School-Based Interventions to Increase Student COVID-19 Vaccination Coverage in Public School Populations with Low Coverage — Seattle, Washington, December 2021–June 2022

COVID-19 can lead to severe outcomes in children (1). Vaccination decreases risk for COVID-19 illness, severe disease, and death (2). On December 13, 2020, CDC recommended COVID-19 vaccination for persons aged ≥16 years, with expansion on May 12, 2021, to children and adolescents (children) aged 12–15 years, and on November 2, 2021, to children aged 5–11 years (3). As of March 8, 2023, COVID-19 vaccination coverage among school-aged children remained low nationwide, with 61.7% of children aged 12–17 years and approximately one third (32.7%) of those aged 5–11 years having completed the primary series (3). Intention to receive COVID-19 vaccine and vaccination coverage vary by demographic characteristics, including race and ethnicity and socioeconomic status (4–6). Seattle Public Schools (SPS) implemented a program to increase COVID-19 vaccination coverage during the 2021–22 school year, focusing on children aged 5–11 years during November 2021–June 2022, with an added focus on populations with low vaccine coverage during January 2022–June 2022.^† The program included strategic messaging, school-located vaccination clinics, and school-led community engagement. Vaccination data from the Washington State Immunization Information System (WAIIS) were analyzed to examine disparities in COVID-19 vaccination by demographic and school characteristics and trends over time. In December 2021, 56.5% of all SPS students, 33.7% of children aged 5–11 years, and 81.3% of children aged 12–18 years had completed a COVID-19 primary vaccination series. By June 2022, overall series completion had increased to 80.3% and was 74.0% and 86.6% among children aged 5–11 years and 12–18 years, respectively. School-led vaccination programs can leverage community partnerships and relationships with families to improve COVID-19 vaccine access and coverage.

With support from local and state public health officials, SPS conducted school-located vaccination clinics at 54 schools during November 2021–June 2022. WAIIS provides monthly reports on school-required and COVID-19 vaccination coverage to SPS; these data are then linked to school system data. WAIIS data were analyzed to ascertain the monthly proportion of kindergarten through grade 12 students completing the primary COVID-19 vaccination^§ series during December 2021–June 2022. The proportions of students completing the primary series were examined by age, race and ethnicity,^¶ language status (monolingual versus multilingual),** use of special education services,^†† school equity tier,^§§ and school baseline vaccination coverage,^¶¶ with January 2022 serving as a baseline for assessing subsequent activities to engage groups with low vaccination coverage. Qualitative and descriptive data regarding efforts by SPS to increase primary COVID-19 vaccination series completion during November 2021–June 2022 were also informally collected from approximately 10 SPS staff members and representatives of the Washington Department of Health and Public Health – Seattle & King County (PHSKC) via virtual meetings and e-mail. This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.***

SPS serves approximately 50,000 students in 106 schools (Table 1). In December 2021, primary COVID-19 vaccination series completion among SPS students aged 5–18 years was 56.5% overall (Figure) and was lowest among students who were non-Hispanic Black or African American (Black) (27.9%) and multilingual (30.0%). During November–December 2021, 55 school-located vaccination clinics were held, with planning led by SPS and supported by PHSKC. These clinics included school day clinics, where children received immunizations with written parental consent but without requiring that a parent be present, and school-located regional clinics during evening or weekend hours. School-day clinics were strategically located at 41 schools selected because of size or known barriers to care.^††† COVID-19 vaccines were also readily available at 29 PHSKC-supported school-based health centers that provide comprehensive primary care to their students.

By January 2022, primary COVID-19 vaccination series completion among SPS students aged 5–18 years had increased from 56.5% to 71.5%. After receipt of school-level student vaccination data in early January 2022, efforts during January–June 2022 focused on schools with continued low (baseline) vaccination coverage. Overall, 26 school-located vaccination clinics were conducted, including 19 during January–March 2022 that were in or near low-coverage schools (i.e., those with primary COVID-19 vaccine series completion rates of ≤50%). These clinics took place after school hours or on the weekend and were open to all SPS students and their family members. SPS administered 12,245 COVID-19 vaccine doses during November 2021–June 2022.

School-located vaccination clinics were complemented by strategies implemented to overcome cultural and linguistic barriers with families. For example, SPS conducted weekly communication with families, including email, telephone calls delivering prerecorded messages, and text messaging using TalkingPoints, a two-way communication platform that provided messaging in six languages.^§§§ SPS also provided communications toolkits created by PHSKC in multiple languages to parent-teacher-student associations and community-based organizations to amplify messaging. Vaccine providers were selected based on their cultural competency (e.g., an independent, Black-owned pharmacy with vaccinators with facility in several African languages).

Tailored school-specific engagements were also conducted. One school used multilingual staff members from its school-based health center to administer vaccines at students’ homes or workplaces if necessary, thereby extending vaccination access beyond the school day. This school increased COVID-19 primary series completion among persons aged 11–21 years from 45% in January 2022 to 93% by June 2022. Another worked with a community health organization to organize health-related events focused on the Somali community and cohosted a school-located vaccination clinic with a local mosque. Each school used different approaches; however, all relied on school health staff members for direct family outreach.

During the period in which SPS specifically focused on students and schools with low baseline vaccination coverage, primary COVID-19 vaccination series completion among SPS students increased 12.3%, from 71.5% in January 2022, to 80.3% by June 2022; among children aged 5–11 years and 12–18 years, coverage increased 21.3% and 3.6%, respectively (Table 2). Primary series completion increased 37.8% among Black students (from 33.3% to 45.9%), 121.8% (from 13.5% to 29.9%) among those aged 5–11 years, and 14.8% (from 53.6% to 61.5%) among those aged 12–18 years. During the same period among multilingual students, overall primary series completion increased 38.7% (from 42.6% to 59.1%), 74.6% (from 28.9% to 50.4%) and 10.6% (from 65.7% to 72.3%) among those aged 5–11 and 12–18 years, respectively. Primary series completion among students at schools with low baseline vaccination coverage also increased, from 36.0% to 51.7% (43.4% increase) overall, from 34.8% to 51.1% (46.9% increase) among students aged 5–11 years, and from 51.9% to 58.5% (11.5% increase) among those aged 12–18 years.

Corresponding author: Tarayn Fairlie, media@cdc.gov.

¹CDC COVID-19 Emergency Response Team; ²Seattle Public Schools, Seattle, Washington; ³Public Health – Seattle & King County, Seattle, Washington; ⁴Seattle Children’s Hospital, Seattle, Washington; ⁵Washington State Department of Health.

References

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Abbreviations: ELL = English language learner; SPS = Seattle Public Schools.
* Race and ethnicity were based on U.S. Department of Education descriptors. Final guidance on maintaining, collecting, and reporting racial and ethnic data to the U.S. Department of Education is available at https://www.govinfo.gov/content/pkg/FR-2007-10-19/pdf/E7-20613.pdf. If the ethnicity aggregate is Hispanic or Latino, race and ethnicity is listed as Hispanic or Latino. If the ethnicity aggregate is non-Hispanic and one race category is selected, student is listed as that race. If two or more race categories are selected, student is listed as multiracial.
^† Language status was either multilingual, defined as student use of ELL services during the 2021–22 school year, or monolingual, with no use of ELL services in 2021–22.
^§ Use of special education services was defined as use of an individual education plan during the 2021–22 school year.
^¶ Defined as the proportion of a school’s students who had completed the primary COVID-19 vaccine series by the first week of January 2022. SPS school health staff members determined in January 2022 that low-coverage schools were those with a student completion rate of ≤50%, and high vaccination coverage schools were those with a completion rate of >50%.
** School equity tiers were defined as either high levels of inequity (Tier 1 or Tier 2) or low levels of inequity (Tier 3 and Tier 4), based on established SPS methodology. https://www.seattleschools.org/wp-content/uploads/2022/02/tier_methodology23.pdf

FIGURE. Completion of the primary COVID-19 vaccination series by students aged 5–18 years, by race and ethnicity* (A) and school coverage status,^† student language status, and equity tier^§ (B) — Seattle Public Schools, December 2021–June 2022

Abbreviations: ET = equity tier; SLVC = school-located vaccination clinic.

* Hispanic or Latino students could be of any race; other racial groups were non-Hispanic. American Indian or Alaska Native students (215), Native Hawaiian or other Pacific Islander students (197), and students with missing race and ethnicity data (18) are excluded from figure.

^† Low- and high-coverage schools have primary COVID-19 series completion rates of ≤50% and >50%, respectively.

^§ Tier 1 and Tier 2 schools represent higher levels of inequity and are designated for additional support from the state; Tier 3 and Tier 4 schools have lower levels of inequity and do not qualify for additional support. https://www.seattleschools.org/wp-content/uploads/2022/02/tier_methodology23.pdf

* Equity Tier 1 and Tier 2 schools represent higher levels of inequity and are designated for additional support from the state; Tier 3 and Tier 4 schools have lower levels of inequity and do not qualify for support. https://www.seattleschools.org/wp-content/uploads/2022/02/tier_methodology23.pdf
^† During January–June 2022. Categories are not mutually exclusive.
^§ Absolute percent change from January to June 2022 for each group was compared with the hypothesized mean increase in completion of 5% for all persons aged 5–18 years, 10% for children aged 5–11 years, and 3% for persons aged 12–18 years based on COVID tracker data showing completion rate changes seen nationally during the study period using a paired t-test. The absolute change was statistically significant (p<0.05) for each group. Comparison across groups was not completed because many of the groups are not mutually exclusive.
^¶ Percent change was calculated as follows: (proportion June 2022 − proportion January 2022) / proportion January 2022.