title: Sustainability of school-located influenza vaccination programs in Florida.
abstract: School-located influenza vaccination (SLIV) programs are a promising strategy for increasing vaccination coverage among schoolchildren. However, questions of economic sustainability have dampened enthusiasm for this approach in the United States. We evaluated SLIV sustainability of a health department led, county-wide SLIV program in Alachua County, Florida. Based on Alachua's outcome data, we modeled the sustainability of SLIV programs statewide using two different implementation costs and at different vaccination rates, reimbursement amount, and Vaccines for Children (VFC) coverage.
  
  
  
  Mass vaccination clinics were conducted at 69 Alachua County schools in 2013 using VFC (for Medicaid and uninsured children) and non-VFC vaccines. Claims were processed after each clinic and submitted to insurance providers for reimbursement ($5 Medicaid and $47.04 from private insurers). We collected programmatic expenditures and volunteer hours to calculate fixed and variable costs for two different implementation costs (with or without in-kind costs included). We project program sustainability for Florida using publicly available county-specific student populations and health insurance enrollment data.
  
  
  
  Approximately 42% (n=12,853) of pre-kindergarten - 12th grade students participated in the SLIV program in Alachua. Of the 13,815 doses provided, 58% (8042) were non-VFC vaccine. Total implementation cost was $14.95/dose or $7.93/dose if "in-kind" costs were not included. The program generated a net surplus of $24,221, despite losing $4.68 on every VFC dose provided to Medicaid and uninsured children. With volunteers, 99% of Florida counties would be sustainable at a 50% vaccination rate and average reimbursement amount of $3.25 VFC and $37 non-VFC. Without volunteers, 69% of counties would be sustainable at 50% vaccination rate if all VFC recipients were on Medicaid and its reimbursement increased from $5 to $10 (amount private practices receive).
  
  
  
  Key factors that contributed to the sustainability and success of an SLIV program are: targeting privately insured children and reducing administration cost through volunteers. Counties with a high proportion of VFC eligible children may not be sustainable without subsidies at $5 Medicaid reimbursement.
authors.affiliation: College of Public Health and Health Professions, University of Florida, Gainesville, FL, United States; Emerging Pathogens Institute, University of Florida, Gainesville, FL, United States.
authors.forename: Cuc H
authors.initials: CH
authors.lastname: Tran
authors.affiliation: College of Public Health and Health Professions, University of Florida, Gainesville, FL, United States; Florida Department of Health in Alachua County, Gainesville, FL, United States.
authors.forename: Joe
authors.initials: J
authors.lastname: Brew
authors.affiliation: College of Public Health and Health Professions, University of Florida, Gainesville, FL, United States; Florida Department of Health in Alachua County, Gainesville, FL, United States.
authors.forename: Nicholas
authors.initials: N
authors.lastname: Johnson
authors.affiliation: College of Public Health and Health Professions, University of Florida, Gainesville, FL, United States; Emerging Pathogens Institute, University of Florida, Gainesville, FL, United States; College of Medicine, University of Florida, Gainesville, FL, United States.
authors.forename: Kathleen A
authors.initials: KA
authors.lastname: Ryan
authors.affiliation: Florida Department of Health in Alachua County, Gainesville, FL, United States.
authors.forename: Brittany
authors.initials: B
authors.lastname: Martin
authors.affiliation: Florida Department of Health in Alachua County, Gainesville, FL, United States.
authors.forename: Catherine
authors.initials: C
authors.lastname: Cornett
authors.affiliation: Florida Department of Health in Alachua County, Gainesville, FL, United States.
authors.forename: Brad
authors.initials: B
authors.lastname: Caron
authors.affiliation: College of Public Health and Health Professions, University of Florida, Gainesville, FL, United States.
authors.forename: R Paul
authors.initials: RP
authors.lastname: Duncan
authors.affiliation: College of Public Health and Health Professions, University of Florida, Gainesville, FL, United States; Emerging Pathogens Institute, University of Florida, Gainesville, FL, United States; College of Medicine, University of Florida, Gainesville, FL, United States.
authors.forename: Parker A
authors.initials: PA
authors.lastname: Small
authors.affiliation: Florida Department of Health in Alachua County, Gainesville, FL, United States.
authors.forename: Paul D
authors.initials: PD
authors.lastname: Myers
authors.affiliation: College of Public Health and Health Professions, University of Florida, Gainesville, FL, United States; Emerging Pathogens Institute, University of Florida, Gainesville, FL, United States; College of Medicine, University of Florida, Gainesville, FL, United States. Electronic address: JGMorris@epi.ufl.edu.
authors.forename: J Glenn
authors.initials: JG
authors.lastname: Morris
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D005431:Florida; D017048:Health Care Costs; D005102:Health Expenditures; D006801:Humans; D017589:Immunization Programs / Q000191:economics*; D007252:Influenza Vaccines / Q000191:economics / Q000627:therapeutic use*; D007251:Influenza, Human / Q000517:prevention & control; D007348:Insurance, Health; D008484:Medicaid; D012574:Schools; D014481:United States; D014611:Vaccination / Q000191:economics* / Q000706:statistics & numerical data
chemical_list: D007252:Influenza Vaccines
keywords: Cost; Immunization; Influenza vaccination; Insurance; School health services; School-aged population