On the front lines of flu season

The room behind the screen is surprisingly calm. Three nurses are preparing surgical gloves, stacking cotton wool and organizing paperwork on fold-out tables. A collection of music stands have been pushed to the side of the stage to make room for this impromptu clinic. On the other side of the screen, a cluster of Cleveland Elementary second-graders clutching green forms wait nervously in the school dining hall. Kate Holbrook, equipped with a google-eyed stress ball and a broad smile, waves in her first patient.

Holbrook is an advanced practice public health nurse, and program manager for the school-based flu vaccination program Shoo the Flu. Launched in 2014, the program aims to improve public health and reduce absenteeism in Oakland schools by providing free flu shots to children. Organizers say they expect to vaccinate over 9,000 children this season.

“The only thing predictable about the flu is that it’s unpredictable,” Holbrook said. Flu, also known as influenza, causes symptoms such as fever, chills, cough, headaches and fatigue. While some may only experience a mild illness, flu can in some cases lead to hospitalization or even death. Students’ attendance is disrupted if they get sick and, as flu is highly contagious, parents and teachers are also at risk, increasing the educational and economic burden of the illness.

Flu viruses are most common during the fall and winter, so Shoo the Flu works in schools throughout October and November, before peak flu season. Although it is difficult to know for certain which strain of the virus will be most prevalent each year, the Food and Drug Administration works with the World Health Organization to determine which vaccines are likely to be most effective.

This year, the Centers for Disease Control and Prevention (CDC) has recommended all patients receive their vaccine as a flu shot, rather than as a nasal spray. Last year Shoo the Flu staffers vaccinated 85 percent of participating children with the nasal mist.

Some at the program worried that participation would drop, as parents are less willing to let their child receive a shot in their absence, fearing their child will be upset. But so far, that hasn’t been a problem, Holbrook said. “Actually they’re kind of surprising me,” she said of Oakland students. “They’re kind of doing fine!”

Although Shoo the Flu is not vaccinating pre-schoolers this year because of the change, Holbrook feels the program is set up to alleviate some of the anxieties children experience when getting a shot. “They’re not at a scary doctor’s office. And sometime having parents or siblings around actually makes them more anxious,” she said.

An hour into Shoo the Flu’s morning at Cleveland Elementary, there have been no tears from the kindergartners nor second graders. In the clinic, students are chatting away with the nurses as they prepare each shot.

Holbrook, dressed in a green Shoo the Flu T-shirt and bright yellow pants, trains many of the staff; they are experts at putting their young patients at ease. Nurses welcome the children and keep them engaged in conversation: What are they dressing up as for Halloween? Who’s their favorite Ninja Turtle? Smiling squidgy stress balls provide a distraction, and something for the kids to hold. The screen between the stage and the dining room ensures privacy and stops cases of the nerves from spreading.

Silas Richard, 7, said he was “a little bit scared” before being called behind the screen for his shot, but returned to assure his peers it was all over soon. His classmate Bronwen Cornford was excited to show off her Shoo the Flu sticker: one of the five adorable-looking cartoon flu germs the program uses as teaching aids.

When a nurse calls out, “We’ve got a runner!” it’s a runaway stress ball—not a student.

Adults, too, have popped in to have their flu shots today. Chris Willging had just dropped her sons off at the school when she decided to stop by to get vaccinated. “It’s a lot easier than going to Kaiser and getting a flu shot there,” she said. “It’s great. You know that they get it, and they get it early in the season.”

Whenever there’s a query over a child’s paperwork—an incomplete form or, with the youngest students, difficulty establishing that they have each document matched to the right child—helpers are on hand to call home. Shoo the Flu provides consent forms in six languages, but Holbrook says staffers continually work to improve participation rates in schools where parent literacy or engagement is low. Nursing students who work with the program may attend staff meetings, hand out flyers at school gates, and help parents fill in the necessary paperwork.

Last year, the CDC estimated the flu vaccine prevented 1.9 million illnesses nationwide. However, last November fewer than half of Americans reported having had a flu shot in 2015. Shoo the Flu staff believe their program is especially important, because vaccinating school-age children against the flu works to protect both the children themselves and the wider population.

A report provided by the program cites data which suggests vaccinating 70 percent of schoolchildren is enough to protect an entire community. This is because, in Holbrook’s words, “school-age children are really the super-spreaders of the flu. They have higher attack rates, they carry more virus and shed more virus.”

Dr. Erica Pan, the director of Alameda County Public Health Department’s Division of Communicable Disease Control and Prevention, agreed. She said that children should be vaccinated, as they are more likely to catch the flu due to their high level of social activity at school. Additionally, they also have a better response to the vaccination than their elderly grandparents. Nationally, senior citizens and children under the age of five have the highest rate of hospitalization from flu. So immunizing school-age children protects them, too, by making the virus less abundant and reducing the risk of flu transmission in the community.

Pan noted that flu shots do not guarantee a person won’t get sick. While the shot itself does not cause the flu, it is most effective in those with strong immune systems. There are also many strains of the virus, and it is impossible for the CDC to anticipate which strains will predominate each season.

However, Pan said, “always, always, some protection is certainly better than none.” Ultimately, Pan recommends the flu vaccine “as a parent and as a pediatric infectious disease clinician, and a public health official,” adding, “it’s safe, effective, and something I do for myself and my family every year.”

Shoo the Flu is offered at all Oakland Unified School District elementary schools, while private and charter schools are encouraged to opt-in. Last year 138 schools participated, with between 5 and 67 percent of students at those schools taking part, according to figures from the program.

Shoo the Flu has partnered with the UC Berkeley School of Public Health to evaluate the program’s impact, but Holbrook said there were no results to report yet. Holbrook said lack of parent participation had stalled initial plans to collect primary data, but those at Berkeley hope to study indirect outcomes—such as school absenteeism and general flu surveillance data in Oakland—to evaluate the program’s success. A new survey is currently pending final approval from participating schools.

John Sasaki, director of communications at OUSD, said the district is happy to partner with Shoo the Flu each year. “We want kids in school every day, learning. If they’re sick, they’re not in school,” he said.

Similar school-based programs are being run across the country. Pan cites Japan, the first country to vaccinate schoolchildren against influenza as policy following an epidemic in 1957, as an example of the strategy’s success.

Back at Cleveland Elementary, Holbrook and her team are working their way through another class. The team is practiced; often, it takes their patient longer to choose which sticker to take home than it takes to administer the shot.

But it’s not always easy. At a recent clinic, Holbrook says she saw a high schooler who started cursing because he was so scared. So far today, only one girl has run into the arms of her teacher—and even she, eventually, got her shot.

“Ok, you ready?” Holbrook asks a kindergartner. “One, two, three… You’re so brave! I can’t believe how brave you are!”

The kindergartner looks at his arm, and then up at the nurse holding the empty syringe.

“It tickled!” he giggles.

Correction: On October 25, 2016, an update was made to this story to clarify that children under the age of 5 may be vaccinated against the flu. An update was also made to clarify that Shoo the Flu is not regularly offered to middle and high schools.