Please write a Lit review for the article and supply me help with more info for the introduction and did you know Research question  Would flu clinics in schools lower student absences? Please provid

Original Research Impact of School Flu Vaccine Program on Student Absences Sara S. Plaspohl, DrPH, CHES 1, Betty T. Dixon, DrPH, RN 2, James A. Streater, EdD, CHES 1, Elizabeth T. Hausauer, MSN, RN 2, Christopher P. Newman, MPH 1, and Robert L. Vogel, PhD 3 Abstract Literature provides evidence that school attendance correlates with academic performance and student success. Influenza is a contributing factor to school absences. Primary prevention for influenza includes immunization. School-located influenza vaccine (SLIV) programs provide greater access for students to be immunized. A retrospective review of preexisting data from four academic years was conducted to examine the relationship between SLIV participation and absenteeism among students at eight public elementary schools in Effingham County, Georgia. Results identified differences in average frequency of absences between SLIV and non-SLIV years as well as between SLIV participants and nonparticipants for the 2 SLIV years.

Implications for practice include the potential for increased herd immunity among students, which may also extend to other parties within the school community and at home, thus promoting overall wellness and future student success.

Keywords immunizations, school-based clinics, collaboration/multidisciplinary teams, academic achievement/attendance, health/wellness, elementary, quantitative research Introduction Scientific literature indicates school absenteeism correlates with lower standardized test scores and dropout rates (Balfanz & Byrnes, 2012). Missing even a few days of school, regardless of cause, can impact student academic performance, shape attitudes about school, and affect school dropout rates (Chang & Romero, 2008; U.S. Department of Education, 2009). McGiboney (2012) examined attendance data among Georgia elementary school students, noting a significant relationship between number of days in school (defined as ‘‘seat time’’), success in school, and ultimately, probability of high school graduation. One cause of school absenteeism is influenza. The effects of influenza are widespread. The virus possesses the capabil- ity to infect large number of people rapidly, impacting 10 %– 20 % of the U.S. population every year (Weycker et al., 2005). Those who become infected develop symptoms that can last several days, leading to bed rest, school/work loss, and increased physician visits. Mortality rates due to influ- enza infection have been estimated to exceed 36,000 each year, and the annual economic impact of influenza in the United States has been estimated between $11 and $18 billion dollars (Davis, King, Moag, Cummings, & Magder, 2008). Infection rates among children are the highest among any age group during a typical influenza season, averaging 25 %–43 % (Weycker et al., 2005). When children are sick with the flu, they miss school, and as indicated earlier, this can have a negative impact on their overall academic success. An increased understanding of the impact of influenza on school-aged children prompted the Centers for Disease Con- trol, the American Academy of Pediatrics, and the American Academy of Family Practitioners to recommend in 2008 that all children aged 6 months through 18 years be immunized every year against influenza (Centers for Disease Control, 2010). Vaccinations against influenza have been demon- strated to substantially lower the cases of influenza and mitigate its dissemination throughout populations (Reichert et al., 2001). Japan utilized vaccination of school children after mass influenza infection of its population led to exten- sive school closures (Reichert et al., 2001). Due to the increased risk of children carrying and disseminating influ- enza to the population, policy initiatives required the vacci- nation of all Japanese school children to allay the disease. As 1Armstrong Atlantic State University, Savannah, GA, USA2Coastal Health District, Savannah, GA, USA3Georgia Southern University, Statesboro, GA, USA Corresponding Author: Sara S. Plaspohl, DrPH, CHES, Armstrong Atlantic State University, 11935Abercorn Street, Solms Hall 201J, Savannah, GA 31419, USA. Email: [email protected] The Journal of School Nursing 2014, Vol. 30(1) 75-80ªThe Author(s) 2013Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1059840513487750jsn.sagepub.com a result of this program, flu-related mortality rates decreased dramatically, supporting conclusions that vaccine-induced herd immunity contributed to Japan’s average life span, which was the highest in the world (Reichert et al., 2001). School-located influenza vaccination (SLIV) programs provide a valuable primary prevention measure via the administration of influenza vaccine by public health depart- ment and school nurses to students within the school setting.

SLIV programs offer an opportunity to vaccinate school children while at school, thus lessening the proliferation of influenza. SLIV programs are efficient in providing access for immunization to large numbers of children, are cost effective when compared to immunizing children in physi- cian offices and clinics, and reduce the indirect costs of vaccination for parents by decreasing the need for their time and work absence to have their child immunized (King et al., 2006; Szilagyi, Iwane, & Humiston, 2003; White, Lavoie & Nettleman, 1999). As noted earlier, the time lost by a student from school due to illness can result in missed learning opportunities (White, Lavoie, & Nettleman, 1999). SLIV programs also serve an important role in lowering the amount of time parents spend caring for sick children and lowering the absenteeism rates for school children. SLIV programs can help reduce the workload burden of primary care providers and increase the overall vaccination rates among school children (Schieber, Kennedy, & Kahn, 2012). SLIV programs are available in some Georgia school dis- tricts, including Effingham County, where an SLIV program has been in effect since the 2010–2011 academic school year. To date, there has been little research to explore the correlation between student participation in SLIV programs and school absenteeism (Hull & Ambrose, 2011). The purpose of this research was to assess the relationship of a local SLIV program in reducing student absences and thus increasing seat time in class for elementary school students in Effingham County, Georgia.

Method A review of retrospective data from two sources was con- ducted to answer two research questions: (1) Was there a difference in average absenteeism among elementary school students for 2 years of pre-SLIV compared to 2 years with SLIV? (2) For the 2 years with SLIV, was there a difference in average absenteeism between elementary school students who were vaccinated in the SLIV program and those who were not vaccinated in the SLIV program? Study subjects included all elementary-grade students (K-5) enrolled in the eight public schools within Effingham County during four academic years, with the first 2 years (2007–2008 and 2008–2009) designated as ‘‘pre-SLIV’’ years because the SLIV program was not yet in place, and the last two (2010–2011 and 2011–2012) designated as ‘‘SLIV’’ years because the SLIV program was in place. One academic year (2009–2010) between the pre-SLIV and SLIV years was excluded from the study at the recommen- dation of the Coastal Health District Nursing Director, as that particular year was considered an anomaly because of the administration of greater than normal influenza vaccina- tions among the entire population due to the prevalence of the H1N1 virus. During early planning, the research team met with the Superintendent of the Effingham County Board of Educa- tion (BOE) to obtain his support for the study. The study was approved by the Armstrong Atlantic State University Institu- tional Review Board prior to the start of data collection. In May 2012, a formal request was then delivered to the Effing- ham County BOE for the first data source that included a series of data for the 4 years to be studied (2 pre-SLIV and 2 SLIV). Each year of data included basic demographic vari- ables of school, grade, gender, and race as well as a number of excused and unexcused school absences for 80 seat days (days in school) after students returned to school in January after the holiday break. An absence was defined as any day when a student was out of school for more than half day for any reason, in keeping with the BOE’s definition of the occurrence. Absences were further categorized as being excused if the student either brought a note from home (e.g., doctor’s excuse for illness) or was out for a school- related activity (e.g., athletic event or band concert), while unexcused absences were those for which the student did not bring a note. It was possible that unexcused absences could include influenza-related illness or other types of excusable reasons for instances where a note was not presented; there- fore, for purposes of the study, all excused and unexcused absences were summarized into an aggregate category of total absences per student without distinguishing the circumstances. The second source of data was provided by the Effingham County Health Department in May 2012 and consisted of the consent forms presented by students at the time of receiving their immunization for the SLIV program. A dichotomous variable was created to indicate whether or not each student was immunized with either nasal-spray flu vaccine or flu shot in the SLIV program during the 2 years of administra- tion. All vaccinated students were then matched to their individual attendance information with a ‘‘yes,’’ while all students who did not receive an immunization at school were categorized as ‘‘no’’ for SLIV participation. The quantitative data were analyzed in three phases with SAS 1 9.3 STAT (SAS Instititue, Inc., Cary, North Carolina). For discussion purposes, the following labels identify each group within the analysis: ‘‘Group A’’ refers to the aggregate of students in the 2 pre-SLIV years (2007–2008 and 2008– 2009); ‘‘Group B’’ refers to the aggregate of students in the 2 SLIV years (2010–2011 and 2011–2012); ‘‘Group B-V’’ refers to the aggregate of students in Group B who were vaccinated in the SLIV program; ‘‘Group B-U’’ refers to the aggregate of students in Group B who were not vaccinated in the SLIV program. 76 The Journal of School Nursing 30(1) In the first phase of analysis, descriptive statistics were generated for demographic variables to obtain a profile of study subjects, including gender, race, average number of days absent per student for each of the 4 years, and SLIV vaccination within the 2 SLIV years. In phase two, indepen- dent ttests were performed to analyze the difference in the overall mean absences between Group A and Group B. In phase three, independent ttests were performed to analyze the difference in the overall mean absences between Group B-V and Group B-U. Statistical models were used to evalu- ate independent effects; all tests used a .05 as the level of significance.

Results The study population for each of the four academic years was consistent in quantity, ranging from 4,674 to 5,201 for the 2 pre-SLIV years and 4,797 to 4,799 for the 2 SLIV years. Gender distribution was evenly split for the students, with slightly more than half (52 %) being male and the remaining 48 % being female. Using BOE categories for self-disclosed race, the student population included 77 % White non-Hispanic, 14 % Black, 4 % Hispanic, 4 % multira- cial, 1 % Asian/Pacific Islander, and <1 % American Indian/ Alaska Native or unknown. For the 2 SLIV years, 940 (20 %) students participated in the vaccination program in the first year of implementation (2010–2011), and 1,230 (26 %) par- ticipated in the second year (2011–2012), reflecting a 30 % increase in the participation rate. Refer to Table 1 for sum- mary of findings. All the students were absent for an average of 2.4 days for 2007–2008 and 2.7 days for 2008–2009, increasing to 3.2 average days missed for 2010–2011 and then 2.6 average days for final year 2011–2012 (Figure 1).

For the 2 SLIV years, the average number of absences was 2.7 days for students who received SLIV vaccination in 2010–2011, decreasing to 2.2 days for 2011–2012; likewise, the average number of absences for students not vaccinated in the SLIV program during those years was 3.3 and 2.8 days, respectively (Figure 2). In order to test the first research question of whether there was a difference in the overall mean absences between the 2 pre-SLIV years (2007–2008 and 2008–2009) and the 2 SLIV years (2010–2011 and 2011–2012), an independent ttest compared aggregate absenteeism for Group A (2.53 days) and Group B (2.89 days), yielding a statistically significant difference of 0.36 days ( p< .0001; 95 % confidence interval [CI] ¼[0.28, 0.44]). To further explore these groups of inter- est, two additional independent ttests were conducted. The first test compared the overall mean absenteeism for Group A (2.53 days) and Group B-V (2.39 days), yielding a statis- tically significant difference of .14 ( p< .0001, 95 % CI ¼ [0.02, 0.26]). The second test compared the overall mean absenteeism of Group A (2.53 days) and Group B-U (3.03 days), yielding a statistically significant difference of .50 ( p< .0001, 95 % CI ¼ [0.42, 0.59]). Refer to Table 2 for summary of findings. In order to test the second research question of whether there was a difference in the overall mean absences during the 2 SLIV years between students who were vaccinated in the SLIV program and those who were not, an indepen- dent ttest compared aggregate absenteeism of Group B-V (2.39 days) and Group B-U (3.03 days), yielding a statisti- cally significant difference of .64 ( p< .0001, 95 % CI ¼ [0.51, 0.78]). Refer to Table 2 for summary of findings. Table 1. Description of Students by Gender, Race, SLIV Participation. Variable Pre-SLIV Years SLIV Years 2007–2008 2008–2009 2010–2011 2011–2012 N (%) N(%) N(%) N(%) Total students 4,764 (100%) 5,201 (100%) 4,797 (100%) 4,799 (100%) Gender Male 2,435 (51%) 2,667 (52%) 2,483 (52%) 2,483 (52%) Female 2,329 (49%) 2,534 (48%) 2,314 (48%) 2,316 (48%) Race White, non-Hispanic 3,701 (78%) 4,018 (77%) 3,696 (77%) 3,699 (77%) Black 668 (14%) 721 (14%) 667 (14%) 684 (14%) Hispanic 169 (4%) 206 (4%) 193 (4%) 180 (4%) American Indian or Alaska Native 5 (<1%) 8 (<1%) 8 (<1%) 6 (<1%) Multiracial 174 (4%) 203 (4%) 183 (4%) 189 (4%) Asian or Pacific Islander 42 (1%) 39 (1%) 42 (1%) 35 (1%) Unknown 5 (<1%) 6 (<1%) 8 (<1%) 6 (<1%) SLIV participation Yes NA NA 940 (20%) 1,230 (26%) No 3,856 (80%) 3,569 (74%) Average # of days absent (stan. dev) 2.4 (2.7) 2.7 (2.6) 3.2 (2.9) 2.6 (2.8) Note . stan. dev ¼standard deviation; SLIV ¼school-located influenza vaccine. Plaspohl et al. 77 Discussion The findings in this study reflect one example of the possible impact of an SLIV program on student absenteeism. Ele- mentary students within one rural school system had access to receiving a primary prevention service, influenza immu- nization, from the local health department and school nurses within their normal school setting. This particular time period was selected because it allowed time for the immuni- zations to take effect after administration and also because it represented the time period of a typical flu season. In order to assess the potential impact of the SLIV pro- gram on absenteeism, 2 years of aggregate pre-SLIV atten- dance data were compared to similar information for 2 years during which time the SLIV program was in place, thus enabling the researchers to utilize a baseline for the measurement. Overall, average absenteeism for the first year was 2.4 days per student during the 80 class days following the seasonal holidays in December, with a subsequent increase during the following 2 years to 2.7 and 3.2 days, fol- lowed by a drop in the fourth year down to 2.6. Data analysis led to the conclusion that there was a statistically significant difference in the average number of absences between Group A and Group B; however, instead of seeing a decline in overall absences after SLIV implementation, there was an increase during 2010–2011. With a 95 % CI of 0.28 and 0.44 for the 0.36-day difference between these two groups, the clinical importance is questionable. Upon preliminary review, one might challenge whether the SLIV program had an impact at all with this opposite-than-expected result. Researchers conducted more analysis to study this unantici- pated finding. Further exploration of the data revealed that the results for the subset of students vaccinated in SLIV (Group B-V) were lower than the aggregate pre-SLIV (Group A) absenteeism average (2.39 vs. 2.53), for a differ- ence of 0.14 days, with a 95 % CI of 0.02 and 0.26. A similar comparison between Group A and Group B-U reflected a higher average absenteeism among Group B-U (3.03 vs.

2.53), for a difference of 0.5 days, with a 95 % CI of 0.42 and 0.59. Both of these findings were statistically significant with p< .0001. On average, Group B-V missed fewer school days than Group A, while Group B-U missed more school days than Group A. Again, one could question the clinical significance of these findings; however, the difference between Group B-U and Group A absences potentially exceeded a half day, suggesting a somewhat stronger rela- tionship between these variables. The final independent ttest to assess differences between absenteeism for Group B-V compared to Group B-U pre- sented a difference of 0.64 days between the two subsets, with 95 % CI of 0.51 and 0.78. This finding was also statis- tically significant at p< .0001 and was the largest difference among all inferential analyses. Group B-V students were in their seats for almost a full day more than Group B-U students. Student participation in the SLIV program increased from 20 % to 26 % during the 2 years of program administration. As participation increased over this period of time, the aver- age number of days absent decreased for both Group B-V and Group B-U, suggesting that the increased utilization of 2.4 2.7 3.2 2.6 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 2007-08 2008-09 2010-11 2011-12 Days SLIV Years Pre-SLIV Years Figure 1. Average absenteeism by school year. 3.3 2.8 2.7 2.2 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 2011-12 2010-11 Not Vaccinated in SLIV Vaccinated in SLIV Days Figure 2. Average absenteeism by school-located influenza vaccine (SLIV) participation. Table 2. Two-Group Comparisons for Mean Days Absent. Group A ( N¼9,965) Group B ( N¼9,596) Group B-V ( N¼2,170) Group B-U ( N¼7,426) Difference Between Groups 95% CI for Difference Between Groups 2.53 2.89 – – 0.16* [0.28, 0.44] 2.53 – 2.39 – 0.14* [0.02, 0.26] 2.53 – – 3.03 0.50* [0.42, 0.59] – – 2.39 3.03 0.64* [0.51, 0.78] * p< .001. 78 The Journal of School Nursing 30(1) the program may have a substantial correlation with increased herd immunity. If SLIV participation continues to increase in the future, will absenteeism continue to decline?

Strengths and Limitations There are several strengths that can be identified for this study. First, the study utilized a population, not a sample, as retrospective data for all Effingham County public ele- mentary school students (K-5) were included in the analysis.

This was the first study in Georgia to assess the potential impact of a local SLIV program on student attendance.

Many of the existing studies on this topic were sponsored by major pharmaceutical companies that produce immuniza- tion vaccines; however, this current research was not indus- try sponsored, thus eliminating the potential for a conflict of interest. This study was a collaborative project involving multiple stakeholders, including a state health district, local health department, two public state universities, and a local county BOE, enabling a rich synthesis of expertise and knowledge to yield a successful project focused on public health and primary prevention for school children. As with all studies, there are limitations to be recognized as well. This study did not address/identify other locations where students could obtain influenza immunization (e.g., pediatrician’s office, health department, etc.). Researchers recognized that some students were immunized at other locations, thus eliminating their need to participate in the SLIV program. Although these students did not access SLIV, the fact that they were immunized should have con- tributed to the resulting absentee averages in a positive man- ner. Another limitation includes the fact that researchers were not able to differentiate between causes associated with student absences, being unable to correlate SLIV administra- tion with reduction in absences directly due to influenza and also not being able to distinguish the variation in severity of absence-causing illnesses.

Implications for School Nursing Practice School nurses can benefit from this study, because the data provide them with credible scientific evidence to support the justification, establishment, and/or continuation of an SLIV program within their local school setting. This study allows them an opportunity to learn about an interdisciplinary, col- laborative effort between partners within a community who worked together and applied preexisting information to sup- port a public health initiative that ultimately keeps students healthier and in the classroom, helping to minimize their absences and contributing to enhanced herd immunity to benefit not just the students but also the school faculty and staff, student families and friends, and other members of the community who interact with the immunized students. Study results may encourage school nurses to adopt an active role supporting an increase in school-located immunizations via initiation of collaborative programs, monitoring overall immunization rates, and informing the school community about the relationship of immunization and attendance.

Conclusion As previously established, the literature provides evidence that student attendance in school increases the likelihood of their academic success. Reducing absenteeism by as little as 1 day correlates to improvement in academic performance (U.S. Department of Education, 2009). This study has con- tributed to scientific evidence by demonstrating the potential impact of an SLIV program on reducing student absences that may be due to influenza. If students have convenient access to this type of primary prevention within their school setting, they should be better able to maintain optimal health that will allow them to miss fewer days of school due to illness and thus be more successful in their academic and future professional careers. This study examined two sequential influenza seasons in which students had access to an SLIV program, and this short amount of time may not adequately establish trends related to absenteeism. Thus, the research team plans to add another year of absenteeism data for the 2012–2013 academic school year, using the same methodology, to further explore a longer longitudinal trend and strengthen reliability of findings. Future research on efficacy of SLIV programs may focus on exploring a more direct link between SLIV participation and herd immunity among other populations within a school setting such as faculty, school nurses, and staff.

Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author(s) received no financial support for the research, author- ship, and/or publication of this article References Balfanz, R., & Byrnes, V. (2012). Chronic absenteeism: Summar- izing what we know from nationally available data . Baltimore, MD: Johns Hopkins University Center for Social Organization of Schools. Centers for Disease Control. (2010). Prevention and control of influenza with vaccines. Recommendations of the advisory committee on immunization practices .Morbidity and Mortality Weekly Report ,59, 1–62. Chang, H. N., & Romero, N. (2008, September). Present, engaged, and accounted for: The critical importance of addressing chronic absence in the early grades . National Center for Chil- dren in Poverty, Mailman School of Public Health, Columbia University. Davis, M. M., King, J. C., Jr., Moag, L., Cummings, G., & Magder, L. S. (2008). Countywide school-based influenza immunization: Plaspohl et al. 79 Direct and indirect impact on student absenteeism. Pediatrics , 122 , e260–e265. Hull, H. F., & Ambrose, C. S. (2011). The impact of school-located vaccination programs on student absenteeism: A review of the U.S. literature. Journal of School Nursing ,27, 34–42. King, J. C., Jr., Stoddard, J. J., Gaglani, M. J., Moore, K. A., Magder, L., McClure, E., ... Neuzil, K. (2006). Effectiveness of school- based influenza vaccination. The New England Journal of Med- icine .355 , 2523–2532. McGiboney, G. W. (2012, June). Changing the conversation . Presentation for Georgia school based flu stakeholders meeting, Georgia Department of Education, Atlanta, GA. Reichert, T. A., Sugaya, N., Fedson, D. S., Glezen, W. P., Simonsen, L., & Tashiro, M. (2001). The Japanese experience with vaccinat- ing schoolchildren against influenza. The New England Journal of Medicine .344 , 889–896. Schieber, R. A., Kennedy, A., & Kahn, E. B. (2012). Early experi- ence conducting school-located vaccination programs for seaso- nal influenza. Pediatrics ,129 , S68. Szilagyi, P. G., Iwane, M. K., & Humiston, S. E. (2003). Time spent by primary care practices on pediatric influenza vaccina- tion visits: Implications for universal influenza vaccination.

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Vaccine .23, 1284–1293. White, T., Lavoie, S., & Nettleman, M. D. (1999). Potential cost savings attributable to influenza vaccination of school-aged children. Pediatrics ,103 , e73. Author Biographies Sara S. Plaspohl , DrPH, CHES, is an assistant professor of health sciences, at the Armstrong Atlantic State University, Savannah, GA, USA.

Betty T. Dixon , DrPH, RN, is a director of Clinical and Nursing Services, at the Coastal Health District, Savannah, GA, USA.

James A. Streater , EdD, CHES, is a professor of health sciences, at the Armstrong Atlantic State University, Savannah, GA, USA.

Elizabeth T. Hausauer , MSN,RN, is the immunizations coordina- tor, at the Coastal Health District, Savannah, GA, USA.

Christopher P. Newman , MPH, is a graduate student at the Arm- strong Atlantic State University, Savannah, GA, USA.

Robert L. Vogel , PhD, is a professor of biostatistics, at the Georgia Southern University. 80 The Journal of School Nursing 30(1) Copyright ofJournal ofSchool Nursing isthe property ofSage Publications Inc.andits content maynotbecopied oremailed tomultiple sitesorposted toalistserv without the copyright holder'sexpresswrittenpermission. However,usersmayprint, download, oremail articles forindividual use.