Ashley Anne Lowe

Interests

Research

Pediatric Asthma, Women's and Children's Health, Intervention Science

Teaching

Dissemination and Implementation Science, School-based Health, Research Methods

Courses

Scholarly Contributions

Journals/Publications

• Hasan, M., Peterson, M., Waldron, E. K., Mottern, N. L., Pargas, N. T., Gerald, L. B., Lowe, A. A., & Wilson, A. M. (2025). Improving a microbial risk assessment tool with direct feedback from school health staff. Microbial Risk Analysis, 30. doi:10.1016/j.mran.2025.100352
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  Due to the impact of COVID-19, publicly available risk-based tools are becoming increasingly popular. However, subject experts develop most of these tools without consulting end users. Thus, this study aimed to explore users' perceptions, vision, and guidance for microbial risk assessment tool development through focus groups. This tool was intended to assist school health staff in decision-making regarding school respiratory viral outbreaks. Partnering with a school district in the Tucson metropolitan area, we conducted three focus groups with school health staff to gather feedback on a risk tool prototype. We discussed the staff's vision for the tool, their feedback on tool capabilities and design, and how they could leverage tool output for informing decisions, advocating with administration, or educating parents, students, or staff. Focus groups were conducted at the district health office, and the transcripts were analyzed by two researchers using inductively informed themes. Thematic analysis revealed that a comprehensive microbial risk assessment tool must have the potential to manage large amounts of data, scope for incorporation of existing data management systems, have real-time data processing, and produce context-specific recommendations for advocacy. Risk tools can expand personalized risk assessment and management strategies. Directly engaging users will advance microbial risk assessment impact and implementation. In the context of schools, a collaborative, comprehensive, digital and real time microbial risk assessment tool is a timely demand by the school health staff to manage microbial risks.
• Lowe, A. A., Mottern, N., DiGioia, O., Dobbins, D., Ivich, K., Jovich, R., Lindstrom Johnson, S., Park, K., Peters, J., Peterson, M., Ravi, P., Rocha, N., Staab, N., Sunenshine, R., Waldron, E., Ward, J., & Gerald, L. B. (2024). Empowering schools with a novel nurse coach model to implement a county-wide school-based stock albuterol inhaler program. Journal of School Nursing.
• Lowe, A. A., Mottern, N., DiGioia, O., Dobbins, D., Ivich, K., Jovich, R., Lindstrom Johnson, S., Park, K., Peters, J., Peterson, M., Ravi, P., Rocha, N., Staab, N., Sunenshine, R., Waldron, E., Ward, J., & Gerald, L. B. (2025). Breathing Easy in Maricopa County, Arizona: Empowering K-12 Schools With a Novel Nurse Coaching Model to Facilitate Implementation of a County-Wide School-Based Stock Albuterol Inhaler Program. Journal of School Nursing. doi:10.1177/10598405241312129
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  To reduce chronic school absenteeism and morbidity and mortality among school-aged children, the prompt administration of albuterol sulfate in schools remains vital. School-based stock inhaler programs are a practical approach to ensure equitable access to life-saving rescue medication for students. School and community partnerships can potentially strengthen program implementation and fidelity by integrating evidence-based practices into routine care. We report the findings of a novel practice facilitation model developed by the Maricopa County Department of Public Health to facilitate the implementation of the Stock Inhaler for Schools Program in K-12 Schools. Three-hundred twenty-four schools participated in the program, with 153 schools reporting a stock inhaler event for a total of 1,310 events across four school years. Most events (78%) were compliant with the protocol for administering the stock inhaler to a student. These findings suggest that implementing a practice facilitation model is feasible and important for enhancing fidelity to program requirements.
• Lowe, A. A., Ravi, P., Hudson, B., Begay, E., Tso, B., Liu, A. H., Bender, B. G., Gerald, L. B., & King, D. K. (2025). Using document analysis methods and implementation science frameworks to conduct a process evaluation of the community asthma program on the Navajo Nation. Translational Behavioral Medicine, 15(Issue 1). doi:10.1093/tbm/ibaf056
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  Background: Asthma affects approximately 8.2% of United States school-aged children, with a significantly higher prevalence among socioeconomically disadvantaged minority children. Among Diné (Navajo) children living on the Navajo Nation, asthma rates exceed 20%. The community asthma program (CAP) was developed in partnership with the Navajo Nation following a year-long community engagement process. CAP is a 7-year, multicomponent, evidence-based intervention designed to improve asthma management within Indian Health Service facilities and Diné K-12 schools. Purpose: This study evaluates CAP’s implementation processes and outcomes using document analysis, guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) and Consolidated Framework for Implementation Research (CFIR) frameworks. We describe our data sources, coding methods, and their contributions to understanding implementation, as well as discuss strengths, limitations, and implications for process evaluation. Methods: CAP research documents were collected from the 2017 community engagement period through the intervention’s conclusion in 2023. When COVID-19 limited access to implementation settings, additional data sources, including email correspondence and meeting minutes, were analyzed using document analysis to examine activities, experiences, and attitudes related to CAP implementation. Results: Multiple data sources, including RE-AIM forms, staff interviews, and research team documents, identified key process indicators and explanatory factors. While these sources provided valuable context, system- and provider-level fidelity indicators are needed to fully assess intervention reach and quality. Conclusions Findings underscore the importance of collecting process data throughout implementation and leveraging diverse data sources to capture the local implementation context comprehensively. Clinical Trial Information: The Clinical Trials Registration # NCT03377647.
• Lowe, A. A., Ravi, P., Hudson, B., Begay, E., Tso, B., Nez, P., Liu, A. H., Bender, B., Gerald, L. B., & King, D. (2024). Using document analysis methods and implementation science frameworks to conduct a process evaluation of the Community Asthma Program on the Navajo Nation. Chronic Disease Prevention.
• Wilson, A. M., Lowe, A. A., Amoh-Asante, N. A., Zhan, Y., Ashraf, A., & Gerald, L. B. (2025). School-informed risk calculator tool for reducing the spread of respiratory viral infection among school-aged children. Indoor Environments, 2(Issue 2). doi:10.1016/j.indenv.2025.100090
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  School health staff need decision support for responding to respiratory viral outbreaks. Quantitative microbial risk assessment (QMRA) tools are an inexpensive and fast resource. Our objectives were to engage school districts to inform the development of a risk-based calculator tool, test the tool across hypothetical cases, and elicit feedback among school health staff. We administered an online survey for Kindergarten (K) - Grade 5 teachers, school health professionals, and other school staff to gather data about respiratory viral disease interventions and model parameters. A risk calculator tool was developed in which users choose hypothetical scenarios to estimate infection risk per individual and compare interventions. Three case studies (CS) were explored: CS1 – Rhinovirus transmission in a general education classroom with “poor” vs. “great” air quality, CS2 – Influenza A virus transmission in a music classroom with vs. without a portable air purifier, CS3 – SARS-CoV-2 transmission in a special education classroom with vs. without open doors/windows. The prototype tool was presented at a national school nursing meeting, and attendees were surveyed on (dis)likes and anticipated tool uses. For the initial survey of Arizona school personnel (n = 132), the top respiratory viral outbreak strategies reported by teachers were hand (94 %) and surface hygiene (85.1 %). For all case studies, infection risks were above thresholds used in other contexts but were comparable to published student respiratory illness incidence data. At the national meeting, school nurses (n = 12) identified potential uses including advocating for interventions to administrators. This work reflects a unique application of community partnership and QMRA to address school health decision support.
• Bender, B. G., Crooks, J., Gerald, J. K., Hudson, B., King, D. K., Kobernick, A., Liu, A. H., Lowe, A. A., Morgan, W., Nez, P., Phan, H., Wightman, P., & Gerald, L. B. (2024). Childhood asthma exacerbations on the Navajo Nation. The journal of allergy and clinical immunology. In practice, 12(8), 2173-2175.e1.
• Bender, B., Bender, B., Crooks, J., Crooks, J., Gerald, J., Gerald, J., Hudson, B., Hudson, B., King, D., King, D., Kobernick, A., Kobernick, A., Liu, A., Liu, A., Lowe, A., Lowe, A., Morgan, W., Morgan, W., Nez, P., , Nez, P., et al. (2024). Childhood asthma exacerbations on the Navajo Nation. Journal of Allergy and Clinical Immunology: In Practice, 12(8). doi:10.1016/j.jaip.2024.04.044
• Broas, E., Lowe, A. A., Ivich, K., Garcia, M., Ward, J., Hollister, J., & Gerald, L. B. (2024). The Implementation and Evaluation of a Stock Epinephrine for Schools Program in Maricopa County, Arizona. The Journal of school nursing : the official publication of the National Association of School Nurses, 40(6), 641-652.
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  The increasing rate of food allergies in children, combined with the role of food as an integral part of the school day has led to the emergence of anaphylaxis as a daily threat to students, regardless of prior allergy diagnosis. Stock epinephrine-non-patient specific epinephrine auto-injectors that may be used during emergencies-is a means for schools to prepare for anaphylactic events and protect children with allergies. The Maricopa County Department of Public Health initiated the School Surveillance and Medication Program (SSMP), a data capture program, to facilitate the process of stocking epinephrine in schools. Spearheaded by the implementation efforts of the Kyah Rayne Foundation, program enrollment increased 146% between the 2020-2021 and 2021-2022 school years. The increased proportion of schools enrolled in the SSMP and the number of school personnel trained to administer epinephrine demonstrates the feasibility of school-centered stock epinephrine programs and validates strategies for increasing program uptake.
• Broas, E., Lowe, A., Ivich, K., Garcia, M., Ward, J., Hollister, J., & Gerald, L. (2024). The Implementation and Evaluation of a Stock Epinephrine for Schools Program in Maricopa County, Arizona. Journal of School Nursing, 40(6). doi:10.1177/10598405231172957
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  The increasing rate of food allergies in children, combined with the role of food as an integral part of the school day has led to the emergence of anaphylaxis as a daily threat to students, regardless of prior allergy diagnosis. Stock epinephrine—non-patient specific epinephrine auto-injectors that may be used during emergencies—is a means for schools to prepare for anaphylactic events and protect children with allergies. The Maricopa County Department of Public Health initiated the School Surveillance and Medication Program (SSMP), a data capture program, to facilitate the process of stocking epinephrine in schools. Spearheaded by the implementation efforts of the Kyah Rayne Foundation, program enrollment increased 146% between the 2020–2021 and 2021–2022 school years. The increased proportion of schools enrolled in the SSMP and the number of school personnel trained to administer epinephrine demonstrates the feasibility of school-centered stock epinephrine programs and validates strategies for increasing program uptake.
• Grant, L., Whitaker, J. A., Yoon, S. K., Lutrick, K., Bhargava, S., Brown, C. P., Zaragoza, E., Fink, R. V., Meece, J., Wielgosz, K., El Sahly, H., Hegmann, K. T., Lowe, A. A., Southworth, A., Tatum, T., Ball, S. W., Levine, M. Z., Thiese, M. S., Battan-Wraith, S., , Barnes, J., et al. (2024). Relative Effectiveness and Immunogenicity of Quadrivalent Recombinant Influenza Vaccine Versus Egg-Based Inactivated Influenza Vaccine Among Adults Aged 18-64 Years: Results and Experience From a Randomized, Double-Blind Trial. Open forum infectious diseases, 11(10), ofae559.
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  Immunogenicity studies suggest that recombinant influenza vaccine (RIV) may provide better protection against influenza than standard-dose inactivated influenza vaccines (SD IIV). This randomized trial evaluated the relative vaccine effectiveness (VE) and immunogenicity of RIV versus SD IIV in frontline workers and students aged 18-64 years.
• Grant, L., Whitaker, J., Yoon, S., Lutrick, K., Bhargava, S., Brown, C., Zaragoza, E., Fink, R., Meece, J., Wielgosz, K., El Sahly, H., Hegmann, K., Lowe, A., Southworth, A., Tatum, T., Ball, S., Levine, M., Thiese, M., Battan-Wraith, S., , Barnes, J., et al. (2024). Relative Effectiveness and Immunogenicity of Quadrivalent Recombinant Influenza Vaccine Versus Egg-Based Inactivated Influenza Vaccine Among Adults Aged 18-64 Years: Results and Experience From a Randomized, Double-Blind Trial. Open Forum Infectious Diseases, 11(10). doi:10.1093/ofid/ofae559
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  Background: Immunogenicity studies suggest that recombinant influenza vaccine (RIV) may provide better protection against influenza than standard-dose inactivated influenza vaccines (SD IIV). This randomized trial evaluated the relative vaccine effectiveness (VE) and immunogenicity of RIV versus SD IIV in frontline workers and students aged 18-64 years. Methods: Participants were randomized to receive RIV or SD IIV and followed for reverse-transcription polymerase chain reaction (RT-PCR)-confirmed influenza during the 2022-2023 influenza season. Sera were collected from a subset of participants before and at 1 and 6 months postvaccination and tested by hemagglutination inhibition for A/H1N1, A/H3N2, B/Yamagata, and B/Victoria and against cell-grown vaccine reference viruses for A/H1N1 and A/H3N2. Results: Overall, 3988 participants were enrolled and vaccinated (25% of the trial sample size goal); RT-PCR-confirmed influenza occurred in 20 of 1963 RIV recipients and 28 of 1964 SD IIV recipients. Relative VE was 29% (95% confidence interval [CI], -26% to 60%). In the immunogenicity substudy (n = 118), the geometric mean titer ratio (GMTR) comparing RIV to SD IIV at 1 month was 2.3 (95% CI, 1.4-3.7) for cell-grown A/H1N1, 2.1 (95% CI, 1.3-3.4) for cell-grown A/H3N2, 1.1 (95% CI,. 7-1.6) for B/Victoria, and 1.4 (95% CI,. 9-2.0) for B/Yamagata. At 6 months, GMTRs were >1 against A/H1N1, A/H3N2, and B/Yamagata. Conclusions: Relative VE of RIV compared to SD IIV did not reach statistical significance, but RIV elicited more robust humoral immune responses to 2 of 4 vaccine viruses at 1 month and 3 of 4 viruses at 6 months after vaccination, suggesting possible improved and sustained immune protection from RIV.
• Lowe, A. A., Gerald, J. K., Clemens, C., & Gerald, L. B. (2024). Compliance to a Standardized Protocol for Stock Albuterol Medication among School Staff. The Journal of school nursing : the official publication of the National Association of School Nurses, 40(6), 630-640.
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  A stock inhaler program provided access to rescue medication (albuterol sulfate) for school children. School staff were provided with a standardized protocol for medication administration. We hypothesized licensed nurses were more likely to report compliant events compared to unlicensed school staff. Stock inhaler events were defined as either compliant or non-compliant. A school protocol compliance score was calculated using the total number of compliant events divided by the total number of all events. The protocol for administration indicated 4 puffs for mild respiratory distress and 8 puffs for severe respiratory distress; therefore, events were defined as compliant if the dose of medication was divisible by 4. A Cragg Poisson hurdle regression was used to examine the association between compliance score and school staff experience. One-hundred fifty-two schools reported 999 stock inhaler events. Of these events, 28% were compliant and 72% of events were non-compliant. After controlling for school organizational type, grades served, and school size, school staff experience was not predictive of protocol compliance. Future efforts should focus on improving protocol compliance among licensed nurses and unlicensed school staff.
• Lowe, A., Gerald, J., Clemens, C., & Gerald, L. (2024). Compliance to a Standardized Protocol for Stock Albuterol Medication among School Staff. Journal of School Nursing, 40(6). doi:10.1177/10598405221128053
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  A stock inhaler program provided access to rescue medication (albuterol sulfate) for school children. School staff were provided with a standardized protocol for medication administration. We hypothesized licensed nurses were more likely to report compliant events compared to unlicensed school staff. Stock inhaler events were defined as either compliant or non-compliant. A school protocol compliance score was calculated using the total number of compliant events divided by the total number of all events. The protocol for administration indicated 4 puffs for mild respiratory distress and 8 puffs for severe respiratory distress; therefore, events were defined as compliant if the dose of medication was divisible by 4. A Cragg Poisson hurdle regression was used to examine the association between compliance score and school staff experience. One-hundred fifty-two schools reported 999 stock inhaler events. Of these events, 28% were compliant and 72% of events were non-compliant. After controlling for school organizational type, grades served, and school size, school staff experience was not predictive of protocol compliance. Future efforts should focus on improving protocol compliance among licensed nurses and unlicensed school staff.
• Ravi, P., Muralidhar, K., Ngaybe, M. G., Nanjaiah, S., Jayakrishna, P., Lowe, A. A., Krupp, K., Wilson, A. M., von Hippel, F. A., Chen, Z., Gerald, L. B., & Madhivanan, P. (2024). Qualitative Study to Explore the Occupational and Reproductive Health Challenges among Women Tobacco Farm Laborers in Mysore District, India. International journal of environmental research and public health, 21(5).
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  Tobacco farm laborers are primarily women and children working for very low wages. The aim of this study was to explore occupational and reproductive health challenges faced by women tobacco farm laborers in Mysore District, India. We conducted interviews and six focus group discussions among 41 women tobacco farm laborers. Codes and themes were generated based on deductive and inductive approaches using the socioecological model. Participants reported symptoms of green tobacco sickness including headaches, back pain, gastric problems, weakness, and allergies during menstruation, pre-natal, and post-natal periods. Participants had poor awareness about the health effects of tobacco farming, and there were gender inequalities in wages and the use of personal protective equipment. Participants received support from family and community health workers during their pregnancy and post-natal period. Women reported wanting maternity benefits from the tobacco board, as well as monetary support and nutritional supplements. There is a need for health education about the environmental dangers of tobacco among farm laborers, and more supportive policies for women farmworkers during pregnancy and post-natal periods.
• Ravi, P., Muralidhar, K., Ngaybe, M., Nanjaiah, S., Jayakrishna, P., Lowe, A., Krupp, K., Wilson, A., von Hippel, F., Chen, Z., Gerald, L., & Madhivanan, P. (2024). Qualitative Study to Explore the Occupational and Reproductive Health Challenges among Women Tobacco Farm Laborers in Mysore District, India. International Journal of Environmental Research and Public Health, 21(5). doi:10.3390/ijerph21050606
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  Tobacco farm laborers are primarily women and children working for very low wages. The aim of this study was to explore occupational and reproductive health challenges faced by women tobacco farm laborers in Mysore District, India. We conducted interviews and six focus group discussions among 41 women tobacco farm laborers. Codes and themes were generated based on deductive and inductive approaches using the socioecological model. Participants reported symptoms of green tobacco sickness including headaches, back pain, gastric problems, weakness, and allergies during menstruation, pre-natal, and post-natal periods. Participants had poor awareness about the health effects of tobacco farming, and there were gender inequalities in wages and the use of personal protective equipment. Participants received support from family and community health workers during their pregnancy and post-natal period. Women reported wanting maternity benefits from the tobacco board, as well as monetary support and nutritional supplements. There is a need for health education about the environmental dangers of tobacco among farm laborers, and more supportive policies for women farmworkers during pregnancy and post-natal periods.
• Ellingson, K. D., Hollister, J., Porter, C. J., Khan, S. M., Feldstein, L. R., Naleway, A. L., Gaglani, M., Caban-Martinez, A. J., Tyner, H. L., Lowe, A. A., Olsho, L. E., Meece, J., Yoon, S. K., Mak, J., Kuntz, J. L., Solle, N. S., Respet, K., Baccam, Z., Wesley, M. G., , Thiese, M. S., et al. (2023). Risk Factors for Reinfection with SARS-CoV-2 Omicron Variant among Previously Infected Frontline Workers. Emerging infectious diseases, 29(3), 599-604.
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  In a cohort of essential workers in the United States previously infected with SARS-CoV-2, risk factors for reinfection included being unvaccinated, infrequent mask use, time since first infection, and being non-Hispanic Black. Protecting workers from reinfection requires a multipronged approach including up-to-date vaccination, mask use as recommended, and reduction in underlying health disparities.
• Gerald, L. B., Simmons, B., Lowe, A. A., Liu, A. H., Nez, P., Begay, E., & Bender, B. (2023). COVID-19 on the Navajo Nation: experiences of Diné families of children with asthma. The Journal of asthma : official journal of the Association for the Care of Asthma, 60(3), 565-573.
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  The first case of COVID-19 on the Navajo Nation (NN) was found on March 17, 2020. Even with strong public health efforts, NN saw the highest per capita infection rate in the US during May of 2020 with 2450/100,000. To determine the impact of COVID-19 on families of children with asthma on the NN, families participating in the NHLBI funded Community Asthma Program were contacted to see if they would share their experiences.
• Gerald, L., Simmons, B., Lowe, A., Liu, A., Nez, P., Begay, E., & Bender, B. (2023). COVID-19 on the Navajo Nation: experiences of Diné families of children with asthma. Journal of Asthma, 60(3). doi:10.1080/02770903.2022.2073550
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  Objective: The first case of COVID-19 on the Navajo Nation (NN) was found on March 17, 2020. Even with strong public health efforts, NN saw the highest per capita infection rate in the US during May of 2020 with 2450/100,000. To determine the impact of COVID-19 on families of children with asthma on the NN, families participating in the NHLBI funded Community Asthma Program were contacted to see if they would share their experiences. Methods: Sixty-six of 193 families (34%) were interviewed. Results: The average age of the child with asthma was 13.5 (SD = 3.9) and 33% were female. Most Diné children with asthma in our study did not contract COVID-19. However, the pandemic had a significant impact on them and their families. Many family members contracted COVID-19, some children lost family members, and half of interviewed parents reported a decline in their child’s mental health. Twenty-five percent of families sought the help of a traditional healer. Many accessed medical care through telehealth and most were able to obtain asthma medications when needed. Conclusions: Despite significant challenges, our research indicated resilience among Navajo families.
• Herring, M. K., Romine, J. K., Wesley, M. G., Ellingson, K. D., Yoon, S. K., Caban-Martinez, A. J., Meece, J., Gaglani, M., Grant, L., Olsho, L. E., Tyner, H. L., Naleway, A. L., Khan, S. M., Phillips, A. L., Solle, N. S., Rose, S., Mak, J., Fuller, S. B., Hunt, A., , Kuntz, J. L., et al. (2023). Severe Acute Respiratory Syndrome Coronavirus 2 Infection History and Antibody Response to 3 Coronavirus Disease 2019 Messenger RNA Vaccine Doses. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America, 76(10), 1822-1831.
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  Data on antibody kinetics are limited among individuals previously infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). From a cohort of healthcare personnel and other frontline workers in 6 US states, we assessed antibody waning after messenger RNA (mRNA) dose 2 and response to dose 3 according to SARS-CoV-2 infection history.
• Wilson, A. M., Ravi, P., Pargas, N. T., Gerald, L. B., & Lowe, A. A. (2023). School health systems under strain: an example of COVID-19 experiences & burnout among school health staff in Pima County, Arizona. BMC public health, 23(1), 1626.
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  School health staff lead and provide a variety of care for children in schools. As school districts have navigated the COVID-19 pandemic, school health staff have faced unprecedented challenges in protecting the health of students and school staff. Our objective was to qualitatively characterize these pandemic challenges and experiences of school health staff in Pima County, Arizona to identify gaps in school health staff support for improving future emergency preparedness.
• Wilson, A., Ravi, P., Pargas, N., Gerald, L., & Lowe, A. (2023). School health systems under strain: an example of COVID-19 experiences & burnout among school health staff in Pima County, Arizona. BMC Public Health, 23(1). doi:10.1186/s12889-023-16532-8
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  Background: School health staff lead and provide a variety of care for children in schools. As school districts have navigated the COVID-19 pandemic, school health staff have faced unprecedented challenges in protecting the health of students and school staff. Our objective was to qualitatively characterize these pandemic challenges and experiences of school health staff in Pima County, Arizona to identify gaps in school health staff support for improving future emergency preparedness. Methods: We conducted two focus group discussions (FGDs) with 48 school health staff in Pima County, Arizona in two school districts using a discussion guide including ten open-ended questions. The FGDs were audio recorded and transcribed verbatim. We used the socioecological model (SEM) to organize the thematic analysis and generate codes and themes; data were analyzed using Atlas.ti software. Findings: The pandemic has significantly challenged school health staff with new pandemic-related job tasks: managing isolation, vaccination, and developing/implementing new and evolving COVID-19 guidelines. School health staff also reported increased stress related to interactions with parents and school administration as well as frustrations with rapid changes to guidance from the health department and policy makers. A common issue was not having enough staff or resources to complete regular job responsibilities, such as providing care for students with non-COVID-19 related health issues. Conclusions: Increased workload for school health staff resulted in physical burnout, mental distress, and disruption of core functions with long term implications for children’s health. These focus groups highlight the need for improved emergency preparedness in schools during pandemics or infectious disease outbreaks. These include basic infrastructure changes (e.g., personnel support from health departments for tasks such as contact tracing to enable school nurses to continue core functions), and increased funding to allow for hazard pay and more school health personnel during emergency situations. In addition, basic school health infrastructure is lacking, and we should include a licensed school health nurse in every school.
• Burns, J., Rivers, P., LeClair, L. B., Jovel, K. S., Rai, R. P., Lowe, A. A., Edwards, L. J., Khan, S. M., Mathenge, C., Ferraris, M., Kuntz, J. L., Lamberte, J. M., Hegmann, K. T., Odean, M. J., McLeland-Wieser, H., Beitel, S., Odame-Bamfo, L., Schaefer Solle, N., Mak, J., , Phillips, A. L., et al. (2022). Pediatric Research Observing Trends and Exposures in COVID-19 Timelines (PROTECT): Protocol for a Multisite Longitudinal Cohort Study. JMIR research protocols, 11(7), e37929.
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  Assessing the real-world effectiveness of COVID-19 vaccines and understanding the incidence and severity of SARS-CoV-2 illness in children are essential to inform policy and guide health care professionals in advising parents and caregivers of children who test positive for SARS-CoV-2.
• Burns, J., Rivers, P., LeClair, L. B., Jovel, K. S., Rai, R. P., Lowe, A. A., Edwards, L. J., Khan, S. M., Mathenge, C., Ferraris, M., Kuntz, J. L., Lamberte, J. M., Hegmann, K. T., Odean, M. J., McLeland-Wieser, H., Beitel, S., Odame-Bamfo, L., Solle, N. S., Mak, J., , Phillips, A. L., et al. (2022). Pediatric Research Observing Trends and Exposures in COVID-19 Timelines (PROTECT): Protocol for a Multisite Longitudinal Cohort Study. JMIR Research Protocols, 11(Issue 7). doi:10.2196/37929
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  Background: Assessing the real-world effectiveness of COVID-19 vaccines and understanding the incidence and severity of SARS-CoV-2 illness in children are essential to inform policy and guide health care professionals in advising parents and caregivers of children who test positive for SARS-CoV-2. Objective: This report describes the objectives and methods for conducting the Pediatric Research Observing Trends and Exposures in COVID-19 Timelines (PROTECT) study. PROTECT is a longitudinal prospective pediatric cohort study designed to estimate SARS-CoV-2 incidence and COVID-19 vaccine effectiveness (VE) against infection among children aged 6 months to 17 years, as well as differences in SARS-CoV-2 infection and vaccine response between children and adolescents. Methods: The PROTECT multisite network was initiated in July 2021, which aims to enroll approximately 2305 children across four US locations and collect data over a 2-year surveillance period. The enrollment target was based on prospective power calculations and accounts for expected attrition and nonresponse. Study sites recruit parents and legal guardians of age-eligible children participating in the existing Arizona Healthcare, Emergency Response, and Other Essential Workers Surveillance (HEROES)-Research on the Epidemiology of SARS-CoV-2 in Essential Response Personnel (RECOVER) network as well as from surrounding communities. Child demographics, medical history, COVID-19 exposure, vaccination history, and parents/legal guardians' knowledge and attitudes about COVID-19 are collected at baseline and throughout the study. Mid-turbinate nasal specimens are self-collected or collected by parents/legal guardians weekly, regardless of symptoms, for SARS-CoV-2 and influenza testing via reverse transcription-polymerase chain reaction (RT-PCR) assay, and the presence of COVID-like illness (CLI) is reported. Children who test positive for SARS-CoV-2 or influenza, or report CLI are monitored weekly by online surveys to report exposure and medical utilization until no longer ill. Children, with permission of their parents/legal guardians, may elect to contribute blood at enrollment, following SARS-CoV-2 infection, following COVID-19 vaccination, and at the end of the study period. PROTECT uses electronic medical record (EMR) linkages where available, and verifies COVID-19 and influenza vaccinations through EMR or state vaccine registries. Results: Data collection began in July 2021 and is expected to continue through the spring of 2023. As of April 13, 2022, 2371 children are enrolled in PROTECT. Enrollment is ongoing at all study sites. Conclusions: As COVID-19 vaccine products are authorized for use in pediatric populations, PROTECT study data will provide real-world estimates of VE in preventing infection. In addition, this prospective cohort provides a unique opportunity to further understand SARS-CoV-2 incidence, clinical course, and key knowledge gaps that may inform public health.
• Clemens, C., Gaither, C., Gerald, L. B., Gerald, J. K., & Lowe, A. A. (2022). Medication Administration Practices in United States' Schools: A Systematic Review and Meta-synthesis.. The Journal of school nursing : the official publication of the National Association of School Nurses, 38(1), 21-34. doi:10.1177/10598405211026300
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  Schools often provide medication management to children at school, yet, most U.S. schools lack a full-time, licensed nurse. Schools rely heavily on unlicensed assistive personnel (UAP) to perform such tasks. This systematic review examined medication management among K-12 school nurses. Keyword searches in three databases were performed. We included studies that examined: (a) K-12 charter, private/parochial, or public schools, (b) UAPs and licensed nurses, (c) policies and practices for medication management, or (d) nurse delegation laws. Three concepts were synthesized: (a) level of training, (b) nurse delegation, and (c) emergency medications. One-hundred twelve articles were screened. Of these, 37.5% (42/112) were comprehensively reviewed. Eighty-one percent discussed level of training, 69% nurse delegation, and 57% emergency medications. Succinct and consistent policies within and across the United States aimed at increasing access to emergency medications in schools remain necessary.
• Clemens, C., Gerald, L. B., Gerald, J. K., & Lowe, A. A. (2022). Compliance to a Standardized Protocol for Stock Albuterol Medication among School Staff. The Journal of School Nursing, 105984052211280. doi:10.1177/10598405221128053
• Fowlkes, A. L., Yoon, S. K., Lutrick, K., Gwynn, L., Burns, J., Grant, L., Phillips, A. L., Ellingson, K., Ferraris, M. V., LeClair, L. B., Mathenge, C., Yoo, Y. M., Thiese, M. S., Gerald, L. B., Solle, N. S., Jeddy, Z., Odame-Bamfo, L., Mak, J., Hegmann, K. T., , Gerald, J. K., et al. (2022). Effectiveness of 2-Dose BNT162b2 (Pfizer BioNTech) mRNA Vaccine in Preventing SARS-CoV-2 Infection Among Children Aged 5-11 Years and Adolescents Aged 12-15 Years - PROTECT Cohort, July 2021-February 2022. MMWR. Morbidity and mortality weekly report, 71(11), 422-428.
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  The BNT162b2 (Pfizer-BioNTech) mRNA COVID-19 vaccine was recommended by CDC's Advisory Committee on Immunization Practices for persons aged 12-15 years (referred to as adolescents in this report) on May 12, 2021, and for children aged 5-11 years on November 2, 2021 (1-4). Real-world data on vaccine effectiveness (VE) in these age groups are needed, especially because when the B.1.1.529 (Omicron) variant became predominant in the United States in December 2021, early investigations of VE demonstrated a decline in protection against symptomatic infection for adolescents aged 12-15 years and adults* (5). The PROTECT prospective cohort of 1,364 children and adolescents aged 5-15 years was tested weekly for SARS-CoV-2, irrespective of symptoms, and upon COVID-19-associated illness during July 25, 2021-February 12, 2022. Among unvaccinated participants (i.e., those who had received no COVID-19 vaccine doses) with any laboratory-confirmed SARS-CoV-2 infection, those with B.1.617.2 (Delta) variant infections were more likely to report COVID-19 symptoms (66%) than were those with Omicron infections (49%). Among fully vaccinated children aged 5-11 years, VE against any symptomatic and asymptomatic Omicron infection 14-82 days (the longest interval after dose 2 in this age group) after receipt of dose 2 of the Pfizer-BioNTech vaccine was 31% (95% CI = 9%-48%), adjusted for sociodemographic characteristics, health information, frequency of social contact, mask use, location, and local virus circulation. Among adolescents aged 12-15 years, adjusted VE 14-149 days after dose 2 was 87% (95% CI = 49%-97%) against symptomatic and asymptomatic Delta infection and 59% (95% CI = 22%-79%) against Omicron infection. Fully vaccinated participants with Omicron infection spent an average of one half day less sick in bed than did unvaccinated participants with Omicron infection. All eligible children and adolescents should remain up to date with recommended COVID-19 vaccinations.
• Fowlkes, A., Yoon, S., Lutrick, K., Gwynn, L., Burns, J., Grant, L., Phillips, A., Ellingson, K., Ferraris, M., LeClair, L., Mathenge, C., Yoo, Y., Thiese, M., Gerald, L., Solle, N., Jeddy, Z., Odame-Bamfo, L., Mak, J., Hegmann, K., , Gerald, J., et al. (2022). Effectiveness of 2-Dose BNT162b2 (Pfizer BioNTech) mRNA Vaccine in Preventing SARS-CoV-2 Infection Among Children Aged 5–11 Years and Adolescents Aged 12–15 Years — PROTECT Cohort, July 2021–February 2022. Morbidity and Mortality Weekly Report, 71(11). doi:10.15585/mmwr.mm7111e1
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  The BNT162b2 (Pfizer-BioNTech) mRNA COVID-19 vaccine was recommended by CDC’s Advisory Committee on Immunization Practices for persons aged 12–15 years (referred to as adolescents in this report) on May 12, 2021, and for children aged 5–11 years on November 2, 2021 (1–4). Realworld data on vaccine effectiveness (VE) in these age groups are needed, especially because when the B.1.1.529 (Omicron) variant became predominant in the United States in December 2021, early investigations of VE demonstrated a decline in protection against symptomatic infection for adolescents aged 12–15 years and adults* (5). The PROTECT† prospective cohort of 1,364 children and adolescents aged 5–15 years was tested weekly for SARS-CoV-2, irrespective of symptoms, and upon COVID-19–associated illness during July 25, 2021–February 12, 2022. Among unvaccinated participants (i.e., those who had received no COVID-19 vaccine doses) with any laboratory-confirmed SARS-CoV-2 infection, those with B.1.617.2 (Delta) variant infections were more likely to report COVID-19 symptoms (66%) than were those with Omicron infections (49%). Among fully vaccinated children aged 5–11 years, VE against any symptomatic and asymptomatic Omicron infection 14–82 days (the longest interval after dose 2 in this age group) after receipt of dose 2 of the Pfizer-BioNTech vaccine was 31% (95% CI = 9%–48%), adjusted for sociodemographic characteristics, health information, frequency of social contact, mask use, location, and local virus circulation. Among adolescents aged 12–15 years, adjusted VE 14–149 days after dose 2 was 87% (95% CI = 49%–97%) against symptomatic and asymptomatic Delta infection and 59% (95% CI = 22%–79%) against Omicron infection. Fully vaccinated participants with Omicron infection spent an average of one half day less sick in bed than did unvaccinated participants with Omicron infection. All eligible children and adolescents should remain up to date with recommended COVID-19 vaccinations.
• Gerald, L. B., Hall‐Lipsy, E., Lowe, A. A., Nash, B., O'Shaughnessy, S., Phan, H., & Volerman, A. (2022). School Stock Inhaler Statutes and Regulations in the United States: A Systematic Review*. Journal of School Health, 92(4), 396-405. doi:10.1111/josh.13142
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  BACKGROUND: Children with asthma should have immediate access to rescue medication. Yet,
• Gerald, L. B., Lowe, A. A., Ravi, P., & Wilson, A. M. (2022). The Changing Job of School Nurses during the COVID-19 Pandemic: A Media Content Analysis of Contributions to Stress. Annals of Work Exposures and Health, 67(1), 101-117. doi:10.1093/annweh/wxac053
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  School nurses and unlicensed assistive personnel (UAPs) are essential to the health and wellness of school children. However, most US schools do not have a full-time licensed nurse. During the COVID-19 pandemic, school nurses and UAPs have been integral in ensuring that the health needs of students were met. They have seen a marked increase in their responsibilities included implementing COVID-19 mitigation strategies, screening for symptoms, testing students and staff, conducting contact tracing and data collection, and ensuring the implementation of rapidly changing COVID-19 guidelines and protocols for schools. The objective of this study was to explore COVID-19 occupational changes and their contributions to stress among school nurses and UAPs through a content analysis of local and national media articles. A Google search of articles published between February 2020 and September 2021 was conducted using the following search terms: ‘school nurse’, ‘COVID-19’, ‘health aide’, ‘stress’, and ‘experiences’. A search was also conducted in Nexis Uni. Articles were included if the topic discussed school nurses or UAPs and COVID-19. All articles that examined nurses in other settings were excluded from the review. We examined topics and themes temporally (from February 2020 to September 2021) and spatially (i.e. the frequency by US state). Overall, 496 media articles discussing school nurses and COVID-19 were included in our review. The highest volume of articles was from September 2021 (22%, 111/496). Other months with relatively high volume of articles included August 2020 (9%, 43/496), January 2021 (10%, 47/496), February 2021 (9%, 44/496), and August 2021 (8%, 39/496). These larger article volumes coincided with notable COVID-19 events, including returning to school in the fall (August 2020 and August 2021), school nurses assisting with vaccine rollouts among adults in the USA (January/February 2021), concerns regarding the delta variant (August/September 2021), and vaccine rollouts for children ages 12–15 (September 2021). The representation of articles spatially (national, state, regional, or local) was 66 (13%) articles at national level, 217 (44%) state level, 25 (5%) regional level, and 188 (38%) local news at the city and/or village level. Pennsylvania had the highest frequency of articles, but when standardized to the state population, Alaska had the highest rate of media per 100 000 people. Three major themes were identified in our analysis: (i) safety; (ii) pandemic-related fatigue/stress; and (iii) nursing shortage/budget. The most represented theme for articles before September 2021 was that of safety. Over time, the themes of pandemic-related fatigue/stress and nursing shortage/budget increased with the most notable increase being in September 2021. The COVID-19 pandemic has resulted in new occupational risks, burdens, and stressors experienced by school nurses and UAPs. School nurses play a critical role in disease surveillance, disaster preparedness, wellness and chronic disease prevention interventions, immunizations, mental health screening, and chronic disease education. Furthermore, they provide a safety net for our most vulnerable children. Given that school nurses were already over-burdened and under-resourced prior to the pandemic, characterization of these new burdens and stressors will inform emergency preparedness resources for school health personnel during future pandemics or outbreaks.
• Lowe, A. A., Gerald, J. K., Clemens, C., & Gerald, L. B. (2022). School-based Stock Inhaler Programs and Neighborhood Disadvantage. Journal of health care for the poor and underserved, 33(2), 1083-1093.
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  Ensuring students with asthma residing in disadvantaged communities have access to rescue medication (albuterol) is important.
• Lowe, A. A., Gerald, J. K., Clemens, C., Gaither, C., & Gerald, L. B. (2022). Medication Administration Practices in United States' Schools: A Systematic Review and Meta-synthesis. The Journal of school nursing : the official publication of the National Association of School Nurses, 38(1), 21-34.
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  Schools often provide medication management to children at school, yet, most U.S. schools lack a full-time, licensed nurse. Schools rely heavily on unlicensed assistive personnel (UAP) to perform such tasks. This systematic review examined medication management among K-12 school nurses. Keyword searches in three databases were performed. We included studies that examined: (a) K-12 charter, private/parochial, or public schools, (b) UAPs and licensed nurses, (c) policies and practices for medication management, or (d) nurse delegation laws. Three concepts were synthesized: (a) level of training, (b) nurse delegation, and (c) emergency medications. One-hundred twelve articles were screened. Of these, 37.5% (42/112) were comprehensively reviewed. Eighty-one percent discussed level of training, 69% nurse delegation, and 57% emergency medications. Succinct and consistent policies within and across the United States aimed at increasing access to emergency medications in schools remain necessary.
• Lowe, A. A., Onge, I. S., & Trivedi, M. (2022). Updates in school-based asthma management. Current Opinion in Allergy & Clinical Immunology, 23(2), 119-131. doi:10.1097/aci.0000000000000883
• Lowe, A. A., Phan, H., Hall-Lipsy, E., O'Shaughnessy, S., Nash, B., Volerman, A., & Gerald, L. B. (2022). School Stock Inhaler Statutes and Regulations in the United States: A Systematic Review. The Journal of school health, 92(4), 396-405.
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  Children with asthma should have immediate access to rescue medication. Yet,
• Lowe, A. A., Simmons, B., Nez, P., Begay, E., Liu, A., King, D., Gerald, J. K., Aaron, K., Wightman, P., Solomon, T., Crooks, J., Phan, H., Morgan, W., Bender, B., & Gerald, L. B. (2022). An asthma collaboration to reduce childhood asthma disparities on the Navajo Nation: Trial protocol for the Community Asthma Program. Public health in practice (Oxford, England), 4, 100289.
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  Navajo children disproportionately experience poor asthma outcomes. Following a one-year community engagement period with key stakeholders from the Navajo Nation, the Community Asthma Program (CAP) was created using evidenced based programs with the goal of reducing asthma disparities among Navajo children. CAP is being evaluated with a six-year, multi-site step-wedge design in three Navajo communities: Tuba City, Chinle and Fort Defiance, Arizona. The primary outcome is asthma exacerbations defined as use of systemic oral corticosteroids, asthma hospitalizations, asthma related ED visits, and ICU admissions. Asthma exacerbations will be measured using data from the electronic medical records of the three community health care centers. Secondary outcomes include will changes in asthma-related events and asthma control. The RE-AIM ( , 2 , 3) , 4) , and 5) ) framework is being used to guide the implementation evaluation which includes iterative collection and analysis of process data to identify facilitators and barriers, describe relevant organizational contexts, and inform strategies for dissemination. The CAP intervention requires community engagement and participation, building community capacity, incorporating evidenced-based guidelines and practices while ensuring program strategies actively involve Navajo community members during all steps of the intervention. The outcome of this trial will allow us to determine the effectiveness of a multi-component, community-focused intervention to improve asthma in a tribal community.
• Lowe, A., Lowe, A., Simmons, B., Simmons, B., Nez, P., Nez, P., Begay, E., Begay, E., Liu, A., Liu, A., King, D., King, D., Gerald, J., Gerald, J., Aaron, K., Aaron, K., Wightman, P., Wightman, P., Solomon, T., , Solomon, T., et al. (2022). An asthma collaboration to reduce childhood asthma disparities on the Navajo Nation: Trial protocol for the Community Asthma Program. Public Health in Practice, 4. doi:10.1016/j.puhip.2022.100289
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  Navajo children disproportionately experience poor asthma outcomes. Following a one-year community engagement period with key stakeholders from the Navajo Nation, the Community Asthma Program (CAP) was created using evidenced based programs with the goal of reducing asthma disparities among Navajo children. CAP is being evaluated with a six-year, multi-site step-wedge design in three Navajo communities: Tuba City, Chinle and Fort Defiance, Arizona. The primary outcome is asthma exacerbations defined as use of systemic oral corticosteroids, asthma hospitalizations, asthma related ED visits, and ICU admissions. Asthma exacerbations will be measured using data from the electronic medical records of the three community health care centers. Secondary outcomes include will changes in asthma-related events and asthma control. The RE-AIM (Reach and representativeness, 2) Effectiveness, 3) Adoption, 4) Implementation, and 5) Maintenance) framework is being used to guide the implementation evaluation which includes iterative collection and analysis of process data to identify facilitators and barriers, describe relevant organizational contexts, and inform strategies for dissemination. The CAP intervention requires community engagement and participation, building community capacity, incorporating evidenced-based guidelines and practices while ensuring program strategies actively involve Navajo community members during all steps of the intervention. The outcome of this trial will allow us to determine the effectiveness of a multi-component, community-focused intervention to improve asthma in a tribal community.
• Lutrick, K., Fowlkes, A., Rivers, P., Herder, K., Santibanez, T. A., LeClair, L., Groover, K., Lamberte, J. M., Grant, L., Odame-Bamfo, L., Ferraris, M. V., Phillips, A. L., Sokol, B., Lowe, A. A., Mathenge, C., Pubillones, F. A., Cottam, B., McLeland-Wieser, H., Jovel, K. S., , Ochoa, J. S., et al. (2022). Parental Intentions and Perceptions Toward COVID-19 Vaccination Among Children Aged 4 Months to 4 Years - PROTECT Cohort, Four States, July 2021-May 2022. MMWR. Morbidity and mortality weekly report, 71(35), 1109-1114.
• Lutrick, K., Fowlkes, A., Rivers, P., Herder, K., Santibanez, T., LeClair, L., Groover, K., Lamberte, J., Grant, L., Odame-Bamfo, L., Ferraris, M., Phillips, A., Sokol, B., Lowe, A., Mathenge, C., Pubillones, F., Cottam, B., McLeland-Wieser, H., Jovel, K., , Ochoa, J., et al. (2022). Parental Intentions and Perceptions Toward COVID-19 Vaccination Among Children Aged 4 Months to 4 Years — PROTECT Cohort, Four States, July 2021–May 2022. Morbidity and Mortality Weekly Report, 71(35). doi:10.15585/mmwr.mm7135a2
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  Approximately 12 million children and adolescents aged ≤18 years in the United States have been infected with SARS-CoV-2, the virus that causes COVID-19, since December 2019,* and COVID-19–associated hospitalization rates increased among children aged
• Wilson, A. M., Ogunseye, O. O., DiGioia, O., Gerald, L. B., & Lowe, A. A. (2022). Barriers to COVID-19 Intervention Implementation in K-5 Classrooms: A Survey of Teachers from a District with Mask Mandates despite a Statewide Mask Mandate Ban. International journal of environmental research and public health, 19(14).
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  The study objective was to characterize K-5 teachers' risk perceptions and experiences with CDC COVID-19 classroom guidance in an Arizona school district with a mask mandate, conflicting with a statewide mask mandate ban.
• Wilson, A., Ogunseye, O., Digioia, O., Gerald, L., & Lowe, A. (2022). Barriers to COVID-19 Intervention Implementation in K-5 Classrooms: A Survey of Teachers from a District with Mask Mandates despite a Statewide Mask Mandate Ban. International Journal of Environmental Research and Public Health, 19(14). doi:10.3390/ijerph19148311
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  The study objective was to characterize K-5 teachers’ risk perceptions and experiences with CDC COVID-19 classroom guidance in an Arizona school district with a mask mandate, conflicting with a statewide mask mandate ban. Methods: Public school teachers (n = 111) were recruited between 14 December 2021, and 31 January 2022, for an anonymous online survey with questions on seven important topics related to: (1) population demographics, (2) teachers’ perceptions of COVID-19 in the workplace, (3) masks, (4) physical distancing, (5) surface transmission routes, (6) air flow, and (7) contact tracing protocols. Descriptive statistics were calculated, and statistically significant differences in categorical responses by grade level taught were investigated with Fisher’s exact test. Results: There were 76 complete responses. No significant differences across grade levels were found. More than half (53%, 43/81) reported not feeling protected from occupational COVID-19 exposure. Lack of mask usage/enforcement was the most frequently listed reason (40%, 17/42). Physical distancing barriers included large student-teacher ratios. Conclusions: Consistent mask guidance at state and local levels, increased financial support, and lower student-teacher ratios may improve the implementation of CDC guidance for classrooms. Conflicting statewide and district-level school mask policies may negatively impact teachers’ risk perceptions.
• Denninghoff, K., Gerald, L. B., Gerald, J. K., Guthrie, C., Klein, E., Lowe, A., Morrison, A., Startup, E., & VanBuren, J. (2021). Randomized Trial of the Feasibility of ED-Initiated School-Based Asthma Medication Supervision (ED-SAMS). Pilot and Feasibility Studies, 7(1), 179. doi:10.21203/rs.3.rs-657980/v1
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  Background: While using an inhaled corticosteroid (ICS) in the weeks after an ED visit reduces repeat visits, few children receive a needed prescription. Because a prescription may not be filled or used, dispensing ICS at discharge and supervising its use at school could overcome both barriers until follow-up care is established. To assess the feasibility of such an intervention, we conducted a pilot study among elementary-age school children with persistent asthma who were discharged from the ED following an asthma exacerbation. Methods: Eligible children were randomly assigned to ED-dispensing of ICS with home supervision or ED-dispensing of ICS with home and school supervision. The primary outcomes were ability to recruit and retain participants, ability to initiate school-supervised medication administration within 5 days of discharge, and participant satisfaction. Results: Despite identifying 437 potentially eligible children, only 13 (3%) were enrolled with 6 being randomized to the intervention group and 7 to the control group. Eleven (85%) randomized participants completed the 90-day interview (primary outcome) and 8 (62%) completed the 120-day interview (safety endpoint). Four (67%) intervention participants started their school regimen within 5 business days and 2 started within 6 business days. Conclusion: While our pilot study did not meet its recruitment goal, it did achieve its primary purpose of assessing feasibility before undertaking a larger, more intensive study. Several major recruitment barriers need to be mitigated before EDs can successfully partner with schools to establish supervised ICS treatment.
• Gerald, L. B., Gerald, J. K., VanBuren, J. M., Lowe, A., Guthrie, C. C., Klein, E. J., Morrison, A., Startup, E., & Denninghoff, K. (2021). Randomized trial of the feasibility of ED-initiated school-based asthma medication supervision (ED-SAMS). Pilot and feasibility studies, 7(1), 179.
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  While using an inhaled corticosteroid (ICS) in the weeks after an ED visit reduces repeat visits, few children receive a needed prescription. Because a prescription may not be filled or used, dispensing ICS at discharge and supervising its use at school could overcome both barriers until follow-up care is established. To assess the feasibility of such an intervention, we conducted a pilot study among elementary-age school children with persistent asthma who were discharged from the ED following an asthma exacerbation.
• Gerald, L., Gerald, J., VanBuren, J., Lowe, A., Guthrie, C., Klein, E., Morrison, A., Startup, E., & Denninghoff, K. (2021). Randomized trial of the feasibility of ED-initiated school-based asthma medication supervision (ED-SAMS). Pilot and Feasibility Studies, 7(1). doi:10.1186/s40814-021-00913-0
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  Background: While using an inhaled corticosteroid (ICS) in the weeks after an ED visit reduces repeat visits, few children receive a needed prescription. Because a prescription may not be filled or used, dispensing ICS at discharge and supervising its use at school could overcome both barriers until follow-up care is established. To assess the feasibility of such an intervention, we conducted a pilot study among elementary-age school children with persistent asthma who were discharged from the ED following an asthma exacerbation. Methods: Eligible children were randomly assigned to ED-dispensing of ICS with home supervision or ED-dispensing of ICS with home and school supervision. The primary outcomes were ability to recruit and retain participants, ability to initiate school-supervised medication administration within 5 days of discharge, and participant satisfaction. Results: Despite identifying 437 potentially eligible children, only 13 (3%) were enrolled with 6 being randomized to the intervention group and 7 to the control group. Eleven (85%) randomized participants completed the 90-day interview (primary outcome) and 8 (62%) completed the 120-day interview (safety endpoint). Four (67%) intervention participants started their school regimen within 5 business days and 2 started within 6 business days. Conclusion: While our pilot study did not meet its recruitment goal, it did achieve its primary purpose of assessing feasibility before undertaking a larger, more intensive study. Several major recruitment barriers need to be mitigated before EDs can successfully partner with schools to establish supervised ICS treatment. Trial registration: ClinicalTrials.gov, NCT03952286. Registered 16 May 2019.
• Lowe, A. A., Gerald, J. K., Clemens, C. J., Stern, D. A., & Gerald, L. B. (2021). Managing respiratory emergencies at school: A county-wide stock inhaler program. The Journal of allergy and clinical immunology, 148(2), 420-427.e5.
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  A total of 15 states allow schools to manage respiratory emergencies among multiple students by using a single albuterol inhaler (stock inhaler) paired with a disposable holding chamber.
• Lowe, A., Gerald, J., Clemens, C., Stern, D., & Gerald, L. (2021). Managing respiratory emergencies at school: A county-wide stock inhaler program. Journal of Allergy and Clinical Immunology, 148(2). doi:10.1016/j.jaci.2021.01.028
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  Background: A total of 15 states allow schools to manage respiratory emergencies among multiple students by using a single albuterol inhaler (stock inhaler) paired with a disposable holding chamber. Objective: Our aim was to evaluate implementation barriers and facilitators, as well as satisfaction with a stock inhaler program across K through12 schools in Pima County, Arizona. Methods: All public, charter, private, and parochial schools were offered supplies, web-based training, and technical assistance at no cost. The RE-AIM (Reach, Effectiveness, Adoption, Implementation and Maintenance) framework was used to evaluate program implementation. School documentation logs were reviewed, school health personnel were surveyed, and a convenience sample of health personnel were interviewed. Chi-square tests evaluated categoric outcomes and Poisson hurdle regression examined stock inhaler use by school organization type, grade levels served, and type of school health personnel employed. Results: In all, 229 schools (68%) participated, reaching 82% of students in the county. A total of 152 schools (66%) used a stock inhaler, accounting for 1038 events. The mean number of puffs administered was 2.7 (SD = 1.2) per event, and most events (79%) involved students with asthma. Although most events (83.9%) resulted in the student returning to class, 15.6% resulted in students being sent home. Only 6 events resulted in 911 calls, and 5 of these led to an ambulance transport. School health personnel reported high levels of satisfaction, and all schools renewed participation for a second year. Program costs were $156 per school. Conclusion: With technical assistance, stock inhaler programs can be feasibly implemented by schools in a wide range of settings, thereby increasing their capacity to safely manage respiratory emergencies.
• Lutrick, K., Rivers, P., Yoo, Y. M., Grant, L., Hollister, J., Jovel, K., Khan, S., Lowe, A., Baccam, Z., Hanson, H., Olsho, L. E., Fowlkes, A., Caban-Martinez, A. J., Porter, C., Yoon, S., Meece, J., Gaglani, M., Burns, J., Mayo Lamberte, J., , Nakayima Miiro, F., et al. (2021). Interim Estimate of Vaccine Effectiveness of BNT162b2 (Pfizer-BioNTech) Vaccine in Preventing SARS-CoV-2 Infection Among Adolescents Aged 12-17 Years - Arizona, July-December 2021. MMWR. Morbidity and mortality weekly report, 70(5152), 1761-1765.
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  The BNT162b2 (Pfizer-BioNTech) mRNA COVID-19 vaccine has demonstrated high efficacy in preventing infection with SARS-CoV-2 (the virus that causes COVID-19) in randomized placebo-controlled Phase III trials in persons aged 12-17 years (referred to as adolescents in this report) (1); however, data on real-word vaccine effectiveness (VE) among adolescents are limited (1-3). As of December 2021, the Pfizer-BioNTech vaccine is approved by the Food and Drug Administration (FDA) for adolescents aged 16-17 years and under FDA emergency use authorization for those aged 12-15 years. In a prospective cohort in Arizona, 243 adolescents aged 12-17 years were tested for SARS-CoV-2 by reverse transcription-polymerase chain reaction (RT-PCR) each week, irrespective of symptoms, and upon onset of COVID-19-like illness during July 25-December 4, 2021; the SARS-CoV-2 B.1.617.2 (Delta) variant was the predominant strain during this study period. During the study, 190 adolescents contributed fully vaccinated person-time (≥14 days after receiving 2 doses of Pfizer-BioNTech vaccine), 30 contributed partially vaccinated person-time (receipt of 1 dose or receipt of 2 doses but with the second dose completed
• Lutrick, K., Rivers, P., Yoo, Y., Grant, L., Hollister, J., Jovel, K., Khan, S., Lowe, A., Baccam, Z., Hanson, H., Olsho, L., Fowlkes, A., Caban-Martinez, A., Porter, C., Yoon, S., Meece, J., Gaglani, M., Burns, J., Lamberte, J., , Miiro, F., et al. (2021). Interim Estimate of Vaccine Effectiveness of BNT162b2 (Pfizer-BioNTech) Vaccine in Preventing SARS-CoV-2 Infection Among Adolescents Aged 12–17 Years — Arizona, July–December 2021. Morbidity and Mortality Weekly Report, 70(5152). doi:10.15585/MMWR.MM705152A2
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  What is already known about this topic? The Pfizer-BioNTech COVID-19 vaccine has been shown to be effective in preventing SARS-CoV-2 infection in adolescents in randomized placebo-controlled Phase III trials. What is added by this report? A prospective cohort of 243 adolescents aged 12–17 years in Arizona completed weekly SARS-CoV-2 testing by nasal swab for 19 consecutive weeks. Under real-world conditions, vaccine effectiveness of full immunization (completion of the second in a 2-dose series ≥14 days earlier) was 92% against SARS-CoV-2 infections irrespective of symptom status. What are the implications for public health practice? In real-world conditions among adolescents aged 12–17 years, the Pfizer-BioNTech vaccine was highly effective in preventing SARS-CoV-2 infection.
• Volerman, A., Lowe, A. A., Pappalardo, A. A., Anderson, C. M., Blake, K. V., Bryant-Stephens, T., Carr, T., Carter, H., Cicutto, L., Gerald, J. K., Miller, T., Moore, N. S., Phan, H., Sadreameli, S. C., Tanner, A., Winders, T. A., & Gerald, L. B. (2021). Ensuring Access to Albuterol in Schools: From Policy to Implementation. An Official ATS/AANMA/ALA/NASN Policy Statement. American journal of respiratory and critical care medicine, 204(5), 508-522.
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  For children with asthma, access to quick-relief medications is critical to minimizing morbidity and mortality. An innovative and practical approach to ensure access at school is to maintain a supply of stock albuterol that can be used by any student who experiences respiratory distress. To make this possible, state laws allowing for stock albuterol are needed to improve medication access. To provide policy recommendations and outline steps for passing and implementing stock albuterol laws. We assembled a diverse stakeholder group and reviewed guidelines, literature, statutes, regulations, and implementation documents related to school-based medication access. Stakeholders were divided into two groups-legislation and implementation-on the basis of expertise. Each group met virtually to review documents and draft recommendations. Recommendations were compiled and revised in iterative remote meetings with all stakeholders. We offer several recommendations for crafting state legislation and facilitating program implementation. ) Create a coalition of stakeholders to champion legislation and implement stock albuterol programs. The coalition should include school administrators, school nurses and health personnel, parents, or caregivers of children with asthma, pediatric primary care and subspecialty providers (e.g., pulmonologists/allergists), pharmacists, health department staff, and local/regional/national advocacy organizations. ) Legislative components critical for effective implementation of stock albuterol programs include specifying that medication can be administered in good faith to any child in respiratory distress, establishing training requirements for school staff, providing immunity from civil liability for staff and prescribers, ensuring pharmacy laws allow prescriptions to be dispensed to schools, and suggesting inhalers with valved holding chambers/spacers for administration. ) Select an experienced and committed legislator to sponsor legislation and guide revisions as needed during passage and implementation. This person should be from the majority party and serve on the legislature's health or education committee. ) Develop plans to disseminate legislation and regulations/policies to affected groups, including school administrators, school nurses, pharmacists, emergency responders, and primary/subspecialty clinicians. Periodically evaluate implementation effectiveness and need for adjustments. Stock albuterol in schools is a safe, practical, and potentially life-saving option for children with asthma, whether asthma is diagnosed or undiagnosed, who lack access to their personal quick-relief medication. Legislation is imperative for aiding in the adoption and implementation of school stock albuterol policies, and key policy inclusions can lay the groundwork for success. Future work should focus on passing legislation in all states, implementing policy in schools, and evaluating the impact of such programs on academic and health outcomes.
• Volerman, A., Lowe, A., Gerald, L., Anderson, C., Blake, K., Bryant-Stephens, T., Carr, T., Carter, H., Cicutto, L., Gerald, J., Jefferson, J., Miller, T., Moore, N., Pappalardo, A., Phan, H., Sadreameli, S., Tanner, A., & Winders, T. (2021). Ensuring access to albuterol in schools: From policy to implementation an official ATS/AANMA/ALA/NASN policy statement. American Journal of Respiratory and Critical Care Medicine, 204(5). doi:10.1164/rccm.202106-1550ST
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  Rationale: For children with asthma, access to quick-relief medications is critical to minimizing morbidity and mortality. An innovative and practical approach to ensure access at school is to maintain a supply of stock albuterol that can be used by any student who experiences respiratory distress. To make this possible, state laws allowing for stock albuterol are needed to improve medication access. Objectives: To provide policy recommendations and outline steps for passing and implementing stock albuterol laws. Methods: We assembled a diverse stakeholder group and reviewed guidelines, literature, statutes, regulations, and implementation documents related to school-based medication access. Stakeholders were divided into two groups-legislation and implementation-on the basis of expertise. Each group met virtually to review documents and draft recommendations. Recommendations were compiled and revised in iterative remote meetings with all stakeholders. Main Results: We offer several recommendations for crafting state legislation and facilitating program implementation. 1) Create a coalition of stakeholders to champion legislation and implement stock albuterol programs. The coalition should include school administrators, school nurses and health personnel, parents, or caregivers of children with asthma, pediatric primary care and subspecialty providers (e.g., pulmonologists/allergists), pharmacists, health department staff, and local/regional/national advocacy organizations. 2) Legislative components critical for effective implementation of stock albuterol programs include specifying that medication can be administered in good faith to any child in respiratory distress, establishing training requirements for school staff, providing immunity from civil liability for staff and prescribers, ensuring pharmacy laws allow prescriptions to be dispensed to schools, and suggesting inhalers with valved holding chambers/spacers for administration. 3) Select an experienced and committed legislator to sponsor legislation and guide revisions as needed during passage and implementation. This person should be from the majority party and serve on the legislature's health or education committee. 4) Develop plans to disseminate legislation and regulations/policies to affected groups, including school administrators, school nurses, pharmacists, emergency responders, and primary/subspecialty clinicians. Periodically evaluate implementation effectiveness and need for adjustments. Conclusions: Stock albuterol in schools is a safe, practical, and potentially life-saving option for children with asthma, whether asthma is diagnosed or undiagnosed, who lack access to their personal quick-relief medication. Legislation is imperative for aiding in the adoption and implementation of school stock albuterol policies, and key policy inclusions can lay the groundwork for success. Future work should focus on passing legislation in all states, implementing policy in schools, and evaluating the impact of such programs on academic and health outcomes.
• Lowe, A. A., Bender, B. G., Gerald, L. B., Kobernick, A. K., Kobernick, A., Liu, A. H., Morgan, W. J., & Solomon, T. G. (2018). Environmental Concerns for Children with Asthma on the Navajo Nation.. Annals of the American Thoracic Society, 15(6), 745-753. doi:10.1513/annalsats.201708-674ps
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  Navajo children living on the reservation have high rates of asthma prevalence and severity. Environmental influences may contribute to asthma on the Navajo Nation and are inadequately understood..We performed a comprehensive, integrative literature review to determine the environmental factors that may contribute to increased asthma prevalence and severity among Navajo children living on the reservation..A systematic search was conducted in four databases regarding the environmental risk factors for asthma in Navajo children living on the reservation. Relevant studies between 1990 and 2017 were examined. Nonexperimental literature was also integrated into the review to describe the environmental injustices that have historically, disproportionately, and systematically affected the Navajo people, thus contributing to respiratory disparities among Navajo children..Eight studies met inclusion criteria for systematic review; however, limited research regarding environmental risk factors specific to asthma and Navajo children living on the reservation was identified. Our integrative review indicated both indoor and outdoor environmental risk factors commonly found on the Navajo reservation appear to be important determinants of asthma..Future research should examine indoor and outdoor air pollution from wood-burning stoves and cook stoves, coal combustion, tobacco and traditional ceremonial smoke, diesel exhaust exposure from long bus rides, indoor allergens, ambient pollutants, and regional dusts. Comprehensive mitigation efforts created in partnership with the Navajo Nation are necessary to address less-recognized risk factors as well as the common risk factors known to contribute to increased childhood asthma prevalence and severity.
• Lowe, A. A., Bender, B., Liu, A. H., Solomon, T., Kobernick, A., Morgan, W., & Gerald, L. B. (2018). Environmental Concerns for Children with Asthma on the Navajo Nation. Annals of the American Thoracic Society, 15(6), 745-753.
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  Navajo children living on the reservation have high rates of asthma prevalence and severity. Environmental influences may contribute to asthma on the Navajo Nation and are inadequately understood.

Proceedings Publications

• Ravi, P., Lowe, A., Simmons, B., Begay, E., Nez, P., Liu, A., Bender, B., Gerald, L., & King, D. (2023, Spring). Findings From the Process Evaluation of the Community Asthma Program on the Navajo Nation. In American Thoracic Society.
• Ye, M., Curiel, C., Lynn, G., Butler, A., Long, D., Cortes, D., Nederveld, A., Colvin, J., Krishnan, J., Lowe, A., & Thakur, N. (2023, Spring). COVID-19 Pandemic-associated Socioeconomic Vulnerability and Challenges to Isolation Across the United States. In American Thoracic Society.
• Begay, E., Bender, B., Gerald, L., Liu, A., Lowe, A., Nez, P., & Simmons, B. (2022, Spring). COVID-19 on the Navajo Nation: Experiences of Dine Families of Children with Asthma. In American Thoracic Society's International Conference.
• Clemens, C., Gerald, L., Gerald, J., & Lowe, A. (2021). Neighborhood Disadvantage and Respiratory Emergencies at School. In American Thoracic Society.
• Begay, C., Bender, B. G., Gerald, L. B., Gerald, J. K., Jim, S., Jones, C., Lee, A., Liu, A. H., Lowe, A. A., & Todacheenie, S. (2020). Indoor Environmental Exposures and Asthma Control Among Navajo Children in Tuba City, Arizona - NNHRRB Approval #NNR-16.247. In B102. CARING FOR LUNG DISEASES IN UNDERSERVED AND VULNERABLE POPULATIONS.
• Begay, C., Bender, B. G., Gerald, L. B., Gerald, J. K., Jim, S., Jones, C., Lee, A., Liu, A. H., Lowe, A. A., Lowe, A. A., & Todacheenie, S. (2020). Indoor Environmental Exposures and Asthma Control Among Navajo Children in Tuba City, Arizona - NNHRRB Approval #NNR-16.247. In American Thoracic Society.
• Lowe, A. A., Begay, J., Bender, B. G., Black, S., Gerald, L. B., Gerald, J. K., & Phan, H. (2019). Caregiver Reported Asthma Outcomes of School-Age Navajo Children in Tuba City, Arizona. In B102. DISPARITIES IN ASTHMA MANAGEMENT.
• Lowe, A. A., Clemens, C. J., Gerald, L. B., & Gerald, J. K. (2019). Implementation of a County-Wide Stock Inhaler for Schools Program in Pima County, Arizona. In B102. DISPARITIES IN ASTHMA MANAGEMENT.

Reviews

• Lowe, A. A., Onge, I. S., & Trivedi, M. (2023. Updates in school-based asthma management(pp 119-131).
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  School-based asthma management is an important component of pediatric asthma care that has the potential to provide more universal evidence-based asthma care to children and mitigate asthma-related health inequities. The purpose of this review is to highlight relevant developments in school-based asthma management over the past 2 years.
• Lowe, A. A., Ravi, P., Gerald, L. B., & Wilson, A. M. (2023. The Changing Job of School Nurses during the COVID-19 Pandemic: A Media Content Analysis of Contributions to Stress(pp 101-117).
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  School nurses and unlicensed assistive personnel (UAPs) are essential to the health and wellness of school children. However, most US schools do not have a full-time licensed nurse. During the COVID-19 pandemic, school nurses and UAPs have been integral in ensuring that the health needs of students were met. They have seen a marked increase in their responsibilities included implementing COVID-19 mitigation strategies, screening for symptoms, testing students and staff, conducting contact tracing and data collection, and ensuring the implementation of rapidly changing COVID-19 guidelines and protocols for schools. The objective of this study was to explore COVID-19 occupational changes and their contributions to stress among school nurses and UAPs through a content analysis of local and national media articles. A Google search of articles published between February 2020 and September 2021 was conducted using the following search terms: 'school nurse', 'COVID-19', 'health aide', 'stress', and 'experiences'. A search was also conducted in Nexis Uni. Articles were included if the topic discussed school nurses or UAPs and COVID-19. All articles that examined nurses in other settings were excluded from the review. We examined topics and themes temporally (from February 2020 to September 2021) and spatially (i.e. the frequency by US state). Overall, 496 media articles discussing school nurses and COVID-19 were included in our review. The highest volume of articles was from September 2021 (22%, 111/496). Other months with relatively high volume of articles included August 2020 (9%, 43/496), January 2021 (10%, 47/496), February 2021 (9%, 44/496), and August 2021 (8%, 39/496). These larger article volumes coincided with notable COVID-19 events, including returning to school in the fall (August 2020 and August 2021), school nurses assisting with vaccine rollouts among adults in the USA (January/February 2021), concerns regarding the delta variant (August/September 2021), and vaccine rollouts for children ages 12-15 (September 2021). The representation of articles spatially (national, state, regional, or local) was 66 (13%) articles at national level, 217 (44%) state level, 25 (5%) regional level, and 188 (38%) local news at the city and/or village level. Pennsylvania had the highest frequency of articles, but when standardized to the state population, Alaska had the highest rate of media per 100 000 people. Three major themes were identified in our analysis: (i) safety; (ii) pandemic-related fatigue/stress; and (iii) nursing shortage/budget. The most represented theme for articles before September 2021 was that of safety. Over time, the themes of pandemic-related fatigue/stress and nursing shortage/budget increased with the most notable increase being in September 2021. The COVID-19 pandemic has resulted in new occupational risks, burdens, and stressors experienced by school nurses and UAPs. School nurses play a critical role in disease surveillance, disaster preparedness, wellness and chronic disease prevention interventions, immunizations, mental health screening, and chronic disease education. Furthermore, they provide a safety net for our most vulnerable children. Given that school nurses were already over-burdened and under-resourced prior to the pandemic, characterization of these new burdens and stressors will inform emergency preparedness resources for school health personnel during future pandemics or outbreaks.