Special Section: School-Located Influenza Vaccination

Improving Immunization Coverage in

a Rural School District in Pierce
County, Washington

The Journal of School Nursing

28(5) 352-357
The Author(s) 2012
Reprints and permission:
sagepub.com/journalsPermissions.nav
DOI: 10.1177/1059840512446069
http://jsn.sagepub.com

Robin M. Peterson, MSN, RN1, Carolyn Cook, MSN, RN2,

Mary E. Yerxa, BSN, RN3, James H. Marshall, MPH4,
Elizabeth Pulos, PhD, MPH4, and
Matthew P. Rollosson, MPH&TM, BSN, RN, CNRN4

Abstract
Washington State has some of the highest percentages of school immunization exemptions in the country. We compared
school immunization records in a rural school district in Pierce County, Washington, to immunization records in the state
immunization information system (IIS) and parent-held records. Correcting school immunization records resulted in an
increase in the number of students classified as fully immunized from 1,189 to 1,564 (p < .0001). We conducted schoolbased immunization clinics that increased the number of fully immunized students to 1,624 (p .013). Immunized students
with certificates of exemption on file suggest exemptions of convenience. Strategies to improve school immunization services
include assigning IIS access to school administrative staff and educating school staff and parents on the importance of
immunization.
Keywords
immunizations, documentation, legal/ethical issues, health education, elementary, policies/procedures, middle/junior/high
school, administration/management
Washington State has some of the highest percentages of
school-aged children exempted from immunizations in the
country. During the 2009-2010 school year, 5.7% of kindergarten students in Washington State were exempted from
immunizations (Centers for Disease Control and Prevention
[CDC], 2011b). The CDC (2011a) estimated that between
2007 and 2008, 62.6% of children ages 19 to 35 months in
Pierce County, Washington, were fully vaccinated, well
below the Healthy People 2020 objective of 80% (U.S.
Department of Health and Humans Services [DHHS],
2012). Data from Pierce County school districts for the
2010-2011 school year showed that 5.4% of children in
kindergarten and 4.74% of kindergarten through Grade 12
students (K-12) were exempted from immunizations, with
higher exemptions in rural districts than urban school
districts (Tacoma-Pierce County Health Department
[TPCHD], 2011).
Several factors contribute to high exemption rates. Parental misconceptions or lack of knowledge about immunizations and concerns about vaccine safety increase the
likelihood of immunization exemption (Gust et al., 2004;
Kennedy, Brown, & Gust, 2005; Salmon et al., 2004).
Salmon et al. (2004) found that misperceptions about vaccine safety and efficacy, susceptibility and severity of

vaccine preventable diseases, and negative beliefs and

attitudes about vaccines held by school staff without formal
health care training increased the likelihood that students
would be exempted from immunizations.
Administrative factors can also play a role in immunization coverage. Rota et al. (2001) found that the percentage of
children exempted from immunizations is inversely proportional to the complexity of obtaining an exemption. Prior to
the 2011-2012 school year, obtaining a philosophical
immunization exemption in Washington State required only
a parents signature on a form available at the schools. Under
these circumstances, obtaining a convenience exemption is
easier than complying with school immunization laws

MultiCare Mobile Health Services, Tacoma, WA, USA

Mary Bridge Mobile Immunization Clinic, MultiCare Health System,
Tacoma, WA, USA
3
Franciscan Childrens Immunization Program, Tacoma, WA, USA
4
Tacoma-Pierce County Health Department, Tacoma, WA, USA
2

Corresponding Author:
Matthew P. Rollosson, Tacoma-Pierce County Health Department, 3629
South D Street, Tacoma, WA 98418, USA
Email: mrollosson@tpchd.org

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Peterson et al.

353

(Calandrillo, 2004; Rota et al., 2001; Washington State

Department of Health [DOH], 2011a).
The purposes of this study were to assess the immunization coverage of students in a rural school district in Pierce
County, assess the completeness of immunization records in
the district, assess the effectiveness of strategies to improve
school immunization record keeping, and assess the effectiveness of school-based immunization clinics at increasing
immunization coverage. The principle investigators of this
study were immunization nurse specialists from the Pierce
County Infant Immunization Initiative (I3), a partnership
between the Tacoma-Pierce County Health Department,
MultiCare Health System, and Franciscan Health System,
and supported by a grant from the Group Health Foundation.

Methodology
We selected a geographically large, rural school district in
Pierce County with low immunization coverage and high
percentages of immunization exemptions. This study was
conducted in two phases: a review of immunization records
and school-based immunization clinics. Baseline data were
collected on February 18, 2010, from school records. Postintervention data for the two phases were collected on May 3
and May 27, 2010. We collected only aggregate data at each
point of data collection and therefore could not evaluate
longitudinal changes for individual students. We used Pearson w2 to statistically evaluate changes in immunization
status.

Review of Immunization Records

We reviewed the school immunization records of children
attending elementary, middle, and high schools in the district and classified each students immunization status
according to the definitions in the Washington Administrative Code (DOH, 2009b):


Complete: Received all required immunizations by

Washington State with a signed certificate of immunization status (CIS) on file at the school.
Conditional: Has not received one or more required
vaccines. Students may attend class for 30 days under
a conditional status. At the end of the 30-day conditional
period, state law requires schools to exclude from
attendance students that have not received the required
vaccines or are not making satisfactory progress toward
completely immunized status.
Exempt: Exempted for medical, philosophical, or
religious reasons, must have a certificate of exemption
(COE) signed by a parent on file at the school.
Out of compliance: A child who does not meet the
requirements of completely immunized, conditional, or
exempt status. Washington State law requires schools
to exclude out of compliance students from attendance.

We also identified students who had not received hepatitis A and human papillomavirus (HPV) vaccines, which are
recommended by the CDCs Advisory Committee on Immunization Practice (ACIP) but not required by Washington
State (CDC, 2010; DOH, 2009b).
We compared students school immunization records to
their records in the Washington State Immunization Information System (IIS). Parents of students who were exempted
from immunizations, admitted under conditional status, or
were out of compliance were contacted by telephone by the
I3 nurses or the school nurse who requested immunization
records held by the parents, offered information about
immunizations, and informed the parents of school-based
immunization clinics that were conducted during the second
phase of this study. We provided records of vaccine doses
missing from students school immunization records to
school administrative staff who corrected the school immunization records.

School-Based Immunization Clinics

We conducted school-based immunization clinics in May
2010, offering all vaccines required by Washington State
law for school entry as well as ACIP-recommended hepatitis
A and HPV vaccines. We mailed customized packets to parents of students who were not completely immunized, which
included information about required vaccines and ACIPrecommended vaccines, vaccine information statements
(VIS), dates of school-based immunization clinics, and
immunization consent forms. Parents were also notified of
the immunization clinics by telephone. Immunization clinics
were held both during and after school hours. Parents were
invited to attend immunization clinics but were not required
to attend.

Results
At baseline, the proportion of completely immunized students in the five schools in the district ranged from 7.8%
to 82.2%. Out of a total of 2,052 students in the district,
1,189 (57.9%) were fully immunized (Table 1). The largest
proportion of students whose records did not reflect completely immunized status was out of compliance (24.8%).
By reconciling the school immunization records with IIS and
parent-held immunization records, the proportion of students classified as completely immunized increased from
57.9% to 76.2% (p < .0001). The proportion of students who
were classified as out of compliance decreased from 24.8%
of the total to 13.6%, immunization exemptions decreased
from 10.5% to 7.9% (p .005), and the proportion of students attending class under conditional status decreased
from 6.8% to 2.2%. An additional 60 students achieved completely immunized status during our school-based immunization clinics, increasing the percentage of fully
immunized students from 76.2% to 79.4% (p .013).

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Peterson et al.

353

(Calandrillo, 2004; Rota et al., 2001; Washington State

Department of Health [DOH], 2011a).
The purposes of this study were to assess the immunization coverage of students in a rural school district in Pierce
County, assess the completeness of immunization records in
the district, assess the effectiveness of strategies to improve
school immunization record keeping, and assess the effectiveness of school-based immunization clinics at increasing
immunization coverage. The principle investigators of this
study were immunization nurse specialists from the Pierce
County Infant Immunization Initiative (I3), a partnership
between the Tacoma-Pierce County Health Department,
MultiCare Health System, and Franciscan Health System,
and supported by a grant from the Group Health Foundation.

Methodology
We selected a geographically large, rural school district in
Pierce County with low immunization coverage and high
percentages of immunization exemptions. This study was
conducted in two phases: a review of immunization records
and school-based immunization clinics. Baseline data were
collected on February 18, 2010, from school records. Postintervention data for the two phases were collected on May 3
and May 27, 2010. We collected only aggregate data at each
point of data collection and therefore could not evaluate
longitudinal changes for individual students. We used Pearson w2 to statistically evaluate changes in immunization
status.

Review of Immunization Records

We reviewed the school immunization records of children
attending elementary, middle, and high schools in the district and classified each students immunization status
according to the definitions in the Washington Administrative Code (DOH, 2009b):


Complete: Received all required immunizations by

Washington State with a signed certificate of immunization status (CIS) on file at the school.
Conditional: Has not received one or more required
vaccines. Students may attend class for 30 days under
a conditional status. At the end of the 30-day conditional
period, state law requires schools to exclude from
attendance students that have not received the required
vaccines or are not making satisfactory progress toward
completely immunized status.
Exempt: Exempted for medical, philosophical, or
religious reasons, must have a certificate of exemption
(COE) signed by a parent on file at the school.
Out of compliance: A child who does not meet the
requirements of completely immunized, conditional, or
exempt status. Washington State law requires schools
to exclude out of compliance students from attendance.

We also identified students who had not received hepatitis A and human papillomavirus (HPV) vaccines, which are
recommended by the CDCs Advisory Committee on Immunization Practice (ACIP) but not required by Washington
State (CDC, 2010; DOH, 2009b).
We compared students school immunization records to
their records in the Washington State Immunization Information System (IIS). Parents of students who were exempted
from immunizations, admitted under conditional status, or
were out of compliance were contacted by telephone by the
I3 nurses or the school nurse who requested immunization
records held by the parents, offered information about
immunizations, and informed the parents of school-based
immunization clinics that were conducted during the second
phase of this study. We provided records of vaccine doses
missing from students school immunization records to
school administrative staff who corrected the school immunization records.

School-Based Immunization Clinics

We conducted school-based immunization clinics in May
2010, offering all vaccines required by Washington State
law for school entry as well as ACIP-recommended hepatitis
A and HPV vaccines. We mailed customized packets to parents of students who were not completely immunized, which
included information about required vaccines and ACIPrecommended vaccines, vaccine information statements
(VIS), dates of school-based immunization clinics, and
immunization consent forms. Parents were also notified of
the immunization clinics by telephone. Immunization clinics
were held both during and after school hours. Parents were
invited to attend immunization clinics but were not required
to attend.

Results
At baseline, the proportion of completely immunized students in the five schools in the district ranged from 7.8%
to 82.2%. Out of a total of 2,052 students in the district,
1,189 (57.9%) were fully immunized (Table 1). The largest
proportion of students whose records did not reflect completely immunized status was out of compliance (24.8%).
By reconciling the school immunization records with IIS and
parent-held immunization records, the proportion of students classified as completely immunized increased from
57.9% to 76.2% (p < .0001). The proportion of students who
were classified as out of compliance decreased from 24.8%
of the total to 13.6%, immunization exemptions decreased
from 10.5% to 7.9% (p .005), and the proportion of students attending class under conditional status decreased
from 6.8% to 2.2%. An additional 60 students achieved completely immunized status during our school-based immunization clinics, increasing the percentage of fully
immunized students from 76.2% to 79.4% (p .013).

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The Journal of School Nursing 28(5)

Table 1. Changes in Students Immunization Status, Totals for All Schools in the District
Baseline

Record review

Immunization clinic

Immunization status

n 2,052

n 2,053

n 2,045

Complete
Exempt
Conditional
Out of compliance

1189
215
139
509

57.9
10.5
6.8
24.8

1564
163
46
280

76.2***
7.9**
2.2
13.6

1624
151
38
232

79.4*
7.4
1.9
11.3

*p .013. **p .005. ***p < .0001.

We found several documentation requirements in the

school immunization records that were frequently associated
with failure to capture all of the vaccine antigens students
had received and resulted in students being categorized as
out of compliance. These included the requirement to document individual antigens in combination vaccines; for example, documenting receipt of each component of a measles,
mumps, and rubella vaccine. Some students that had
received pertussis-containing vaccines were documented
as having received only diphtheria and tetanus toxoids.
Receipt of the varicella component of combination vaccines
or history of chickenpox infection was also not documented
in some records. These errors were more common when the
source of data was a printed record from a providers office
than when a CIS generated by the IIS was used as the data
source.

Discussion
Immunization coverage for students in this district was
underrepresented in the schools records. While the increase
in the percentage of completely immunized students from
our school-based immunization clinics reached statistical
significance, reconciling the schools immunization records
with IIS and parent-held records had the greatest impact on
the immunization status of students in the district. In our
study, school administrative staff made student immunization records available to the I3 nurses who then reviewed
those records. As part of a program to improve immunization coverage in Cincinnati, school health clerks conducted
biannual audits of immunization records to identify students
whose immunization status was not in compliance with state
immunization laws (Toole & Perry, 2004).
In Washington State, school nurses may assign access to
the IIS to school staff who are responsible for verifying
and documenting students immunizations (DOH, 2011b).
School staff may then retrieve students immunization
records from the IIS and print CISs, which can then be
signed by parents and placed on file. The administrative staff
at the schools in this district reported that they had not been
granted access to the IIS. We believe that assigning access to
the IIS to school staff would improve the completeness of
school immunization records and reduce the workload of
school nurses.

Inadequate school nurse staffing can jeopardize school

health programs, including immunizations. With support
from the American Academy of Pediatrics (AAP), the
National Association of School Nurses (NASN) recommends a minimum ratio of one school nurse for every 750
students in the general population (AAP Council on School
Health, 2008; NASN, 2010). The Washington State Nursing
Care Quality Assurance Commission and Office of Superintendent of Public Instruction (2000, 2006) recommend a
ratio of one school nurse for every 1,500 students. In
2010, Washington State had an average student-to-school
nurse ratio of 2,031 (NASN, 2011). At our baseline data collection, there were 2,052 students in the district with one
school nurse for all of the schools in the district.
The proportion of students in Pierce County exempted
from immunizations varies between school districts. School
nurses from districts with high immunization coverage and
low exemption rates report receiving support to enforce state
immunization laws from district superintendents and school
principals (V. H. Gobeske, personal communication, January 24, 2012). In a survey of schools in four states, Salmon
et al. (2005) found that immunization policies and procedures varied between schools, some of which were not in
compliance with state immunization laws. Over 15% of the
respondents in states that do not permit philosophical immunization exemptions reported accepting philosophical
exemptions in their schools.
Because of the failure to record individual antigens in
combination vaccines, we recommended changing the data
entry fields in the schools immunization database to allow
single entry for combination vaccines rather than requiring
multiple entries for individual antigens. In 2008, the
Washington State DOH revised the CIS form, removing the
COE from the reverse side of the form (DOH, 2009a). We
received anecdotal reports that parents had been directed
by school staff to sign an exemption form when a childs
immunization records were unavailable at the time of school
registration. We recommended relocating the blank COE
forms to less convenient locations on school premises to discourage school staff from directing parents to sign a COE
rather than complete a CIS.
Most parents were receptive to information provided by
the school nurse and immunization nurse specialists and
were grateful for the school-based immunization clinics. A

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Peterson et al.

355

number of parents reported that they were unaware that their

children needed vaccines. Some parents of students with
COEs on file and parents of students classified as out of
compliance had not submitted records that documented the
student as completely immunized. School administrative
staff were also receptive to the I3 nurses interventions and
instruction regarding herd immunity and the risks of
vaccine-preventable illnesses. With the goal of protecting
children from disease, staff members were motivated to
identify strategies to improve immunization coverage in the
district. As the front line of enforcement of school immunization laws, school administrative staff are critical to
improving compliance.

Strategies to Improve Immunization Coverage

School nurses play an integral role in achieving and maintaining high coverage of childhood immunizations. Educating parents, students, teachers, and school administrative
staff about school immunization laws and the benefits of
vaccines is a key strategy in improving compliance with
state immunization laws (Grace, 2006; Kinne & Bobo,
2010; Salmon et al., 2004).
Both parents and school administrative staff may be misinformed about vaccine safety and the value of vaccines in
protecting the health of students and the health of their communities (Salmon et al. 2004). We found that parents were
receptive to and appreciated personalized communication
regarding required immunizations from the school nurse and
immunization nurses. In a survey of school personnel in San
Diego County, respondents reported that personalized communication with parents was one of their most effective strategies to improving compliance with state immunization
laws (Linton et al., 2003). Salmon et al. recommended that
parents primary contact for vaccine information should be
school nurses and other health care professionals.
Although we cannot account for the disparity in immunization rates between rural districts and urban districts in
Pierce County, several factors can contribute to low immunization rates. Barriers to immunization include lack of a
medical home, clinic hours that conflict with a parents work
schedule, lack of transportation, and the cost of immunization (Toole & Perry, 2004). School-based immunization
clinics improve access to immunizations for students whose
parents may be unable to take time off from work to obtain
immunizations (Toole & Perry). Vaccines for Children
(VFC) is a federal program that provides immunizations free
of charge to persons under 19 years of age who meet eligibility requirements (CDC, 2011c). In addition to the federal
program, Washington State makes vaccines available to persons under 19 years of age who do not meet the VFC requirements (DOH, 2011c). School nurses can assess students
access to immunizations and refer them to appropriate community resources (AAP Council on School Health, 2008;
Grace, 2006).

Conclusions
A large proportion of immunizations received by students in
the district were not captured in the schools immunization
database. Reconciling the schools immunization database
with IIS and parent-held immunization records resulted in
significant improvement in the proportion of students documented as fully immunized. Although Washington State law
permits school nurses to delegate access to the IIS to school
staff, none of the staff at the schools in this district had been
granted access to the system. School staff may use the IIS to
generate CISs which can be signed by parents and placed in
students records, reducing the number of errors of the types
that we found. Although we did not collect data on the reasons for exemptions, data collected from the district at the
end of the 2010-2011 school year indicated that 93% of
immunization exemptions were for philosophical reasons
(TPCHD, 2011). Reports of school staff directing parents
to complete COEs rather than submit immunization records,
the ease with which philosophical exemptions could be
obtained in Washington State, and the observation that
reconciling the schools immunization records with IIS and
parent-held immunization records resulted in a significant
decrease in the number of exemption suggest that a substantial proportion of philosophical exemptions are convenience
exemptions. These findings were used to successfully support a revision of immunization requirements in Washington
State in 2011. Beginning July 2011, parents who wish to
exempt their children from immunization for philosophical
reasons are required to have a COE signed by a health care
professional, documenting receipt of information on the benefits and risks of vaccines (DOH, 2011a).
The percentage of immunization exemptions in this
school district remains greater than that for Pierce County
and Washington State even after our district-wide interventions. This suggests that other factors such as vaccine hesitancy and broader access issues may still be a factor for
many parents. Further study is warranted to assess the nature
of these factors; however, our work in this district suggests
that providing training to school administrative staff and
ensuring access to IIS and educating parents and school staff
on the importance of immunizations can result in a substantial decrease in the number of philosophical exemptions to
immunizations required for school entry.
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) disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article: This
study was funded by a grant from the Group Health Foundation.
Carolyn Cook thanks Denise Stinson for her contribution to this
work. Carolyn Cook, Robin Peterson, and Mary Yerxa thank the
Pierce County Immunization Coalition for its support of their work.

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The Journal of School Nursing 28(5)

Matthew Rollosson thanks Gini Gobeske and Nigel Turner for their
review of this manuscript.

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Mary E. Yerxa, BSN, RN, is an immunization/project nurse at

Franciscan Childrens Immunization Program, Tacoma, WA, USA.
James H. Marshall, MPH, is epidemiologist I at Tacoma-Pierce
County Health Department, Tacoma, WA, USA. He is now a
research associate at the Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute,
Boston, MA, USA.

Bios
Robin M. Peterson, MSN, RN, is a coordinator at MultiCare
Mobile Health Services, Tacoma, WA, USA.
Carolyn Cook, MSN, RN, is a clinic nurse at Mary Bridge Mobile
Immunization Clinic, MultiCare Health System, Tacoma, WA,
USA.

Elizabeth Pulos, PhD, MPH, is epidemiologist II at Tacoma-Pierce

County Health Department, Tacoma, WA, USA.
Matthew P. Rollosson, MPH&TM, BSN, RN, CNRN, is a community health nurse II at Tacoma-Pierce County Health Department, Tacoma, WA, USA.

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