Massachusetts has enacted a comprehensive program to support school students with asthma and allergies.  It requires and funds extensive staff development for school nurses in asthma and allergy management related activities, including tobacco use, teaching self management, accessing benefits for students with disabilities, and case management for students with chronic conditions.  State laws ban pesticide application at schools when students are present and require parental notification in advance of pesticide applications.  State funds promote indoor air quality programs.  Massachusetts meets 15 of 18 core policy standards and ten of 15 extra credit indicators.

Medication & Treatment

Medication Policies

Massachusetts General Law 71.54B (2002) requires the state department of public health to establish regulations governing the administration of medications in school settings. 105 CMR 210.003 (1994) mandates local boards of education, in consultation with their local boards of health, to adopt policies and procedures governing the administration of prescription medications. These policies should include:

• Designation of a supervising school nurse
• Response to a medication emergency
• Dissemination of information to parents and guardians
• Procedures for the resolution of questions between parents and the school

The policy also allows schools to administer epinephrine by auto-injector in life-threatening situations during the school day.

105 CMR 210.006 (1994) allows the self administration of medication by students according to terms of an agreement among the student, school nurse, and parent or guardian and authorization from the student’s health care provider.  Massachusetts General Law 71.54B adds another safeguard by stating that school districts may not prohibit students with asthma or other respiratory diseases from possessing and self-administering prescription inhalers.

All levels of Emergency Medical Technicians in Massachusetts are allowed to carry and trained to use epinephrine auto-injectors.

Identification and Reporting

All students in Massachusetts must have a health record maintained by the school nurse, covering basic health information such as screening and examination results, services and treatments.  For students with special health needs, this record includes information about prescribed medications, their Individual Health Care Plans (IHCP), emergency measures and parental authorizations.  This legal record transfers with the student and is maintained for seven years after the student graduates or leaves the school. 

Management of students with asthma and allergy is covered in Chapter 7, “Students Requiring Specialized Health Services.”  Steps that schools are required to take for students with food allergies, including development of an IHCP and Allergy Action Plan, are outlined in Chapter 9, “Nutritional Health.” 

Models of these forms, as well as the Massachusetts Asthma Action Plan, along with detailed instructions and information, legal requirements and resources are outlined in the Manual. 

School nurses participate in development of ICHPs and are tasked with record-keeping as well as communicating with parents/guardians and the Department of Health.  In schools with the Essential School Health Services program, school nurses must report the number of students with asthma, monthly peak flow measurements, nebulizer assessments, and medication use. 

Asthma and Allergy Management Policies

Massachusetts provides official guidance for schools to manage food allergies through its publication, Managing Life Threatening Food Allergies in Schools, which was distributed to all school superintendents in 2002.  The booklet provides detailed guidelines and resources to help local districts develop their own policies covering nursing case management, medication management, health screenings, medical and emergency procedures, reporting, referrals and staff education.   

For asthma, Massachusetts aligns its law M.G.L. c.71B and implementation Code 603 C.M.R. 28.00 with the provisions of the Individuals with Disabilities Education Act (IDEA).  Procedures for managing students with asthma are included in the Comprehensive School Health Manual from the Massachusetts Department of Public Health, updated in 2007, which instructs school nurses to use the Massachusetts Asthma Action Plan (MAAP) and coordinate the student’s care with the family, the student’s physician, and school staff members.  Other guidance and resources are also provided in the Manual. 

The Massachusetts Department of Public Health convened an Asthma Working Group in 2002.  This coalition developed a state-wide Asthma Strategic Action Plan with components dedicated to school health, including development of standards for all Massachusetts schools.  The state funded 109 school districts (representing slightly less than a third of all Massachusetts public school districts) to develop model school health service programs called “Enhanced School Health Services” with asthma as a major focus.  Of these, 103 districts continued the ESHS in 2005-2006, serving about 538,000 children.  

Health Services Capacity

Massachusetts builds the health services capacity of its schools by promoting policies such as a nurse in every school, school-based health centers and case management for chronic illnesses.  Student health services in Massachusetts are supervised by the Massachusetts Department of Public Health and are thoroughly detailed in its recently revised and updated Comprehensive School Health Manual, available at http://www.maclearinghouse.com/schoolhealthmanual.htm.

Massachusetts’ recommended nurse-to-student ratio is one full-time equivalent (FTE) certified nurse per 250 to 500 students.  Massachusetts has a State Health Services Coordinator and requires each school district to have a Health Services Coordinator.   The state supports 72 school-based health centers (SBHCs).  SBHCs operate as licensed satellite clinics of a hospital or clinic and provide students with access to primary care in the school setting. 

Asthma management of children in schools with a SBHC is supported by the services of a primary health care practitioner and educational materials for children and their parents.  

Awareness

Under the guidance of its publication, Managing Life Threatening Food Allergies in Schools, teachers and other school staff must receive training in school policies and procedures for food allergies.  Massachusetts also requires training of foodservice personnel in serving students with special dietary needs and in procedures for dealing with allergic reactions to foods.

Required staff development includes continuing education training or funding for school nurses in administration of medications; case management for students with chronic health conditions; identifying and tracking students with chronic health conditions; accessing benefits for students with disabilities; teaching self-management to students with chronic health conditions; tobacco use prevention and tobacco use cessation.  Asthma awareness training covering the schools’ asthma program, policy and procedures is required for all school staff. 

School nurses are responsible for coordinating activities for staff awareness and education regarding students with special health needs, including sharing Individual Health Care Plans as appropriate and coordinating with health and science teachers to include asthma awareness in the school health curriculum.

School Environment

Massachusetts established The Healthy Schools Council in 2001 to address environmental issues. The inter-agency council is made up of representatives from the Departments of Education, Public Health, Labor and Workforce Development, Environmental Protection, and Food and Agriculture, the Division of Occupational Safety, the Executive Office of Environmental Affairs, the Office of Technical Assistance, the Attorney General’s Office, the State Fire Marshall’s Office and the Board of Higher Education.  The council identified a list of the most important issues for schools to address in terms of environmental health and safety and drafted a resource booklet for state-wide distribution by the Department of Education (DOE) and others.  Relevant issues covered are HVAC systems, IPM programs and vehicle exhaust concerns. 

Indoor Air Quality

The Massachusetts Coalition for Occupational Safety and Health (MassCOSH) is promoting State Bill HD3056 to improve IAQ in schools, and encourage use of Tools for Schools.  Current oversight of school maintenance is in part regulated by Massachusetts General Laws Chapter 70B, #8 and Massachusetts Code Regulations Title 603, #38.14, which require school districts to spend a percentage of their funds allocated for maintenance in order to be eligible for state funding for school construction and emergency repairs.  Massachusetts General Law Chapter 70B § 3 was amended in 2006 to create the Massachusetts School Building Authority and school building grants program for projects related to IAQ and other environmental issues. 

In addition, the DPH conducts an IAQ program that conducts assessments in public schools (and other public buildings) to evaluate the ventilation system, determine the potential for microbial growth and locate the point sources of environmental concerns. 

Chapter 208 of the Acts of 2004 established the Massachusetts School Building Authority, which assumed responsibility for the Commonwealth’s school building assistance (SBA) program.  The MSBA funds new school construction as well as renovation for Massachusetts schools.  Funding is available for development of IAQ programs in schools.         

Chapter 85 of the Acts of 2000, Section 11 prohibits the spraying of pesticides indoor or outdoor on school property while children are present. Written notification must be given to school staff, students, and their parents or guardians at least two working days before pesticides are applied and must also be posted prior to the pesticide application in a common area. The law further requires each school to adopt and implement an integrated pest management plan that covers both indoor and outdoor areas.

Outdoor Air Quality

School bus retrofitting to reduce diesel exhaust has been undertaken in several Massachusetts communities including Boston, Medford, Mohawk and Cambridge.  Massachusetts General Law Chapter 90, Title 16A and the Department of Environmental Protection Regulation 310 CMR 7.11(1) (b) limit idling of school buses to five minutes.

Tobacco Policies

General Law  71.2Aprohibits tobacco use of any kind by any primary or secondary public school student on school grounds during normal hours.  General Law 71:37H also prohibits the use of any tobacco product within school buildings, school facilities or on school grounds or buses by any individual, including school personnel.

Tobacco use prevention is required in the health curriculum for all students, and state funding is available for schools to develop and implement a tobacco use prevention program.  Smoking cessation services for students are not required. 

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