To help communities stay healthier, the Centers for Disease Control and Prevention (CDC) offers the Vaccines for Children (VFC) program, which provides pediatric vaccines recommended by the Advisory Committee on Immunization Practices at no cost to children who might not otherwise be vaccinated because of inability to pay. Most of these programs are based in private doctor’s offices, hospitals, or public health clinics.
But in Charleston County, South Carolina, there’s an additional option: the school nurse’s office.
The Charleston County School District (CCSD) program came about soon after Ellen Nitz, BSN, RN, became the school district’s director of nursing services in 2019. In that role, she oversees 125 school nurses at 80 schools. Spread across 100 square miles of South Carolina’s Lowcountry, CCSD serves 48,000 students.
Nitz had previously served as the nurse manager with CCSD and worked closely with the South Carolina Department of Health and Environmental Control (DHEC) to ensure that kids moving into the district had the vaccinations they needed to attend in-person classes. Requirements for specific vaccines can vary from state to state, so keeping on top of new arrivals who don’t always have all the shots needed was a big part of her job.
She found that there were many reasons why kids weren’t always current with the recommended vaccination schedule. Many had parents who were unable to get time off work to take them to a doctor’s appointment.
Another common obstacle was financial; despite VFC vaccines being offered free of charge by the federal government, some families could not afford the associated administrative fee charged by the provider offering the shots, which can be up to $15.
Nitz got to thinking that there must be a way to bring those immunizations into the schools where kids spend so much time each week, thus eliminating the need for a doctor or clinic visit.
“I really started putting my head together with our DHEC partner and asking, ‘What is the possibility of school nurses becoming VFC providers?’” she says.
Throughout this process, Nitz worked closely with Marsha Glatt, RN, who was serving as the immunization program manager for the Lowcountry region of DHEC at the time. They met with other immunization program leaders in the state and worked out the logistics of how school nurses could provide vaccines across the district.
In 2019, they developed a proposal to submit to the CDC to establish a VFC program in the school system. No other school in the state had such a program, so it took some work to convince the powers that be in the state education department to allow them to move forward with the plan.
“After a lot of research, we found out that New Mexico has two programs, which would make ours the third school-based program to be able to have a VFC provider,” Nitz says.
As the program took root, Nitz realized she needed more hands-on help to implement it, and advertised for an immunization nurse coordinator.
“When the job became available, I applied for it,” Glatt says. Given her extensive background in vaccination efforts and her knowledge of DHEC and local public health regulations, she was an obvious choice to lead the effort.
“I have always believed that there are situations where parents can’t get off work to take their children to get their vaccine, and we needed to make it more accessible, especially to underserved children,” Glatt says.
Successes and Challenges
Since 2020, the VFC program in CCSD schools has administered more than 2,000 routine childhood vaccines to students who need them. In 2022, it delivered 1,300 flu vaccines.
The program is entirely voluntary, and parents must sign a consent form if they want their child to be vaccinated at school. Because it’s a completely optional process, there hasn’t been much pushback or controversy about it, Glatt says. COVID-19 vaccines are not included as part of this effort because the district is unable to properly store and handle them.
In ramping up the program, Glatt says she relied on lessons learned while working at DHEC during the hard-hitting 2009 H1N1 flu pandemic, particularly regarding how to work with public health officials to get vaccines into arms quickly.
“I was able to get DHEC to let the Lowcountry offer flu vaccines in the schools. One other nurse and I vaccinated 1,742 children in 14 days,” she says.
While the pace of vaccination currently isn’t that intense, there were some challenges, especially early on, posed by the remote nature of some areas within the district and ongoing COVID-19 pandemic difficulties.
“We were the largest school district in the nation that stayed open five days a week” during the height of the pandemic, Nitz says. CCSD schools shut down between March and May 2020 when the state mandated it.
“As soon as we could, we opened up all of our schools with the proper risk mitigators in place,” she says. These included plexiglass dividers, universal masking, and encouraging hand hygiene and social distancing.
Because CCSD remained fully open throughout the pandemic, more than 1,000 new students arrived from other states and districts that were still using virtual learning. For some children, in-person learning is critical, and CCSD’s commitment to providing that appealed to some families whose children needed that option. That influx of new children naturally brought some who needed routine vaccinations.
Extensive COVID-19 testing and contact tracing also diverted school nurses’ time and energy from the VFC program.
In addition, “Geographically, we are an extremely large district and all the beautiful waters we live around separate us a little bit,” Nitz says. That meant physically getting vaccine doses to schools was sometimes challenging.
While the program been able to overcome most of those initial challenges, another ongoing challenge remains: Paperwork. “Because our computer system that we use at CCSD cannot talk to the state vaccine registry, we are having to input information into the different systems manually,” Glatt says.
The team is working out how to link the two systems, but because running a VCF program within a school district is so new, the system hasn’t caught up yet.
Best Practices Advice
Glatt has some practical advice for others who might be interested in establishing a similar program.
Since vaccines need to be kept at specific temperatures, and getting the right equipment in place to safely store vaccines is a critical piece of building a program that works, “You have to make sure you have storage and handling,” she says. This is a key reason why COVID-19 vaccines were excluded from the pediatric vaccination program in the district — some of these specialized storage and handling requirements have changed over time but still need careful consideration. However, CCSD does have a separate initiative, in partnership with the Medical University of South Carolina (MUSC), which has provided more than 11,700 COVID-19 vaccines to staff and students at CCSD schools via mass vaccination clinics at the schools. By providing dedicated dates for COVID-19 vaccinations, they were able to enroll enough people to ensure there would be little to no waste of vaccine doses. During those clinics, MUSC provides the vaccines as well as the personnel to administer them.
Glatt also recommends allowing parents to be present while their child gets vaccinated, although this is not a requirement as long as a parent gives consent.
“With any public health program, you have to build trust with the people you’re working with,” she says, and for pediatric vaccinations, that includes the parents as well as the children.
For some parents, being able to meet the person administering shots and having an opportunity to ask questions directly goes a long way toward building trust.
Glatt says at one school, nearly all the parents showed up on vaccine day, and that made for a busy vaccination area. But given that there was a high language barrier at that school, the parents needed to get their questions answered, which was done with the assistance of one of the school’s interpreters.
When the group administered follow-up shots for those kids, “not one of the parents showed up,” indicating that they were satisfied that the kids were safe and in good hands.
Nitz adds that in many cases, the kids are very comfortable with the school nurse because it’s someone they already know and see regularly in school.
“We’re school nurses. We deal with children all the time — that’s our specialty,” she says. That familiarity means that many of the kids are less frightened of getting a shot from the school nurse than from a doctor or nurse they might not know as well at a clinic.
Expanding Access
Glatt hastens to add that programs like this are not meant to replace the important work of physicians, but rather to extend their reach to people who might otherwise struggle to access them.
“I believe in vaccinations,” Glatt says. “I believe they’re the number one public health success story.”
Nitz agrees that the program is an important way to support students’ health. “It is a lot of work, but it really pays off. School health is the key not only to academic success but really to lifelong health.”
School nurses, she says, are the frontline providers in many ways.
“They’re the ones who really see the needs of these kids,” she says, “even before some of our parents may realize.”