Symptoms of Depression, Anxiety, and Post-Traumatic Stress Disorder, and Suicidal Ideation Among School Nurses in Prekindergarten through Grade 12 Schools - United States, March 2022.

School nurses are integral to creating safe environments in U.S. schools. Many experienced increased work burden and stress during the COVID-19 pandemic. CDC collaborated with the National Association of School Nurses and the National Association of State School Nurse Consultants to distribute a 121-item online, anonymous survey to school nurses nationwide during March 7-30, 2022. Among the 7,971 respondents, symptoms of depression, anxiety and PTSD, and suicidal ideation were measured, and prevalence ratios were used to identify associations with demographics, workplace characteristics, and support. Results found high levels of work-related stressors and indicated that employment characteristics, COVID-19-related job duties, and other workplace stressors and supports affected school nurse mental health. The survey findings underscore the mental health challenges many school nurses experienced during the 2021/2022 school year. The findings can inform supportive policies and practices to reduce workplace stressors and increase workplace supports for school nurses.

Characteristics Associated With School Health Services for the Management of Chronic Health Conditions.

It is unknown how health services staff (school nurse or school physician) or school characteristics are associated with the number of services provided for chronic health conditions in schools. Using data from the 2014 School Health Policies and Practices Study, four services (identification or school-based management, tracking, case management, and referrals) were analyzed using a multivariable ordered logistic regression. Approximately 57.2% of schools provided all four, 17.5% provided three, 10.1% provided two, 5.8% provided one, and 9.4% did not provide any such services. Schools with a school nurse were 51.5% (p < .001) more likely to provide all four, and schools with access to consult with a school physician were 15.4% (p < .05) more likely, compared to schools without one. Schools comprised of mostly racial/ethnic minority students (less than or equal to 50% non-Hispanic White) were 14.7% (p < .05) less likely to provide all four, compared to schools with greater than 50% White students.

Trends in the Use of Telehealth During the Emergence of the COVID-19 Pandemic - United States, January-March 2020.

In February 2020, CDC issued guidance advising persons and health care providers in areas affected by the coronavirus disease 2019 (COVID-19) pandemic to adopt social distancing practices, specifically recommending that health care facilities and providers offer clinical services through virtual means such as telehealth.* Telehealth is the use of two-way telecommunications technologies to provide clinical health care through a variety of remote methods.† To examine changes in the frequency of use of telehealth services during the early pandemic period, CDC analyzed deidentified encounter (i.e., visit) data from four of the largest U.S. telehealth providers that offer services in all states.§ Trends in telehealth encounters during January-March 2020 (surveillance weeks 1-13) were compared with encounters occurring during the same weeks in 2019. During the first quarter of 2020, the number of telehealth visits increased by 50%, compared with the same period in 2019, with a 154% increase in visits noted in surveillance week 13 in 2020, compared with the same period in 2019. During January-March 2020, most encounters were from patients seeking care for conditions other than COVID-19. However, the proportion of COVID-19-related encounters significantly increased (from 5.5% to 16.2%; p<0.05) during the last 3 weeks of March 2020 (surveillance weeks 11-13). This marked shift in practice patterns has implications for immediate response efforts and longer-term population health. Continuing telehealth policy changes and regulatory waivers might provide increased access to acute, chronic, primary, and specialty care during and after the pandemic.

Trends in the use of cigarettes, cigars, and marijuana among students with and without asthma, 2003-2017.

Aim: Asthma has symptoms that can be exacerbated by using combustible products such as tobacco and marijuana. This study assessed the prevalence and trends in current use of cigarettes, cigars, and marijuana among U.S. high school students with and without asthma. Methods: The national Youth Risk Behavior Survey (YRBS) is a biennial, school-based, nationally representative survey of U.S. students in grades 9-12. Trends during 2003-2017 in current (past 30-day) use of cigarettes, cigars, and marijuana among students with and without asthma were examined using logistic regression. Asthma was defined as reporting that a doctor or nurse ever told the student they had asthma. T-tests were used to compare cigarette, cigar, and marijuana use by asthma status and year, frequency of use, and student characteristics. Results: During 2003-2017, both current cigarette and cigar smoking decreased (p < 0.05) with rates that were similar among students with and without asthma. There was no significant linear change in current marijuana use, irrespective of asthma status. During most years, cigarette, cigar, and marijuana use were more common among students with asthma than without. In 2017, the most frequent use of cigarettes, cigars, and marijuana was among those with asthma than without. Differences in cigarette, cigar, and marijuana use by asthma status were apparent by demographic subgroups. Conclusions: Given the adverse respiratory effects of tobacco and marijuana smoking, efforts to educate all youth about the dangers of using these substances is critical, particularly among those with asthma.

The Role of School Health Services in Addressing the Needs of Students With Chronic Health Conditions.

Children and adolescents in the United States spend many hours in school. Students with chronic health conditions (CHCs) may face lower academic achievement, increased disability, fewer job opportunities, and limited community interactions as they enter adulthood. School health services provide safe and effective management of CHCs, often for students with limited access to health care. A systematic review to assess the role of school health services in addressing CHCs among students in Grades K-12 was completed using primary, peer-reviewed literature published from 2000 to 2015, on selected conditions: asthma, food allergies, diabetes, seizure disorders, and poor oral health. Thirty-nine articles met the inclusion criteria and results were synthesized; however, 38 were on asthma. Direct access to school nursing and other health services, as well as disease-specific education, improved health and academic outcomes among students with CHCs. Future research needs to include standardized definitions and data collection methods for students with CHCs.

Prevalence and Costs of Five Chronic Conditions in Children.

The objective is to examine the prevalence and health-care costs associated with asthma, epilepsy, hypertension, food allergies, and diabetes in children aged 0-18 years. Prevalence was calculated using 2005-2012 Medical Expenditure Panel Survey (MEPS) data, a population-based, nationally representative sample. Using MEPS, two-part models estimated the cost of each condition for all children while controlling for sociodemographic categories. Prevalence rates varied by race and ethnicity across conditions. Females had higher prevalence of all chronic conditions, except epilepsy. An additional US$1,377.60-US$9,059.49 annually were spent on medical expenses for children aged 0-18 years, with asthma, diabetes, or epilepsy compared to children without these conditions. This is the first study to examine the costs and prevalence of chronic health conditions in children and adolescents using a single data set. Understanding the odds of having a condition by sociodemographic categories highlights disparities that can potentially inform school nurses on the best allocation of resources to serve students.

Disruptions to School and Home Life Among High School Students During the COVID-19 Pandemic - Adolescent Behaviors and Experiences Survey, United States, January-June 2021.

Youths have experienced disruptions to school and home life since the COVID-19 pandemic began in March 2020. During January-June 2021, CDC conducted the Adolescent Behaviors and Experiences Survey (ABES), an online survey of a probability-based, nationally representative sample of U.S. public- and private-school students in grades 9-12 (N = 7,705). ABES data were used to estimate the prevalence of disruptions and adverse experiences during the pandemic, including parental and personal job loss, homelessness, hunger, emotional or physical abuse by a parent or other adult at home, receipt of telemedicine, and difficulty completing schoolwork. Prevalence estimates are presented for all students and by sex, race and ethnicity, grade, sexual identity, and difficulty completing schoolwork. Since the beginning of the pandemic, more than half of students found it more difficult to complete their schoolwork (66%) and experienced emotional abuse by a parent or other adult in their home (55%). Prevalence of emotional and physical abuse by a parent or other adult in the home was highest among students who identified as gay, lesbian, or bisexual (74% emotional abuse and 20% physical abuse) and those who identified as other or questioning (76% and 13%) compared with students who identified as heterosexual (50% and 10%). Overall, students experienced insecurity via parental job loss (29%), personal job loss (22%), and hunger (24%). Disparities by sex and by race and ethnicity also were noted. Understanding health disparities and student disruptions and adverse experiences as interconnected problems can inform school and community initiatives that promote adolescent health and well-being. With community support to provide coordinated, cross-sector programming, schools can facilitate linkages to services that help students address the adverse experiences that they faced during the ongoing COVID-19 pandemic. Public health and health care professionals, communities, schools, families, and adolescents can use these findings to better understand how students' lives have been affected during the pandemic and what challenges need to be addressed to promote adolescent health and well-being during and after the pandemic.

Practices That Support and Sustain Health in Schools: An Analysis of SHPPS Data.

BACKGROUND: The Whole School, Whole Community, Whole Child (WSCC) model provides an organizing framework for schools to develop and implement school health policies, practices, and programs. The purpose of this study was to examine the presence of practices that support school health for each component of the WSCC model in US schools. METHODS: Data from the School Health Policies and Practices Study 2014 were analyzed to determine the percentage of schools with practices in place that support school health for WSCC components. RESULTS: Less than 27% of schools had a school health council that addressed any specific WSCC component, but more than 50% had a coordinator for all but one component. The use of other practices that support school health varied widely across the WSCC components. For example, more than 80% of schools reported family engagement for health education and nutrition environment and services, but less than 50% reported family engagement for other components. CONCLUSIONS: These results indicate that many US schools are using practices that support school health and align with WSCC components, but improvement is needed. These results also highlight discrepancies in the types of practices being used.

The impact of HIPAA authorization on willingness to participate in clinical research.

PURPOSE: This study systematically examined the impact of inclusion of Health Insurance Portability and Accountability Act (HIPAA) authorization on the willingness of African Americans of diverse sociodemographic characteristics to participate in a clinical research study and explored reasons for nonparticipation. METHODS: For a purposive sample of 384 African American outpatients at four metropolitan primary care clinics from August 2005 through May 2006, willingness to participate in a hypothetic clinical research study of an antihypertensive medication under one of two experimental conditions was compared. Interviewees were randomly assigned to undergo informed consent alone (control group) or informed consent with HIPAA authorization (HIPAA group). They were asked whether they would participate and reasons for their decisions. RESULTS: A smaller proportion of interviewees in the HIPAA group were willing to enroll in the study (27% vs. 39%; p = 0.02), with an adjusted odds ratio of 0.56 (95% confidence interval = 0.36-0.91). Those in the HIPAA group were more likely to give reasons related to privacy (p < 0.001), poor understanding of the form (p = 0.01), and mistrust or fear of research (p = 0.04) for nonparticipation. CONCLUSIONS: The inclusion of HIPAA authorization within the informed consent process may adversely affect the willingness of African Americans to participate in clinical research and may raise concerns about privacy, understanding the forms, and mistrust or fear of research.

Improving providers' assessment and management of childhood overweight: results of an intervention.

OBJECTIVE: Pediatric primary care providers' adherence to recommendations for the assessment and management of childhood overweight is low. There are scarce data addressing how to improve provider practices. This study evaluated the effect of provider training and office-based tool dissemination on pediatric providers' assessment and management of childhood overweight. METHODS: Provider practices before and after training and office-based tool dissemination were compared. Participants were resident and faculty providers at 6 urban, community-based primary care clinics affiliated with an academic medical center. Three months after completion of two 1-hour training sessions, clinic sites were provided with tools in bulk, and office staff were coached to distribute the tools during patient encounters. Provider practices were ascertained by medical record abstraction at baseline and at 3 and 6 months. The proportion of medical records with documentation of recommended practices, including recording of body mass index percentile (BMI%), obtaining a nutrition-activity history, and providing nutrition-activity counseling, was compared with chi(2) tests and logistic regression. RESULTS: During the initial 3 months after training, provider documentation of recommended practices did not significantly improve compared with baseline. During the subsequent 3 months, after office-based distribution of tools, provider documentation of recommended practices improved significantly compared with baseline (28.8% vs 11.6% for BMI% [P < .001], 80.2% vs 49.8% for nutrition-activity history [P < .001], and 47.7% vs 33.3% for nutrition-activity counseling [P < .001]). CONCLUSIONS: Pediatric providers' adherence to recommendations for the assessment and management of childhood overweight may improve with provider training linked to the office-based distribution of tools to promote performance of recommendations.

Safety of Second-Dose Single-Antigen Varicella Vaccine.

BACKGROUND AND OBJECTIVE: In 2006, routine 2-dose varicella vaccination for children was recommended to improve control of varicella. We assessed the safety of second-dose varicella vaccination. METHODS: We identified second-dose single-antigen varicella vaccine reports in the Vaccine Adverse Event Reporting System during 2006 to 2014 among children aged 4 to 18 years. We analyzed reports by age group (4-6 and 7-18 years), sex, serious or nonserious status, most common adverse events (AEs), and whether other vaccines were administered concomitantly with varicella vaccine. We reviewed serious reports of selected AEs and conducted empirical Bayesian data mining to detect disproportional reporting of AEs. RESULTS: We identified 14 641 Vaccine Adverse Event Reporting System reports after second-dose varicella vaccination, with 494 (3%) classified as serious. Among nonserious reports, injection site reactions were most common (48% of children aged 4-6 years, 38% of children aged 7-18 years). The most common AEs among serious reports were pyrexia (31%) for children aged 4 to 6 years and headache (28%) and vomiting (27%) for children aged 7 to 18 years. Serious reports of selected AEs included anaphylaxis (83), meningitis (5), encephalitis (16), cellulitis (52), varicella (6), herpes zoster (6), and deaths (7). One immunosuppressed adolescent was reported with vaccine-strain herpes zoster. Only previously known AEs were reported more frequently after second-dose varicella vaccination compared with other vaccines. CONCLUSIONS: We identified no new or unexpected safety concerns for second-dose varicella vaccination. Robust safety monitoring remains an important component of the national varicella vaccination program.

Adverse events following a third dose of measles, mumps, and rubella vaccine in a mumps outbreak.

During a 2009-2010 mumps outbreak in a New York State village, a third dose of measles, mumps, and rubella (MMR) vaccine was administered to children in three schools as a control measure. Information on local and systemic adverse events (AE) was collected by a self-report survey distributed to all children in grades 6-12. A comprehensive search for AE following MMR vaccination was conducted using physician records and the Vaccine Adverse Events Reporting System (VAERS). A literature search was performed for published reports pertaining to AE associated with mumps-containing vaccine, using the Jeryl-Lynn strain, from 1969 to 2011. A total of 1755 individuals received the third dose; 1597 (91.0%) returned the survey. Of those, 115 (7.2%) reported at least one local or systemic AE in the 2 weeks following vaccination. The most commonly reported AE were "pain, redness, or swelling at the injection site" (3.6%) and "joint or muscle aches" (1.8%). No serious AE were reported in the survey, physician records or through VAERS. The proportions of AE found in the present study were lower than or within the range of those reported in prior studies of first- and second-dose MMR vaccine studies. The results of this study suggest that a third dose of MMR vaccine administered in an outbreak setting is safe, with injection site reactions reported more frequently than systemic reactions. However, to assess risk for rare or serious AE after a third dose of MMR vaccine, longer term studies would be required.

Preconsent education about research processes improved African Americans' willingness to participate in clinical research.

OBJECTIVE: To determine whether preconsent education about research processes and protections affects the willingness of African Americans to participate. STUDY DESIGN AND SETTING: This study examined the willingness of 192 African American outpatients (stratified by age, gender, and education) to participate in a hypothetical clinical study under varying consent conditions: phase I participants underwent a typical informed consent process and were asked to indicate whether they would be willing to participate in the hypothetical clinical study and the reasons for their decision; their responses were used to develop a preconsent educational digital video disk (DVD). Phase II participants viewed the DVD before the consent process. We compared the proportion of those who stated they were willing to participate in the clinical study using Fisher's exact tests and used qualitative methods to analyze open-ended responses. RESULTS: When the consent process included education about research processes and protections, significantly more patients reported willingness to participate in the hypothetical clinical study (43% vs. 27%; P=0.002). Patients receiving preconsent education were significantly less likely to cite mistrust, fear of side effects, lack of perceived benefits, and privacy as reasons for not participating. CONCLUSION: Preconsent education may improve the willingness of African Americans to participate in clinical research and may address important concerns about research participation.

Adverse Events Following Trivalent Inactivated Influenza Vaccination in Children: Analysis of the Vaccine Adverse Event Reporting System.

BACKGROUND: The Advisory Committee on Immunization Practices' recommendations for influenza vaccination of children have expanded from the long-standing recommendation to vaccinate high-risk children aged ≥6 months, to vaccinating all 6- to 23-month-olds (2004), 2- to 4-year-olds (2006), and 5- to 18-year-olds (2008). OBJECTIVE: To identify new or unexpected adverse events (AEs) after trivalent inactivated vaccine (TIV) in children. METHODS: We analyzed reports after TIV to the Vaccine Adverse Event Reporting System from 1990-2006 in children aged 2 to 17 years, and from the 2008-2009 influenza season in children aged 5 to 17 years. Empiric Bayesian data mining techniques were used to identify new or unexpected AEs during 1990-2006. RESULTS: During 1990-2006, the Vaccine Adverse Event Reporting System received 2054 reports of children aged 2 to 17 years with a peak in the 2003-2004 influenza season. In 2008-2009, 506 reports describing 5 to 17 year olds were received. The serious reports of tests performed after TIV were approximately 10% of all reports from 2001-2006, and 6% of the reports in the 2008-2009 season. Data mining showed an increased proportion of medication errors and Guillain Barré Syndrome (GBS). The findings of GBS could not be interpreted as causally related to vaccination. Among 201 reports of medication error, 94% had no AE reported other than the medication error itself. CONCLUSION: In this analysis, we found no unexpected AEs. Our review of medication error and GBS reports suggests that ongoing monitoring in these areas is appropriate.