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 Self-reported census of vaccination records Data cleaning & feedback Schools receive vaccination & exemption records (shot cards, Immunization Information Systems (IIS), parent records) Random sample of schools and/or students collected by state immunization programs (may be CDC generated) Data submitted to state immunization program, aggregated for statelevel reporting Local reports, assessment, and programmatic improvements from self-reported census data Data submitted to CDC via Program Annual Report and Progress Assessments (PAPA) National reports, applied research and assessment, and programmatic improvements 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.
Estimated Percentage of Children Enrolled in Kindergarten who were Exempt from One or More Vaccines, Medical vs. Nonmedical - United States, 2015-16 School Year *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. 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 statespecific terms)
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 Source: 2015-2016 MMWR
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
Thank you. jmunderwood@cdc.gov (770)718-1471 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.