Model Programs for
Hepatitis A, B, and C Prevention


 School-based programs for adolescents 


Houston Middle School Initiative (Texas)

Program name: Houston Middle School Initiative
Population served: Adolescents
Eligibility: 5th and 6th grade students in two Houston area school districts
Region served: Houston, TX
Funding: National Foundation for Infectious Diseases, Episcopal Health Charities, Houston Endowment, GlaxoSmithKline, Texas Department of Health and Human Services, City of Houston Department of Health and Human Services, Saint Luke’s Episcopal Hospital, and other organizational and individual volunteers.
When did program begin?: Project took place during the 1998-2001 school years
Number of clients: Over three years, the program vaccinated about 14,000 students.
Contact: William J. Martone, MD
Senior Executive Director
National Foundation for Infectious Diseases
4733 Bethesda Avenue, Suite 750
Bethesda, MD 20814
Phone: (301) 656-0003
Fax: (301) 907-0878
Website: None


In a public health initiative of hepatitis B education and immunization programs in Houston, Texas middle schools showed that underserved adolescents could be successfully vaccinated through school-based programs. The initiative identified factors associated with and barriers to program participation and receiving a complete vaccine series. A separate survey of fourth graders’ parents of diverse socioeconomic status (SES) found additional potential barriers to this approach.

The Houston middle school initiative was initiated to improve immunization rates among the underserved in Texas, a border state with a large unimmunized population. During the three school years from 1998 through 2001, participating schools in two Houston area school districts offered school-based hepatitis B immunization for 5th or 6th grade students. Participating schools had a high percentage of students from lower socioeconomic levels (as measured by percentages of children receiving free lunch and percentages of "at risk" youth based on school system profiles). The program provided all immunization doses free at school with parental consent. Educational activities included orientation for participating school nurses, a video for students shown in schools, and speaking engagements at parent organizations. One environmental influence was a state school entrance requirement for hepatitis B vaccination by age 12, which took effect in year three of the program.

Sponsored by the NFID, the project received financial and/or indirect support from Episcopal Health Charities (year 1 and year 2), Houston Endowment (year 3), GlaxoSmithKline, the Texas Department of Health and Human Services, the city of Houston Department of Health and Human Services, Saint Luke’s Episcopal Hospital, and other organizational or individual volunteers. program were having Medicaid or private insurance and being female.

Middle School Program Results
Each year the majority of participants received all three doses in the hepatitis B series, and the percentage of those receiving the full series increased each year. Some students received all doses at school, while others had one or two outside of the program. Over three years, the program immunized about 14,000 students. Factors associated with completing the series included race and ethnicity (Latinos 81%, whites 77%, and blacks 69%); Medicaid or private insurance among whites; and being female among Latinos and blacks. Researchers concluded that, since access was equal, cultural differences independent of socioeconomics might affect immunization decisions. More study of these factors is warranted.

Barriers to Participation
The primary barrier to participation was the state requirement that parents sign a consent form for each immunization. Forgotten consent forms and the repeated need for teachers and nurses to collect forms impeded sign-up and scheduling.

In a separate survey regarding hepatitis B immunization consent and site preferences conducted among fourth graders’ parents of diverse socioeconomic status, 27% of parents said they preferred to sign consent for each dose, and almost half wanted to sign all three forms and be present for all immunizations. These preferences remained consistent across all ethnicities and incomes. Addressing parental preferences in a way that does not hinder immunization completion will be an important issue for school-based programs to resolve.

Most parents in both high and low SES groups preferred the school clinic for immunization; however, 36% of parents in the higher income group preferred receiving the vaccination series from a private doctor versus 28% in the lower SES group. Latinos were more likely to prefer the school site.

The survey of parents identified another potential barrier: lack of parental knowledge about hepatitis B and the vaccine. For example, large percentages of parents did not know that hepatitis B is transmitted by unprotected sex (60%), IV drug use (55%), or exposure to infected blood (39%). Almost one in 10 thought you could get the disease from the vaccine.

Although the school requirement for hepatitis B vaccine took effect during the final year of the immunization campaign, the program noticed no difference in the number of children needing immunization. Possible explanations are that no change occurred because it was a new regulation that parents and schools were not familiar with or that the requirement was not well-enforced. Enforcement is an important aspect of improving immunization rates through school requirements.

After discussing the issues related to adolescent and adult immunization among the ethnically diverse populations in the U.S. and Canada, the panelists proposed a number of approaches for achieving full immunization among all populations. In addition to supporting the recommendations of individual presenters, the panel agreed on broad strategic principles and actions to address immunization disparities comprehensively. These recommendations include:

  • Initiate and advocate for government-sponsored adolescent and adult immunization programs that provide infrastructure and support for vaccine purchase, vaccine administration, and educational programs.
  • Develop a clear, harmonized immunization schedule and immunization standards that include all vaccines recommended for adolescents and adults.
    • Where possible, use age-based, universal recommendations rather than risk-based categories. Identifying risk status is more difficult than determining age for providers trying to follow guidelines.
    • Make the standards as simple as possible to facilitate use.
    • Distribute these standards widely to providers to create a standard of practice and provide practical guidance.
  • Encourage the expanded involvement of nontraditional vaccine providers who offer immunizations at convenient sites in the community.
  • Bring government-funded immunization services to institutions housing or serving high-risk or underserved populations. These include:
    • Sexually transmitted disease clinics
    • Prisons
    • Nursing homes and hospitals, where standing orders and prompts might be written
  • Initiate and advocate for state middle school entry immunization requirements for adolescents.
  • Develop educational interventions to improve the knowledge, attitudes, and skills of healthcare providers.
    • Increase provider understanding of and response to the needs, preferences, and cultural issues of underserved adolescent and adult populations.
    • Encourage writers and publishers of medical school textbooks on internal medicine topics to address immunization issues comprehensively.
    • Include outreach to healthcare providers who treat high-risk adolescents and adults they can play an important role in informing their patients about vaccination needs. Also involve obstetricians and gynecologists, who often serve as primary care providers for women.
  • Create educational interventions to improve the knowledge, attitudes, and behaviors of consumers.
    • Target campaigns and materials to underserved audiences to maximize their effectiveness. Make sure products and messages reflect the needs, preferences, and cultural sensitivities of the audience.
    • Create developmentally appropriate materials for adolescents.
  • Increase the use of interventions shown to be effective in increasing immunization rates, such as provider reminders, patient reminder/recall, assessment and feedback, and standing orders.
    • Offer immunization record cards for adults to fill out and keep for reference.
  • Advocate for state insurance commissions to require all medical insurance underwriters to provide coverage for recommended routine vaccinations for adolescents and adults.
  • Conduct pilot projects to evaluate new approaches and use the results to refine programs and strategies; disseminate results to promote wider use of effective programs.
  • Require all medical insurance programs, both public and private, to pay for recommended immunizations for adolescents and adults and to remunerate healthcare providers sufficiently for vaccine services.

  • Immunization Action Coalition

    Hepatitis Prevention Programs

    1573 Selby Avenue, Ste. 234
    St. Paul, MN 55104
    Tel: (651) 647-9009   Fax: (651) 647-9131