- Split View
-
Views
-
Cite
Cite
Timothy R Shope, Benjamin H Walker, Laura Aird, Linda Southward, Judith M Martin, Influenza Vaccine Requirements in United States Child Care Centers, Journal of the Pediatric Infectious Diseases Society, Volume 9, Issue 5, November 2020, Pages 566–572, https://doi.org/10.1093/jpids/piz078
- Share Icon Share
Abstract
Influenza vaccine is the most effective means to prevent influenza for the high-risk population of child care attendees. This national survey assessed child care center directors’ reports of seasonal influenza vaccine requirements for children and adult caregivers.
This was a 2016 telephone-based survey of child care center directors randomly selected from a national database of licensed United States child care centers and queried about influenza vaccine requirements. Conceptually related items were grouped into 4 indexes: general infection control, use of health consultants, quality of child care, and pandemic influenza preparedness. These indexes, along with other center and director characteristics, were used to predict director-reported influenza vaccine requirements.
Of 518 child care center directors, only 24.5% and 13.1% reported an influenza vaccine requirement for children and adult caregivers, respectively. Center and director characteristics and the indexes were not associated with a director-reported influenza vaccine requirement. After adjusting for covariates, only having a state influenza vaccine law for children and an adult influenza vaccine requirement predicted having a child influenza vaccine requirement. Only having a child influenza vaccine requirement predicted having an adult vaccine requirement.
Director-reported influenza vaccine requirements for children and adult caregivers were influenced primarily by state influenza vaccine laws. Given the high risk of children in child care and low director-reported influenza vaccine requirements, more states should pass laws requiring influenza vaccine for children and adult caregivers at child care programs.
Nearly 1 in 4 children <5 years of age in the United States (US) regularly attend large-group early education and child care settings such as Head Start, child care centers, and preschool programs [1]. These children are at high risk for infection with influenza [2] and for spreading influenza into the community [3]. Infants <6 months of age are too young to receive the influenza vaccine, have the highest morbidity and mortality [4], and are vulnerable to infection transmitted by unimmunized adult caregivers and other children. Influenza is spread primarily through droplets, and therefore nonpharmaceutical interventions to mitigate the spread of influenza, such as respiratory etiquette, hand hygiene, and social distancing are typically not very effective in these settings [5, 6]. The effectiveness of excluding children who are ill is also limited, because though influenza can cause severe respiratory disease, many young children who are infected with influenza have illnesses indistinguishable from the common cold, are infectious before developing symptoms, and shed the virus for at least a week [7, 8]. Thus, the most effective strategy for reducing influenza transmission in early education and child care settings is immunization.
However, there have been few published reports assessing influenza vaccination in children and adult caregivers in early education and child care settings. All states have immunization laws for children entering child care settings and schools, which helps ensure high vaccination rates for most vaccine-preventable diseases [9–11]. However, few states require influenza vaccination in child care or schools, despite the high risk in younger children [11]. Without state vaccine laws, many decisions about influenza vaccine requirements for children and adult caregivers are made by center directors. We therefore conducted a national survey of licensed child care center directors in 2016 to determine the frequency of director-reported influenza vaccine requirements for children and adult caregivers, and state- and center-level factors that might influence these requirements.
METHODS
Survey Development
Questionnaire domains and content were developed in 2008 by a group with experience working with child care centers on managing infectious diseases [12]. The questionnaire was piloted with child care center directors and modified to improve content and face validity. Surveys were conducted in 2008 and 2016. Items relevant to this study regarding director-reported influenza vaccine requirements were added for the 2016 survey, and only 2016 data were analyzed and reported in this study.
Data Source and Participants
Data were derived from a nationwide telephone-based survey of directors of licensed US child care centers. The survey was conducted in 2016 by researchers at the Wolfgang Frese Survey Laboratory at the Social Science Research Center at Mississippi State University and was fielded as part of a larger study that assessed pandemic influenza preparedness. The study used a simple random sample of 2500 centers that was drawn from a sampling frame of 180 000 centers derived from databases of licensed child care centers provided by each state. From this random sample of centers, we removed incorrect/disconnected numbers, poor connections, and programs that were no longer in business and not meeting screening criteria—either nonlicensed or home- or school-based programs (Figure 1). Five hundred eighteen respondents completed the survey. For dichotomous response options with a 50% distribution, the sampling error for the total dataset (N = 518) was no larger than ±4.3% at a 95% confidence level. Telephone interviewers read from a written questionnaire to query the center directors and interviews were approximately 15–20 minutes in length. This study was reviewed and approved by the institutional review boards of the American Academy of Pediatrics (AAP), Naval Medical Center Portsmouth, Mississippi State University, and the University of Pittsburgh.
Definitions
The following definitions and words in italics will be used throughout this manuscript.
Advisory Committee on Immunization Practices (ACIP) Recommendations
A federal committee that establishes recommendations for routine immunization of adult and pediatric populations in the United States.
State Influenza Vaccination Laws
All states have laws requiring immunizations for adults and children entering school that are based on, but may lag, ACIP recommendations [9–11]. At the time of the survey administration, 4 states (Connecticut, New Jersey, Ohio, and Rhode Island) had laws requiring influenza immunization for children in child care settings [11], and 2 states had laws for adult caregivers (Rhode Island [13] and California [14]).
State Child Care Regulations
Standards written by state governments that set minimum requirements for establishing and maintaining child care licensing. Child care regulations may incorporate or refer to state immunization laws.
Child Care Center Requirements
Rules determined by child care center directors or their franchises that establish policies and practices for day-to-day business. To maintain licensure, centers adhere to licensing regulations; however, center requirements may exceed minimum state regulations.
Measures
The 2 primary outcomes were the reported influenza vaccination requirement for children and the reported influenza vaccination requirement for adult caregivers. These outcomes were assessed by asking the center director: Do you require an annual influenza vaccine for children 5 and under? and Do you require an annual influenza vaccine for adult caregivers?
We included an indicator of state influenza vaccination laws for children in child care centers as well as 4 indexes that could be associated with child care center directors’ inclusion of a vaccination requirement: the General Infection Control Index, the Health Consultant Index, the Quality Indicators Index, and the Pandemic Influenza Preparedness Index. We calculated each of these indexes by summing positive responses to individual items (each counting as 1 point, higher is better; see Supplementary Appendix). These indexes were created for this study and a previous one [12] and have undergone face and content validity, but no further psychometric testing.
The General Infection Control Index is an 8-item index (range, 0–8) that assessed directors’ competency with measures that incorporated disease surveillance and infection control and prevention practices. The Health Consultant Index is a 5-item index (range, 0–5) based on responses to questions about the use of a health consultant, including the general employment of consultants; using written agreements; using paid consultants; frequency of phone advice received; and frequency of in-person visits the consultant made to the center. The Quality Indicators Index (2 items; range, 0–2) assessed if the program was, or was in the process of being, accredited by an accrediting body (eg, National Association for the Education of Young Children) and if the director met the AAP minimum qualifications for director education, experience, and number of children attending the center [15]. Last, the Pandemic Flu Preparedness Index assessed respondents’ preparedness for pandemic influenza based on 4 items (range, 0–4), including concern about pandemic influenza; having been contacted about pandemic influenza; planning for pandemic influenza; and preparation for pandemic influenza.
Other predictor variables included Head Start program status, average daily attendance, and directors’ years of experience. As a proxy of prior experience with severe influenza, we included an indicator of whether the director was working in the same center during the 2009 H1N1 influenza pandemic.
Analytic Approach
We used separate multivariable logistic regression models, controlling for the following predictors of child and caregiver vaccination requirements: state influenza vaccination law; General Infection Control Index; Health Consultants Index; Quality Indicators Index; and Pandemic Influenza Preparedness Index. Models were adjusted for Head Start status, directors’ years of experience, and whether the director worked in the same center prior to 2009. Missing data (n = 153 [29%]) were handled using multiple imputation by chained equations with 30 imputations [16]. The imputation model included all of the variables in our analytic model. The results of our analysis were similar when using listwise deletion. All analyses were performed with Stata/SE software version 14 (StataCorp, College Station, Texas).
RESULTS
The cooperation rate (518 completed interviews) / (518 completed interviews + 349 refusals) was 59%. All states were represented except Montana and Rhode Island. Detailed child care center and director characteristics are presented in Table 1. On average, directors responding to the survey were experienced (mean, 19.0 years [standard deviation {SD}, 10.0 years]) and had large enrollments (mean, 61.6 [SD, 29.2]). More than half of respondents (54.7%) worked in the same center during the 2009 H1N1 pandemic influenza and 14.7% worked in Head Start programs. Overall, 24.5% of respondents reported having an influenza vaccination requirement for children while 13.1% reported a vaccination requirement for adult caregivers. The 37 respondents from states with a child care influenza vaccination law (Connecticut [n = 7], New Jersey [n = 14], Ohio [n = 16], and Rhode Island [n = 0]) were more likely to report having a vaccination requirement for children (52.8% vs 22.3%, P < .001). However, 85.7% of Connecticut and New Jersey center directors reported an influenza vaccine requirement for children compared with only 6.7% of Ohio directors.
Characteristic . | No. (%) . |
---|---|
NAEYC-accredited programs | 186 (38) |
Head Start | 76 (15) |
Youngest age | |
0–6 weeks | 56 (11) |
7 weeks to 24 months | 351 (68) |
≥25 months | 111 (21) |
Average daily attendance, mean (SD) | 61.6 (29.2) |
Most common racial background of attendees | |
White | 250 (50) |
Black | 46 (9) |
Latino/Latina | 57 (11) |
Other | 8 (2) |
Mixed background without a single most common race | 142 (28) |
Director’s highest level of education | |
High school diploma or associate’s degree | 166 (32) |
Bachelor’s degree | 236 (46) |
Master’s degree or higher | 114 (22) |
Director has degree in early childhood education or child development | 362 (77) |
Director’s total years of experience, mean (SD) | 19 (10) |
Director worked in same center in 2009 | 282 (55) |
Director-reported influenza vaccine requirement for children | 123 (24.5) |
Director-reported influenza vaccine requirement for adult caregivers | 68 (13.1) |
Center is in state with influenza vaccine law for children | 37 (7.1) |
General Infection Control Index (range, 3–8), mean (SD) | 7.07 (0.26) |
Health Consultant Index (range, 0–5), mean (SD) | 1.21 (1.71) |
Quality Indicators Index (range, 0–2), mean (SD) | 0.97 (0.73) |
Pandemic Influenza Preparedness Index (range, 0–4), mean (SD) | 1.16 (0.91) |
Characteristic . | No. (%) . |
---|---|
NAEYC-accredited programs | 186 (38) |
Head Start | 76 (15) |
Youngest age | |
0–6 weeks | 56 (11) |
7 weeks to 24 months | 351 (68) |
≥25 months | 111 (21) |
Average daily attendance, mean (SD) | 61.6 (29.2) |
Most common racial background of attendees | |
White | 250 (50) |
Black | 46 (9) |
Latino/Latina | 57 (11) |
Other | 8 (2) |
Mixed background without a single most common race | 142 (28) |
Director’s highest level of education | |
High school diploma or associate’s degree | 166 (32) |
Bachelor’s degree | 236 (46) |
Master’s degree or higher | 114 (22) |
Director has degree in early childhood education or child development | 362 (77) |
Director’s total years of experience, mean (SD) | 19 (10) |
Director worked in same center in 2009 | 282 (55) |
Director-reported influenza vaccine requirement for children | 123 (24.5) |
Director-reported influenza vaccine requirement for adult caregivers | 68 (13.1) |
Center is in state with influenza vaccine law for children | 37 (7.1) |
General Infection Control Index (range, 3–8), mean (SD) | 7.07 (0.26) |
Health Consultant Index (range, 0–5), mean (SD) | 1.21 (1.71) |
Quality Indicators Index (range, 0–2), mean (SD) | 0.97 (0.73) |
Pandemic Influenza Preparedness Index (range, 0–4), mean (SD) | 1.16 (0.91) |
Data are presented as No. (%) unless otherwise indicated.
Abbreviations: NAEYC, National Association for the Education of Young Children; SD, standard deviation.
aReflects total sample. Totals for individual variables may vary due to missing data.
Characteristic . | No. (%) . |
---|---|
NAEYC-accredited programs | 186 (38) |
Head Start | 76 (15) |
Youngest age | |
0–6 weeks | 56 (11) |
7 weeks to 24 months | 351 (68) |
≥25 months | 111 (21) |
Average daily attendance, mean (SD) | 61.6 (29.2) |
Most common racial background of attendees | |
White | 250 (50) |
Black | 46 (9) |
Latino/Latina | 57 (11) |
Other | 8 (2) |
Mixed background without a single most common race | 142 (28) |
Director’s highest level of education | |
High school diploma or associate’s degree | 166 (32) |
Bachelor’s degree | 236 (46) |
Master’s degree or higher | 114 (22) |
Director has degree in early childhood education or child development | 362 (77) |
Director’s total years of experience, mean (SD) | 19 (10) |
Director worked in same center in 2009 | 282 (55) |
Director-reported influenza vaccine requirement for children | 123 (24.5) |
Director-reported influenza vaccine requirement for adult caregivers | 68 (13.1) |
Center is in state with influenza vaccine law for children | 37 (7.1) |
General Infection Control Index (range, 3–8), mean (SD) | 7.07 (0.26) |
Health Consultant Index (range, 0–5), mean (SD) | 1.21 (1.71) |
Quality Indicators Index (range, 0–2), mean (SD) | 0.97 (0.73) |
Pandemic Influenza Preparedness Index (range, 0–4), mean (SD) | 1.16 (0.91) |
Characteristic . | No. (%) . |
---|---|
NAEYC-accredited programs | 186 (38) |
Head Start | 76 (15) |
Youngest age | |
0–6 weeks | 56 (11) |
7 weeks to 24 months | 351 (68) |
≥25 months | 111 (21) |
Average daily attendance, mean (SD) | 61.6 (29.2) |
Most common racial background of attendees | |
White | 250 (50) |
Black | 46 (9) |
Latino/Latina | 57 (11) |
Other | 8 (2) |
Mixed background without a single most common race | 142 (28) |
Director’s highest level of education | |
High school diploma or associate’s degree | 166 (32) |
Bachelor’s degree | 236 (46) |
Master’s degree or higher | 114 (22) |
Director has degree in early childhood education or child development | 362 (77) |
Director’s total years of experience, mean (SD) | 19 (10) |
Director worked in same center in 2009 | 282 (55) |
Director-reported influenza vaccine requirement for children | 123 (24.5) |
Director-reported influenza vaccine requirement for adult caregivers | 68 (13.1) |
Center is in state with influenza vaccine law for children | 37 (7.1) |
General Infection Control Index (range, 3–8), mean (SD) | 7.07 (0.26) |
Health Consultant Index (range, 0–5), mean (SD) | 1.21 (1.71) |
Quality Indicators Index (range, 0–2), mean (SD) | 0.97 (0.73) |
Pandemic Influenza Preparedness Index (range, 0–4), mean (SD) | 1.16 (0.91) |
Data are presented as No. (%) unless otherwise indicated.
Abbreviations: NAEYC, National Association for the Education of Young Children; SD, standard deviation.
aReflects total sample. Totals for individual variables may vary due to missing data.
Table 2 shows the unadjusted univariate and adjusted multivariable logistic regression analyses of director-reported child and adult influenza vaccination requirements. Notably, the predictor variables and the strengths of association were similar before and after adjustment. After adjustment, these results demonstrate that directors operating child care centers in states with an influenza vaccination law had greater odds of reporting an influenza vaccination requirement in their center compared with those in states with no law (odds ratio [OR], 4.29 [95% confidence interval {CI}, 2.08–8.85]). Additionally, having an adult caregiver vaccination requirement was associated with greater odds of having a child requirement (OR, 7.53 [95% CI, 4.24–13.38]). For the adjusted model predicting adult caregiver vaccination requirements, the only significant predictor was having a child vaccination requirement (OR, 7.39 [95% CI, 4.17–13.10]). No other director or child care center characteristics from Table 1 were significantly associated with having either a child or adult vaccination requirement.
Predictor . | Child Requirement . | . | Staff Requirement . | . |
---|---|---|---|---|
. | Univariate OR (95% CI) . | Multivariable OR (95% CI) . | Univariate OR (95% CI) . | Multivariable OR (95% CI) . |
State child care influenza vaccine law | 3.69b (1.86–7.31) | 4.29b (2.08–8.85) | 0.79 (.27–2.30) | 0.47 (.15–1.44) |
General Infection Control Index | 1.16 (.94–1.43) | 1.14 (.89–1.45) | 1.14 (.86–1.51) | 1.01 (.74–1.38) |
Health Consultant Index | 1.03 (.91–1.16) | 1.03 (.89–1.19) | 0.98 (.84–1.15) | 0.93 (.77–1.11) |
Quality Indicators Index | 1.07 (.79–1.45) | 1.05 (.74–1.49) | 1.17 (.80–1.71) | 1.11 (.72–1.70) |
Pandemic Influenza Preparedness Index | 1.15 (.91–1.44) | 1.12 (.86–1.46) | 1.16 (.87–1.54) | 1.06 (.77–1.47) |
Head Start status | 0.97 (.53–1.75) | 0.81 (.39–1.65) | 1.80 (.96–3.40) | 1.91 (.91–4.02) |
No. of children attending center | 0.99 (.98–1.00) | 0.99 (.98–1.00) | 1 .00 (.99–1.01) | 1.00 (.99–1.01) |
Director’s years of experience | 0.99 (.97–1.01) | 0.98 (.96–1.01) | 1.01 (.98–1.03) | 1.01 (.98–1.04) |
Worked same center in 2009 season | 1.12 (.75–1.68) | 1.33 (.81–2.18) | 0.93 (.56–1.54) | 0.86 (.47–1.57) |
Director-reported child vaccine requirement | … | … | 6.56b (3.79–11.34) | 7.39b (4.17–13.10) |
Director-reported adult caregiver vaccine requirement | 6.56b (3.79–11.34) | 7.53b (4.24–13.38) | … | … |
Predictor . | Child Requirement . | . | Staff Requirement . | . |
---|---|---|---|---|
. | Univariate OR (95% CI) . | Multivariable OR (95% CI) . | Univariate OR (95% CI) . | Multivariable OR (95% CI) . |
State child care influenza vaccine law | 3.69b (1.86–7.31) | 4.29b (2.08–8.85) | 0.79 (.27–2.30) | 0.47 (.15–1.44) |
General Infection Control Index | 1.16 (.94–1.43) | 1.14 (.89–1.45) | 1.14 (.86–1.51) | 1.01 (.74–1.38) |
Health Consultant Index | 1.03 (.91–1.16) | 1.03 (.89–1.19) | 0.98 (.84–1.15) | 0.93 (.77–1.11) |
Quality Indicators Index | 1.07 (.79–1.45) | 1.05 (.74–1.49) | 1.17 (.80–1.71) | 1.11 (.72–1.70) |
Pandemic Influenza Preparedness Index | 1.15 (.91–1.44) | 1.12 (.86–1.46) | 1.16 (.87–1.54) | 1.06 (.77–1.47) |
Head Start status | 0.97 (.53–1.75) | 0.81 (.39–1.65) | 1.80 (.96–3.40) | 1.91 (.91–4.02) |
No. of children attending center | 0.99 (.98–1.00) | 0.99 (.98–1.00) | 1 .00 (.99–1.01) | 1.00 (.99–1.01) |
Director’s years of experience | 0.99 (.97–1.01) | 0.98 (.96–1.01) | 1.01 (.98–1.03) | 1.01 (.98–1.04) |
Worked same center in 2009 season | 1.12 (.75–1.68) | 1.33 (.81–2.18) | 0.93 (.56–1.54) | 0.86 (.47–1.57) |
Director-reported child vaccine requirement | … | … | 6.56b (3.79–11.34) | 7.39b (4.17–13.10) |
Director-reported adult caregiver vaccine requirement | 6.56b (3.79–11.34) | 7.53b (4.24–13.38) | … | … |
Abbreviations: CI, confidence interval; OR, odds ratio.
aReflects the total sample. Totals for individual variables may vary due to missing data. Estimates are based on multiply imputed data.
b P < .001.
Predictor . | Child Requirement . | . | Staff Requirement . | . |
---|---|---|---|---|
. | Univariate OR (95% CI) . | Multivariable OR (95% CI) . | Univariate OR (95% CI) . | Multivariable OR (95% CI) . |
State child care influenza vaccine law | 3.69b (1.86–7.31) | 4.29b (2.08–8.85) | 0.79 (.27–2.30) | 0.47 (.15–1.44) |
General Infection Control Index | 1.16 (.94–1.43) | 1.14 (.89–1.45) | 1.14 (.86–1.51) | 1.01 (.74–1.38) |
Health Consultant Index | 1.03 (.91–1.16) | 1.03 (.89–1.19) | 0.98 (.84–1.15) | 0.93 (.77–1.11) |
Quality Indicators Index | 1.07 (.79–1.45) | 1.05 (.74–1.49) | 1.17 (.80–1.71) | 1.11 (.72–1.70) |
Pandemic Influenza Preparedness Index | 1.15 (.91–1.44) | 1.12 (.86–1.46) | 1.16 (.87–1.54) | 1.06 (.77–1.47) |
Head Start status | 0.97 (.53–1.75) | 0.81 (.39–1.65) | 1.80 (.96–3.40) | 1.91 (.91–4.02) |
No. of children attending center | 0.99 (.98–1.00) | 0.99 (.98–1.00) | 1 .00 (.99–1.01) | 1.00 (.99–1.01) |
Director’s years of experience | 0.99 (.97–1.01) | 0.98 (.96–1.01) | 1.01 (.98–1.03) | 1.01 (.98–1.04) |
Worked same center in 2009 season | 1.12 (.75–1.68) | 1.33 (.81–2.18) | 0.93 (.56–1.54) | 0.86 (.47–1.57) |
Director-reported child vaccine requirement | … | … | 6.56b (3.79–11.34) | 7.39b (4.17–13.10) |
Director-reported adult caregiver vaccine requirement | 6.56b (3.79–11.34) | 7.53b (4.24–13.38) | … | … |
Predictor . | Child Requirement . | . | Staff Requirement . | . |
---|---|---|---|---|
. | Univariate OR (95% CI) . | Multivariable OR (95% CI) . | Univariate OR (95% CI) . | Multivariable OR (95% CI) . |
State child care influenza vaccine law | 3.69b (1.86–7.31) | 4.29b (2.08–8.85) | 0.79 (.27–2.30) | 0.47 (.15–1.44) |
General Infection Control Index | 1.16 (.94–1.43) | 1.14 (.89–1.45) | 1.14 (.86–1.51) | 1.01 (.74–1.38) |
Health Consultant Index | 1.03 (.91–1.16) | 1.03 (.89–1.19) | 0.98 (.84–1.15) | 0.93 (.77–1.11) |
Quality Indicators Index | 1.07 (.79–1.45) | 1.05 (.74–1.49) | 1.17 (.80–1.71) | 1.11 (.72–1.70) |
Pandemic Influenza Preparedness Index | 1.15 (.91–1.44) | 1.12 (.86–1.46) | 1.16 (.87–1.54) | 1.06 (.77–1.47) |
Head Start status | 0.97 (.53–1.75) | 0.81 (.39–1.65) | 1.80 (.96–3.40) | 1.91 (.91–4.02) |
No. of children attending center | 0.99 (.98–1.00) | 0.99 (.98–1.00) | 1 .00 (.99–1.01) | 1.00 (.99–1.01) |
Director’s years of experience | 0.99 (.97–1.01) | 0.98 (.96–1.01) | 1.01 (.98–1.03) | 1.01 (.98–1.04) |
Worked same center in 2009 season | 1.12 (.75–1.68) | 1.33 (.81–2.18) | 0.93 (.56–1.54) | 0.86 (.47–1.57) |
Director-reported child vaccine requirement | … | … | 6.56b (3.79–11.34) | 7.39b (4.17–13.10) |
Director-reported adult caregiver vaccine requirement | 6.56b (3.79–11.34) | 7.53b (4.24–13.38) | … | … |
Abbreviations: CI, confidence interval; OR, odds ratio.
aReflects the total sample. Totals for individual variables may vary due to missing data. Estimates are based on multiply imputed data.
b P < .001.
Discussion
To our knowledge, this study is the first to evaluate influenza vaccine requirements in children and adults at child care centers across a nationwide sample. State influenza vaccine laws significantly increased director-reported influenza vaccine requirements for children. Likewise, having a child vaccine requirement was associated with a requirement for adult caregivers. Overall, we found that directors of licensed US child care centers infrequently reported influenza vaccine requirements for children (24.5%) and adult caregivers (13.1%). Head Start, use of health consultants, program accreditation, and director education and experience have all been associated with higher-quality policies and practices in child care programs [15, 17–20]. However, these factors and others potentially related to quality and influenza preparedness, such as experience as a director during the severe 2009 H1N1 pandemic influenza, did not influence director-reported influenza vaccine requirements.
The ACIP establishes federal vaccination recommendations from which all states derive laws for vaccination of children entering child care and schools and, less commonly, adults in healthcare and other settings [9–11]. State vaccination laws may lag the ACIP recommendations. States also establish and enforce licensing regulations for child care programs, which may incorporate state vaccine laws. The ACIP has recommended influenza vaccine for children aged 6–23 months since 2004, for children aged 24–59 months since 2006, and all people aged 6 months and older since 2008 [21]. Despite these longstanding ACIP recommendations, at the time of our study, only 4 states had influenza vaccine laws for children in child care centers: Connecticut (January 2011), New Jersey (September 2008), Ohio (March 2015), and Rhode Island (August 2015) [11]. In states without an influenza vaccination law, there is no legal barrier preventing center directors from implementing an influenza vaccine requirement. However, our data suggest that in the absence of a state law, directors are much less likely to require influenza vaccine for children in child care centers.
The limited available data indicate that state immunization laws for children attending child care programs improve immunization rates [22]. Nationwide, influenza immunization rates among children aged 6 months to 4 years have risen from 63.6% in the 2010–2011 influenza season, plateauing to 70.4% in 2013–2015, then falling slightly to 67.8% in 2017–2018 [23]. In contrast, after influenza vaccination laws for children in child care were passed in New Jersey and Ohio, New Jersey reached a statewide influenza vaccination rate of 88% in 2012 [22] and Connecticut saw a statewide increase from 67.8% in the 2009–2010 influenza season to 84.1% in the 2012–2013 season with a corresponding decrease in influenza-associated hospitalizations [24].
While it is encouraging to see that state laws may translate to better influenza immunization rates for children, our data show that despite a strong association of a state law with a director-reported influenza vaccine requirement, laws fall short of universal director-reported vaccine requirement. In Connecticut and New Jersey, 85.7% of directors in each state reported a child vaccine requirement vs 6.7% of Ohio directors. The Ohio law was passed the year before the 2016 survey, resulting in limited adoption by child care centers, compared to more longstanding laws in Connecticut and New Jersey. There are other factors that may undermine complete compliance with a state vaccine law. For example, a study in Philadelphia demonstrated that immunization rates in child care centers were substantially below standards established by state law [25]. This may be due to a lack of a state program for monitoring center records, with no consequence negatively impacting centers’ licensure. Another issue may be that many states allow religious and philosophical exemptions. Directors may incorporate these exemptions into their policies and therefore may not consider the state law for influenza vaccine a true condition that would impact licensure. In Connecticut, after implementing the influenza vaccine law, exemptions for this vaccine rose significantly to 5.1%, compared to 1.7% for all other vaccines [24]. The AAP supports laws requiring immunization to attend child care and school and views nonmedical exemptions for required immunizations as “inappropriate for individual, public health, and ethical reasons and advocates for their elimination” [26].
Influenza immunization of adults who work in child care settings is also important because these caregivers have very close contact with children who are at the highest-risk age group for influenza morbidity and mortality [4] and are often unimmunized by parental choice or unable to be immunized because they are <6 months of age. Each season, the Centers for Disease Control and Prevention estimates the effectiveness of the seasonal vaccine to prevent laboratory-confirmed influenza. Even with an influenza vaccine effectiveness in children of 61% during the 2018–2019 season [27], children who have been immunized may remain vulnerable to influenza from adult caregivers who, similar to healthcare workers [28], sometimes come to work while ill [29] and infected with influenza. Our study demonstrates that across the US, requirements for adult caregiver influenza immunization are not common and that the only significant predictor of directors’ requiring the influenza vaccine for adults was having a child influenza vaccine requirement. We are aware of only 2 states with influenza vaccine laws for child care providers: California [14] and Rhode Island [13]. We were not able to measure the effect of these laws because California’s law was passed at the time the survey was in progress and there were no respondents from Rhode Island.
Given the paucity of influenza vaccine laws for adult caregivers working in child care settings, it is not surprising that reported influenza vaccination rates are low. A small number of city- or state-level studies showed low baseline influenza vaccine rates (22%–30%) among child care workers through the 2009–2010 influenza seasons [30–32], with a more recent study in St Louis during the 2013–2014 and 2014–2015 influenza seasons demonstrating 58% and 47%, respectively [29].
From a public health policy standpoint, the argument is straightforward and like that for healthcare workers [33]: Influenza vaccination should be required for adults who work in child care settings as a condition of employment to protect vulnerable individuals who are cared for as a part of the job. Employer-required influenza vaccination programs at healthcare organizations have successfully increased vaccine rates to near 100%, but these are not widespread [34]. However, a larger problem is that despite all states having laws that require a minimum number of immunizations for children entering child care and school, very few require any immunizations for child care employees, and even fewer have a system for tracking the requirements [29, 35, 36]. This is despite widespread parental and child care staff support for such policies [29, 32, 36] and ACIP recommendations.
Our study has some limitations. The questionnaire items underwent content and face validation but no further psychometric testing. Data were derived from interviews with directors who might have been influenced by response or social desirability bias, possibly increasing reported vaccination requirements, although reported rates were decidedly low. This study reported influenza vaccine requirements but not vaccination rates. Decisions to vaccinate, in lieu of requirements, are made by parents and adult caregivers, and vaccination rates are likely to be significantly higher than the director-reported vaccination requirements. Directors who reported a lack of influenza vaccine requirement may not reflect their beliefs and practices. We did not measure many factors that have been shown to influence parent and child care provider uptake of influenza vaccine such as knowledge, attitudes, and behaviors [31, 32]. The strengths of our study include the randomly selected national sample and a significantly high cooperation rate for research of this type, yielding a representative sample of US child care center directors.
Conclusions
Child care center directors across the US infrequently require child and adult caregiver influenza vaccination. Individual state laws for child influenza vaccination significantly increase director-reported child and adult caregiver influenza vaccine requirements. Given the large percentage of young children being cared for in early education and child care settings, the importance of reducing influenza spread, and the influenza-related morbidity and mortality in children birth to age 5 years, state laws should be implemented to require seasonal influenza vaccine for children in child care centers and their adult caregivers, and state child care licensing agencies should enforce these requirements.
Supplementary Data
Supplementary materials are available at the Journal of The Pediatric Infectious Diseases Society online (http://jpids.oxfordjournals.org). Supplementary materials consist of data provided by the author that are published to benefit the reader. The posted materials are not copyedited. The contents of all supplementary data are the sole responsibility of the authors. Questions or messages regarding errors should be addressed to the author.
Notes
Author contributions. T. R. S. participated in study concept and design, writing the questionnaire, acquisition and analysis of data, and drafting/revising the manuscript. B. H. W. participated in acquisition and analysis of data and drafting/revising the manuscript. L. A. participated in study concept and design, writing the questionnaire, and revising the manuscript. L. S. participated in acquisition and analysis of data and revising the manuscript. J. M. M. participated in study concept and design and drafting/revising the manuscript. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
Financial support. This work was supported by the Centers for Disease Control and Prevention (grant numbers 1U01DD000233 and 5U38OT000167-03).
Potential conflicts of interest. All authors: No reported conflicts.
All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.
References