Impact of SchoolBased Flu Immunization Program on Student

Impact of School-Based Flu Immunization Program on Student Absenteeism April 23, 2014 Susan Dawson President E 3 Alliance Ruth Roberts Director of Student Health Hays CISD Jonathan Morgan Director of Health System Alignment Lone Star Circle of Care © 2014 E 3 Alliance

#fluvaccine @missingschoolmatters @e 3 alliance © 2014 E 3 Alliance

? What are the ways student absences harm our families, our schools, and our

? When we started this work, how many days were Central Texas students absent

2. 4 Million Student Absences in Central Texas per Year Source: E 3 Alliance

Agenda • • How we got here Why are students absent? How absences impact

Background • In 2011, Central Texas superintendents chose increased attendance as #1 way community and funders could assist districts: 1. “Triple Bottom Line” benefit: − Students can learn when in class − Teachers have more time to teach − Increased revenue to districts 2. Unlike teacher quality or staffing, communities can directly and positively impact student attendance • E 3 Alliance spearheading regional approach to increase attendance © 2014 E 3 Alliance

Poorest Students Have Much Higher Absenteeism Absences Central Texas High Schools, 2009 -10 Average Days Absent 18 16 16 16 15 14 12 10 10 8 12 8 6 4 7 5 2 0 Non-Low Income Asian Black Free Lunch Hispanic Source: E 3 Alliance analysis of PEIMS data at UT Education Research Center. White © 2014 E 3 Alliance

Central Texas Has More Absences Than Texas on Average at Every Grade 14 Average Number of Absences, By Grade, 2010 -11 Average Days Absent 12 +3 days 10 8 6 4 2 0 KG 1 2 Source: E 3 Alliance analysis of PEIMS data at the UT Austin Education Research Center 3 4 5 6 Grade Central Texas 7 8 9 10 Texas © 2014 E 3 Alliance 11 12

Average Number of Absences Central Texas Low Income Students Miss More School Than Students in All Other Urban Areas in Texas 14 Average Number of Absences in High School by Economic Status for Urban MSAs Throughout Texas, 2010 -11 13, 0 12 11, 4 10 9, 6 8 6 7, 5 8, 4 8, 2 7, 6 11, 6 10, 0 8, 0 4 2 0 Non-low Income Dallas El Paso Houston Low Income San Antonio Source: E 3 Alliance analysis of PEIMS data at the UT Austin Education Research Center Central Texas © 2014 E 3 Alliance 10

Average Number of Absences Central Texas Low Income Students Miss More School Than Students in All Other Urban Areas in Texas 14 Average Number of Absences in High School by Economic Status for Urban MSAs Throughout Texas, 2010 -11 13, 0 12 11, 4 10 9, 6 8 6 7, 5 8, 4 8, 2 7, 6 11, 6 10, 0 8, 0 4 2 0 Non-low Income Dallas El Paso Houston Low Income San Antonio Source: E 3 Alliance analysis of PEIMS data at the UT Austin Education Research Center Central Texas © 2014 E 3 Alliance 11

Our Goal: Increase student attendance by 2 percentage points (average 3 days/student) MORE STUDENTS

Educators Community Students Improved Attendance Missing School Matters Taskforce Parents & Families Employers •

Why are students absent and what can we do about it? © 2014 E

Absence Reasons Study Ø Who misses school, where and why? ü First of its kind study in the state (maybe US? ) ü Data to drive regional decision-making: How community systems help or hinder students to improve attendance © 2014 E 3 Alliance

What Did We Find? % of Absences by Absence Reason Acute Illness 48% (8124) 5% (751) Skipping Chronic Illness Comb. 4% (707) Family Emergency 4% (654) Routine Dental Appt 3% (465) Preventative Medical 2% (352) Travel 2% (326) 2% (254) Mental Health Issue Suspension (not ISS) 1% (247) 1% (173) Family Responsibility 0% Source: E 3 Alliance analysis of absence data from 9 schools in PISD & HCISD, 1/14/13 -3/8/13 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% © 2014 E 3 Alliance

Number of Students Absent Medical Absences More Variable than Non-Medical Absences Over Time 2000 1800 1600 1400 1200 1000 800 600 400 200 0 14 -янв 21 -янв Source: E 3 Alliance analysis of Absence data from 9 schools in PISD & HCISD, 1/14/13 -3/8/13 28 -янв 4 -фев 11 -фев Study Week Medical 18 -фев 25 -фев Non-medical © 2014 E 3 Alliance 4 -мар

Average # Absences Per Day Acute Illness Matches Overall Absence Pattern Absences By Week August–March 2012 -13 350 300 250 200 150 100 50 0 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 2 3 4 5 6 7 8 9 10 12 13 Week of the Year August HCISD PISD Source: E 3 Alliance analysis of Absence data from 9 schools in PISD & HCISD August through March 2012 -13 HCISD Acute Illness Study Period March PISD Acute Illness © 2014 E 3 Alliance

Average # Absences Per Day Acute Illness Matches Overall Absence Pattern Absences By Week August–March 2012 -13 350 Holiday Break 300 250 200 150 100 50 0 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 Week of the Year August HCISD PISD Source: E 3 Alliance analysis of Absence data from 9 schools in PISD & HCISD August through March 2012 -13 HCISD Acute Illness 2 3 4 5 6 7 8 9 10 12 13 Study Period March PISD Acute Illness © 2014 E 3 Alliance

Average # Absences Per Day Absences By Week August–March 2012 -13 350 18% 300 16% 14% 250 12% 200 10% 150 8% 6% 100 4% 50 2% 0 0% 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 1 3 4 Week of the Year August HCISD 2 PISD HCISD Acute Illness 5 7 8 9 10 12 13 Study Period PISD Acute Illness Source: E 3 Alliance analysis of Absence data from 9 schools in PISD & HCISD August 2012 through March 2013 Influenza-Like Illness doctor visit data from Austin/Travis County Health and Human Services 6 March Dr visits flu-like illness © 2014 E 3 Alliance % of Doctor visits for flu-like illness Secondary ‘Flu’ Peak Matches Acute Illness Absences

How do student absences impact students and schools? © 2014 E 3 Alliance

Absences and Poor Achievement are Highly Correlated • ½ of all students are absent 6 or more days; those students account for 85% of all absences • A high school student absent 10 or more days is THREE TIMES as likely to drop out as one absent 5 or fewer days • Students retained in 9 th grade have FOUR TIMES the absences as those who go on to 10 th grade, and are TEN TIMES as likely to drop out! © 2014 E 3 Alliance 23

What are Schools Doing About Absences? ü Local awareness campaigns ü Attendance officers – direct outreach with communities and families ü Partnerships with truancy courts ü Community- and campus-based clinics ü Registered nurses in schools Ø Launched regional campaign Missing School Matters – 2011 © 2014 E 3 Alliance

Absences Increased at Similar Rate to Student Enrollment Until 2011 -12 3, 0 2, 5 390 360 330 300 270 240 210 180 150 120 90 60 30 - $12 M+ regional savings since campaign started! 2, 0 1, 5 1, 0 0, 5 - Number of Students (in Thousands) Number of Absences (in Millions) Students and Absence Counts, Central Texas, 2001 -02 to 2012 -13 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Absences Students Source: E 3 analysis of PEIMS data at UT Austin Education Research Center for 2002 -2011; TEA ad hoc request for 2012, 2013 © 2014 E 3 Alliance 26

Can We Impact Absences by Reducing Flu? • Flu Immunization Taskforce started last October

Can We Impact Absences by Reducing Flu? • Limited flu vaccinations – not mandatory and inconsistent • Few (10 -20%? ? ) of CTX students vaccinated • Identified models that are providing vaccines at no cost to districts or families (El Paso et al) § Vaccines for Kids/CHIP/Private all covered • Reviewed national models and findings © 2014 E 3 Alliance

Influenza: More Cases of Disease Than All Other *1 -3 Vaccine-preventable Diseases Combined Influenza: 15+ Million Estimated Annual Cases of Influenza are Between 15 & 63 Million 1 -2 In 2011, ~32 K cases of other infectious diseases including: 3 □ Pertussis □ Varicella □ Hepatitis □ Meningococcal Disease □ Mumps *Estimated value based on US Census of 310, 002 1. CDC. Seasonal Influenza: questions & answers. http: //www. cdc. gov/flu/about/qa/disease. htm. Accessed December 5, 2012. 2. US Census Bureau. US and world population clocks. http: //www. census. gov/main/www. popclock. html. Accessed December 5, 2012. 3. CDC MMWR. 2012; 60: 1762 -1775. © 2014 E 3 Alliance 29

Children Are Primary Cause of Infection 1 -2 Extended Community ` Family Members and other close contacts Children Daycare, Preschool & School-aged Classmates 1. Glezen. WP, et al. N Engl Med. 1978; 298: 587 -592. 2. Weycker D, et al. Vaccine. 2005; 23: 1284 -1293. © 2014 E 3 Alliance 30

Mass Vaccination of School-aged Children Can Have a Community-wide Impact • Obligatory in-school vaccination of children in Japan demonstrated protection of these children against influenza • Vaccination reduced 1 influenza in the community • The number of influenza related deaths reduced from 10 to 3 out of 100 Thousand from 1962 -1986 1. Reichert TA, et al. N Engl J Med. 2001; 344: 889 -896. 2. Ghendon YZ, et al. Epidemial Infect. 2006; 134: 71 -78. © 2014 E 3 Alliance 31

Progress to Date • Agreed to target Elementary Schools in 5 districts - Fall ’ 14 § § Most vulnerable to illness Most likely to spread to others Easiest to manage in-school programs 56 schools (all ES’s in DV/Hays/Manor/Pflugerville) plus pilot in 8 AISD elementaries) ü Lone Star Circle of Care committed to implementing model across Central Texas districts!! © 2014 E 3 Alliance 32

Progress to Date • Travis Cty HD & DSHS eagerly working with us, helping navigate state rules to make it happen! • Letter out to all superintendents notifying of intent and timeline • Calculated potential return: $1. 4 Million!! • Districts working on common consent form • LSCC application as targeted provider and state vaccine order to be submitted early summer • Need to identify partners for outreach and funding support – YOU!! © 2014 E 3 Alliance 33

What will a flu immunization campaign look like? © 2014 E 3 Alliance

Lone Star Circle of Care • A non-profit, federally qualified healthcare center network operating across five central Texas counties • Committed to community-wide access for all patients, focusing on the underserved • Proud health care home to over 100, 000 Central Texans • Over 30 clinics offering care in several service lines: Pediatrics, Family Medicine, OB/GYN, Senior, Dental, Optometry, Integrated Behavioral Health, and Pharmacy • Growing presence in Central Texas school districts offering primary care and behavioral health service • Routinely partner with other area healthcare providers to provide high quality, comprehensive care © 2014 E 3 Alliance 35

Remove Barriers to Access • Refrigerated mobile units will take flu vaccines directly to schools • ALL students and staff will be offered vaccines AT NO COST to districts or families • Licensed nurse on-site to administer • Offered in nasal mist or shot (if necessary) • Elementary schools make it easier to administer – should complete 2 or more schools/day © 2014 E 3 Alliance 36

Implementation Timeline District Agreements In Place Plan Verbally Approved by State Q 1 ‘ 14 Q 2 ‘ 14 Consent Forms Collected Q 3 ‘ 14 Outreach Planning LSCC Committed As Provider Storage Facilities In Place & Approved, Vaccines Ordered Immunizations in 56 Schools Campaign Evaluation Q 1 ‘ 15 Q 4 ‘ 14 Community Outreach School Starts Expansion Planning © 2014 E 3 Alliance

Consent Forms • Common consent form (English & Spanish) to be used across all

Consent Forms • Common consent form (English & Spanish) to be used across all districts • Very complex, 4 pages required • Consent required before any actions - important to get as many returned as possible • Replicating St. David’s Foundation dental van teacher and school incentive program to increase consent form return rate © 2014 E 3 Alliance 40

Bottom Line ü Plan to offer flu vaccines at no charge to districts or families in 56 schools in fall 2014! ü Year 1 Target: 50% vaccination rate or over 20, 000 students and staff ü Unique opportunity to leverage objective data and community collaboration to benefit our region ü HUGE potential benefit to student health, absences avoided, lost work time, etc. Ø Need help from the community to encourage families to take advantage of immunizations © 2014 E 3 Alliance 41

? What outreach to the community can best increase participation? ü 56 target schools

The conclusions of this research do not necessarily reflect the opinions or official position of the Texas Education Agency, the Texas Higher Education Coordinating Board, or the State of Texas. www. e 3 alliance. org © 2014 E 3 Alliance

Schools Included ü Del Valle ISD: All 8 Elementary Schools ü Hays CISD: All 13 Elementary Schools ü Manor ISD: All 7 Elementary Schools ü Pflugerville ISD: All 19 Elementary Schools ü Austin ISD: 8 Pilot Schools: Houston, Langford, Perez, Rodriguez, Widen Elementary Schools and Uphaus, Webb, and Dobie Pre-K Centers © 2014 E 3 Alliance 44

Return To Community: • Total expected school-based immunizations: • Target participation rates: ~21, 000 50% students 80% staff • • $1, 172 K $ 125 K $ 81 K $1, 378 K Avoided costs of missed student, parent, staff days: Avoided costs of medical treatment: Avoided Tamiflu prescription costs: Total Pilot savings to community: © 2014 E 3 Alliance 45