Alameda County Public Health Department, Division of Communicable Disease Control and Prevention, Immunization Section
The Community Immunity Honor Society – Raising Immunization Rates in Schools
With a diverse population of over 1.5 million people, Alameda County California is the seventh most populous county in the state. Located in California's scenic Bay Area, it has 14 incorporated cities, the largest of which is Oakland with 420,000 residents, as well as several unincorporated communities. The vision of the Alameda County Public Health Department (ACPHD) is to ensure that everyone in Alameda County, no matter who they are, where they live, how much money they make or the color of their skin, leads a healthy, fulfilling and productive life. The Public Health Department works in partnership with the community to ensure the optimal health and well-being of all people through a dynamic and responsive process, respecting the diversity of the community and challenging ourselves to provide for present and future generations. In Alameda County, contemporary concerns such as an affordable housing crisis, crime, violence and substance abuse have merged with traditional public health concerns such as disease outbreaks, environmental hazards and access to health care.
Vaccines are one of the most notable achievements in public health in the 20th century (https://www.cdc.gov/mmwr/preview/mmwrhtml/00056803.htm). To prevent the spread of communicable diseases in schools and to protect California students from disease, California has immunization laws that apply to all schools, public and private, that say which immunizations are required for entry into child care, kindergarten and 7th grade. Over the course of the last decade, the up-to-date kindergarten immunization rates in Alameda County were consistently lower than the California state average rates. While it was theorized that the lower rates were likely due to high numbers of families with personal belief exemptions in the county, an analysis of immunization rates conducted in late 2014 determined something different: that the lower rates were due to much higher Conditional Entrantâ€ rates than were typically seen in California. A Conditional Entrantâ€ is supposed to mean a student who, at the point in time of kindergarten entry, does not yet have all immunizations required for school, but is also not due for any given immunizations because the minimum interval from previous doses received has not yet occurred.
When the Immunization Team staff at ACPHD investigated further, however, it was determined that the bulk of those students who had been reported as Conditional Entrants did not actually meet the Conditional Entrant definition. They were, simply, behind on their immunizations and should never have been allowed to enter school at all until they were brought up-to-date. To address our findings, we decided to implement a variety of activities:
Conducted in person visits to schools with lowest immunizations rates to discuss and train staff in how to interpret and implement California immunization school law
Created a listing of different school Community Immunityâ€ rankings (Honor society, Honorable Mention, Hopefuls and Non-Immunes) and shared this list with all schools so it was seen and reviewed by peers
Sent certificates of excellence signed by our local health officer to those schools who had outstanding immunization rates
Sent simple tools to schools to use during spring enrollment
Monitored immunization rates during fall reporting
The result was that during the 15-16 school year, kindergarten immunization rates in Alameda County improved over 7 percentage points. This was the largest increase of any county in the rate of fully-immunized students. 95.9% of Alameda County's kindergarteners were up-to-date on their immunizations, as opposed to 88.6% the previous year. Activities continued for another year and during 2016-2017, immunization rates increased again, with 97.2% of kindergarteners fully immunized.
The result has been school staff who are better trained and better engaged in immunization law, and a much higher percentage of kindergarteners fully protected from dangerous diseases. Examples of the Community Immunity Honor Roll are available at our website, http://www.acphd.org/media/398838/community-immunity-honor-society.pdf and other resources are available at http://www.acphd.org/iz/resources/school-resources.aspx. These activities, especially the creation of the Community Immunity Honor Society ranking list, have had a positive impact in the school community and they are now part of our annual work plan.
The problem that we addressed was the fact that, since data has been recorded in California, Alameda County had always had consistently lower immunization rates at kindergarten entry than the California average.
Kinder Up-to-Date IZ Rate YR 2010-11 YR 2011-12 YR 2012-13 YR 2013-14 YR 2014-15
California 90.66% 90.96% 90.16% 90.16% 90.40%
Alameda County 90.17% 89.95% 88.94% 88.94% 88.59%
This was perplexing to us because Alameda County is a fairly urban county with a high concentration of pediatric providers. Being in Northern California, it was hypothesized that maybe the reason that immunization rates were lower was due to higher concentrations of personal belief exemptors (prior to January 1, 2016, it was legal to be philosophically opposed to immunizations for kindergarten entry in California). Upon closer examination, however, the personal belief exemption rates for Alameda County over the course of the last decade have been remarkably low. This was not what was bringing our overall up-to-date immunization rates down.
Kinder Personal Belief Exemption Rates YR 2010-11 YR 2011-12 YR 2012-13 YR 2013-14 YR 2014-15
California 2.33% 2.39% 2.79% 3.15% 2.54%
Alameda County 1.24% 1.35% 1.65% 1.78% 1.54%
The rates of conditional entrants, however, had been consistently higher than the state average. Conditional entrants are those students who, at the point in time of kindergarten entry, do not yet have all immunizations required for school, but are also not due for any given immunizations because the minimum interval from previous doses received have not yet occurred. For example, if two doses of MMR vaccine separated by at least 28 days are required for kindergarten entry and the student received an MMR vaccine two weeks prior to entry, that child would be considered a Conditional Entrant. The student, while not yet having received two MMRs, is considered to be up-to-date at that point in time. The child is allowed to enter school on the condition that the family and school work together to ensure that the next needed doses are received when they are due. Alameda County's Conditional Entrant rates looked as though many children were entering school without receiving the full complement of immunizations, but also not due for any vaccines at the time of school entry.
Kinder Conditional Entrant Rates at School Entry YR 2010-11 YR 2011-12 YR 2012-13 YR 2013-14 YR 2014-15
California 6.82% 6.48% 6.78% 6.50% 6.86%
Alameda County 8.46% 8.58% 11.02% 9.05% 9.68%
There are around 20,000 kindergarteners each year in Alameda County. After compiling and analyzing the above data, Alameda County Public Health Department (ACPHD) set out to determine why so many of our kindergarten students were considered conditional entrants. We visited the schools with the highest conditional entrant rates and analyzed individual immunization records of students. We determined that the vast majority of students who had been reported as conditional entrants did not truly fulfill the conditional entrance criteria. We also realized that many of the staff at schools tasked with tracking immunization records of students had never been properly trained. Finally, we realized that there really were not any negative ramifications for schools that had high conditional entrant rates, or, for that matter, low up-to-date immunization rates. We set out to change all of that.
Our model practices were innovative takes on training, materials, and marketing.
? Our trainings focused on those schools with the lowest immunization rates â€“ we included school principals, nurses and front desk staff to ensure that everyone was aware of the law and how to appropriately implement it and track students.
? Our materials included the creation of two new items â€“ 1) Community Immunity ranked lists of schools divided into four categories: Honor Society, Honorable Mention, Hopefuls, Non-Immunes; and 2) Certificates of excellence signed by our Health Officer for those schools that were part of the Community Immunity Honor Society
? In terms of marketing, we sent letters to all school principals explaining the importance of fully immunized students and included the ranked lists. In this regard, schools saw how they compared to their peer schools. It created an environment of friendly competition as we received phone calls from schools asking what they needed to do to be get out of the Non-Immuneâ€ category. This simple intervention was a new take on the data that is available for all to see on a statewide website www.shotsforschool.org . The website shows individual immunization rates for schools instead of an entire city or county. Showing all of the schools in one ranked place had a tremendous impact for raising awareness. The certificates of excellence were also well-received. Schools felt great pride and even called and thanked us for acknowledging their hard work and ensuring that students were up-to-date upon school entry.
Data demonstrate that the interventions worked. Immunization rates increased and conditional entrant rates decreased significantly between 2014-15 and 2015-16 school years.
Kinder Up-to-Date IZ Rate YR 2014-15 YR 2015-16 YR 2016-17
California 90.40% 92.80% 95.60%
Alameda County 88.59% 95.90% 97.20%
Kinder Conditional Entrant Rates at School Entry YR 2014-15 YR 2015-16 YR 2016-17
California 6.86% 4.40% 1.90%
Alameda County 9.68% 2.50% 1.30%
The use of ranked lists and certificates to help motivate people is not necessarily new, but it had never been done in Alameda County and it was incredibly well received. The ranked lists were also organized alphabetically by city, so that schools could easily find themselves on the list and see the Community Immunity category where they ranked. The data to create the lists was all publicly accessible at http://www.shotsforschool.org/k-12/reporting-data/, but we arranged it differently to make it easier for schools to understand. This simple, innovative tweak made the difference in schools comprehending how their individual piece contributed to the entire county. A link to this year's list is available at http://www.acphd.org/media/398838/community-immunity-honor-society.pdf. Prior lists are available at our office. The first list published (year 2014-15) had over 40 schools in the Non-Immune category. The next year there were only two school considered to be Non-Immune. There will always be turnover in schools and there will always be new staff that need training, but we feel as if we've established some interventions that are easily sharable and implementable to help schools into the future. It is a model that is easy to replicate in other jurisdictions.
There seems to be great power in a list that is well laid out and publicized. The idea of the school Community Immunity Honor Society list came actually from the San Francisco Hep B Free campaign's honor roll for providers who test for chronic hepatitis B infection (https://www.sfhepbfree.org/clinician-honor-roll ). An employee at ACPHD used to work at San Francisco Department of Public Health and remembered physicians calling and asking what do I have to do to be on that list? When we received phone calls at ACPHD asking how to be moved to a different category on the list, we knew that we were finally making an impact.
Our goal was, of course, to increase immunization rates for kindergarteners in Alameda County and ensure that our kindergarteners were fully protected from dangerous diseases. We also wanted at least 80% of our schools to have immunization rates of 90% or higher.
Our timeline is dictated by what is required by schools in terms of annual immunization reporting.
Schools must report the immunization status of their kindergarteners to the California Department of Public Health (CDPH) each fall (October-November)
CDPH analyzes data and publishes school results in the spring (March-April)
ACPHD takes publicized information and creates Community Immunity ranked lists and Certificates of Excellence, then sends to all schools with personalized cover letters and additional training materials (April-May)
ACPHD visits schools with lower immunization rates to ensure that they are well prepared for coming enrollment season (April-May)
ACPHD emails schools and sends letters to schools at the start of school to ensure that they have all proper tools (one of our favorite attachments that we created is posted at http://www.acphd.org/media/422887/school-iz-requirements.pdf ) needed for proper immunization checking. We also encourage them to call us if they have any questions at all (August-September)
ACPHD monitors immunization reports as they are submitted and follows up with any schools who appear to be reporting sub-optimal rates (September-October)
Repeat all of the above once schools have reported
Other stakeholders involved include schools, school districts, superintendent offices, and local health care providers. It does take a village to ensure that a child is fully vaccinated. At the time of school entry, schools are instructed to not allow students to enter school who have not met all immunization requirements according to California law. A child who is behind on immunizations often needs a number of vaccinations immediately so that no school is missed. We work closely with the Northern California chapter of AAP to encourage their physicians to be flexible at the back-to-school time of year so that their patients can be seen quickly for immunization-only visits. We also conduct several Back-to-School clinics in conjunction with Public Health Nursing at our own Health Department so that children are vaccinated quickly.
Costs for all of these interventions are rather minimal. All of the printing of certificates, letters, and ranked lists are done in-house as part of regular operations. There are usually at least two mailings to approximately 350 schools, each costing about $1. Not including staff time for these interventions, the overall operational costs for supplies, printing and postage do not exceed $1500/year.
We are submitting this Community Immunity Ranking List idea for schools as a model practice because it is an inexpensive way to engage schools, it is easy to implement, and it is extremely easy to evaluate. Evaluation questions we included in this overall effort were:
Did immunization rates improve at the school?
Are there more schools entering the Honor Society category this year?
How many schools received certificates of excellence this year?
Are there more schools entering the Non-Immune category this year? The Hopeful category?
What is the overall kindergarten up-to-date rate for Alameda County?
What is the overall conditional entrant rate for Alameda County?
How many schools reported their rates this year as compared to last? Is the number going up or down?
The results of each of the above questions dictates the actions that we took to address the issue. We contact schools whose performance/immunization rates have decreased, and we acknowledge schools where performance/immunization rates have improved.
As previously stated, after our first year of implementation, our overall kindergarten immunization rate in Alameda County improved over 7 percentage points.â€”more than any other county. 95.9% of Alameda County's kindergarteners were up-to-date on their immunizations, as opposed to 88.6% the previous year. Activities continued for another year and during 2016-2017, immunization rates increased again, with 97.2% of kindergarteners fully immunized. We do anticipate that our success will plateau, but there will always be schools moving from one category to the other who will either need acknowledgment of their success or technical assistance to address their shortcomings.
This project is sustainable in that it doesn't rely on additional staff or outside staff â€“ it simply means incorporating this list development and mailing interventions into an annual workplan. The annual data analysis is reliant dependent upon when CDPH analyzes and posts their data â€“ and sometimes that is a bit unpredictable, but that is the only drawback. Once the templates for these ranked lists and certificates are created, they are easy for health departments to replicate each year and they make a big difference with schools. The Alameda County Public Health Department has distributed the ranked Community Immunity lists to schools for the past three years â€“ and schools seem to now expect it. We do receive calls asking when the next lists will be available, especially from those schools who are eager to move up to a better category. We are submitting this idea for consideration as a model practice because it is easy, it is inexpensive, it makes an impact, and it is sustainable.