrect descriptions of assessment methods

Limitations

State vaccination requirements vary by state

Data collection processes vary in each state immunization program – Policies

• Documentation deadlines, exemptions, provisional enrollment, grace periods

– Requirements • Vaccine, vaccine doses, documentation

– Methods • Census vs. sample, collection timelines

Next Steps

Obtain immunization program’s feedback to develop 2016-17 kindergarten school assessment questionnaire

Continue to expand use of a census to collect vaccination and exemption data

Continue to provide technical assistance by reviewing and improving data collection tools

Promote SVAP data use for applied research by CDC and partner organizations

Summary

CDC partners with immunization programs monitor annual vaccination coverage and exemptions in kindergartners

Each immunization program follows different vaccination requirements, policies, and data collection methods – Must be considered when conducting annual kindergarten

vaccination assessment – Limits comparison

Continual improvement in data collection methods through

relationships with immunization programs can help to improve data quality in kindergarten school assessment

Public Health Implications

The SVAP is the nation’s largest school-based immunization surveillance system

CDC and immunization program collaboration strengthens data quality and use

Kindergarten vaccination coverage and exemption data are used to evaluate state, city, and territory immunization programs, policies, and impact

Specialized technical assistance, including methodology adjustments, results in stronger vaccination surveillance data to guide immunization programs action

For more information, contact CDC 1-800-CDC-INFO (232-4636) TTY: 1-888-232-6348 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.

Thank you.

jmunderwood@cdc.gov (770)718-1471