Maintaining childhood immunization rates promotes herd immunity for selected vaccine preventable diseases. School vaccination requirements are an effective tool for maintaining vaccination rates and controlling communicable disease. School nurses play important roles in verifying student vaccination, educating parents and linking families to vaccine providers. However, evidence linking school nurses and vaccination rates is lacking. We examined the association between presence of a school nurse and school-level immunization rates in Arizona.
METHODS:
Using 2014–2015 school-level data from the Arizona Department of Health Services, we performed a cross-sectional analysis of vaccination data for all 903 schools serving Arizona 6th graders. Data included presence of a school nurse; 6thgrade immunization and medical exemption rates; enrollment, school type (public, private, or charter), and county. To account for socioeconomic status (SES), we used the percent of students eligible for the National School Lunch Program (NSLP) from the Arizona Department of Education. School-level immunization rates were calculated by creating z-scores for seven vaccinations (Diptheria-Tetanus-Pertussis, Meningococcus, Polio, Measles-Mumps-Rubella, Hepatitis B, and Varicella) and averaging each school’s seven vaccine-specific z-scores. T-tests were used for bivariate analysis; multivariate linear regression models were used with robust standard errors to account for potential district level clustering effects.
RESULTS:
Complete data were available for 761 (84%) schools. School-level immunization rates ranged from 90.1% (Meningococcus) to 98.1% (Varicella). Schools with a nurse had higher overall combined average immunization rates than those without a nurse (96.1% vs 95.0%, respectively, p=0.0013). After adjusting for school enrollment, medical exemption rates, school type and percentage of NSLP students, the relationship was no longer significant. SES was identified as an effect modifier; a significant association between presence of a school nurse and immunization rate was identified for schools with the highest NSLP percentages. Presence of a school nurse was associated with an approximate 2 percentage point increase in immunization rates for all 7 vaccines examined in schools falling in the highest NSLP percentage quartile (i.e., lowest SES quartile).
CONCLUSIONS:
This public health-led multi-jurisdictional collaborative team identified an association between school nurses and immunization rates at Arizona schools serving lower income populations. While previous studies have shown an inverse relationship between SES and immunization rates, our study is the first to explore the nuanced interactions between school nurses and SES and their association with higher school vaccination rates. School nurses play critical roles in increasing vaccination rates and preventing disease spread in lower SES schools.