San Mateo County Grand Jury • 2011-2012

Whooping Cough Immunization Rates – a San Mateo County Success Story Issue | Background | Findings | Conclusions |

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Note: Missing finding numbers detected: F15, F16, F17, F18, F19, F20, F21, F22, F23, F24, F25, F26, F27, F28, F29, F30, F31, F32, F33, F34, F35, F36, F37, F38, F39, F40, F41, F42, F43, F44, F45, F46, F47, F48, F49, F50, F51, F52, F53, F54, F55, F56, F57, F58, F59, F60, F61, F62, F63, F64, F65, F66, F67, F68, F69, F70, F71, F72, F73, F74, F75, F76, F77, F78, F79, F80, F81, F82, F83, F84, F85, F86, F87, F88, F89, F90, F91, F92, F93, F94, F95, F96, F97, F98, F99, F100, F101, F102, F103, F104, F105, F106, F107, F108, F109, F110, F111, F112, F113, F114, F115, F116, F117, F118, F119, F120, F121, F122, F123, F124, F125, F126, F127, F128, F129, F130, F131, F132, F133, F134, F135, F136, F137, F138, F139, F140, F141, F142, F143, F144, F145, F146, F147, F148, F149, F150, F151, F152, F153, F154, F155, F156, F157, F158, F159, F160, F161, F162, F163, F164, F165, F166, F167, F168, F169, F170, F171, F172, F173, F174, F175, F176, F177, F178, F179, F180, F181, F182, F183, F184, F185, F186, F187, F188, 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Findings and Recommendations 15 findings

F1
California AB354, signed by Governor Brown on September 29, 2010, amended California Health and Safety Code §§120325 and 120335 to require all incoming seventh through twelfth graders to be immunized against pertussis or have permanent medical exemptions (PMEs) or personal based exemptions (PBEs) on file before the start of the 2011 school year.
No recommendations for this finding
F2
According to the law, students were to be prohibited from attending class at the start of the 2011 academic year until they had been vaccinated or submitted PMEs or PBEs. California SB614 extended the deadline for another 30 days.
No recommendations for this finding
F3
The County Health Officer extended the deadline a second 30 days and urged principals to be flexible and individualized in enforcing this requirement.
No recommendations for this finding
F4
The County Health Officer worked directly with the County Office of Education Superintendent to communicate requirements to all affected public and private schools.
No recommendations for this finding
F5
The County Health Officer delayed opening public immunization clinics until October 2011, after the State deadline extension expired, as a means of encouraging as many students as possible to see their private physicians for this immunization and other health matters. Two hundred to three hundred students used this service.
No recommendations for this finding
F6
Schools were required to report their data through the California Public Health Department-managed Shots for School.org website by December 1, 2011. As of January 24, 2012, seven San Mateo County schools had not yet reported their data. A continuation high school was the last to report on March 6, 2012.
No recommendations for this finding
F7
The Shots for School.org website did not allow schools to report results until 100 percent of the students had a current Tdap immunization, a PME or a PBE on file, resulting in schools’ inability to report data even if only one student of hundreds was outstanding.
No recommendations for this finding
F8
Individual school kindergarten immunization rate data are available by school on California’s CDPH Immunization Branch website and on BayCitizen.org. The pertussis data obtained by the Grand Jury was obtained from CDPH pre-publication with the assistance of a San Mateo County Immunization Program official.
Related Recommendations (2)
R1
of availability, post the San Mateo County pertussis immunization rates, by school, on its website, along with some targeted education interpreting the data and emphasizing the importance of immunizations. Alternatively, if the California Public Health Immunization Branch posts the data on its website, a link to that site, with appropriate background information, would be sufficient.
R2
At the same time, similarly post data or a link to it for San Mateo County kindergarten immunization rates by school.
F9
The overall reported pertussis immunization rate for the County’s incoming seventh through twelfth graders was 98.8 percent, a level that is sufficient to provide herd immunity and be considered a success. 8
Related Recommendations (1)
R3
By August 2012, evaluate and apply appropriate lessons learned from the success of the pertussis immunization program to the childhood immunization program to increase the immunization rate of kindergarten students in San Mateo County. Attachment A Pertussis Assessment Totals for all Grades by San Mateo County School (As reported by the schools to the CDPH Shots for Schools Website) 11 12 13 14
F10
The CDPH Immunization Branch expected to publish results by County, and possibly line-by-line for school, by the end of April 2012.
No recommendations for this finding
F11
Four San Mateo County schools out of 130 reporting had PBE rates exceeding 10 percent, with three exceeding 25 percent. One additional school exceeded 10% exemptions due to two PMEs. All five were private, charter, or virtual (on-line) schools.
No recommendations for this finding
F12
One on-line school, California Virtual Academy of the Jefferson School District, accounted for 34 percent of all PBEs in the County (173 out of 511). Only 95 of its students are San Mateo County residents, with 26 of those filing PBEs.
No recommendations for this finding
F13
Adjusting the www. Shots for Schools.org data to include only enrolled students that are San Mateo County residents reduces the County PBE rate to 0.8 percent from 1.1 percent.
No recommendations for this finding
F14
California is one of 18 states that allow PBEs for immunizations. AB 2109, submitted to the California legislature on Feb 23, 2012, would make it more difficult to claim a PBE by requiring “written statements from a medical practitioner stating that they (exemption requestors) have been informed of the risks and benefits of vaccines and the communicable disease they are said to prevent.” Conclusions
No recommendations for this finding
F2011 Page 4
Investigation This report is based on information and data obtained from the following sources: • Interview with San Mateo County Immunization Program Management • Interview with a senior San Mateo County Public Health Official • Interview with a San Mateo County High School Principal • Review of Pertussis Data reported to Shots for Schools.org website • Review of Informational Materials communicating State law requirements 9 http://shotsforschool.org/index.html. 4 • Review of State and County Public Health and Immunization program websites • Review of California AB 354, SB 614, AB2019 • Review of California Health and Safety Code Sections 120325 - 120380 • Review of BayCitizen.org website • Additional footnoted References Specific Additional Investigation Elements In addition to the details described in Background and the information obtained through the interviews and document reviews listed above, the Grand Jury evaluated the following: documentation associated with outbreak investigations; policy/guidance with respect to school compliance with the exclusion from class State mandate; the use of public clinics to support immunization efforts; and individual school data reported to the Shots for School website. Investigation of Outbreaks The Grand Jury reviewed documentation of a September 2011 pertussis outbreak infecting eight individuals at a Redwood City elementary school. A San Mateo County Public Health Communicable Disease Investigator coordinated the investigation. The documents provided included copies of the California Reportable Disease Information Exchange (Cal-REDIE) Outbreak Morbidity Report, and various letters, case notices, emails, handwritten progress notes, specimen collection forms, doctor and laboratory reports, letters to parents unable to be reached by phone, requests to pediatric clinics for pertussis vaccination records of patients, Pertussis (Whooping Cough) Exposure Notices, and doctor authorizations for student returns to school. The review of these documents indicated a prompt and effective response to control the outbreak by attempting to quickly identify those who may have been exposed to the eight infected individuals and to communicate exposure notices with specific instructions to all of them. Notices of “multiple case” exposures were distributed to school classes, soccer and football teams, a Cub Scout troop and individuals, based upon interviews with parents, teachers/coaches and students. These exposure notices were provided in English and Spanish. Exclusion From Class Mandate Enforcement In reviewing the program materials provided to schools, the Grand Jury noted that that the County Health Officer encouraged the schools to be flexible in their application of the state mandate that schools exclude non-immunized or exempt students from attending classes until documentation was submitted. Specific language supporting this follows: “As for the issue of the timing for exclusion, I urge you to be flexible and individualized. Frequently, those who are not compliant are the same ones that can’t afford to miss out on any of their education.”10 10Extracted from a County Health Officer email embedded in a September 16, 2011 email from County Superintendent of Schools to Superintendents, Subject: “FW: Tdap: proposed final letter and clinic flyers” 5 The County Health Officer separately explained that there was a low public-health risk to this flexible approach, given that 2011 was the year following the five-year disease peak when natural immunity would be highest and a relatively low number of cases could be expected. The Grand Jury did not attempt to determine how many districts or schools chose to enforce the State mandate versus adopt the more flexible approach sanctioned by the County Health Officer. Enforcing the State mandate would have impacted financial reimbursement from the State under the Average Daily Attendance funding system, where funding is based on a daily tally of the number of enrolled students who report for class. The County Health Officer acknowledged this as another factor considered in encouraging a flexible approach. Public Immunization Clinics In addition to extensive communication and information support, the County provided another service in support of compliance with the law. As noted in Background, it opened public immunization clinics where students could get the immunizations needed at no charge. As a matter of strategy, these clinics were not opened until October 2011, after the initial and extended 30-day deadlines expired. The County Health Officer wanted to encourage students to see their own physicians for these immunizations, as many students at this age become sexually active and have other new potential health issues and risks. The opportunity to discuss these issues with their doctors would not happen in the immunization clinic setting. According to the County Health Officer, only 200 - 300 students (of almost 47,000 immunized) received their immunizations at public clinics, evidence of the effectiveness of this strategy. Reporting of Results by Individual Schools The deadline for all schools to report their results to the Shots for School.org website was December 1, 2011. On January 24, 2012 the Grand Jury obtained from the CDPH Division of Communicable Disease Control a spreadsheet that included all of the San Mateo County data available at the time. (See, Attachment A: Pertussis Assessment Totals for all Grades by San Mateo County School.) Seven of 130 County schools had not yet reported their data. The Grand Jury obtained results for the seven remaining schools from a San Mateo County Immunization Program representative to complete the spreadsheet. The last school to report results, a continuation high school, did so on March 6, 2012. CDPH expects to release its final report at the end of April 2012. Since the system is locked to schools once they report their data, the Grand Jury has no reason to expect any changes to reported results when the final data are released. The Grand Jury determined the following: • The overall reported pertussis immunization rate for the County’s incoming seventh through twelfth graders was 98.8 percent (46,899 of 47,450 enrolled) vs. the County’s (informal) target of 85-90 percent, stated to be sufficient to provide herd immunity. • According to the CDPH spreadsheet, 511 (1.1 percent) students in County public and private schools filed Tdap PBEs. According to the County Health Officer, there are no anti-immunization groups active in the County at this time, a factor helping maintain high immunization rates. 6 • Forty-seven out of 130 schools reported 100 percent immunization rates and just five reported exemption rates exceeding 10 percent. Three of those exceeded 25 percent. They were all small private, charter, or virtual (on-line) schools. o Kaplan Academy (Bayshore Elementary District) (cid:1) 16 PBEs of 55 enrolled – 29.1 percent o California Virtual Academy (CAVA) (Jefferson Elementary District) (cid:1) 173 PBEs of 673 enrolled – 25.7 percent* o Linda Mar Educational Center (Pacifica District) (cid:1) 5 PBEs of 19 enrolled – 26.3 percent o Charter Learning Center (San Carlos Elementary District) (cid:1) 7 PBEs of 57 enrolled – 12.3 percent o Wings Learning Center (Private School) (cid:1) 2 PMEs of 15 enrolled – 13.3 percent *The large PBE numbers for CAVA (33.9 percent of the total PBEs for the County) prompted further Grand Jury investigation. CAVA is an on-line school operating out of Simi Valley, CA headquarters. The Grand Jury requested CAVA provide data on its San Mateo County residents only. CAVA reported an enrollment of 95 San Mateo County seventh through twelfth grade students. Of those, 26 (27.4 percent) submitted PBEs, very close to its total school-wide percentage of 25.7%.11 As a reference point for comparison purposes, the CDPH published 2010-11 immunization rates by school for the childhood vaccination series12. For those immunizations, the San Mateo County confirmed PBE rate was 2.04 percent, in the middle of the range of nine Bay Area counties and approximately the same rate as the statewide 2.16 percent.13 Bay Citizen.org has analyzed the Shots for School.org data for Bay Area counties and provides interactive graphs, summary data and search tools on its website enabling easy access to county, school district and individual school data for kindergarten immunizations. 14. According to the Bay Citizen site, these data are provided “so you can see which schools are most susceptible to an infectious outbreak.” It is unknown at this time whether the site will include similar seventh through twelfth grade pertussis data when it is released. The Grand Jury questioned whether the data reported by schools to the site was accurate. The CDPH Immunization Branch directs a “selective review” process that is executed at the County level. The State selects a certain number of schools at random to review immunization records for its students to compare results against recommended childhood immunizations.15 The County Health Officer has further expanded this effort to encompass additional schools. No evidence of deliberate misreporting has been uncovered, and individual errors and discrepancies are addressed as part of this process. (Schools are given a ten-day grace period to get student 11 Adjusting the CDPH spreadsheet data to exclude the non San Mateo County residents yields an even higher immunization rate of 99.1 percent versus 98.8 percent and lower PBE rate of 0.8 percent versus 1.1 percent. 12 http://www.cdph.ca.gov/programs/immunize/Documents/2010IZRateTable.pdf 13 http://www.baycitizen.org/data/immunizations/ 14 Ibid. This monitoring program currently surveys compliance with immunizations required up to two years of age 7 records complete either through immunizations or exemptions). According to the County Immunization Program representative interviewed, some schools are “amazingly compulsive” and others “less diligent” in their management of immunization records. It is not known at this time whether the State or County will extend the selective review process to include pertussis vaccination records in the future. Findings 1) California AB354, signed by Governor Brown on September 29, 2010, amended California Health and Safety Code §§120325 and 120335 to require all incoming seventh through twelfth graders to be immunized against pertussis or have permanent medical exemptions (PMEs) or personal based exemptions (PBEs) on file before the start of the 2011 school year. 2) According to the law, students were to be prohibited from attending class at the start of the 2011 academic year until they had been vaccinated or submitted PMEs or PBEs. California SB614 extended the deadline for another 30 days. 3) The County Health Officer extended the deadline a second 30 days and urged principals to be flexible and individualized in enforcing this requirement. 4) The County Health Officer worked directly with the County Office of Education Superintendent to communicate requirements to all affected public and private schools. 5) The County Health Officer delayed opening public immunization clinics until October 2011, after the State deadline extension expired, as a means of encouraging as many students as possible to see their private physicians for this immunization and other health matters. Two hundred to three hundred students used this service. 6) Schools were required to report their data through the California Public Health Department-managed Shots for School.org website by December 1, 2011. As of January 24, 2012, seven San Mateo County schools had not yet reported their data. A continuation high school was the last to report on March 6, 2012. 7) The Shots for School.org website did not allow schools to report results until 100 percent of the students had a current Tdap immunization, a PME or a PBE on file, resulting in schools’ inability to report data even if only one student of hundreds was outstanding. 8) Individual school kindergarten immunization rate data are available by school on California’s CDPH Immunization Branch website and on BayCitizen.org. The pertussis data obtained by the Grand Jury was obtained from CDPH pre-publication with the assistance of a San Mateo County Immunization Program official. 9) The overall reported pertussis immunization rate for the County’s incoming seventh through twelfth graders was 98.8 percent, a level that is sufficient to provide herd immunity and be considered a success. 8 10) The CDPH Immunization Branch expected to publish results by County, and possibly line-by-line for school, by the end of April 2012. 11) Four San Mateo County schools out of 130 reporting had PBE rates exceeding 10 percent, with three exceeding 25 percent. One additional school exceeded 10% exemptions due to two PMEs. All five were private, charter, or virtual (on-line) schools. 12) One on-line school, California Virtual Academy of the Jefferson School District, accounted for 34 percent of all PBEs in the County (173 out of 511). Only 95 of its students are San Mateo County residents, with 26 of those filing PBEs. 13) Adjusting the www. Shots for Schools.org data to include only enrolled students that are San Mateo County residents reduces the County PBE rate to 0.8 percent from 1.1 percent. 14) California is one of 18 states that allow PBEs for immunizations. AB 2109, submitted to the California legislature on Feb 23, 2012, would make it more difficult to claim a PBE by requiring “written statements from a medical practitioner stating that they (exemption requestors) have been informed of the risks and benefits of vaccines and the communicable disease they are said to prevent.” Conclusions 1) The County’s high pertussis immunization rate indicates that San Mateo County Public Health, in partnership with the County Office of Education and local School Districts, did an effective job implementing an aggressive new state mandate and provided a high level of protection against future pertussis outbreaks. The Grand Jury acknowledges their excellent work. 2) The decision to not restrict students from attending class before submitting required documentation was a low public health risk in 2011, given that pertussis tends to peak every five years and 2010 was a peak year. County Public Health and School Officials operated on the basis that the students least likely to provide the documentation on a timely basis were the ones who would be most harmed by being excluded from classes. Loss of Average Daily Attendance funds was apparently also a consideration. 3) The relatively low number of students getting immunizations through the public clinics indicated the success of the County Health Officer’s strategy to have as many students as possible schedule office visits with their individual physicians for the immunizations. 4) Childhood immunization reporting on the Shots for Schools website allows for a category of “conditional” where data are not yet available. The fact that the pertussis on-line reporting form did not allow for conditional reporting contributed to delays in reporting and required heavy follow-up by the State, County and School Districts to achieve closure. 5) The relatively high rates of PBEs in small charter, private or on-line schools are a lower public health risk than equivalent levels in large public or private schools. It does not 9 appear that schools actively encouraged PBE filings in any significant numbers in order to achieve faster closure and enable reporting of their data to the State. 6) Since high rates of PBEs from vaccines of any type could increase risks of contracting contagious, preventable diseases in a school setting, parents should have convenient access to such data for schools they are considering, similar to the access they have to academic test scores.
No recommendations for this finding

Conclusions 6

No Responses Found 3

Government entities assigned to respond to this report. No response documents have been linked in our database.

County of San Mateo Agency
San Mateo County Board of Supervisors Elected County Office
San Mateo County County Superintendent of Schools Elected County Office