School Health Services Update: June 13, 2019

Dear Colleagues,

Many schools are already finished for the year and many more are ending this week and next.  This is the final MDPH Email Update for the 2018-2019 School Year and the final MDPH Email Update from me as the Director of School Health Services!  As you know, I am retiring as of June 28th as well as Janet Burke, Medication Administration Program Coordinator, who also retires the end of the month!

Working with each of you has been such a wonderful experience, and I will cherish the memories forever. Life is fleeting, so I have decided to retire and leave behind the workforce (and the daily commute to Boston!) so I can enjoy reading, biking, walking the beach and watching my grandchildren grow up (after I catch up on my sleep!). I have worked as a school nurse for over 25 years, and although these have been some of the best years of my life, I am looking forward to the next chapter.  I wish I could personally thank each one of you for the support and guidance you have given me while we worked together. I have grown personally and professionally in this role, and am very gratified with the work I have done here at the Department, the privilege I have had serving students and families, the honor to work with school health personnel across the state, my fortune to learn with colleagues at DPH and the departmental changes I have helped to effect. I have thoroughly enjoyed my time and I have been honored and humbled to work with all of you.  I do hope that we will all keep in touch.

After July 1, 2019, Jill Clark, the Director of the Division of Child/Adolescent and Reproductive Health, will be the contact for the School Health Unit until new staff are onboard.  The hiring process for all three Unit positions, the Director of School Health Services, the School Health Coordinator and the Medication Administration Program Coordinator is currently underway.  Please feel free to contact Jill at with any concerns and questions in the interim.

Remember that we all do better when we all do better!  Thank you again for your support and for helping us all to serve our children better!

I wish you all the best!

Mary Ann


SHIELD School Nurse Leadership Institute: Advocate. Inspire. Change

School nurses from across the state participated in the second annual School Nurse Leadership Institute at Boston University!  A warm thank you to Beverly Heinz-Lacey, RN, MPH, Director of SHIELD and Leslie Tellalian, MSEd, Director of Lifelong Learning at the BU School of Public Health for their expert coordination and facilitation of this program. This leadership program included school nurses, public health nurses and nurses from school-based healthcenters; these nurses have worked together to develop a shared vision for moving school nursing forward in Massachusetts!  It was an opportunity to support and celebrate one another while creating a learning community.  Speakers included public health faculty from the Boston University School of Public Health as well as such notable nursing leaders as Karen Daley, PhD, RN, FAAN, Past President of the American Nurses Association, and Erin Maughan, Erin Maughan, PhD, MS, RN, PHNA-BC, FNASN, FAAN, Director of Research at NASN!  I encourage all of you to consider participating in this leadership program in the future…remember ALL school nurses are leaders and the experts in health in their schools!

School Nurse professionals from SHIELD were in the spotlight this week as the Population Health Exchange School Nurse Leadership Institute was underway.

In this picture, Boston University School of Public Health professor, Jacey Greece, DSc, MPH, discusses planning successful methods of practical application to school nursing leaders from across the state!

Congratulations to School Nurses who will be presenting the SBIRT in Schools model at the School Nurses International Conference in Sweden this summer!

Rita Casper, RN, MBA, Director of Nursing for the Andover Public Schools, Doreen Crowe, Doreen Crowe, MEd, BSN, RN, Director of Nursing Services, Wilmington Public Schools, Cathy Riccio, Cathy J Riccio BSN,  MS, MSN, RN, Nurse Leader for the Newburyport Public Schools and Shanyn A Toulouse, MEd, BSN, RN, NCSN, Northeast Regional School Nurse Consultant, (all members of the first cohort, the Nurse Empowerment Team at the SHIELD School Nurse Leadership Institute) will be headed to Sweden this summer to present on the success of SBIRT in their districts!

We wish them safe travels, much learning and great fun!

DESE Update: June 7th, 2019

By Andree EntezariJune 11th, 2019in DESE Updates
1. Dual Language Program Training:

The Department is sponsoring two identical two-day trainings for district and school leaders who are considering establishing a dual language program in their district or school.  The first training will be June 24 and 25 at Bridgewater State University, and the second will June 26 and 27 at Hudson High School. Registration is open online at the links above. Anyone with questions can email Phyllis Hardy, executive director of the Multistate Association for Bilingual Education, Northeast at using the subject line “Implementing DLE District Leadership Training”.

Picture of the Week:
On June 7, DESE recognized 57 Schools of Recognition at the State House. Here, Commissioner Riley presents the team from Winship Elementary in Boston with their certificate.

3. Reminder about Distinguished Teachers and Principals:

The Department keeps a file of distinguished teachers and principals for consideration for membership on advisory boards and on task forces and as candidates for special recognition programs. While DESE has a rich base of veteran educators represented in the current group, the agency would like to increase representation from educators who have at least five years of experience but who are at the earlier end of their career. The list would also benefit from additional educators who work in secondary schools. If anyone you know fits that description, please use this form to provide confidential and specific information about them. Please keep this recommendation confidential and do not share it with the individual or collaborate with a colleague to complete it. Please submit the form by June 14.

4. Influence 100 Reminder:

The Department is launching Influence 100, an initiative to increase the racial and ethnic diversity of superintendents in Massachusetts, create more culturally responsive districts and leaders across the state, and promote better outcomes for students. Influence 100 includes a fellowship program for qualified educators who desire to move into the superintendent role in the next five years, and the initiative also includes support for school districts to become more culturally responsive and diversify their educator workforce.  The application deadline is June 14, and DESE will announce the pilot districts by June 30. The application takes between 45 and 90 minutes to complete. For more information, please go to:

  • Family engagement specialist wanted: The Department is looking to hire a family engagement specialist to coordinate DESE’s family engagement work, including efforts to build internal capacity to help districts and schools engage with families. The specialist will also support implementation of the Statewide Family Engagement Center Grant. The position is expected to be a five-year, federally-funded, full-time positions with benefits. The Department is seeking a strong and diverse pool of candidates and will begin reviewing applications on June 18.
  • Condition of Education 2019: Last month, the National Center for Education Statistics released its annual “Condition of Education” report. The “At a Glance” and “Highlights” sections make it easier to find information on specific topics.
  • Behavioral health system listening sessions: This summer, the Executive Office of Health and Human Services invites the public to attend listening sessions and inform the design of a behavioral health ambulatory treatment system that will better address the treatment needs of patients and their families, whether those needs relate to addiction, mental illness, or a combination of illnesses. The next two listening sessions are on June 18 in West Barnstable and June 19 in Brockton.

Tagged: , ,

Jill Gasperini


Hometown: Jill is from the
Pacific Northwest. She grew up
in Tacoma, Washington under
the shadow of Mount Rainier

Favorite Desert: Jill loves
anything with chocolate!

Self Care: Jill loves Yoga and
believes that self care is essential
to a happy and healthy life

Hobbies: Jill sings in her
community chorus and recently
sang at Carnegie Hall


Jill Gasperini is the School Nurse Leader in
Lexington, MA and oversees the health services
program for the school district. Jill evaluates the
school nurses' practice, is a representative for
school administrators and community
stakeholders, supports policy development and
implementation, and is responsible for
recruiting, hiring, and staffing school nurses. Jill
ensures school nurses have the learning
opportunities to keep up with the skills required
for the position. Jill strongly believes school
nurses need support in order to do their job;
her role as Nurse Leader is to provide them
with the support they need to do their jobs well.


Jill has a Master's degree from the University of
Washington in Nursing Administration. She has
been working as the Nurse Leader in the
Lexington Schools for thirteen years. Jill formerly
worked in hospital settings and was attracted to
school nursing for the ability to work without
sacrificing the time she wanted to spend with her
family. She soon found the scope of school nursing
practice extensive and challenging. Integrating
health care in the academic setting demanded a
keen desire to fulfill an important mission:
"Children must be healthy to learn and learn to be
healthy." It became clear there was no better
professional aspiration for her than to take care of
children and families, to teach them about their
bodies, medications, and the importance of
staying healthy.


I worked in hospitals for most of my career and then came into school nursing later. I
live in Lexington and thought that by becoming a school nurse it'd allow me to be more
involved in the schools and the community, while at the same time having a schedule
that would be similar to my children. It was important for me to work but I also wanted
to balance the needs of my family. Once I started working in school nursing I fell in love
with it! As a Nurse Leader I encourage nursing students to have their clinical
experiences in the offices because it’s an unknown nursing specialty. They can see the
work and then that results in a higher interest in pursuing it as a career. Helping
children to be safe and working with families is such a tremendously important way to


One of the challenges is finding experienced school nurses to do the work. When we
have an opening, we see many applicants but not all of them understand the
importance of having a school nurse license. That second license is required in order to
practice school nursing. Many nurses don’t even know they need to have the school
nurse license in order to practice in schools. Then there's the sheer volume and scope
of the work school nurses need to do. The need is huge as 25% of children have some
sort of medical issue, so there is plenty to do! In addition, there are the daily demands
of children coming to school ill or children not yet diagnosed with a health problem
that the school nurse is helping to manage and support. The school nurse will help a
family understand that a child needs more support. The school nurses also must
integrate public health nursing since we are viewed as public health providers for the
community. We are involved in flu clinics and making sure that children are immunized
in accordance with state requirements. Making sure enough school nurses are available
to get the work done is a challenge for me on a daily basis because the needs change


Anytime the opportunity presents itself to make a difference in the lives of children
and their families is meaningful work. I take great pride seeing Lexington children
being safe and well cared for during the day by a strong school nursing staff. Lexington
school nurses are incredibly smart and their clinical expertise is excellent. The children
that come to the school nurse are getting a very high level of nursing care. I take a
great sense of pride in the work we are doing in Lexington.


They should try to find a work situation where mentoring is offered. Developing skills
and confidence comes from other school nurses who are available to help them learn
and grow. School nurses are often isolated, everybody else in the building doesn’t do
what they do. Lexington believes very strongly in mentoring as a support to the school
nurse. New school nurses should also join the professional organization (MA school
nurse organization-MSNO). MSNO offers lots of learning opportunities to become
connected to other school nurses not only through professional events, newsletters,
and social media, but also through the School Nurse Network. Everyday there is
messaging where school nurses are asking questions and trying to get advice on


Collaboration with other professionals is extremely important as everyone brings a
different and important perspective. Student health needs can be complex especially in
the area of mental health as it involves families. Having excellent support between
social workers and counselors not only in the school system but in the community is
important to ensure everyone's needs are being met. Lexington school nurses belong
on a myriad of task forces and teams that help support these needs. There is a school
nurse on the district wide child protection task force, a nurse on the district wide crisis
management task force, and a nurse on the professional learning task force. School
nurses have important data that we can share because all of our work is captured
electronically and we can easily collate data around health and are experienced in
moving the community forward in health matters. It’s important to share leadership
and school nurses have the leadership capability to represent nursing on the district
wide task forces. The school nurses meet on a monthly basis and report on what’s going
on and we bring in experts to guide our practice. There is still more work to be done
and more ways school nurses should be at the table and involved, but that takes time.
We have always had a supportive superintendent which has made a huge difference in
Lexington. Paul Ash, former Superintendent of Lexington Public Schools once said to
me “I believe school nurses are the heart of the school." What a tremendous
acknowledgement from the superintendent! A Nurse Leader must find support coming
from the top. I just loved it when Dr. Ash expressed his support, because school nurses
are the heart of the school!

"I am proud of Lexington school nurses and the wonderful work they are doing.
They are so smart and leaders in and of themselves and do such tremendous

School Health Services Update: May 22nd, 2019

By Andree EntezariMay 23rd, 2019

Dear Colleagues,

It is with both sadness and joy we say goodbye to Alison Brill, the School Health Unit Coordinator, who will be leaving to travel and then relocate to Chicago to be closer to family.  Alison has inspired us, challenged us, and brought much enjoyment to the School Health Services Team!  She has led us through the recent procurement process with proficiency, tenacity and a smile on her face! We are deeply appreciative of her work and service to our program, to the Department and to school health personnel and children throughout the Commonwealth!  We wish her the very best in her next adventure! We will miss her presence very much!


Caitlin Pettengill, DNP, RN, the Assistant Director of School Health Services, is currently on a medical leave from the Department and we wish her well.  She will be missed during her absence and we look forward to her return after her maternity leave.

During this period of transition, please be sure to contact your Regional Consultant (contact information below) with all school health and nursing practice questions and concerns.  Please contact Janet Burke ( with any school related Medication Administration Program issues, Bob Leibowitz ( with all data reporting questions, and myself ( with all school health program inquiries.   We hope to return your calls and emails in a timely manner.

As previously announced, I am retiring effective June 28, 2019.  My position, Director of School Health Services, has been posted to the MassCareers website and is available for submission of applications at:  The job description is attached (please note the Posting Number is: 190003M2 ).  Please share this opportunity widely!

Please see School Nurses in the News for the many accomplishments that school nurses have achieved that demonstrates their dedication and commitment to the work they do for our children!

I’m sure that many of you are looking forward to the long Memorial Day Holiday and the warm and sunny weather forecasted for the next few days!  Please take some time to relax and reflect on all you have done to provide service to our students while remembering the service of our veterans who have lost their lives in service to our country.

We are deeply grateful.

Mary Ann and the School Health Team

“There is nothing stronger than these two: patience and time. They will do it all.” – Leo Tolstoy, writer


Paula R. Rock, DNP, RN, Supervisor for Medical Services for the Lighthouse School,  in Chelmsford, recently graduated from University of Massachusetts Lowell on Friday, May 17, 2019 with her DNP!  She was selected to represent UML and present her poster at the Eastern Nursing Research Society (ENRS) Conference in April, “School Nursing and Pain Assessment in Students with Intellectual and Developmental Disabilities” .  She is planning to submit her work for publication.

Congratulations to Tracy Rose-Tynes, MS, BSN, RN, Nurse Manager of School Health Services for Cambridge Public Schools, for completing her Master’s Degree Organizational and Professional Communications.

Her thesis is entitled "The Relationship Between Teen Use Of E-Cigarettes, Perceptions of Health and Academic Achievement" and she is excited to share her E-cigarette presentation with anyone who would like to know more about  this topic.

Elizabeth Nightingale, MS, BSN, RN, District Nurse Leader for the Sandwich Public Schools received her MS in Nursing - Clinical Nurse Leadership​ from UMass Amherst!!  Her project focused on the school population with "Frequent Health Office Encounters".​

And congratulations to Sandy Sorenson, BSN, RN, NSCN, Shrewsbury Public Schools Nurse who recently became accredited as a  Nationally Certified School Nurse!

We are so very proud of all of these accomplished women and nurses!


There are still a handful of seats available for the Summer Leadership Institute for School and Public Health Nurses. Anyone who is interested may register here:  Story mapping, Strategic communications in public health, Health Equity and an inspirational speaker, Karen Daley, formerly President of the ANA, who will talk about her leadership journey and the role of nurses in population health.


SBIRT in Schools

June 7, 2019 - (8:30AM-11:30AM for half day session/8:30-3PM for full day session)

Mount Wachusett Community College | Gardner, MA

To Register:


State Epidemiologist 617-983-6800 For Calls Related to Infectious Disease and Immunizations ONLY.
Central Cynthia Tomlin 978-567-6250, ext. 10142 978-875-2009
Metrowest Jill Connolly 781-848-4000, ext. 7841 781-603-7697
Northeast Shanyn Toulouse 978-420-1919 978-761-2307
Southeast Ann Linehan 508-580-7363
West Diane Colucci 413-750-2511

Mary Ann Gapinski, MSN, RN, NCSN
Director of School Health Services
MA Department of Public Health
250 Washington Street – 5th Floor
Boston, MA  02108

Article: Immunization Division News: Measles in Massachusetts – 2019

By Andree EntezariMay 17th, 2019in SHIELD Updates

Due to routine childhood immunization with the MMR vaccine, measles was declared eliminated from the United States in 2000. That disease elimination success story is currently in jeopardy as, according to CDC, from January 1 to May 10, 2019, 839 individual cases of measles have been confirmed in 23 states. This was an increase of 75 cases from the previous week and is the greatest number of cases reported in the U.S. since 1994. Measles has received extensive media attention, in Massachusetts and nationally, during the first few months of 2019.

In Massachusetts there has been one confirmed case to date in 2019, out of 87 cases investigated. Last year, in contrast, 24 suspected measles cases were investigated during the same time period (with zero confirmed cases).

The recent confirmed case in Massachusetts received quite a bit of publicity following an MDPH press release on 4/1/19 describing possible public exposures throughout the state. Individual towns where exposures took place were notified by MDPH epidemiologists. Forty of the 85 suspected cases of measles in MA in 2019 have been reported since 4/1/19. Clearly, healthcare providers are suspecting measles in patients with compatible illness. There were no secondary cases identified.

There have also been measles exposures on airlines involving Massachusetts passengers, a traveler with measles who went through Boston by bus in February, and several rumors about measles in Massachusetts that have turned out to be false.

MDPH issued a Clinical Measles Alert on 4/17/19, urging healthcare providers to do the following:

  • Assess staff and patient immunity to measles today, and vaccinate those without evidence of immunity**
  • Consider measles in patients who:

·        Present with febrile rash illness and clinically compatible measles symptoms (cough, coryza [runny nose] or conjunctivitis)

·        Recently traveled internationally or were exposed to someone who recently traveled

·        Have not been vaccinated against measles

  • If you suspect measles, do the following immediately:
  1. Promptly isolate patients to minimize disease transmission.
  2.  Immediately report a suspect measles case to your local board of health and to the MDPH Divisions of Epidemiology and Immunization at 617-983-6800. Cases diagnosed in Boston should be reported to the Boston Public Health Commission at 617-534-5611.
  3. Obtain specimens for testing from patients with suspected measles, including serum and an NP swab or throat swab. Call 617-983-6800 to arrange testing at the MA State Public Health Laboratory.

A press release recommending MMR vaccination entitled “Public Health Officials Urge Massachusetts Residents to Get Vaccinated Against Measles Now” was posted on the MDPH website on 4/30/19.

Upcoming measles-related training: A CDC Clinician Outreach and Communication Activity (COCA) conference call is scheduled on Tuesday, May 21, from 2-3 PM, entitled Most Measles Cases in 25 Years: Is This the End of Measles Elimination in the United States? For more information go to

MDPH Immunization Updates: Measles is also discussed by MDPH epidemiologists at the regional Immunization Updates taking place this spring. There are still in-person trainings and webinars available:

CDC Measles Toolkit and Other Resources for Healthcare Providers

CDC Measles Toolkits for healthcare providers and state/local health departments: CDC has recently developed web-based tools (posters, fact sheets, FAQs) for measles education and control. They are available at and will have items added to them as they are developed. For up-to-date answers to questions, visit Frequently Asked Questions (FAQs) about Measles in the U.S. at

Measles Resources:

CDC Measles Website:

CDC MMR FAQs for Healthcare Providers:

CDC Measles FAQs:

CDC measles fact sheet for parents (available in English and Spanish):

MDPH Measles Chapter:

  • Appendix A and B of the measles chapter contain measles specimen collection instructions, and a one-page document describing initial steps to take when measles is suspected in a provider office.

MDPH Measles Fact Sheets:

English - Measles  Chinese (Simplified) - 麻疹  Haitian Creole - Lawoujòl

Portuguese - Sarampo  Spanish - Sarampión  Vietnamese - Bệnh Sởi

Have questions about immunizations? Contact us!Immunization Division | 617-983-6800Vaccine Unit | 617-983-6828MIIS Help Desk | 617-983-4335

MMR Vaccination and Int'l Travel,

Evidence of Immunity

MMR Vaccination Before International Travel

Before any international travel—

  • Infants 6—11 months old need 1 dose of measles vaccine. Infants who get one dose of MMR vaccine before their first birthday should get two more doses according to the routinely recommended schedule (one dose at 12 through 15 months of age and another dose at 4 through 6 years of age or at least 28 days later).
  • Children 12 months and older need 2 doses separated by at least 28 days
  • Teenagers and adults who do not have evidence of immunity** against measles should get 2 doses separated by at least 28 days

**Evidence of Immunity

Acceptable presumptive evidence of immunity against measles includes at least one of the following:

  • Written documentation of adequate vaccination: one or more doses of a measles-containing vaccine administered on or after the first birthday for preschool-age children and adults not at high risk; two doses of measles-containing vaccine for school-age children and adults at high risk, including college students, healthcare personnel, and international travelers
  • Laboratory evidence of immunity
  • Laboratory confirmation of measles
  • Birth before 1957 (year of birth is not acceptable evidence of immunity for healthcare providers)


Please call MDPH at 617-983-6800 if you have questions and concerns about measles.


Divisions of Epidemiology and Immunization

Bureau of Infectious Disease and Laboratory Sciences

Massachusetts Department of Public Health (MDPH)

305 South Street, Jamaica Plain, MA 02130


School Health Services Update: May 17th, 2019

Dear Colleagues,

It is the season for award ceremonies and graduations! Please see the section on School Nurses in the News for a listing of School Nurses and other colleagues who have been recognized for their achievements!  It is amazing the impact and accomplishments of School Nurses have our students and families across the state due to the dedication of these professionals!  Please continue to send me any exciting news of colleagues that I can share!

Hope to see many of you at the School-based Medicaid program for school nurses this coming Thursday, May 23rd.  Just a reminder that this program is being held to discuss Nursing services in schools (including pre-planned services, 1-on-1 nursing, unplanned visits, and health screenings, etc.):

  • When: 8:30AM – 11:30AM
  • Where: UMass, Worcester campus

Thank you for all you do, every day! And all that you accomplish beyond the school day!

Mary Ann and the School Health Team

“All you need is one person to say yes to an idea." -- Joy Mangano, inventor and entrepreneur


  • Sarah Delconte-Consentino, RN, School Nurse in the Nashoba Regional School District, coordinated effort for the American Heart Association - High School Hands Only CPR Challenge.  A feature article appeared on the front page of the local paper, The Item:
  • Last week, David Narkewicz, Mayor of the City of Northampton, proclaimed Wednesday, May 8, 2019, as National School Nurse Day and to honor the Northampton Public School Nurses.
  • Shanyn A Toulouse, MEd, BSN, RN, NCSN, Northeast Regional School Nurse Consultant, and Rita Casper, MBA, RN, Director of Nursing for the Andover Public Schools, are both quoted in the article below discussing immunization clinics to prevent measles outbreaks in the schools in the Northeast.

Precautionary measures | Merrimack Valley |

A record-breaking comeback of measles has sparked local efforts to stop the extremely contagious disease from forging into Merrimack Valley homes. Andover, Haverhill, Lawrence, Methuen, North ...

  • School Nurses who recently became Nationally Certified as a School Nurse!  Congratulations to all!
    • Suzan Allen, M.Ed, RN, NCSN,  Billerica Public School Nurse
    • Maureen Battcock BSN, RN, NCSN, Billerica Public School Nurse
    • Rebecca Blanton, BSN, RN, NCSN, Assabet Valley Collaborative School Nurse
    • Mary Ellen Carroll-Reed, MBA, RN, BSN, NCSN, Barnstable Public School Nurse
    • Pamela Ciborowski, RN, MBA, RN, BSN, NCSN,  Barnstable Public Schools Nursing & Wellness Coordinator
    • Janice Roberts, BSN, RN, NCSN, Billerica Public School Nurse
    • Katy Smith, RN, NCSN, Deerfield Elementary School Nurse
    • Patricia H. Stacy, BSN, RN, NCSN, Narragansett Middle School
  • Nancy Boutin, MSN, RN, School Nurse in the Nashoba Regional School District, recently graduated this past weekend from Southern New Hampshire University as a member of Sigma Theta Tau with her Masters in Nursing, Nurse Education
  • ​​​Susan M. Lofquist, MSN, RN, NCSN, School Nurse at the Oakmont Regional High School, received her Master of Science in Nursing from Southern New Hampshire University in January.
  • More Exemplar School Nurse Websites from the Dedham Public Schools
  • Congratulations to Doreen Crowe, MEd, BSN, RN, Director of Nursing Services for the Wilmington Public Schools, on receiving her Initial Administrator License as a Supervisor/ Director from the Department of Elementary and Secondary Education (DESE)!  Doreen is willing to share her experience with other Nurse Managers seeking a Supervisor/Director licensure following the same path

CDC CLINICIAN OUTREACH AND COMMUNITY ACTIVITY (COCA) ON MULTI-STATE MEASLES OUTBREAKJoin the CDC COCA call on May 21, to hear measles experts discuss the current multi-state outbreak. During this COCA Call, clinicians will learn what makes 2019 a historic year for measles, and what they can do to help identify cases and stop measles transmission.Date: Tuesday, May 21, 2019Time: 2:00 – 3:00 p.m., ESTA few minutes before the webinar begins, please click the link below to join: iPhone one-tap:  US: +16468769923,,118484474# or +16699006833,,118484474#
Or Telephone:  Dial: US: +1 646 876 9923 or +1 669 900 6833Webinar ID: 118 484 474The closed captioned video for this COCA Call will be posted here soon after the live call.Free continuing education (CE) is available for this COCA Call.At the conclusion of the session, the participant will be able to accomplish the following:

  • Identify the clinical presentation of measles.
  • Discuss current measles epidemiology in the United States.
  • List measles vaccine recommendations.
  • Describe measles guidance in health care settings.

At the conclusion of the session, the participant will be able to accomplish the following:

  • Cite background information on the topic covered during the presentation.
  • Discuss CDC’s role in the topic covered during the presentation.
  • Describe the topic’s implications for clinicians.
  • Discuss concerns and/or issues related to preparedness for and/or response to urgent public health threats.
  • Promote health improvement, wellness, and disease prevention in cooperation with patients, communities, at-risk populations, and other members of an interprofessional team of health care providers.


School Nurses are requested to attend!

Background: Massachusetts state education, health and human services agencies are working collaboratively to create a comprehensive Prenatal-to-Grade 12 Family Engagement Framework for use in home visiting programs, early intervention services, early education and care programs, public school settings, and more. The Spring 2019 Regional Family Engagement Stakeholder Coalition Meetings will bring together members from a variety of fields to provide insight, guidance, and feedback on the work currently underway to draft the Framework and its implementation plan.

Who: Community organizations, parents, grandparents, practitioners, school and district personnel and other stakeholders with an interest in informing a Prenatal through Post-Secondary family engagement framework are welcome to participate.  Here are some examples of state, regional and local organizations that may want to join:

  • ICC Parent Leaders
  • Home Visitors
  • CFCE/PCHP coordinators
  • Head Start Family Engagement Coordinators
  • Preschool Expansion Grant Coordinators
  • Family Centers (CT)
  • Family Resource Centers (DCF)
  • Early childhood and after-school  programs
  • Museums
  • Libraries
  • Businesses
  • Philanthropic
  • Judicial Branch organizations
  • ABE/GED programs
  • McKinney Vento liaisons
  • SEPAC members
  • PTA members
  • School committee members
  • MSAA
  • State SAC
  • PCEI members
  • Teachers Union
  • Pediatricians
  • Mental health clinicians
  • Advocacy Organizations


June 10th

Marlboro, MA


June 19th

Taunton,  MA


June 21st

Lawrence, MA


Additional Information: To register please click here.

If you have any questions, please contact the Office of Student and Family Support at DESE at or 781-338-3010.


Please be advised that the Department of Elementary and Secondary Education (DESE) has recently published an updated version of form 28M/12 for the purposes of providing service delivery information for submission of interim claims when reimbursable Medicaid services are provided to students placed in Out-of-District programs. Please see Special Education Administrative Advisory SPED 2019-3: for additional information.


Thanks to Linda Cahill, DNP, MSN, RN, Nursing Supervisor, Brockton Public Schools, and Kim Fallon, BSN, BA, CPN, a resource for school personnel to provide appropriate gender sensitive interactions and responses to Lesbian, Gay, Bisexual, Transgender, Queer/Questioning, Intersexual, Asexual (LGBTQIA+)* (the symbol “+” stands for any additional group not represented by the LGBTQIA acronym) has been created and  posted under Social Emotional Health in SHIELD resources – located here:

Thank you to Linda and Kim as well as contributors to this toolkit, Kelly MacNeill and Karen Rufo, from the Natick Public Schools for their willingness to share this valuable resource with school personnel!


Attached is the information about concerning the Elms College MSN Summer semester courses. Classes start on July 9 so there is still plenty of time for school nurses to touch base with Cindy Dakin, Director of the Graduate Nursing Studies or to sign up for a class to try the program out. As a reminder:  school nurses are welcome to take up to 9 credits before they need to apply to the Elms MSN program. For more information contact:   Cynthia L. Dakin, PhD, RN, Professor, Director Graduate Nursing Studies, School of Nursing, Elms College, 430 Berchmans Hall, 291 Springfield Street Chicopee, MA 01013-2839; phone: (413)265-2455


Introducing the Redesigned School Module


Thursday May 30, 2019


Register Now

This webinar will review:

  • MIIS Registration
  • Simplified access to the School Immunization Survey
  • Results from the 2018-19 School Immunization Survey
  • Live Q&A

Questions? Contact Us:

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State Epidemiologist 617-983-6800 For Calls Related to Infectious Disease and Immunizations ONLY.
Central Cynthia Tomlin 978-567-6250, ext. 10142 978-875-2009
Metrowest Jill Connolly 781-848-4000, ext. 7841 781-603-7697
Northeast Shanyn Toulouse 978-420-1919 978-761-2307
Southeast Ann Linehan 508-580-7363
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Mary Ann Gapinski, MSN, RN, NCSN
Director of School Health Services
MA Department of Public Health
250 Washington Street – 5th Floor
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Building Strong Children

By Andree EntezariMay 10th, 2019in SHIELD Updates
By Erin D. Maughan

The number of students with chronic and complex health conditions significantly affects a teacher’s ability to teach and meet the needs of the whole child—especially combined with the impact of societal issues such as poverty, violence, and the growing population of families who speak a language other than English at home. Education in America is free, but healthcare is not. This fact presents a unique divide among schools and even within classrooms, where some students have parents who have good healthcare coverage and seek medical attention regularly, while others come from families who are limited to emergency room visits for chronic illnesses or only see a healthcare professional in life-threatening situations.

School nurses can help bridge this divide. Often, they are the only healthcare professional that students see regularly. So when a class includes Paul (who has missed multiple days of school, seems distracted when he does attend, and often has a deep, penetrating cough), Keisha (who stays in her seat during class but always seems drowsy), Aidan (whose disruptive behavior makes instruction difficult), and Anni (who is struggling to learn English), the school nurse should be one of the first resources their teacher turns to.

Unfortunately, not every school has a nurse. Only about 50 percent of schools have a full-time registered nurse for at least 30 hours per week, and 18 percent do not have a nurse at all.1

While the National Association of School Nurses (NASN) recommends that every student have access to a school nurse every day, the presence of a nurse in school depends on state nurse practice acts and regulations. NASN recommends that the severity of a student population’s health needs should factor into how many school nurses should staff a school. Home and family factors, such as poverty and home languages other than English, should also factor into determining adequate nurse staffing.2

Currently, more than 61,000 school nurses work in K–12 schools.3 According to the National Center for Education Statistics, there are 52 million students in our nation’s public schools. Studies indicate that as many as 27 percent of American children have chronic health conditions (such as asthma, diabetes, severe food allergies, and seizure disorders), which school nurses are trained to help manage.4

With so many students in need of medical care in school—whether that care is related to a chronic illness or an emergency situation—and so few nurses in schools to help them, policymakers, educators, and the general public must understand all that school nurses do so they can advocate for having one in every public school.

Meeting Students’ Needs

Building Strong ChildrenIt would seem that teacher preparation programs would be the perfect place for educators to learn how school nurses enable teachers to focus on instruction. Yet few education courses cover what, exactly, school nurses do.

A skilled school nurse can be a lifesaver (both literally and figuratively) for teachers. School nurses have medical training to deal with the physical and mental illnesses of students as well as the entire school population. To help ensure school nurses have the skills needed to address current health concerns, NASN recommends that a school nurse have a minimum of a bachelor’s degree in nursing as well as a registered nurse (RN) license. A bachelor’s program in nursing covers the leadership skills of community and public health nursing, whereas shorter programs, such as associate degree RN programs or licensed practical/vocational nurse (LPN/LVN) programs, may mention these areas but do not emphasize them. Such skills are critical for school nurses to obtain so they can meet their students’ complex health needs. It may be appropriate for aides and LPNs/LVNs to perform certain healthcare-related tasks, but only when an RN is providing proper oversight.

Of course, school nurses’ primary purpose is to keep students healthy and safe so they are ready to learn. School nurses do this in several different ways. These include working with students to manage chronic health conditions (e.g., observing them use an inhaler during an asthma attack or helping them check their blood sugar), identifying students who might have an undiagnosed health condition that is impeding their well-being and ability to learn, and reinforcing current medical and legislative policies that affect student health (e.g., allowing students to carry their inhalers and including a school nurse on appropriate individualized student educational team meetings).

School nurses make sure students know how to manage their conditions by taking their medication or adhering to other treatments. Technological innovations and medical advancements happen quickly, and school nurses work hard to stay up to date. In so doing, they act as the bridge between the school and a student’s healthcare provider to ensure a student’s needs are met.

Some children who have complex medical issues require treatments ranging from catheters to gastrointestinal tubes. School nurses work with teachers and other school staff so that everyone on the educational team understands how best to support students’ needs. They also work hard to connect families struggling with poverty or serious health issues to community resources such as health insurance, food pantries, language assistance programs, and transportation services, as well as offsite healthcare providers.

As a school nurse for several years, I found home and family factors underlying many children’s health concerns. For example, learning that a student did not have electricity and heat at home helped me understand his poor health and helped his teachers understand his academic struggles. By connecting his family to social service agencies in the community, progress was made in helping the student feel well enough to focus on learning. As is so often the case, school nurses do more than hand out Band-Aids and ice packs and check for lice!

School nurses spend much of their time ensuring that all students in the school are ready to learn, and they help to identify those who may be at risk of not progressing academically. To that end, school nurses conduct vision and hearing screenings and follow up with families to ensure students receive eyeglasses or other treatments. If a family member or a teacher is concerned about a student, a school nurse can provide individual screenings and follow-up as well.

In addition, discussions about a student with the school nurse might result in some suggestions that a non–medically trained professional might not provide. For instance, if a student is frequently asking to use the toilet and has shown recent weight loss, a school nurse might suggest that the student see a healthcare provider, as these can be signs of diabetes.

School nurses also serve as health leaders in a school by ensuring that current, evidence-based practices are in place so that the school environment supports students—for example, eliminating environmental asthma triggers such as idling cars or buses near school buildings and playing fields to ensure students with asthma can participate in physical activity.*

School nurses can provide general evidence-based health education, specific trainings, or health promotion activities for students and school staff on a variety of topics. For example, school nurses may train school staff on what to do in a medical emergency or provide outreach to parents when there is an increase in a specific illness among students, to help minimize its further spread.

Monitoring the health of a school community by collecting data is another key practice of school nursing. It was actually a school nurse who identified the first case of H1N1 (swine flu), whose spread reached pandemic proportions in 2009,5 and school nurses have identified measles, pertussis, tuberculosis, and other communicable disease outbreaks in their school communities by virtue of tracking symptoms and immunity. Electronic school health records facilitate their ability to analyze data quickly,6 and to work with local health departments to stop outbreaks and prevent them in the future through improved prevention methods.

School nurses also provide valuable information to school leaders regarding major concerns that can affect a student’s ability to attend school and learn. Unlike the administrators or staff who take the calls reporting a student’s absence, school nurses have an overarching view of the school community’s physical health and can address the underlying physical, social, and mental health causes of absenteeism.

A Return on Investment

Building Strong ChildrenI loved being a school nurse, but, covering multiple schools, I often felt stretched thin. After seeing the overwhelming health needs students had, I decided to earn a doctoral degree in nursing, hoping to make a greater impact. I soon realized there was a dearth of research on the positive impact of school nurses, so I focused on marshalling the evidence to support the benefits of school nursing. However, measuring the effects of school nursing is complex because school nurses are part of a larger team. Also, the standard “random control trial” does not work well in many situations; we do not want to withhold health interventions from students in the name of seeing what works.

This is not to say no evidence exists. Many researchers have shown that when school nurses intervene, they can help decrease rates of student absenteeism and early dismissals of students due to health concerns.7 Often, student absences are related to unknown or poorly controlled chronic conditions that school nurses can assess; then they can help students and their families better manage these conditions, leading to improved attendance.8

Research shows that school immunization rates are higher when a school nurse is present to follow up with parent concerns and help connect families to healthcare providers.9 In addition, school nurses have been found to help students stop smoking, lose weight, avoid pregnancy, and improve their mental health, all factors that influence student learning.10 Besides helping to keep students in school, school nurses may decrease a school’s liability, as researchers have found that when school nurses provide medication to students, fewer medication errors occur.11

My current role as the director of research at NASN is to gather research on school nursing and ensure that school nurses follow evidence-based practices. One of my greatest pleasures is helping school nurses collect and use their school’s data to illustrate the importance of what they do and how it affects student health.

Generally, people agree that having a school nurse is good for a school. Yet, in a time of tightening budgets and increased class sizes, districts often choose to disinvest in school nursing. But researchers have found that having a school nurse actually results in returns on the investment—not only in dollars saved but in time spent on instruction.

One study that investigated the amount of time principals and other staff focused on health concerns instead of instruction found that when there was a school nurse in the building, the principal saved nearly one hour and clerical staff about 46 minutes that they otherwise would have spent on student health. Teachers were also able to devote more time to instruction when a school nurse was present. Using these data, the study’s authors calculated the savings per school to be $133,174.89, which translates to a $1.84 return on investment for every dollar invested.12

Another analysis, this one from school nurses in the Massachusetts Essential School Health Services program, found that for every dollar spent on school nurses, society gains $2.20.13 It is important to note that this analysis only measured program benefits as savings in the costs of medical procedures, parents’ lost productivity (when they take their students out of school for treatment or come to school to give them medication), and teachers’ lost productivity (when they have to deal with students’ health issues instead of teaching). This study did not look at emergency room visits, hospitalizations, or 911 calls, nor did it factor in school nurses’ prevention and promotion efforts to help individual students better manage their conditions and improve their health.

Return-on-investment studies that have focused on prevention often show higher returns on investment. For example, Trust for America’s Health found that for every dollar spent to support community prevention programs that address smoking and promote exercise, $5.60 would be saved after five years.14 In Canada, every dollar spent on measles, mumps, and rubella immunizations saves $16,15 and every dollar spent on mental health and addictions saves $7 in healthcare costs and $30 in lost productivity and social costs.16 Prevention and promotion efforts that focus on children save all of society millions of dollars but require an initial investment.

Given that education dollars always seem to be tight, school districts have found innovative funding streams for school nursing. Some school districts partner with local public health departments to share the cost of nurses, while others have partnered with local healthcare systems or community agencies.†

With the emphasis on decreasing hospital admissions and increasing hospital and community partnerships, hospitals have also become involved in funding or providing school nurses.

Although each state’s Medicaid laws are different, school districts or other health entities employing school nurses can bill Medicaid for reimbursement of particular procedures performed in schools. As a result, some school districts have been able to hire additional school nurses with these reimbursed funds.

Investing in school nurses helps students stay healthy and ensures they’re ready to learn so they can graduate and become productive citizens. As Frederick Douglass once said, “It is easier to build strong children than to repair broken men.” With nurses in schools, educators, families, and school nurses can work together to build strong children.

Erin D. Maughan is the director of research for the National Association of School Nurses. Previously, she was an associate professor in the College of Nursing at Brigham Young University. A former school nurse, she has also worked as a school nurse consultant for the Utah Department of Health.

*For more on common environmental problems in the school setting, see “First, Do No Harm” in the Winter 2011–2012 issue of American Educator. (back to the article)

†School districts that have partnered with local health departments include Austin Independent School District (link is external), Akron Public Schools (link is external), Dayton Public Schools (link is external), and Provo City School District (link is external). (back to the article)

1. Centers for Disease Control and Prevention, Results from the School Health Policies and Practices Study 2014 (Washington, DC: Department of Health and Human Services, 2015), 75.

2. National Association of School Nurses, School Nurse Workload: Staffing for Safe Care (Silver Spring, MD: National Association of School Nurses, 2015).

3. Health Resources and Services Administration, The U.S. Nursing Workforce: Trends in Supply and Education (Washington, DC: Department of Health and Human Services, 2013), 16.

4. Robert Wood Johnson Foundation, Chronic Care: Making the Case for Ongoing Care (Princeton, NJ: Robert Wood Johnson Foundation, 2010), 12.

5. “Swine-Origin Influenza A (H1N1) Virus Infections in a School—New York City, April 2009,” Morbidity and Mortality Weekly Report, April 30, 2009.

6. National Association of School Nurses, School Nurse Role in Electronic School Health Records (Silver Spring, MD: National Association of School Nurses, 2014).

7. Nina Jean Hill and Marianne Hollis, “Teacher Time Spent on Student Health Issues and School Nurse Presence,” Journal of School Nursing 28 (2012): 181–186; Nicole Pennington and Elizabeth Delaney, “The Number of Students Sent Home by School Nurses Compared to Unlicensed Personnel,” Journal of School Nursing 24 (2008): 290–297; and Susan K. Telljohann, Joseph A. Dake, and James H. Price, “Effect of Full-Time versus Part-Time School Nurses on Attendance of Elementary Students with Asthma,” Journal of School Nursing 20 (2004): 331–334.

8. Michelle L. Moricca, Merry A. Grasska, Marcia BMarthaler, et al., “School Asthma Screening and Case Management: Attendance and Learning Outcomes,” Journal of School Nursing 29 (2013): 104–112.

9. Daniel A. Salmon, Lawrence H. Moulton, Saad B. Omer, et al., “Knowledge, Attitudes, and Beliefs of School Nurses and Personnel and Associations with Nonmedical Immunization Exemptions,” Pediatrics 113, no. 6 (2004): e552–e559.

10. National Association of School Nurses, Role of the School Nurse (Silver Spring, MD: National Association of School Nurses, 2011).

11. “Fewer School Nurses Leads to Greater Medication Errors,”, May 7, 2012,
leads-to-greater-medication-errors (link is external).

12. Mary J. Baisch, Sally P. Lundeen, and M. Kathleen Murphy, “Evidence-Based Research on the Value of School Nurses in an Urban School System,” Journal of School Health 81 (2011): 74–80.

13. Li Yan Wang, Mary Vernon-Smiley, Mary Ann Gapinski, et al., “Cost-Benefit Study of School Nursing Services,” JAMA Pediatrics 168 (2014): 642–648.

14. Jeffrey Levi, Laura M. Segal, and Chrissie Juliano, Prevention for a Healthier America: Investments in Disease Prevention Yield Significant Savings, Stronger Communities (Washington, DC: Trust for America’s Health, 2009).

15. Public Health Agency of Canada, Canadian Immunization Guide, Part 1 (Ottawa: Public Health Agency of Canada, 2014), 7.

16. Ontario Ministry of Health and Long-Term Care, Every Door Is the Right Door: Towards a 10-Year Mental Health and Addictions Strategy; A Discussion Paper (Toronto: Ministry of Health and Long-Term Care, 2009), 16.

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5 Ways to Become an Outstanding Nurse Leader

Health Leaders
By Jennifer Thew RN     May 03, 2019

It's Nurses Week—a time to pause and celebrate all that nurses do. And, as the healthcare industry shares its gratitude this week for nurses, it must not forget to include nurse leaders when giving thanks. Because it's not easy being a nurse leader.

"As nurse leaders, we help create circles of care, safety, reliability, quality, and trust for the patients and communities. We are guardians at the gate of all of these things," Cole Edmonson, DNP, RN, NEA-BC, FAAN, chief clinical officer at AMN Healthcare, Inc., said during the AONE 2019 Keynote introduction.

"Leadership in healthcare is not an easy path and, in order to do it well, we have to take time to develop ourselves and those around us," Edmonson said.

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While much has changed since the time of Florence Nightingale, the original nurse leader,  the qualities that make a nurse leader great have not.

"We must be willing to be brave, courageous, authentic, vulnerable, and practice forgiveness to create the future," Edmonson said.

AONE 2019's opening keynote presentation, "Get Out of Line: Step Up, Stand Out & Succeed" by Sarah Robb O'Hagan, founder of EXTREMEYOU and former executive at companies such as Nike, Gatorade, and Virgin Atlantic, covered how to develop some of the qualities Edmonson mentioned.

Below are five ways O'Hagan said nurse leaders can propel themselves toward personal and professional success.

1. Get Out of Line
"[Get out of line] means stepping up, standing out, kicking butt, and stepping out of the line of others around you to take risks and create new value for your organization," O'Hagan said. "Often it can be uncomfortable. Many of us choose not to do that because we don't want to take a risk and fail."

During the keynote, O'Hagan shared a personal story when she took a risk and it paid off. On her first day in a marketing position at Virgin Atlantic airlines—after moving from New Zealand to New York for the job—she was informed that the person who hired her was no longer with the company. Fortunately, she still had a job but secretly wondered if the "last in, first out" philosophy would be implemented. As she noticed the chaos that had developed in the department, she made a bold move by drafting a marketing plan and slipping it under the marketing president's door.

"That could have gone one of two ways, but what ended up happening is I got a promotion," she said.

While O'Hagan was new to the company, she had enough career and marketing knowledge to fill in the leadership gap that occurred when the hiring manager left the company.

The lesson here: Embrace your knowledge and experience and don't be afraid to share solutions with others.

"If you recognize those moments where your experiences [can fill a gap you see] in front of you and you're solving a problem for someone else, it can be incredibly, incredibly successful" she said. "I always say to everyone, scan for opportunities around you."

2. Make Failure Your Fuel
With the rare exception, nobody likes to fail. According to O'Hagan, fear of failure is increasing.

"For about the past 50 years, every generation from the boomers to Gen X to the millennials to Gen Z has statistically become more scared of failing. We do not like taking risks," she said.

But willingness to fail, and to learn from it, is necessary for personal and professional development.

"We have a generation that is scared of failure and, therefore, somewhat risk averse. [If] people are going to develop the best sides of themselves, they actually need to take risks every now and then," she said. "If you don't experience different environments, different types of work, you don't know where you are going to shine, and you want to learn where are you at your very best."

Nurse leaders should keep this in mind especially when working with younger generations of nurses."Talk to the younger people on your team because [a willingness to fail] is actually the most important thing," she said. "When we start our careers, in the world we live in today, there's this feeling that I have to look perfect on Instagram. I have to have a perfect resume on LinkedIn. And, guess what, you actually have to fail."

3. Play Your Specialist Game
O'Hagan asked the AONE attendees: Where do you excel? What excites you? She said once nurse leaders answer those questions, they should embrace their strengths because that will help build a foundation of success.

"Once you know you at your very best, if you find yourself playing in an organization that really wants that out of you, you will be more confident, and you will be more involved," O'Hagan said.

4. Bring Out the Extreme in Others
For nurse leaders, bringing out the best in others is the key to developing an outstanding and engaged nursing staff.

"If we're doing a good job of knowing who we are at our core as leaders, then the most important thing is how you bring out the best in others, so they can play to their full potential," O'Hagan said.

Leaders can encourage staff to reflect on their positive attributes and exceptional skills. Then the leaders should commit to helping the nurses develop those skills at their organization. O'Hagan said committing to diversity in age, ethnicity, gender, and skill can also contribute to an organization's success.

"Diversify those different styles and points of view and the team because that is when you will perform at your best. I do think it's important to partner with those that are least like you," she said.

5. Break Yourself to Make Yourself
"Get yourself out of your comfort zone," O'Hagan said. "It may be at work, it may be in your personal life, but take on a new adventure. Just get out of your comfort zone so that you're being exposed to new and different things."

By being uncomfortable, says O'Hagan, leaders can challenge their most stubborn beliefs.

"Often those beliefs are things that we think we're not good at and we're not giving ourselves enough of a chance," she said.

For example, O'Hagan says she labeled herself as terrible at finance. But when working at Gatorade, she realized she didn't have the option of not feeling comfortable with the subject.

"I took myself back to what I call 'remedial education' and did a finance for executives course and discovered at the age of 38 that I absolutely loved it," she said. "And, because I now had real-world experience that I could apply to what I was learning, it suddenly made sense. I'm never going to be a powerful finance person but at least I now feel confident in that fundamental."

"Sign up for an initiative or a project with other people. It might be that you are needing to transfer to a different kind of hospital or somewhere else [in your current organization]. You have to get out of the places of comfort if you're really going to allow yourself to blossom and find new areas of growth."
Jennifer Thew, RN, is the senior nursing editor at HealthLeaders.

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Articles: An alarming number of children in America can’t afford food

Experts say many people that are ‘food insecure’ work low-paid jobs, yet still don’t qualify as SNAP recipients
By: Jeanette Settembre
Published: May 2, 2019 4:53 p.m. ET

Millions of Americans don’t have enough money to buy healthy food –– and kids are most at risk.

A staggering 97% of counties in the U.S. are home to people who can’t afford or don’t have access to healthy food, according to a study released Wednesday by Feeding America, a Chicago-based nonprofit organization that has a network of more than 200 food banks nationwide.

Out of America’s 3,142 counties, the rates of food insecurity range from 3% in Steele County, N.D., to as much as 36% in Jefferson County, Miss., the report found. And children are suffering the most: One in six kids (or 12.5 million children) are considered to be food insecure, and an estimated 750,000 live in New York City and Los Angeles.

These families are more likely to live in disadvantaged urban areas and also southern U.S. states –– areas with “food deserts” that don’t have easy access to healthy food. Experts say many families that are “food insecure” often work low-paid jobs to pay for rent and utilities, and other expenses like school supplies for their children. They may have little left over for healthy food, but may not always qualify for SNAP (Supplemental Nutrition Assistance Program), formerly known as food stamps.

Approximately 12.5 million children in the U.S. are considered ‘food insecure,’ and an estimated 750,000 of them live in New York City and Los Angeles.

Mississippi is the state with the highest rate of food insecurity (19.2%) or the state with the least access to food; followed by Arkansas with 17.3%; Louisiana with 16.5%; Alabama with 16.3%; Oklahoma with 15.8%; New Mexico with 15.5%; Texas with 14.9%; and Georgia with 14.4%.

The national cost on average of a meal was $3.02 in 2017, down from $3.06 in 2016, according to the study. That said, 43% of counties in the U.S. have meal costs that are higher than the national average, with some costing nearly double. The average cost of a meal on the West Coast is $3.27 and $3.32 in the Northeast.

The South is where 87% of people live in food deserts. These are areas that typically have low-income residents and where many of those who are food insecure live, according to the most recent study. Without access to healthy food, people tend to eat cheaper, less nutritious meals that can negatively impact health leading to illnesses like diabetes, the authors explained.

Of those people living in counties where healthy food is scarce, 29% are not eligible for most federal nutrition assistance programs. To be eligible for SNAP benefits, a household’s gross monthly income must be at or below 130% of the federal poverty level. So for a three person family, that would be $2,213 a month, or around $26,600 a year.

Without access to healthy food, people tend to eat cheaper, less nutritious meals that can negatively impact health leading to illnesses like diabetes.

SNAP benefits can buy any food product aside from beer, wine, liquor, cigarettes, tobacco or any nonfood items like vitamins and medicines, which are exempt. The benefits are strictly for food meant to be eaten or prepared at home –– so items that are prepared in store and hot foods aren’t included, though items like fresh fruit, and snacks like pretzels and ice cream are covered at some convenient stores.

The number of authorized SNAP retailers increased by 4% between 2013 and 2017, and more than 80% of SNAP benefits are spent at big-box stores and supermarkets, according to the Center on Budget and Policy Priorities.

For the first time, the U.S. Department of Agriculture gave retailers the green-light to allow people to use SNAP benefits to shop for food online. SNAP participants can spend their benefits at any retailer that accepts electronic benefit transfer (EBT) cards.

Last month, the USDA announced a two-year pilot program, now live in New York state, at grocery retailers Walmart, Amazon and ShopRite. The pilot program will eventually expand into other parts of New York along with Iowa, Alabama, Maryland, Nebraska, New Jersey, Oregon and Washington.

People who receive SNAP will be able to order groceries from Walmart WMT, -0.68% online to get in-store pick up or delivery. And AmazonFresh AMZN, -1.62% and Prime Pantry is not charging a membership fee for SNAP recipients, the company said in a blog post. To access the portal, users can create an Amazon account or sign in and type in their SNAP EBT card number. Only New York cards are accepted at this time.

In counties where healthy food is scarce, 29% are not eligible for most federal nutrition assistance programs like SNAP, formerly known as food stamps.

However, some worker advocates have criticized Walmart and Amazon’s move to cater to more SNAP recipients. The new access to online shopping will allow these companies to tap into the SNAP market profiting off of lower-income families, many of whom work at their stores.

For SNAP parents who are stuck in low-paid jobs and their children, that’s something of a Catch 22.

Walmart is the No. 1 employer of SNAP recipients in Arizona, Kansas, Ohio, Washington and Pennsylvania, and thousands of low-wage Amazon employees are on food stamps, according to an April 2018 report from Amazon raised its minimum wage to $15 an hour for all U.S. employees in November 2018 after criticism over low pay and poor working conditions.

Amazon disputes those findings. “We encourage anyone to compare our median pay and benefits to other retailers,” Lori Torgerson, a spokeswoman for Amazon told MarketWatch in an email. “Amazon increased our starting minimum wage for all full-time associates to $15 per hour.”

“This compensation is in addition to our benefits package that includes comprehensive health, vision and dental insurance, retirement, generous parental leave and training for in-demand jobs through our Career Choice program,” she added.

Amazon could not confirm whether there are fewer Amazon employees receiving SNAP benefits since it upped its minimum wage last year.

The new access to online shopping will allow Amazon and Walmart to tap into more low-income families that use SNAP, many of whom work at their stores.

Walmart, the world’s largest retailer, pays entry-level workers $11 an hour. When asked for comment regarding criticism about providing a new online service for SNAP recipients instead of paying low wage workers more, a spokeswoman for Walmart said: “We think services like grocery pick-up should be available to everyone, regardless of income or individual circumstances. It’s pretty shocking to hear that someone would disagree with that.”

Catering to SNAP participants is not a new strategy: Major retailers like Walmart, Sam’s Club, Costco COST, -0.96% and brands like Kroger KR, -0.82% Kmart and Albertson’s have allowed SNAP recipients to buy goods with their EBT cards for years.

“This move was an inevitable extension of the SNAP market,” Michele Simon, a public health attorney and author of “Food Stamps: Follow the Money,” told MarketWatch. “There’s a lot of money here. If retailers can encourage more SNAP spending they’re going to look for ways to do that.”

But since Congress does not require data collection on SNAP product purchases, it’s unclear what kinds of foods are being bought and exactly how much retailers are making off the $63 million SNAP market.

Trying to get government data on the nation’s food assistance program has been an eight year quest for South Dakota’s Argus Leader, leading to an ongoing Supreme Court case hearing with supermarket trade association arguing against the release of information.

“We don’t even know how these taxpayer dollars are being spent,” Simon said. “Is this really the best thing for public health? Or is it making it easier for people to buy soda, chips and junk and food?”